ATI Mental Health Proctored Exam

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The client is responsive and able to fully respond by opening their eyes and attending to a normal tone of voice and speech. What is the level of consciousness?

Alert

The client is able to open their eyes and respond but is drowsy and falls asleep readily. What is the level of consciousness?

Lethargic

The client requires vigorous or painful stimuli (pinching a tendon or rubbing the sternum) to elicit a brief response. They might not be able to respond verbally. What is the level of consciousness?

Stuporous

The client is unconscious and does not respond to painful stimuli. What is the level of consciousness?

Comatose

How to test a client’s immediate memory

Ask the client to repeat a series of numbers or a list of objects

How to test a client’s recent memory

Ask the client to recall recent events, such as visitors from the current day, or the purpose of the current mental health appointment or admission

How to test a client’s remote memory

Ask the client to state a fact from his past that is verifiable, such as his birth date or his mother’s maiden name

How to assess a client’s ability to calculate

Ask the client to count backward from 100 in sevens

How to assess a client’s ability to think abstractly

Ask the client to interpret something complex such as, "A bird in the hand is worth two in the bush."

Glasgow coma scale

Used to obtain a baseline assessment of a client’s level of consciousness; highest score is 15 and indicates that the client is awake and responding appropriately; a score of 7 or less indicates that the client is in a coma

Serious mental illness

Includes disorders classified as severe and persistent mental illnesses; clients often have difficulty with ADLs; can be chronic or recurrent

A charge nurse is discussing mental status exams with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (Select all that apply)

A. "To assess cognitive ability, I should ask the client to count backward by sevens."
B. "To assess affect, I should observe the client’s facial expression."
C. "To assess language ability, I should instruct the client to write a sentence."
D. "To assess remote memory, I should have the client repeat a list of objects."
E. "To assess the client’s abstract thinking, I should ask the client to identify our most recent presidents."

A. Counting backward by sevens is an appropriate technique to assess a client’s cognitive ability. B. Observing a client’s facial expression is appropriate when assessing affect. C. Writing a sentence is an indication of language ability. Remote language is tested by asking the client to state a fact from his past that his verifiable (date of birth). Abstract thinking is tested by asking the client to interpret something.

A nurse is planning care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention?

A. Assist the client with systematic desensitization therapy.
B. Teach the client appropriate coping mechanisms.
C. Assess the client for comorbid health conditions.
D. Monitor the client for adverse effects of the medications.

D. Monitoring for adverse effects of medications is an example of a psychobiological intervention. Systematic desensitization is cognitive and behavioral. Teaching coping mechanisms is a counseling or health teaching. Assessing for comorbid conditions is health promotion and maintenance.

A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority?

A. Coordinate holistic care with social services.
B. Identify the client’s perception of her mental health status.
C. Include the client’s family in the interview.
D. Teach the client about her current mental health disorder.

B. Assessment is the priority action. Identifying the client’s perception of her mental health status provides important information about the client’s psychosocial history.

A nurse is told during change of shift report that a client is stuporous. When assessing the client, which of the following findings should the nurse expect?

A. The client arouses briefly in response to a sternal rub.
B. The client has a glasgow coma scale score less than 7.
C. The client exhibits decorticate rigidity.
D. The client is alert but disoriented to time and place.

A. A client who is stuporous requires vigorous or painful stimuli to elicit a response. B & C occur with comatose patients.

A nurse is planning a peer group discussion about the DSM-5. Which of the following information is appropriate to include in the discussion? (Select all that apply)

A. The DSM-5 includes client education handouts for mental health disorders.
B. The DSM-5 establishes diagnostic criteria for individual mental health disorders.
C. The DSM-5 indicates recommended pharmacological treatment for mental health disorders.
D. The DSM-5 assists nurses in planning care for client’s who have mental health disorders.
E. The DSM-5 indicates expected assessment findings of mental health disorders.

B, D, & E. The DSM-5 establishes diagnostic criteria, assists nurses in planning care, and identifies expected findings for mental health disorders. The DSM-5 does not contain client education handouts or recommended pharmacological treatment.

Beneficence

The quality of doing good, can be described as charity

Autonomy

The client’s right to make their own decisions

Justice

Fair and equal treatment for all

Fidelity

Loyalty and faithfulness to the client and to one’s duty

Veracity

Honesty when dealing with a client

Requirements for restraining a patient

Provider must prescribe the restraint in writing; time limits are based on age, 4 hr for adults, 2 hr for ages 9-17, 1 hr for age 8 and younger; must be reviewed every 24 hr; documentation must be done every 15-30 min

False imprisonment

Confining a client to a specific area if the reason for such confinement is for the convenience of the staff

Assault

Making a threat to a client’s person

Battery

Touching a client in a harmful or offensive way

A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission?

A. A client who has schizophrenia with delusions of grandeur
B. A client who has manifestations of depression and attempted suicide a year ago
C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod
D. A client who has bipolar disorder and paces quickly around the room while talking to himself

C. A client who is a current danger to self or others is a candidate for a temporary emergency admission.

A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. The nurse’s actions are an example of which of the following torts?

A. Invasion of privacy
B. False imprisonment
C. Assault
D. Battery

B. Secluding a client for the convenience of the staff is false imprisonment.

A client tells a nurse, "Don’t tell anyone but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me." Which of the following actions should the nurse take?

A. Keep the client’s communication confidential, but talk to the client daily, using therapeutic communication to convince him to admit to hiding the knife.
B. Keep the client’s communication confidential, but watch the client and his roommate closely.
C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others.
D. Report the incident to the health care team, but do not inform the client of the intention to do so.

C. The information presented by the client is a serious safety issue that the nurse must report to the health care team, using the ethical principle of veracity.

A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? (Select all that apply)

A. "Client ate most of his breakfast."
B. "Client was offered 8 oz of water every hr."
C. "Client shouted obscenities at assistive personnel."
D. "Client received chlorpromazine 15 mg by mouth at 1000."
E. "Client acted out after lunch."

B, C, & D. Documentation must include how much water was offered and how often, a description of the client’s verbal communication, and the dosage and time of medication administration. Intake and behavior should be documented in the client’s medical record.

A nurse hears a newly licensed nurse discussing a client’s hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first?

A. Notify the nurse manager.
B. Tell the nurse to stop discussing the behavior.
C. Provide an in-service program about confidentiality.
D. Complete an incident report.

B. The greatest risk to this client is invasion of privacy through the sharing of confidential information in a public place. The first action the nurse should take is to tell the newly licensed nurse to stop discussing the client’s hallucinations in a public location.

A nurse is caring for the parents of a child who has demonstrated changes in behavior and mood. When the mother of the child asks the nurse for reassurance about her son’s condition, which of the following responses should the nurse make?

A. "I think your son is getting better. What have you noticed."
B. "I’m sure everything will be okay. It just takes time to heal."
C. "I’m not sure whats wrong. Have you asked the doctor about your concerns?"
D. "I understand you’re concerned. Let’s discuss what concerns you specifically."

D. This reflects upon and accepts the parents’ feelings and allows them to clarify what they are feeling. A interjects the nurse’s opinion. B provides false reassurance. C avoids addressing the parent’s concerns directly and indicates disinterest.

Altruism

Dealing with anxiety by reaching out to others

Sublimation

Dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression

Suppression

Voluntarily denying unpleasant thoughts and feelings

Repression

Unconsciously putting unacceptable ideas, thoughts, and emotions out of awareness

Regression

Sudden use of childlike or primitive behaviors that do not correlate with the person’s current developmental level

Displacement

Shifting feelings related to an object, person, or situation to another less threatening object, person, or situation

Reaction formation

Overcompensating or demonstrating the opposite behavior of what is felt

Undoing

Performing an act to make up for prior behavior

Rationalization

Creating reasonable and acceptable explanations for unacceptable behavior

Dissociation

Creating a temporary compartmentalization or lack of connection between the person’s identity, memory, or how they perceive the environment

Denial

Pretending the truth is not reality to manage the anxiety of acknowledging what is real

Compensation

Emphasizing strengths to make up for weaknesses

Identification

Conscious or unconscious assumption of the characteristics of another individual or group

Intellectualization

Separation of emotional and logical facts when analyzing or coping with a situation or event

Conversion

Responding to stress through the unconscious development of physical manifestations not caused by a physical illness

Splitting

Demonstrating an inability to reconcile negative and positive attributes of self or others

Projection

Attributing one’s unacceptable thoughts and feelings onto another who does not have them

Mild anxiety

Occurs in normal experience of everyday living, increases one’s ability to perceive reality, has an identifiable cause

Moderate anxiety

Slightly reduced perception and processing of information occurs and selective inattention can occur, ability to think clearly is hampered but learning and problem solving can still occur, may show increased HR and RR

Severe anxiety

Perceptual field is greatly reduced with distorted perceptions, learning and problem solving do not occur, may cause increased HR and RR

Panic level anxiety

Characterized by markedly disturbed behavior, cannot process what is occurring in the environment and can lose touch with reality, experiences extreme fight and horror

A nurse is caring for a client who smokes and has lung cancer. The client reports, "I’m coughing because I have that cold that everyone has been getting." The nurse should identify that the client is using which of the following defense mechanisms?

A. Reaction formation
B. Denial
C. Displacement
D. Sublimation

B. This is an example of denial, which is pretending the truth is not reality to manage the anxiety of acknowledging what is real.

A nurse is providing preoperative teaching for a client who was just informed that she requires emergency surgery. The client has a respiratory rate 30/min and says, "This is difficult to comprehend. I feel shaky and nervous." The nurse should identify that the client is experiencing which of the following levels of anxiety?

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

B. Moderate anxiety decreases problem-solving and may hamper the client’s ability to understand information. Vital signs may increase somewhat, and the client is visibly anxious.

A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary information to the client? (Select all that apply.)

A. Reassure the client that everything will be okay.
B. Discuss prior use of coping mechanisms with the client.
C. Ignore the client’s anxiety so that she will not be embarrassed.
D. Demonstrate a calm manner while using simple and clear directions.
E. Gather information from the client using closed-ended questions.

B & D. Discussing the prior use of coping mechanisms assists the client in identifying ways of effectively coping with the current stressor. Providing a calm presence assists the client in feeling secure and promotes relaxation. Clients experiencing moderate levels of anxiety often benefit from the direction of others.

Transference

Occurs when the client views a member of the health care team as having characteristics of another person who has been significant to the client’s personal life

Countertransference

Occurs when a health care team member displaces characteristics of people in her past onto a client

A nurse is talking with a client who is at risk for suicide following the death of his spouse. Which of the following statements should the nurse make?

A. "I feel very sorry for the loneliness you must be experiencing."
B. "Suicide is not the appropriate way to cope with loss."
C. "Losing someone close to you must be very upsetting."
D. "I know how difficult it is to lose a loved one."

C. This statement is an empathetic response that attempts to understand the client’s feelings. A focuses on the nurse’s feelings. B implies judgment. D focuses on the nurse’s experiences.

A charge nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse. Which of the following characteristics should the nurse include in the discussion? (Select all that apply)

A. The needs of both participants are met.
B. An emotional commitment exists between the participants.
C. It is goal-directed.
D. Behavioral change is encouraged.
E. A termination date is established.

C, D, & E. A therapeutic nurse-client relationship is goal-directed, encourages positive behavioral change, and has an established termination date. It should focus on the client only. An emotional commitment is a characteristic of an intimate or social relationship rather than a therapeutic relationship.

A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions indicates transference behavior?

A. The client asks the nurse whether she will go out to dinner with him.
B. The client accuses the nurses of telling him what to do just like his ex-girlfriend.
C. The client reminds the nurse of a friend who died from a substance overdose.
D. The client becomes angry and threatens to harm himself.

B. When a client views the nurse as having characteristics of another person who has been significant to his personal life, such as his ex-girlfriend, this indicates transference.

A nurse is planning care for the termination phase of a nurse-client relationship. Which of the following actions should the nurse include in the plan of care?

A. Discussing ways to use new behaviors
B. Practicing new problem-solving skills
C. Developing goals
D. Establishing boundaries

A. Discussing ways for the client to incorporate new healthy behaviors into life is an appropriate task for the termination phase. B occurs in the working phase. C & D occur in the orientation phase.

A nurse is orienting a new client to a mental health unit. When explaining the unit’s community meetings, which of the following statements should the nurse make?

A. "You and a group of other clients will meet to discuss your treatment plans."
B. "Community meetings have a specific agenda that is established by staff."
C. "You and the other clients will meet with staff to discuss common problems."
D. "Community meetings are an excellent opportunity to explore your personal mental health issues."

C. Community meetings are an opportunity for clients to discuss common problems or issues affecting all members of the unit.

Primary prevention

Promotes health and prevents mental health problems from occurring; teaching a community education program on stress reduction techniques

Secondary prevention

Focuses on early detection of mental illness; screening older adults in the community for depression

Tertiary prevention

Focuses on rehabilitation and prevention of further problems in clients who have previous diagnoses; leading a support group for clients who have completed a substance use disorder program

Partial hospitalization programs

Provide intense short term treatment for clients who are well enough to go home every night and who have a responsible person at home to provide support and a safe environment

Assertive community treatment

Includes nontraditional case management and treatment by an inter professional team for clients who have severe mental illness and are noncompliant with traditional treatment; helps to reduce reoccurrences of hospitalizations and provides crisis intervention, assistance with independent living, and information regarding resources for necessary support services

A nurse is caring several clients who are attending community-based mental health programs. Which of the following clients should the nurse plan to visit first?

A. A client who recently burned her arm while using a hot iron at home.
B. A client who requests that her antipsychotic medication be changed due to some new adverse effects.
C. A client who says he is hearing a voice that tells him he is not worth living anymore.
D. A client who tells the nurse he experienced manifestations of severe anxiety before and during a job interview.

C. A client who hears a voice telling him he is not worthy is at greatest risk for self-harm, and the nurse should visit this client first.

A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse plan as a method of tertiary prevention?

A. Educating clients on health promotion techniques to reduce the risk of depression
B. Performing screenings for depression at community health programs
C. Establishing rehabilitation programs to decrease the effects of depression
D. Providing support groups for clients at risk for depression

C. Rehabilitation programs are an example of tertiary prevention, which deals with prevention of further problems in clients already diagnosed with mental illness. A & D are primary prevention. B is secondary prevention.

A nurse is working in a community mental health facility. Which of the following services does this type of program provide? (Select all that apply)

A. Educational groups
B. Medication dispensing programs
C. Individual counseling programs
D. Detoxification programs
E. Family therapy

A, B, C, & E. Community mental health facilities provide educational programs, medication dispensing programs, individual counseling programs, and family therapy. Detoxification programs are provided in a partial hospitalization program.

A nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe mental illness and requires supervision much of the time. The client’s wife works all day but is home by late afternoon. Which of the following strategies should the nurse suggest as appropriate follow-up care?

A. Receiving daily care from a home health aide
B. Having a weekly visit from a nurse case worker
C. Attending a partial hospitalization program
D. Visiting a community mental health center on a daily basis

C. A partial hospitalization program can provide treatment during the day while allowing the client to spend nights at home, as long as a responsible family member is present. Daily care provided by a home health aide and weekly visits from a case worker will not provide adequate care and supervision. Visiting a community mental health center daily will not provide consistent supervision.

A nurse is caring for a group of clients. Which of the following clients should a nurse consider for referral to an assertive community treatment (ACT) group?

A. A client in an cute care mental health facility who has fallen several times while running down the hallway
B. A client who lives at home and keeps "forgetting" to come in for his monthly antipsychotic injection for schizophrenia
C. A client in a day treatment program who says he is becoming more anxious during group therapy
D. A client in a weekly grief support group who says she still misses her deceased husband who has been dead for 3 months

B. An ACT group works with clients who are nonadherent with traditional therapy, such as the client in a home setting who keeps "forgetting" his injection.

Free association

Therapeutic tool that is the spontaneous, uncensored verbalization of whatever comes to a client’s mind

Psychodynamic psychotherapy

Focuses on the client’s present state rather than his early life

Interpersonal psychotherapy (IPT)

Assists clients in addressing specific problems

Dialectical behavior therapy

Cognitive-behavioral therapy for clients who have a personality disorder and exhibit self-injurious behaviors; focuses on gradual behavior changes and provides acceptance and validation for these clients

Classical psychoanalysis

Therapeutic process of assessing unconscious thoughts and feelings, focuses on past relationships; clients attend many sessions over the course of months to years

Operant conditioning

The client receives positive rewards for positive behavior (positive reinforcement)

A nurse is teaching a client who has an anxiety disorder and is scheduled to begin classical psychoanalysis. Which of the following client statements indicates an understanding of this form of therapy?

A. "Even if my anxiety improves, I will need to continue this therapy for 6 weeks."
B. "The therapist will focus on my past relationships during our sessions."
C. "Psychoanalysis will help me reduce my anxiety by changing my behaviors."
D. "This therapy will address my conscious feelings about stressful experiences."

B. Classical psychoanalysis places a common focus on past relationships to identify the cause of the anxiety disorder.

A nurse is discussing free association as a therapeutic tool with a client who has major depressive disorder. Which of the following client statements indicates understanding of this technique?

A. "I will write down my dreams as soon as I wake up."
B. "I may begin to associate my therapist with important people in my life."
C. "I can learn to express myself in a nonaggressive manner."
D. "I should say the first thing that comes to my mind."

D. Free association is the spontaneous, uncensored vernalization of whatever comes to a client’s mind. A is dream analysis. B is transference. C is assertiveness training.

A nurse is preparing to implement cognitive reframing techniques for a client who has an anxiety disorder. Which of the following techniques should the nurse include in the plan of care? (Select all that apply)

A. Priority restructuring
B. Monitoring thoughts
C. Diaphragmatic breathing
D. Journal keeping
E. Meditation

A, B, & D. Cognitive reframing utilizes priority restructuring, monitoring thoughts, and journal keeping. Diaphragmatic breathing and meditation are used in behavioral therapy.

A nurse is caring for a client who has a new prescription for disulfiram for treatment of alcohol use disorder. The nurse informs the client that this medication can cause nausea and vomiting if he drinks alcohol. Which of the following types of treatment is this method an example?

A. Aversion therapy
B. Flooding
C. Biofeedback
D. Dialectical behavior therapy

A. Aversion therapy pair a maladaptive behavior with unpleasant stimuli to promote a change in behavior.

A nurse is assisting with systematic desensitization for a client who has an extreme fear of elevators. Which of the following actions should the nurse implement with this form of therapy?

A. Demonstrate riding in an elevator, and then ask the client to imitate the behavior.
B. Advise the client to say "stop" out loud every time he begins to feel an anxiety response related to an elevator.
C. Gradually expose the client to an elevator while practicing relaxation techniques.
D. Stay with the client in an elevator until his anxiety response diminishes.

C. Systematic desensitization is the planned, progressive exposure to anxiety-provoking stimuli. During this exposure, relaxation techniques suppress the anxiety response. A is modeling. B is thought stopping. D is flooding.

Group process

Verbal and nonverbal communication that occurs during group sessions, including how the work progresses

Group norm

The way the group behaves during sessions, and, over time, it provides structure for the group

Homogeneous group

A group in which all members share a certain chosen characteristic, such as diagnosis or gender

Orientation phase of a group

Primary focus is defining the purpose and goals of the group

Working phase of a group

Primary focus is promoting problem solving skills to facilitate behavioral changes

Termination phase of a group

Primary focus is marking the end of group sessions

Nuclear families

Include children who reside with married parents

Blended families

Include children who live with one biological or adoptive parent and a nonrelated stepparent who are married

Cohabitating families

Include children who live with one biological parent and nonrelated adult who are cohabitating

Extended families

Include children living with one biological or adoptive parent and a related adult who is not their parent (grandparent, aunt, uncle, etc.)

Other families

Include children living with related or nonrelated adults who are neither biological nor adoptive parents (grandparents, adult siblings, foster parents)

Enmeshed boundaries

Thoughts, roles, and feelings blend so much that individual roles are unclear

Rigid boundaries

Rules and roles are completely inflexible, these families tend to have members that isolate themselves

A nurse wants to use democratic leadership with a group whose purpose is to learn appropriate conflict resolution techniques. The nurse is correct in implementing this form of group leadership when she demonstrates which of the following actions?

A. Observes group techniques without interfering with the group process
B. Discusses a technique and then directs members to practice the technique
C. Asks for group suggestions of techniques and then support discussion
D. Suggests techniques and asks group members to reflect on their use

C. Democratic leadership supports group interaction and decision making to solve problems. A is laissez-faire leadership. B & D are autocratic leadership.

A nurse is planning group therapy for clients dealing with bereavement. Which of the following activities should the nurse include in the initial phase? (Select all that apply)

A. Encourage the group to work toward goals
B. Define the purpose of the group
C. Discuss termination of the group
D. Identify informal roles of members within the group
E. Establish an expectation of confidentiality within the group

B, C, & E. During the initial phase, the nurse should identify the purpose of the group, discuss termination of the group, and set the tone of confidentiality. A & D take place during the working phase.

A nurse working on an acute mental health unit forms a group to focus on self-management of medications. At each of meetings, two of the members use the opportunity to discuss their common interest in gambling on sports. This is an example of which of the following concepts?

A. Triangulation
B. Group process
C. Subgroup
D. Hidden agenda

D. A hidden agenda is when some group members have a different goal than the stated group goals.

A nurse is conducting a family therapy session. The adolescent son tells the nurse that he plans ways to make his sister look bad so his parents will think he’s the better sibling, which he believes will give him more privileges. The nurse should identify this dysfunctional behavior as which of the following?

A. Placation
B. Manipulation
C. Blaming
D. Distraction

B. Manipulation is the dysfunctional behavior of using dishonesty to support an individual agenda.

A nurse is working with an established group and identifies various member roles. Which of the following should the nurse identify as an individual role?

A. A member who praises input from other members
B. A member who follows the direction of other members
C. A member who brags about accomplishments
D. A member who evaluates the group’s performance toward a standard

C. An individual who brags about accomplishments is acting in an individual role that does not promote the progression of the group toward meeting goals.

Expected findings of acute stress (fight or flight)

Apprehension, unhappiness or sorrow, decreased appetite, increased vital signs, increased metabolism and glucose use, depressed immune system

Expected findings of prolonged stress (maladaptive response)

Chronic anxiety or panic attacks, depression, chronic pain, sleep disturbances, weight gain or loss, increased risk for myocardial infarction and stroke, poor diabetes control, hypertension, fatigue, irritability, decreased ability to concentrate, increased risk for infection

Biofeedback

Use of a sensitive mechanical device to assist the client to gain voluntary control of such autonomic functions as heart rate and blood pressure

A nurse is preparing to provide an educational seminar on stress to other nursing staff. Which of the following information should the nurse include in the discussion?

A. Excessive stressors cause the client to experience distress.
B. The body’s initial adaptive response to stress is denial.
C. Absence of stressors results in homeostasis.
D. Negative, rather than positive, stressors produce a biological response.

A. Distress is the result of excessive or damaging stressors, such as anxiety or anger.

A nurse is discussing acute vs prolonged stress with a client. Which of the following effects should the nurse identify as an acute stress response? (Select all that apply)

A. Chronic pain
B. Depressed immune system
C. Increased blood pressure
D. Panic attacks
E. Unhappiness

B, C, & E. Depressed immune system, increased blood pressure, and unhappiness are responses to acute stress. Chronic pain and panic attacks are responses to prolonged stress.

A nurse is teaching a client about stress-reduction techniques. Which of the following client statements indicates understanding of the teaching?

A. "Cognitive reframing will help me change my irrational thoughts to something positive."
B. "Progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate."
C. "Biofeedback causes my body to release endorphins so that I feel less stress and anxiety."
D. "Mindfulness allows me to prioritize the stressors that I have in my life so that I have less anxiety."

A. Cognitive reframing helps the client look at irrational thoughts in a more realistic light and to restructure those thoughts in a more positive way. B is biofeedback. C is physical exercise. D is priority restructuring.

A client says she is experiencing increased stress because her significant other is "pressuring me and my kids to go live with him. I love him, but I’m not ready to do that." Which of the following recommendations should the nurse make to promote a change in the client’s situation?

A. Learn to practice mindfulness
B. Use assertiveness techniques
C. Exercise regularly
D. Rely on the support of a close friend

B. Assertive communication allows the client to assert her feelings and then make a change in the situation.

A nurse is caring for a client who states, "I’m so stressed at work because of my coworker. He expects me to finish his work because he’s too lazy!" When discussing effective communication, which of the following statements by the client to his coworker indicates client understanding?

A. "You really should complete your own work. I don’t think it’s right to expect me to complete your responsibilities."
B. "Why do you expect me to finish your work? You must realize that I have my own responsibilities."
C. "It is not fair to expect me to complete your work. If you continue, then I will report your behavior to our supervisor."
D. "When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities."

D. This response demonstrates assertive communication, which allows the client to state his feelings about the behavior and then promote a change. A can prompt a defensive reaction. B implies criticism. C is aggressive and threatening.

Indications for electroconvulsive therapy (ECT)

Clients with major depressive disorder whose manifestations are not responsive to pharmacological treatment, clients who are suicidal or homicidal and need rapid treatment, clients who are experiencing psychotic manifestations, clients who have schizophrenia with catatonic manifestations, clients who have schizoaffective disorder, clients who are pregnant and have a schizophrenia spectrum disorder, clients who have bipolar disorder with rapid cycling, clients who are unresponsive to treatment with lithium and antipsychotic medications

Medication management during ECT

IM injection of atropine sulfate 30 min prior to decrease secretions that could cause aspiration, short acting anesthetic at the time of the procedure, muscle relaxant (succinylcholine) after the anesthetic to decrease the risk for injury

Transcranial magnetic stimulation (TMS)

Noninvasive therapy that uses magnetic pulsations to stimulate the cerebral cortex of the brain, indicated for clients with major depressive disorder who are not responsive to pharmacological treatment

Vagus nerve stimulation (VNS)

Provides electrical stimulation through the vagus nerve to the brain through a device that is surgically implanted under the skin on the client’s chest; indicated for clients with depression that is resistant to pharmacological treatment and/or ECT

A nurse is providing teaching for a client who is scheduled to receive ECT for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching?

A. "It is common to treat depression with ECT before trying medications."
B. "I can have my depression cured if I receive a series of ECT treatments."
C. "I should receive ECT once a week for 6 weeks."
D. "I will receive a muscle relaxant to protect me from injury during ECT."

D. A muscle relaxant, such as succinylcholine, is administered to reduce the risk for injury during induced seizure activity. ECT should be used when meds are ineffective. ECT does not cure depression. ECT treatment is typically 2-3 times a week for a total of 6-12 treatments.

A charge nurse is discussing TMS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A. "TMS is indicated for clients who have schizophrenia spectrum disorders."
B. "I will provide postanesthesia care following TMS."
C. "TMS treatments usually last 5-10 minutes."
D. "I will schedule the client for daily TMS treatments for the first several weeks."

D. TMS is commonly prescribed daily for a period of 4-6 weeks. TMS is not indicated for schizophrenic patients. Postanesthesia care is not necessary after TMS. The procedures lasts 30-40 min.

A nurse is assessing a client immediately following an ECT procedure. Which of the following findings should the nurse expect? (Select all that apply)

A. Hypotension
B. Paralytic ileus
C. Memory loss
D. Nausea
E. Confusion

C, D, & E. Transient short term memory loss, nausea, and confusion are expected findings immediately following ECT. BP usually elevates after ECT. Paralytic ileum is not a finding.

A nurse is leading a peer group discussion about the indications for ECT. Which of the following indications should the nurse include in the discussion?

A. Borderline personality disorder
B. Acute withdrawal related to a substance use disorder
C. Bipolar disorder with rapid cycling
D. Dysphoric disorder

C. ECT is indicated for the treatment of bipolar disorder with rapid cycling.

A nurse is planning care for a client following surgical implantation of a VNS device. The nurse should plan to monitor for which of the following adverse effects? (Select all that apply)

A. Voice changes
B. Seizure activity
C. Disorientation
D. Dysphagia
E. Neck pain

A, D, & E. Voice changes, dysphagia, and neck pain are potential adverse effects of VNS. Seizure activity and disorientation are associated with ECT.

Generalized anxiety disorder

Client exhibits uncontrollable, excessive worry for at least 6 months; impairment in or more areas of functioning

Body dysmorphic disorder

Client has preoccupation with perceived flaws or defects in physical appearance

Risk factors for anxiety

Female, family history, acute medical condition, medication adverse effects, substance use/withdrawal

Expected findings of a panic attack

Four or more of the following: palpitations, shortness of breath, choking or smothering sensation, chest pain, nausea, feelings of depersonalization, fear of dying or insanity, chills or hot flashes

Manifestations of generalized anxiety disorder

Restlessness, muscle tension, avoidance of stressful activities or events, increased time and effort required to prepare for stressful activities or events, procrastination in decision making, seeks repeated reassurance

Standardized screening tools for anxiety disorders

Hamilton rating scale for anxiety, fear questionnaire (phobias), panic disorder severity scale, yale-brown obsessive compulsive scale, hoarding scale self-report

Medications for anxiety disorders

SSRIs, SNRIs, benzodiazepines, buspirone, beta blockers, antihistamines, anticonvulsants (mood stabilizing)

A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons?

A. Narcissistic behavior
B. Fear of rejection from staff
C. Attempt to reduce anxiety
D. Adverse effect of antidepressant medication

C. Clients who have OCD demonstrate repetitive behaviors in an attempt to suppress persistent thoughts or urges that cause anxiety.

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

A. Discuss new relaxation techniques
B. Show the client how to change his behavior
C. Distract the client with a television show
D. Stay with the client and remain quiet

D. During a panic attack, the nurse should quietly remain with the client. This promotes safety and reassurance without additional stimuli. During a panic attack, the client is unable to concentrate on learning new information and further stimuli should be avoided.

A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect? (Select all that apply)

A. Excessive worry for 6 months
B. Impulsive decision making
C. Delayed reflexes
D. Restlessness
E. Need for reassurance

A, D, & E. Generalized anxiety disorder is characterized by uncontrollable, excessive worry for more than 3 months, restlessness, and the need for repeated reassurance. GAD is characterized by procrastination and muscle tension rather than impulsivity and delayed reflexes.

A nurse is caring for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first?

A. Assessing the client’s risk for self harm
B. Instilling hope for positive outcomes
C. Encouraging the client to participate in group therapy sessions
D. Encouraging the client to participate in treatment decisions

A. The greatest risk to a client who has an anxiety or obsessive-compulsive disorder is self-harm or suicide. This should be assessed first.

A nurse is caring for a client who has acute stress disorder and is experiencing severe anxiety. Which of the following statements should the nurse make?

A. "Tell me about how you are feeling right now."
B. "You should focus on the positive things in your life to decrease your anxiety."
C. "Why do you believe you are experiencing this anxiety?"
D. "Let’s discuss the medications your provider is prescribing to decrease your anxiety."

A. Asking an open-ended question is therapeutic and assists the client in identifying anxiety. Offering advice and asking "why" questions are nontherapeutic. Clients experiencing severe anxiety are unable to concentrate or learn.

Acute stress disorder

Exposure to traumatic events causes anxiety, detachment, and other manifestations about the event for at least 3 days but for no more than 1 month following the event (becomes PTSD if it persists longer than 1 month)

Adjustment disorders

A stressor triggers a reaction causing changes in mood and/or dysfunction in performing usual activities, less severe than ASD and PSTD

Depersonalization

The feeling that a person is observing one’s own personality or body from a distance

Derealization

The feeling that outside events are unreal or part of a dream or that objects appear larger or smaller than they should

Dissociative amnesia

Inability to recall personal information regarding stressful events for a period of time

Dissociative fugue

Type of dissociative amnesia in which the client travels to a new area and is unable to remember one’s own identity and at least some of one’s past, can last weeks to months

Dissociative identity disorder

Client displays more than one distinct personality with a stressful event precipitating the change from one personality to another

Expected findings of ASD and PTSD

Flashbacks, nightmares, avoidance of things that bring back memories of the trauma, trying to avoid thinking about the event, anxiety or depressive disorders, anger/irritability, decreased interest in current activities, guilt, negative self-beliefs, cognitive distortions, detachment from others, inability to experience positive emotional experiences, dissociative manifestations, aggression, hypervigilance with heightened startle response, inability to focus, sleep disturbances, destructive behavior (suicidal thoughts)

Medications for ASD and PTSD

Antidepressants to decrease depression and anxiety (fluoxetine, venlafaxine, mirtazapine, amitriptyline), prazosin (decreases manifestations of hypervigilance and insomnia), propranolol (decreases vital signs and manifestations of anxiety, panic, hypervigilance, and insomnia)

Eye movement desensitization and reprocessing (EMDR)

Therapy using rapid eye movements during desensitization techniques in a multi-phase process; contraindicated for clients who have acute suicidal ideation, psychosis, severe dissociative disorders, detached retina or glaucoma, or severe substance use disorder

A nurse working on an acute mental health unit is caring for a client who has PTSD. Which of the following findings should the nurse expect? (Select all that apply)

A. Difficulty concentrating on tasks
B. Obsessive need to talk about the traumatic event
C. Negative self-image
D. Recurring nightmares
E. Diminished reflexes

A, C, & D. Manifestations of PTSD include the inability to concentrate, feeling guilty and having a negative self image, and recurring nightmares. Clients avoid talking about the event and are hypervigilant.

A nurse is involved in a serious and prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse use to help prevent developing a trauma-related disorder? (Select all that apply)

A. Avoid thinking about the incident when it is over
B. Take breaks during the incident for food and water
C. Debrief with others following the incident
D. Hold emotions in check in the days following the incident
E. Take advantage of offered counseling

B, C, & E. Taking breaks for food and water, debriefing after the event, and taking advantage of counseling can help prevent development of a trauma-related disorder.

A nurse is collecting an admission history for a client who has acute stress disorder (ASD). Which of the following information should the nurse expect to collect?

A. The client remembers many details about the traumatic incident
B. The client expresses heightened elation about what is happening
C. The client states he first noticed manifestations of the disorder 6 weeks after the traumatic incident occurred.
D. The client expresses a sense of unreality about the traumatic event

D. The client who has ASD often expresses dissociative manifestations regarding the event, which includes a sense of unreality. Clients with ASD are usually unable to remember details about the incident and react with negative emotions and manifestations occur immediately to a few days following the event.

A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization?

A. The client explains that her body seems to be floating above the ground
B. The client has the idea that someone is trying to kill her and steal her money
C. The client states that the furniture in the room seems to be small and far away
D. The client cannot recall anything that happened during the past 2 weeks

C. Stating that one’s surroundings are far away or unreal in some way is an example of derealization. A is depersonalization. B is a paranoid delusion. D is amnesia.

A nurse in an acute mental health facility is planning care for a client who has dissociative fugue. Which of the following interventions should the nurse add to the plan of care?

A. Teach the client to recognize how stress brings on a personality change in the client
B. Repeatedly present the client with information about past events
C. Make decisions for the client regarding routine daily activities
D. Work with the client on grounding techniques

D. Grounding techniques are useful for client who have a dissociate disorder and are experiencing manifestations of derealization. A is best for dissociative identity disorder. Flooding should be avoided to decrease anxiety. The nurse should encourage the client to make his own decisions.

Seasonal affective disorder (SAD)

A form of depression that occurs seasonally, usually during the winter, when there is less daylight; best treated with light therapy

Dysthymic disorder

Milder form of depression that usually has an early onset and lasts at least 2 years for adults and 1 year for children; contains at least 3 clinical findings of depression

A nurse working in an acute mental health facility is caring for a 35-year-old female client who has manifestations of depression. The client lives at home with her partner and two young children. She currently smokes and has a history of chronic asthma. Which of the following factors put the client at risk for depression? (Select all that apply)

A. Age
B. Gender
C. History of chronic asthma
D. Smoking
E. Being married

A, B, C, & D. Being between the ages of 15-40, being female, having a chronic illness, and substance use are risk factors for depression.

A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurse’s priority?

A. Placing the client on one-to-one observation
B. Assisting the client to perform ADLs
C. Encouraging the client to participate in counseling
D. Teaching the client about medication adverse effects

A. The greatest risk for a client who has MDD and comorbid anxiety is injury due to self harm. The highest priority intervention is placing the client on one-to-one observation.

A nurse working in an outpatient clinic is providing teaching to a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching?

A. "I can expect my problems with PMDD to be worst when I’m menstruating."
B. "I will use light therapy 30 min a day to prevent further recurrences of PMDD."
C. "I am aware that my PMDD causes me to have rapid mood swings."
D. "I should increase my caloric intake with a nutritional supplement when my PMDD is active."

C. A clinical finding of PMDD is emotional lability. Clinical findings of PMDD are present during the luteal phase of the menstrual cycle just prior to menses. Light therapy is best for SAD. PMDD increases the risk for weight gain due to overeating so the client should not increase her caloric intake.

A charge nurse is discussing the care of a client who has MDD with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A. "Care during the continuation phase focuses on treating continued manifestations of MDD."
B. "The treatment of MDD during the maintenance phase lasts for 6-12 weeks."
C. "The client is at greatest risk for suicide during the first weeks of an MDD episode."
D. "Medication and psychotherapy are most effective during the acute phase of MDD."

C. The client is at greatest risk for suicide during the acute phase of MDD. Care in the continuation phase focuses on relapse prevention. The maintenance phase of treatment can last for a year or more. Med therapy and psychotherapy are used during the continuation phase.

A nurse is interviewing a 25-year-old client who has a new diagnosis of dysthymic disorder. Which of the following findings should the nurse expect?

A. Wide fluctuations of mood
B. Report of a minimum of 5 clinical findings of depression
C. Presence of manifestations for at least 2 years
D. Inflated sense of self-esteem

C. Manifestations of dysthymic disorder last for at least 2 years in adults. A occurs in bipolar disorder. B occurs with MDD. Dysthymic disorder causes a decreased self-esteem.

Rapid cycling

Four or more episodes of hypomania or acute mania within 1 year

Bipolar I
Bipolar II
Cyclothymic disorder

In BI the client has at least one episode of mania alternating with major depression. In BII the client has one or more hypomanic episodes alternating with major depressive disorders. In cyclothymic disorder the client has at least 2 years of repeated hypomanic manifestations that do not meet the criteria for hypomanic episodes alternating with minor depressive episodes.

Mood Disorders Questionnaire

A standardized tool that places mood progression on a continuum from hypomania (euphoria) to acute mania (extreme irritability and hyperactivity) to delirious mania (completely out of touch with reality)

A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care? (Select all that apply)

A. Provide flexible client behavior expectations
B. Offer concise explanations
C. Establish consistent limits
D. Disregard client complaints
E. Use a firm approach with communication

B, C, & E. Offering concise explanations improves the client’s ability to focus. Setting limits decreases the risk for client manipulation. Using a firm approach promotes structure.

A nurse is teaching a newly licensed nurse about the use of ECT for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding?

A. "ECT is the recommended initial treatment for bipolar disorder."
B. "ECT is contraindicated for clients who have suicidal ideation."
C. "ECT is effective for client’s who are experiencing severe mania."
D. "ECT is prescribed to prevent relapse of bipolar behavior."

C. ECT is appropriate for the treatment of severe mania associated with bipolar disorder. Pharmacological intervention is the recommended initial treatment. ECT is effective in suicidal patients. ECT is prescribed for acute episodes of bipolar disorder rather than the prevention of relapse.

A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following responses should the nurse make?

A. "Why do you think you feel the need to give money away?"
B. "I am here to provide care and cannot accept this from you."
C. "I can request that your case manager discuss appropriate charity options with you."
D. "You should know that giving away your money is inappropriate."

B. This statement is matter of fact and concise and is a therapeutic response. A is a why question. C does not recognize the possibility of poor judgment. D offers disapproval.

A nurse in an acute mental health facility is caring for a client who has bipolar disorder. Which of the following is the priority nursing action?

A. Set consistent limits for expected client behavior
B. Administer prescribed medications as scheduled
C. Provide the client with step by step instructions during hygiene activities
D. Monitor the client for escalating behavior

D. Monitoring for escalating behavior addresses the client’s priority need for safety and is therefore the priority nursing action.

A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching? (Select all that apply)

A. Use caffeine in moderation to prevent relapse
B. Difficulty sleeping can indicate a relapse
C. Begin taking your medications as soon as a relapse begins
D. Participating in psychotherapy can help prevent a relapse
E. Anhedonia is a clinical manifestation of a depressive relapse

B, D, & E. Sleep disturbances and anhedonia can indicate a relapse. Psychotherapy is helpful in preventing a relapse. The client should caffeine use and should take prescribed medications to prevent and minimize a relapse.

Schizotypal personality disorder

The client has impairments of personality (self and interpersonal) functioning but is not as severe as schizophrenia

Delusional disorder

The client experiences delusional thinking for at least 1 month but self or interpersonal functioning are not markedly impaired

Brief psychotic disorder

The client has psychotic manifestations that last 1 day to 1 month in duration

Schizophreniform disorder

The client has manifestations similar to schizophrenia but the duration is 1-6 months and social/occupational dysfunction might not be present

Positive symptoms of psychotic disorders

Manifestation of things that are not normally present such as hallucinations, delusions, alterations in speech, and bizarre behavior

Negative symptoms of psychotic disorders

Absence of things that are normally present, more difficult to treat; blunted or flat affect, alogia (poverty of thought or speech), anergia (lack of energy), anhedonia (lack of pleasure or joy), avocation (lack of motivation)

Ideas of reference

Misconstrues trivial events and attaches personal significance to them, such as believing that others are talking about them

Persecution

Feels singled out for harm by others (being hunted down by the FBI)

Grandeur

Believe that they are all powerful and important, like a god

Thought broadcasting

Believe that their thoughts are being heard by others

Flight of ideas/loose association

The client might say sentence after sentence but each sentence can relate to a different topic

Neologisms

Made up words that have meaning only to the client

Echolalia

The clients repeat words spoken to them

Clang association

Meaningless rhyming of words

Word salad

Words jumbled together with little meaning or significance to the listener

A nurse is caring for a client who has substance-induced psychotic disorder and is experiencing auditory hallucinations. The client states, "The voices won’t leave me alone!" Which of the following statements should the nurse make? (Select all that apply)

A. "When did you start hearing the voices?"
B. "The voices are not real, or else we would both hear them."
C. "It must be scary to hear voices."
D. "Are the voices telling you to hurt yourself?"
E. "Why are the voices talking to only you?"

A, C, & D. The nurse should ask directly about the hallucination, focus on the client’s feelings, and assess for command hallucinations and the client’s risk for injury to self or others.

A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (Select all that apply)

A. Auditory hallucination
B. Lack of motivation
C. Use of clang association
D. Delusion of persecution
E. Constantly waving arms
F. Flat affect

A, C, D, & E. Hallucinations, speech alterations, delusions, and bizarre movements are positive symptoms. Lack of motivation and flat affect are negative symptoms.

A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization?

A. "I am a superhero and am immortal."
B. "I am no one, and everyone is me."
C. "I feel monsters pinching me all over."
D. "I know that you are stealing my thoughts."

B. This indicates the client is experiencing loss of identity or depersonalization. A is a delusion of grandeur. C is a tactile hallucination. D is thought withdrawal.

A nurse is caring for a client on an acute mental health unit The client reports hearing voices that are telling her to "kill your doctor." Which of the following actions should the nurse take first?

A. Use therapeutic communication to discuss the hallucination with the client
B. Initiate one-to-one observation of the client
C. Focus the client on reality
D. Notify the provider of the client’s statement

B. A client who is experiencing a command hallucination is at risk for injury to self or others and should be placed on one-to-one observation.

A nurse is speaking with a client who has schizophrenia when he suddenly seems to stop focusing on the nurse’s questions and begins looking at the ceiling and talking to himself. Which of the following actions should the nurse take?

A. Stop the interview at this point, and resume later when the client is better able to concentrate.
B. Ask the client, "Are you seeing something on the ceiling?"
C. Tell the client, "You seem to be looking at something on the ceiling. I see something there, too."
D. Continue the interview without comment on the client’s behavior.

B. The nurse should ask the client directly about the hallucination to identify client needs and assess for a potential risk for injury.

Characteristics of personality disorders

Inflexibility/maladaptive responses to stress, compulsiveness and lack of of social restraint, inability to emotionally connect in social and professional relationships, tendency to provoke interpersonal conflict, ability to merge personal boundaries with others

Cluster A personality disorders (odd or eccentric traits)

Paranoid (distrust and suspiciousness), schizoid (emotional detachment, disinterest in close relationships, indifference to praise or criticism), and schizotypal (interpersonal difficulties, eccentric appearance, magical thinking)

Cluster B personality disorders (dramatic, emotional, or erratic traits)

Antisocial (disregard for others), borderline (instability of affect, identity, and relationships as well as splitting behaviors, manipulation, impulsiveness, and fear of abandonment), histrionic (emotional attention-seeking behavior), and narcissistic (arrogance, grandiose views of self-importance, the need for consistent admiration, and lack of empathy)

Cluster C personality disorders (anxious or fearful traits, insecurity and inadequacy)

Avoidant (social inhibition and avoidance of all situations that require interpersonal contact), dependent (extreme dependency in a close relationship), and obsessive-compulsive (perfectionism with a focus on orderliness and control)

Medications for personality disorders

Antidepressants, anxiolytics, antipsychotics, and mood stabilizers

A nurse manager is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A. "I can promote my client’s sense of control by establishing a schedule."
B. "I should encourage clients who have a schizoid personality disorder to increase socialization."
C. "I should practice limit-setting to help prevent client manipulation."
D. "I should implement assertiveness training with clients who have antisocial personality disorder."

C. When caring for a client who has a personality disorder, limit-setting is appropriate to help prevent client manipulation. The nurse should ask for the client’s input instead of making a schedule, avoid trying to increase socialization for a client who has schizoid, and implement assertiveness training for clients who have dependent and histrionic personality disorders.

A nurse is caring for a client who has avoidant personality disorder. Which of the following statements is expected from a client who has this type of personality disorder?

A. "I’m scared that you’re going to leave me."
B. "I’ll go to group therapy if you’ll let me smoke."
C. "I need to feel that everyone admires me."
D. "I sometimes feel better if I cut myself."

A. Clients who have avoidant personality disorder often have fear of abandonment. This type of statement is expected. B occurs in antisocial personality disorder. C occurs in narcissistic personality disorder. D occurs in borderline personality disorder.

A nurse is caring for a client who has borderline personality disorder. The client says, "The nurse on the evening shift is always nice! You are the meanest nurse ever!" The nurse should recognize the client’s statement as an example of which of the following defense mechanisms?

A. Regression
B. Splitting
C. Undoing
D. Identification

B. Splitting occurs when a person is unable to see both positive and negative qualities at the same time. The client who has BPD tends to see a person as all bad one time and all good another time.

A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (Select all that apply)

A. Demonstrates extreme anxiety when placed in a social situation
B. Has difficulty making even simple decisions
C. Attempts to convince other clients to give him their belongings
D. Becomes agitated if his personal area is not neat and orderly
E. Blames others for his past and current problems

C & E. Exploitation/manipulation and failure to accept personal responsibility are findings of antisocial personality disorder. A occurs in avoidant personality disorder. B occurs in narcissistic personality disorder. D occurs in OCD.

A charge nurse is preparing a staff education session on personality disorders. Which of the following personality characteristics associated with all of the personality disorders should the charge nurse include in the teaching? (Select all that apply)

A. Difficulty in getting along with other members of a group
B. Belief in the ability to become invisible during times of stress
C. Display of defense mechanisms when routines are changed
D. Claiming to be more important than other persons
E. Difficulty understanding why it is inappropriate to have a personal relationship with staff

A, C, & E. Difficulty with social and professional relationships, maladaptive response to stress, difficulty understanding personal boundaries are characteristics seen in all personality disorders. B & D do not occur in all personality disorders.

Confabulation

The client can make up stories when questioned about events or activities that she does not remember; this can seem like lying, but it is actually an unconscious attempt to save self-esteem and prevent admitting that she does not remember the occasion

Delirium

Rapid over a short period of time (hours or days), emergency; impairments in memory, judgment, ability to focus, and ability to calculate (can fluctuate at night); altered LOC, rapid personality changes, labile mood, unstable vital signs; cause unknown

Neurocognitive disorder

Gradual deterioration over months or years; impairments in memory, judgment, speech (aphasia), ability to recognize familiar objects (agnosia), executive functioning, and movement (apraxia), do not change throughout the day; LOC unchanged, personality change is gradual, vital signs are stable; irreversible

Cholinesterase inhibitors

Donepezil, rivastigmine, galantamine; slow cognitive deterioration of alzheimer’s; contraindicated in patients who have asthma or other obstructive pulmonary disorders; start low dose and gradually increase; give once daily at bedtime

Cholinesterase side effects

Nausea, vomiting, diarrhea, bradycardia, syncope

Cholinesterase interactions

NSAIDs cause GI bleeding; antihistamines, TCAs, and conventional antipsychotics reduce effectiveness

. A nurse is caring for a client who has early stage Alzheimer’s disease and a new prescription for donepezil. The nurse should include which of the following statements when teaching the client about the medication?

A. "You should avoid taking over-the-counter acetaminophen while on donepezil."
B. "You can expect the progression of cognitive decline to slow with donepezil."
C. "You will be screened for underlying kidney disease prior to starting donepezil."
D. "You should stop taking donepezil if you experience nausea or diarrhea."

B. Donepezil slows the cognitive deterioration of Alzheimer’s disease. Clients should avoid NSAIDs, not acetaminophen. Clients should be screened for heart and pulmonary disease. The client should not abruptly stop the medication.

A nurse in a long-term care facility is caring for a client who has major neurocognitive disorder and attempts to wander out of the building. The client states, "I have to get home." Which of the following statements should the nurse make?

A. "You have forgotten that this is your home."
B. "You cannot go outside without a staff member."
C. "Why would you want to leave? Aren’t you happy with your care?"
D. "I am your nurse. Let’s walk together to your room."

D. It is appropriate for the nurse to introduce herself with each new interaction and to promote reality in a calm, reassuring manner. A is argumentative. B is a negative statement. C is a why question.

A home health nurse is making a visit to a client who has Alzheimer’s disease to assess the home for safety. Which of the following suggestions should the nurse make to decrease the client’s risk for injury? (Select all that apply)

A. Install childproof door locks.
B. Place rugs over electrical cords.
C. Mark cleaning supplies with colored tape.
D. Place the client’s mattress on the floor.
E. Install light fixtures above stairs.

A, D, & E. Door locks that are difficult to open reduce the risk of the client wandering. Placing the client’s mattress on the floor and installing lights above stairs reduce the risk for falls. Rugs are a fall hazard. Cleaning supplies should be in locked cupboards.

A nurse is making a home visit to a client who is in the late stage of Alzheimer’s disease. The client’s partner, who is the primary caregiver, wishes to discuss concerns about the client’s nutrition and the stress of providing care. Which of the following actions should the nurse take?

A. Verify that a current power of attorney document is on file.
B. Instruct the client’s partner to offer finger foods to increase oral intake.
C. Provide information on resources for respite care.
D. Schedules the client for placement of an enteral feeding tube.

C. Providing information on resources for respite care is an appropriate action to provide the client’s partner with a break from caregiver responsibilities.

A nurse is performing an admission assessment for a client who has delirium related to an acute UTI. Which of the following findings should the nurse expect? (Select all that apply)

A. History of gradual memory loss
B. Family report of personality changes
C. Hallucinations
D. Unaltered level of consciousness
E. Restlessness

B, C, & E. The client who has delirium can experience rapid personality changes, perceptual disturbances, and restlessness. Delirium is rapid and LOC is altered.

Effects of alcohol intoxication

Excess: slurred speech, nystagmus, memory impairment, altered judgment, decreased motor skills, decreased LOC, respiratory arrest, peripheral collapse, and death Chronic: direct cardiovascular damage, liver damage, erosive gastritis and GI bleeding, acute pancreatitis, sexual dysfunction

Alcohol withdrawal manifestations

Abdominal cramping, vomiting, tremors, restlessness, inability to sleep, increased HR/RR/BP/temp, transient hallucinations or illusions, anxiety, and tonic clonic seizures

Effects of benzodiazepine intoxication

Increased drowsiness and sedation, agitation, slurred speech, uncoordinated motor activity, nystagmus, disorientation, nausea/vomiting, respiratory depression, decreased LOC

Benzodiazepine withdrawal manifestations

Anxiety, insomnia, diaphoresis, hypertension, possible psychotic reactions, hand tremors, nausea, vomiting, hallucinations or illusions, psychomotor agitation, and possible seizure activity

Effects of cannabis intoxication

Lung cancer, chronic bronchitis, occurrence of paranoia, increased appetite, dry mouth, tachycardia

Cannabis withdrawal manifestations

Irritability, aggression, anxiety, insomnia, lack of appetite, restlessness, depressed mood, abdominal pain, tremors, diaphoresis, fever, headache

Effects of cocaine intoxication

Dizziness, irritability, tremor, blurred vision, hallucinations, seizures, extreme fever, tachycardia, hypertension, chest pain, possible cardiovascular collapse and death

Cocaine withdrawal manifestations

Depression, fatigue, craving, excess sleeping or insomnia, dramatic unpleasant dreams, psychomotor retardation, agitation

Effects of amphetamine intoxication

Impaired judgment, psychomotor agitation, hypervigilance, extreme irritability, tachycardia, elevated BP

Amphetamine withdrawal manifestations

Craving, depression, fatigue, sleeping

Effects of nicotine intoxication

Hypertension, stroke, respiratory disease, irritation to oral mucous membranes, cancer

Nicotine withdrawal manifestations

Abstinence syndrome evidenced by irritability, craving, nervousness, restlessness, anxiety, insomnia, increased appetite, difficulty concentrating, anger, and depressed mood

Effects of opioid intoxication

Slurred speech, impaired memory, pupillary changes, decreased respirations and LOC, and maladaptive behavioral or psychological changes (impaired judgment or social functioning)

Opioid withdrawal manifestations

Abstinence syndrome which begins with sweating and rhinorrhea progressing to piloerection, tremors, and irritability followed by severe weakness, diarrhea, fever, insomnia, pupil dilation, nausea, vomiting, pain in the muscles and bones, and muscle spasms

Effects of inhalant intoxication

Behavioral or psychological changes, dizziness, nystagmus, uncoordinated movements or gait, slurred speech, drowsiness, hyporeflexia, muscle weakness, diplopia, stupor or coma, respiratory depression, and possible death; no withdrawal manifestations

Effects of hallucinogen intoxication

Anxiety, depression, paranoia, impaired judgment, impaired social functioning, pupil dilation, tachycardia, diaphoresis, palpitations, blurred vision, tremors, incoordination, and panic attacks

Hallucinogen withdrawal manifestations

Hallucinogen persisting perception disorder: visual disturbances or flashback hallucinations can occur intermittently for years

Effects of caffeine intoxication

Commonly occurs with ingestion of greater 250 mg (one 2 oz high energy drink can contain 215-240 mg caffeine); tachycardia and arrhythmias, flushed face, muscle twitching, restlessness, diuresis, GI disturbances, anxiety, insomnia

Caffeine withdrawal manifestations

Can occur within 24 hr of last consumption; headache, nausea, vomiting, muscle pain, irritability, inability to focus, drowsiness

A nurse is planning a staff education program on substance use in older adults. Which of the following is appropriate for the nurse to include in the presentation?

A. Older adults require higher doses of a substance to achieve a desired effect.
B. Older adults commonly use rationalization to cope with a substance use disorder.
C. Older adults are at an increased risk for substance use following retirement.
D. Older adults develop substance use to mask manifestations of dementia.

C. Retirement and other life change stressors increase the risk for substance use in older adults.

A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect? (Select all that apply)

A. Bradycardia
B. Fine tremors of both hands
C. Hypotension
D. Vomiting
E. Restlessness

B, D, & E. Fine tremors of both hands, vomiting, and restlessness are expected findings of alcohol withdrawal. Alcohol withdrawal would cause tachycardia rather than bradycardia and hypertension rather than hypotension.

A nurse is planning care for a client who is experiencing benzodiazepine withdrawal. Which of the following interventions should the nurse identify as the priority?

A. Orient the client frequently to time, place, and person.
B. Offer fluids and nourishing diet as tolerated.
C. Implement seizure precautions.
D. Encourage participation in group therapy sessions.

C. The greatest risk to the client is injury. Implementing seizure precautions is the priority intervention.

A nurse is caring for a client who has alcohol use disorder. The client is no longer experiencing withdrawal manifestations. Which of the following medications should the nurse anticipate administering to assist the client with maintaining abstinence from alcohol?

A. Chlordiazepoxide
B. Bupropion
C. Disulfiram
D. Carbamazepine

C. The nurse should expect the administer disulfiram to help the client maintain abstinence from alcohol. A & D are for alcohol withdrawal. B is for nicotine withdrawal.

A nurse is providing teaching to the family of a client who has a substance use disorder. Which of the following statements by a family member indicate an understanding of the teaching? (Select all that apply)

A. "We need to understand that she is responsible for her disorder."
B. "Eliminating any codependent behavior will promote her recovery."
C. "She should participate in an Al-Anon group to help her recover."
D. "The primary goal of her treatment is abstinence from substance use."
E. "She needs to discuss her feelings about substance use to help her recover."

B, D, & E. Families should be aware of codependent behavior, such as enabling, that can promote substance use rather than recovery. Abstinence is the primary treatment goal for a client who has a substance use disorder. Clients must acknowledge their feelings about substance use as part of a substance use recovery program. Clients are responsible for their recovery not their disease. Al-Anon is for family members.

A nurse is preparing to obtain a nursing history from a client who has a new diagnosis of anorexia nervosa. Which of the following questions should the nurse include in the assessment? (Select all that apply)

A. "What is your relationship like with your family."
B. "Why do you want to lose weight?"
C. "Would you describe your current eating habits?"
D. "At what weight do you believe you will look better?"
E. "Can you discuss your feelings about your appearance?"

A, C, & E. An anorexia assessment should include family and interpersonal relationships, current eating habits, and the client’s perception of the issue. B is a "why" question and D promotes cognitive distortion.

A nurse is caring for an adolescent client who has anorexia nervosa with rapid weight loss and a current weight of 90 lb. Which of the following statements indicates the client is experiencing the cognitive distortion catastrophizing?

A. "Life isn’t worth living if I gain weight."
B. "Don’t pretend like you don’t know how fat I am."
C. "If I could be skinny, I know I’d be popular."
D. "When I look in the mirror, I see myself as obese."

A. This reflects catastrophizing because the client’s perception of her appearance or situation is much worse than her current condition. B is personalization. C is overgeneralization.

A nurse is performing an admission assessment of a client who has bulimia nervosa with purging behavior. Which of the following is an expected finding? (Select all that apply)

A. Amenorrhea
B. Hypokalemia
C. Mottling of the skin
D. Slightly elevated body weight
E. Presence of lanugo on the face

B & D. Hypokalemia and a normal weight or slightly elevated weight are findings of bulimia. Amenorrhea, skin mottling, and lanugo are expected findings of anorexia.

A nurse on an acute care unit is planning care for a client who has anorexia nervosa with binge-eating and purging behavior. Which of the following nursing actions should the nurse include in the client’s plan of care?

A. Allow the client to select preferred meal times.
B. Establish consequences for purging behavior.
C. Provide the client with a high-fat diet at the start of treatment.
D. Implement one-to-one observation during meal times.

D. The nurse should closely monitor the client during and after meals to prevent purging. The nurse should provide structured milieu including meal times, a positive approach to client care, and should limit high-fat foods.

A nurse is caring for a client who has bulimia nervosa and has stopped purging behavior. The client tells the nurse that she is afraid she is going to gain weight. Which of the following responses should the nurse make?

A. "Many clients are concerned about their weight. However the dietitian will ensure that you don’t get too many calories in your diet."
B. "Instead of worrying about your weight, try to focus on other problems at this time."
C. "I understand you have concerns about your weight, but first, let’s talk about your recent accomplishments."
D. "You are not overweight, and the staff will ensure that you do not gain weight while you are in the hospital. We know that is important to you."

C. This acknowledges the client’s concern and then focuses the conversation on the client’s accomplishments, which can promote client self-esteem and self-image. A, B, & D minimize and generalize the client’s concern.

Illness anxiety disorder

Misinterprets physical manifestations as evidence of a serious disease process

Conversion disorder

Client exhibits neurologic manifestations in the absence of a neurologic diagnosis

Factitious disorder

The conscious decision by the client to report physical or psychological manifestations for atttention

A nurse is discussing the risk factors for somatic symptom disorder with a newly licensed nurse. Which of the following risk factors should the nurse include? (Select all that apply)

A. Age older than 65 years
B. Anxiety disorder
C. Female gender
D. Coronary artery disease
E. Obesity

B & C. Anxiety disorder and female gender are risk factors for somatic symptom disorder. Age 16-25 years is a risk factor for somatic symptom disorder. Coronary artery disease and obesity are risk factors for somatic symptom disorders.

A nurse is reviewing the medical record of a client who has conversion disorder. Which of the following findings should the nurse identify as placing the client as risk for conversion disorder?

A. Death of a child 2 months ago
B. Recent weight loss of 30 lb
C. Retirement 1 year ago
D. History of migraine headaches

A. The death of a child 2 months ago is an acute stressor that places the client at risk for conversion disorder.

A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect? (Select all that apply)

A. Obsessive thoughts about disease
B. History of childhood abuse
C. Avoidance of health care providers
D. Depressive disorder
E. Narcissistic personality

A, B, C, & D. Obsessive thoughts about disease, a history of child abuse, avoidance of health care providers, and a depressive disorder are expected findings in a client who has illness anxiety disorder. Low self-esteem, rather than narcissism, is an expected finding in a client who has illness anxiety disorder.

A nurse is developing a plan of care for a client who has conversion disorder. Which of the following actions should the nurse include?

A. Encourage the client to spend time alone in his room
B. Monitor the client for self-harm once per day
C. Allow the client unlimited time to discuss physical manifestations
D. Discuss alternative coping strategies with the client

D. The nurse should discuss alternative coping strategies with the client. The nurse should encourage communication with others, continuously monitor the client for risk of self-harm, and should set a time limit for discussion of physical manifestations.

A nurse is counseling a client who has factitious disorder imposed on another. Which of the following client statements should the nurse expect?

A. "I had to pretend I was injured in order to get disability benefits."
B. "I know that my abdominal pain is caused by a malignant tumor."
C. "I needed to make my son sick so that someone else would take care of him for a while."
D. "I became deaf when I heard that my husband was having an affair with my best friend."

C. A client who has factitious disorder imposed on another often consciously injures another person or causes them to be sick due to a personal need for attention or relief of responsibility. A is malingering. B is found in illness anxiety disorder. D is found in conversion disorder.

Benzodiazepines

Alprazolam, diazepam, lorazepam, chlordiazepoxide, clorazepate, oxazepam, clonazepam; used to treat anxiety disorders, seizure disorders, insomnia, muscle spasm, alcohol withdrawal (prevention and treatment of acute manifestations), induction of anesthesia, and amnesic prior to surgery or procedures

Side effects of benzodiazepines

CNS depression (sedation, lightheadedness, ataxia, decreased cognitive function), anterograde amnesia, paradoxical response (insomnia, excitation, euphoria, anxiety, rage)

Atypical anxiolytic/nonbarbiturate anxiolytics

Buspirone; less potential for dependency than other antianxiety meds, does not result in sedation or potentiate effects of other CNS depressants; initial responses take 1 week and at least 2-6 weeks to reach full effects; should not be used with MAOIs or grapefruit juice

Side effects of buspirone

Dizziness, nausea, headache, lightheadedness, agitation

Selective serotonin reuptake inhibitors (SSRIs)

Paroxetine, sertraline, citalopram, escitalopram, fluoxetine, fluvoxamine; may take up to 4 weeks to produce therapeutic medication levels; used to treat depression, anxiety disorders, and trauma/stressor related disorders; should not be used with MAOIs or TCAs

Side effects of SSRIs

Early adverse effects: nausea, diaphoresis, tremor, fatigue, drowsiness Later adverse effects: sexual dysfunction, weight gain, headache GI bleeding, weight changes, hyponatremia, serotonin syndrome (agitation confusion, disorientation, difficulty concentrating, anxiety, hallucinations, hyperreflexia, fever, diaphoresis, incoordination, tremors), bruxism (teeth grinding), withdrawal syndrome (nausea, sensory disturbances, anxiety, tremor, malaise, unease)

Serotonin norepinephrine reuptake inhibitors (SNRIs)

Venlafaxine, duloxetine, desvenlafaxine; used for major depression, panic disorders, and generalized anxiety disorder; should not be used with MAOIs, alcohol, opioids, antihistamines, or sedatives/hypnotics

Side effects of SNRIs

Headache, nausea, agitation, anxiety, dry mouth, sleep disturbances, hyponatremia, anorexia/weight loss, hypertension, sexual dysfunction

A nurse working in a mental health clinic is providing teaching to a client who has a new prescription for diazepam for generalized anxiety disorder. Which of the following information should the nurse provide?

A. Three to six weeks of treatment is required to achieve therapeutic benefit
B. Combining alcohol with diazepam will produce a paradoxical response
C. Diazepam has a lower risk for dependence than other antianxiety medications
D. Report confusion as a potential indication of toxicity

D. Confusion is a potential indication of diazepam toxicity that the client should report. Buspirone, rather than diazepam, requires 3-6 weeks to achieve therapeutic benefit. Combining alcohol with diazepam would cause CNS and respiratory depression. Diazepam is highly addictive and should be used short term.

A nurse working in an emergency department is caring for a client who has benzodiazepine toxicity due to an overdose. Which of the following actions is the nurse’s priority?

A. Administer flumazenil
B. Identify the client’s level of orientation
C. Infuse IV fluids
D. Prepare the client for gastric lavage

B. When taking the nursing process approach to client care, the initial step is assessment.

A nurse is caring for a client who is to begin taking fluoxetine for treatment of generalized anxiety disorder. Which of the following statements indicates the client understands the use of this medication?

A. "I will take the medication at bedtime."
B. "I will follow a low-sodium diet while taking this medication."
C. "I will need to discontinue this medication slowly."
D. "I will be at risk for weight loss with long term use of this medication."

C. When discontinuing fluoxetine, the client should taper the medication slowly to reduce the risk of withdrawal syndrome. Fluoxetine should be taken in the morning to minimize sleep disturbances. The client is at risk for hyponatremia and weight gain while taking fluoxetine.

A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine. Which of the following findings should the nurse report to the provider as indications of serotonin syndrome? (Select all that apply)

A. Hypothermia
B. Hallucinations
C. Muscular flaccidity
D. Diaphoresis
E. Agitation

B, D, & E. Hallucinations, diaphoresis, and agitation are indications of serotonin syndrome. Fever and muscle tremors are indications of serotonin syndrome.

A nurse is caring for a client who takes paroxetine to treat PTSD. The client states that he grinds his teeth during the night, which causes pain in his mouth. The nurse should identify which of the following interventions as possible measures to manage the client’s bruxism? (Select all that apply)

A. Concurrent administration of buspirone
B. Administration of a different SSRI
C. Use of a mouth guard
D. Changing to a different class of antianxiety medication
E. Increasing the dose of paroxetine

A, C, & D. Concurrent administration of buspirone, using a mouth guard, and changing to a different class are effective measures. Other SSRIs will have the same effect. Increasing the dose will worsen the bruxism.

Tricyclic antidepressants (TCAs)

Amitriptyline, imipramine, doxepin, nortriptyline, amoxapine, trimipramine; used to treat depressive disorders, neuropathic pain, fibromyalgia, anxiety disorders, insomnia, and bipolar disorder; should not be used in clients who have seizure disorders; should not be used with MAOIs and antihistamines

Side effects of TCAs

Orthostatic hypotension, anticholinergic effects (dry mouth, blurred vision, photophobia, urinary hesitancy or retention, constipation, tachycardia), sedation, toxicity (dysrhythmias, mental confusion, agitation, seizures, coma), decreased seizure threshold, excessive sweating, increased appetite

Monoamine oxidase inhibitors (MAOIs)

Phenelzine, isocarboxazide, tranylcypromine, selegiline; used to treat depression, bulimia, and atypical depression; should not be taken with SSRIs, TCAs, or OTC meds; avoid caffeine and tyramine (aged cheese, pepperoni, salami, avocados, figs, bananas, smoked fish, protein, some dietary supplements, some beers, and red wine)

Side effects of MAOIs

CNS stimulation (anxiety, agitation, hypomania, mania), orthostatic hypotension, hypertensive crisis, rash

Atypical antidepressants

Bupropion, inhibits dopamine uptake; used to treat depression, alternative to SSRIs for those unable to tolerate the sexual dysfunction side effects, an aid to quit smoking, and prevent of SAD; should not be used with MAOIs or SSRIs; contraindicated in patients with anorexia or bulimia

Side effects of bupropion

Headache, dry mouth, GI distress, constipation, increased HR, nausea, restlessness, insomnia, appetite suppression leading to weight loss, seizures at high doses

Mirtazapine

Atypical antidepressant, increases the release of serotonin and norepinephrine; therapeutic effects occur sooner with less sexual dysfunction than SSRIs; well tolerated but adverse effects include sleepiness, increased appetite and weight gain, and elevated cholesterol

Trazodone

Atypical antidepressant, moderate selective blockade of serotonin receptors; sedation may be an issue so it can be indicated in a client who has insomnia caused by an SSRI; may cause priapism

A nurse is providing teaching to a client who has a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?

A. "While taking this medication, I’ll need to stay out of the sun to avoid a skin rash."
B. "I may feel drowsy for a few weeks after starting this medication."
C. "I cannot eat my favorite pizza with pepperoni while taking this medication."
D. "This medication will help me lose the weight that I have gained over the last year."

B. Sedation is an adverse effect of amitriptyline during the first few weeks of therapy. Skin rash is associated with SSRIs. Foods such as pepperoni should be avoided if the client is taking an MAOI. TCAs cause weight gain not weight loss.

A nurse is caring for a client who is taking phenelzine. For which of the following adverse effects should the nurse monitor? (Select all that apply)

A. Elevated blood glucose level
B. Orthostatic hypotension
C. Priapism
D. Headache
E. Bruxism

B & D. Orthostatic hypotension and headache are adverse effects of phenelzine. Priapism is an adverse effect of trazodone. Bruxism is an adverse effect of SSRIs.

A nurse is review the medical record of a client who has a new prescription for bupropion for depression. Which of the following findings is the priority for the nurse to report to the provider?

A. The client has a family history of SAD.
B. The client currently smokes 1.5 packs of cigarettes per day.
C. The client had a motor vehicle crash last year and sustained a head injury.
D. The client has a BMI of 25 and has gained 10 lb over the last year.

C. The greatest risk to the client is development of seizures. Bupropion can lower the seizure threshold and should be avoided by clients who have a history of a head injury. This is the highest priority.

A nurse is teaching a client who has a new prescription for imipramine how to minimize anticholinergic effects. Which of the following instructions should the nurse include in the teaching? (Select all that apply)

A. Void just before taking the medication
B. Increase the dietary intake of potassium
C. Wear sunglasses when outside
D. Change positions slowly when getting up
E. Chew sugarless gum

A, C, & E. Voiding just before taking the med will minimize urinary hesitancy and retention. Wearing sunglasses when outside will minimize photophobia. Chewing sugarless gum will minimize dry mouth.

A charge nurse is discussing mirtazapine with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding?

A. "This medication increases the release of serotonin and norepinephrine."
B. "I will need to monitor the client for hyponatremia while taking this medication."
C. "This medication is contraindicated for clients who have an eating disorder."
D. "Sexual dysfunction is a common adverse effect of this medication."

A. Mirtazapine provides relief from depression by increasing the release of serotonin and norepinephrine. Hyponatremia is an adverse effect of venlafaxine. Bupropion is contraindicated for clients who have an eating disorder. Sexual dysfunction is an adverse effect of SSRIs.

Lithium carbonate

Mood stabilizer, produces neurochemical changes in the brain including serotonin receptor blockade, decreases atrophy and/or increases neuronal growth; used in the treatment of bipolar disorders to control episodes of acute mania, help prevent the return of mania or depression, and decrease the incidence of suicide

Side effects of lithium

Nausea, diarrhea, abdominal pain, fine hand tremors, polyuria, mild thirst, weight gain, renal toxicity, goiter and hypothyroidism, bradydysrhythmias, hypotension, electrolyte imbalances, and toxicity

Early lithium toxicity

Less than 1.5 mEq/L; manifestations: diarrhea, nausea, vomiting, thirst, polyuria, muscle weakness, fine hand tremors, slurred speech, lethargy

Advanced lithium toxicity

1.5-2.0 mEq/L; manifestations: mental confusion, sedation, poor, coordination, coarse tremors, ongoing GI distress (nausea, vomiting, diarrhea)

Severe lithium toxicity

2.0-2.5 mEq/L; manifestations: extreme polyuria of dilute urine, tinnitus, giddiness, jerking movements, blurred vision, ataxia, seizures, severe hypotension and stupor leading to coma, possible death from respiratory complications; greater than 2.5 mEq/L can lead to coma and death

Lithium interactions

Diuretics and NSAIDs can lead to toxicity; anticholinergics can cause abdominal discomfort due to urinary retention and polyuria

Mood-stabilizing antiepileptic drugs

Carbamazepine, valproate, lamotrigine; help treat and manage bipolar disorder and prevent relapse of manic and depressive episodes, particularly useful for clients who have mixed mania and rapid cycling bipolar disorders

Side effects of antiepileptic drugs

Carbamazepine: nystagmus, double vision, vertigo, staggering gait, headache, leukopenia, anemia, thrombocytopenia, teratogenesis, hypoosmolarity, skin disorders Lamotrigine: double or blurred vision, dizziness, headache, nausea, vomiting, serious skin rashes Valproate: nausea, vomiting, indigestion, hepatotoxicity, pancreatitis, thrombocytopenia, teratogenesis, weight gain

Antiepileptic drugs interactions

Use additional birth control; avoid grapefruit juice

A nurse is caring for a client who is prescribed lithium therapy. The client states that he wants to take ibuprofen for osteoarthritis pain relief. Which of the following statements should the nurse make?

A. "That is a good choice. Ibuprofen does not interact with lithium."
B. "Regular aspirin would be a better choice than ibuprofen."
C. "Lithium decreases the effectiveness of ibuprofen."
D. "The ibuprofen will make your lithium level fall too low."

B. Aspirin is recommended as a mild analgesic rather than ibuprofen due to the risk for lithium toxicity.

A nurse is discussing early indications of toxicity with a client who has a new prescription for lithium carbonate for bipolar disorder. The nurse should include which of the following manifestations in the teaching? (Select all that apply)

A. Constipation
B. Polyuria
C. Rash
D. Muscle weakness
E. Tinnitus

B & D. Polyuria and muscle weakness are early signs of lithium toxicity. Diarrhea is an early indication, not constipation. Tinnitus is an indication of severe toxicity. Lithium toxicity does not cause rash.

A nurse is discussing routine follow-up needs with a client who has a new prescription for valproate. The nurse should inform the client of the need for routine monitoring of which of the following?

A. AST/ALT and LDH
B. Creatinine and BUN
C. WBC and granulocyte counts
D. Serum sodium and potassium

A. Routine monitoring of liver function tests is necessary due to the risk for hepatotoxicity. Routine monitoring of the others is not necessary.

A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder. Prior to administration of lithium carbonate, the client’s lithium blood level 1.2 mEq/L. Which of the following actions should the nurse take?

A. Administer the next dose of lithium carbonate as scheduled.
B. Prepare for administration of aminophylline.
C. Notify the provider for a possible increase in the dosage of lithium carbonate.
D. Request a stat repeat of the client’s lithium blood level.

A. During a manic episode, the lithium blood level should be 0.8-1.4 mEq/L. It is appropriate to administer the next dose as scheduled.

A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client’s adult daughter, which of the following statements is the priority to report to the provider?

A. "My mother has diabetes that is controlled by her diet."
B. "My mother recently completed a course of prednisone for acute bronchitis."
C. "My mother received her flu vaccine last month."
D. "My mother is currently on furosemide for her congestive heart failure."

D. Diuretics, such as furosemide, are contraindicated for use with lithium due to the risk for toxicity. This is the greatest risk for the client and is therefore the highest priority to report to the provider.

First generation (conventional) antipsychotics

Chlorpromazine (low potency), haloperidol (high potency), fluphenazine (high potency), loxapine (medium potency), thioridazine (low potency), thiothixene (high potency), perphenazine (medium potency), trifluoperazine (high potency); block dopamine, acetylcholine, histamine, and norepinephrine receptors; avoid alcohol and other CNS depressants and hazardous activities

Side effects of first gen antipsychotics

Agranulocytosis, anticholinergic effects (dry mouth, blurred vision, photophobia, urinary hesitancy or retention, constipation, tachycardia), EPS, neuroendocrine effects (gynecomastia, weight gain, menstrual irregularities), neuroleptic malignant syndrome (sudden high fever, BP changes, diaphoresis, tachycardia, muscle rigidity, drooling, decreased LOC, coma, tachypnea), orthostatic hypotension, sedation, seizures, severe dysrhythmias, sexual dysfunction, skin effects, liver impairment

Extrapyramidal side effects

Acute dystonia (severe spasm of the tongue, neck, face, and back), pseudoparkinsonism (bradykinesia, rigidity, shuffling gait, drooling, tremors), akathisia (inability to sit or stand still), tardive dyskinesia (involuntary movements of the tongue and face, arms, legs, and trunk)

Second and third generation (atypical) antipsychotics

Risperidone, asenapine, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, ziprasidone, aripiprazole (third gen); block serotonin and, to a lesser degree, dopamine receptors; treat positive and negative symptoms of schizophrenia; avoid alcohol and other CNS depressants and hazardous activities; should not be used with TCAs

Side effects of second and third gen antipsychotics

Metabolic syndrome, orthostatic hypotension, anticholinergic effects (urinary hesitancy or retention, dry mouth), agitation, dizziness, sedation, sleep disruption, mild EPS (tremor), elevated prolactin levels, sexual dysfunction

A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat affect. The nurse should anticipate a prescription of which of the following medications?

A. Chlorpromazine
B. Thiothixene
C. Risperidone
D. Haloperidol

C. Second gen antipsychotics, such as risperidone, are effective in treating negative symptoms of schizophrenia, such as lack of grooming and flat affect. A, B, & D are first gen antipsychotics that are used mainly to control positive symptoms of schizophrenia.

A nurse is caring for a client who takes ziprasidone. The client reports difficulty swallowing the oral medication and becomes extremely agitated with injectable administration. The nurse should contact the provider to discuss a change in which of the following medications? (Select all that apply)

A. Olanzapine
B. Quetiapine
C. Aripiprazole
D. Clozapine
E. Asenapine

C, D, & E. Aripiprazole and clozapine are available in orally disintegrating tablets which are appropriate for clients who have difficulty swallowing tablets. Asenapine is available in a sublingual tablet which is appropriate for clients who have difficulty swallowing tablets.

A charge nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which of the following manifestations should the charge nurse identify as being effectively treated by first generation antipsychotics? (Select all that apply)

A. Auditory hallucinations
B. Withdrawal from social situations
C. Delusions of grandeur
D. Severe agitation
E. Anhedonia

A, C, & D. Positive symptoms of schizophrenia such as auditory hallucinations, delusions of grandeur, and severe agitation are treated with first gen antipsychotics. B & E are negative symptoms and are best treated with second gen antipsychotics.

A nurse is assessing a client who is currently taking perphenazine. Which of the following findings should the nurse identify as an extrapyramidal symptom (EPS)? (Select all that apply)

A. Decreased LOC
B. Drooling
C. Involuntary arm movements
D. Urinary retention
E. Continual pacing

B, C, & E. Drooling, involuntary arm movements, and continual pacing are EPS.

A nurse is providing discharge teaching for a client who has schizophrenia and a new prescription for iloperidone. Which of the following client statements indicates understanding of the teaching?

A. "I will be able to stop taking this medication as soon as I feel better."
B. "If I feel drowsy during the day, I will stop taking this medication and call my provider."
C. "I will be careful not to gain too much weight while taking this medication."
D. "This medication is highly addictive and must be withdrawn slowly."

C. Antipsychotic meds, such as iloperidone, have a high risk for significant weight gain. Antipsychotic meds are long term treatment. Drowsiness is not a reason to discontinue the med. Antipsychotic meds are not considered addictive.

CNS stimulants

Methylphenidate, amphetamine mixture, dextroamphetamine; used to treat ADHD in children and adults; should not be used with MAOIs, caffeine, alcohol, or OTC cold and decongestant meds; oral med should be taken 30-45 min before meals with the last dose given by 4 pm

Side effects of CNS stimulants

Insomnia, restlessness, weight loss related to reduced appetite, growth suppression, cardiovascular effects, development of psychotic manifestations, withdrawal reaction, hypersensitivity skin reaction to transdermal methylphenidate (hives, papules)

Atomoxetine

SNRI used to treat ADHD in children and adults; should not be used with MAOIs, OTC meds, or alcohol; use with caution if taken with SSRIs

Side effects of atomoxetine

Appetite/growth suppression, weight loss, nausea, vomiting, upper abdominal pain, suicidal ideation, hepatotoxicity, headache, insomnia irritability

Desipramine, imipramine, clomipramine

TCAs used to treat depression, autism spectrum disorder, ADHD, panic disorder, separation anxiety disorder, social phobia, school phobia, and OCD in children; contraindicated in clients who have seizure disorders; should not be used with MAOIs, antihistamines, anticholinergic agents, alcohol, benzodiazepines, and opioids

Side effects of desipramine, imipramine, and clomipramine

Orthostatic hypotension, anticholinergic effects (dry mouth, blurred vision, photophobia, urinary hesitancy or retention, constipation, tachycardia), weight gain related to increased appetite, sedation, toxicity (dysrhythmias, mental confusion, agitation), decreased seizure threshold, excessive sweating

Alpha2-adrenergic agonists

Guanfacine, clonidine; used to treat ADHD; extended release clonidine is contraindicated for children younger than 6 years old; should not be used with CNS depressants, alcohol, antihypertensives, or foods with high-fat content

Side effects of alpha agonists

Sedation, drowsiness, fatigue, hypotension, bradycardia, weight gain, nausea, vomiting, constipation, dry mouth

A nurse is teaching the parents of a child who has autism spectrum disorder and a new prescription for imipramine about indications of toxicity. Which of the following should the nurse include in the teaching? (Select all that apply)

A. Seizures
B. Agitation
C. Photophobia
D. Dry mouth
E. Irregular pulse

A, B, & E. Seizures, agitation, and irregular pulse are indications of TCA toxicity. Photophobia and dry mouth are anticholinergic effects.

A nurse is providing teaching to an adolescent client who has a new prescription for clomipramine for OCD. Which of the following information should the nurse provide?

A. Eat a diet high in fiber
B. Check temperature daily
C. Take medication first thing in the morning before eating
D. Add extra calories to the diet as between-meal snacks

A. Eating a diet high in fiber will decrease constipation, an anticholinergic effect associated with TCA use. Checking temp daily is unnecessary. The med should be taken at bedtime. Following a well-balanced diet plan rather than adding extra calories as snacks will help prevent weight gain.

A nurse is providing teaching to an adolescent client who is to begin taking atomoxetine for ADHD. The nurse should instruct the client to monitor for which of the following adverse effects? (Select all that apply)

A. Somnolence
B. Yellowing skin
C. Increased appetite
D. Fever
E. Malaise

B, D, & E. Yellowing skin, fever, and malaise are potential indications of hepatotoxicity that should be reported. Insomnia, rather than somnolence, is an adverse effect of atomoxetine. Decreased appetite is an adverse effect of atomoxetine.

A nurse is caring for a school age child who has conduct disorder and a new prescription for methylphenidate transdermal patches. Which of the following information should the nurse provide about the medication?

A. Apply the patch once daily at bedtime
B. Place the patch carefully in a trash can after removal
C. Apply the transdermal patch to the anterior waist area
D. Remove the patch each day after 9 hr

D. The transdermal patch is applied once daily in the morning and is removed after 9 hr. The patch should be folded and flushed down the toilet to discard. The patch should be applied to a clean, dry area on the hip, the waist area should be avoided.

A nurse is teaching a client who has intermittent explosive disorder about a new prescription for fluoxetine. Which of the following information should the nurse provide? (Select all that apply)

A. An adverse effect of this medication is CNS depression
B. Administer the medication in the morning
C. Monitor for weight loss while taking this medication
D. Therapeutic effects of this medication will take 1-3 weeks to fully develop
E. This medication blocks the synaptic reuptake of serotonin in the brain.

B, C, & E. Fluoxetine should be administered in the morning to avoid insomnia, can result in weight loss, and blocks the synaptic reuptake of serotonin. An adverse effect of fluoxetine is CNS stimulation rather than CNS depression. Fluoxetine takes 4 weeks to fully develop therapeutic effects.

Medications for abstinence withdrawal

Benzodiazepines (chlordiazepoxide, diazepam, lorazepam, oxazepam) and adjunct medications (carbamazepine, clonidine, propranolol, atenolol)

Intended effects of benzodiazepines for alcohol withdrawal

Maintenance of vitals, decrease in the risk of seizures, decrease in the intensity of withdrawal manifestations, and substitution therapy during alcohol withdrawal

Intended effects of adjunct medications for alcohol withdrawal

Decrease in seizures (carbamazepine), decrease of autonomic response (clonidine, propranolol, atenolol), and decrease in craving (propranolol, atenolol)

Disulfiram

Daily oral med used for alcohol aversion therapy; concurrent use with alcohol will cause acetaldehyde syndrome (nausea, vomiting, weakness, sweating, palpitations, hypotension); avoid any products that contain alcohol (cough syrup, aftershave lotion, mouthwash, hand sanitizer, vanilla extract)

Naltrexone

Pure opioid antagonist that suppresses the craving and pleasurable effects of alcohol, also used for opioid withdrawal; concurrent use with opioids increases the risk for overdose of opiates; take with meals to decrease GI distress

Acamprosate

Taken orally 3x a day to reduce the unpleasant effects of alcohol abstinence (dysphoria, anxiety, restlessness); diarrhea may result, maintain adequate fluid intake; avoid use in pregnancy

Methadone substitution

Oral opioid agonist that replaces the opioid to which the client has a physical dependence; prevents abstinence syndrome from occurring and removes the need to obtain illegal opioids; used for withdrawal and long term maintenance; must be slowly tapered; must be administered from an approved treatment center

Clonidine

Assists with opioid withdrawal effects related to autonomic hyperactivity (diarrhea, nausea, vomiting) but does not reduced the craving; avoid activities that require mental alertness until drowsiness subsides; encourage the client to chew sugarless gum, suck on hard candy, sip on small amounts of water, or suck on ice chips to treat dry mouth

Buprenorphine

Agonist-antagonist opioid used for both withdrawal and maintenance; decreases feelings of craving and can be effective in maintaining compliance; can be prescribed by a primary care provider

Nicotine replacement therapy

Nicotine gum, patch, nasal spray, lozenges, or inhaler; substitute for the nicotine in cigarettes or chewing tobacco; doubles the rate of tobacco cessation

Nicotine replacement therapy client education

Chew nicotine slowly and intermittently over 30 min; avoid eating or drinking 15 min prior to and while chewing nicotine gum or lozenges; do not use nicotine gum longer than 6 months; avoid using any nicotine products while wearing the patch; remove patch prior to MRI; allow lozenges to slowly dissolve in the mouth (20-30 min)

Varenicline

Nicotinic receptor agonist that promotes the release of dopamine simulate the pleasurable effects of nicotine; reduces cravings for nicotine as well as the severity of withdrawal manifestations; reduces incidence of relapse; take after a meal; can cause neuropsychiatric effects (unpredictable behavior, mood changes, thoughts of suicide); banned for use in clients who are commercial truck or bus drivers, air traffic controllers, or airplane pilots

A nurse is providing teaching to a client who has alcohol use disorder and a new prescription for carbamazepine. Which of the following information should the nurse include in the teaching?

A. "This medication will help prevent seizures during alcohol withdrawal."
B. "Taking this medication will decrease your cravings for alcohol."
C. "This medication maintains your blood pressure at a normal level during alcohol withdrawal."
D. "Taking this medication will improve your ability to maintain abstinence from alcohol."

A. Carbamazepine is used during withdrawal to decrease the risk for seizures. Carbamazepine promotes safe withdrawal rather than a decrease in cravings or abstinence. Clonidine and propranolol are used to maintain BP.

A nurse is assisting in the discharge planning for a client following alcohol detoxification. The nurse should anticipate prescriptions for which of the following medications to promote long-term abstinence from alcohol? (Select all that apply)

A. Lorazepam
B. Diazepam
C. Disulfiram
D. Naltrexone
E. Acamprosate

C, D, & E. Disulfiram promotes abstinence through aversion therapy. Naltrexone promotes abstinence by suppressing the craving and pleasurable effects. Acamprosate decreases the unpleasant effects resulting from abstinence. A & B are prescribed for short-term use during withdrawal.

A nurse is evaluating a client’s understanding of a new prescription for clonidine for the treatment or opioid use disorder. Which of the following statements by the client indicates an understanding of the teaching?

A. "Taking this medication will help reduce my craving for heroin."
B. "While taking this medication, I should keep a pack of sugarless gum."
C. "I can expect some diarrhea from taking this medicine."
D. "Each dose of this medication should be placed under my tongue to dissolve."

B. Clonidine commonly causes clients to experience dry mouth. Chewing sugarless gum is an effective method to address this adverse effect. Clonidine does not reduce cravings, but reduces diarrhea. Buprenorphine is administered sublingually.

A nurse is discussing the use of methadone with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (Select all that apply)

A. "Methadone is a replacement for physical dependence to opioids."
B. "Methadone reduces the unpleasant effects associated with abstinence syndrome."
C. "Methadone can be used during opioid withdrawal and to maintain abstinence."
D. "Methadone increases the risk for acetaldehyde syndrome."
E. "Methadone must be prescribed and dispensed by an approved treatment center."

A, B, C, & E. Methadone replaced the opioid the client is dependent on, prevents abstinence syndrome from occurring, is used for both withdrawal and long-term maintenance, and must be prescribed by an approved treatment center. Disulfiram places the client at risk acetaldehyde syndrome.

A nurse is teaching a client who has tobacco use disorder about the use of nicotine gum. Which of the following information should the nurse include in the teaching?

A. Chew the gm for no more than 10 min.
B. Rinse out the mouth immediately before chewing the gum.
C. Avoid eating 15 min prior to chewing the gum.
D. Use of the gum is limited to 90 days.

C. The client should avoid eating or drinking 15 min prior to and while chewing the gum. The gum should be chewed gradually over 30 min. Use of the gum is not recommended for longer than 6 months.

Necessary loss

Part of the cycle of life, anticipated but can still be intensely felt

Actual loss

Any loss of a valued person or item

Perceived loss

Any loss defined by a client that is not obvious to others

Maturational loss

Losses normally expected due to the developmental processing of life

Situational loss

Unanticipated loss caused by an external event

Numbness or protest (Bowlby stage of grief)

Client is in denial over the reality of the loss and experiences feelings of shock

Disequilibrium (Bowlby stage of grief)

Client focuses on the loss and has an intense desire to regain what was lost

Disorganization and despair (Bowlby stage of grief)

Client feels hopelessness which impacts the client’s ability to carry out tasks of daily living

Reorganization (Bowlby stage of grief)

Client reaches acceptance of the loss

Shock and disbelief (Engel stage of grief)

Client experiences a sense of numbness and denial over the loss

Developing awareness (Engel stage of grief)

Client becomes aware of the reality of the loss resulting in intense feelings of grief, this begins within hours of the loss

Restitution (Engel stage of grief)

Client carries out cultural/religious rituals, such as funeral, following the loss

Resolution of the loss (Engel stage of grief)

Client is preoccupied with the loss, over about a 12 month time period this preoccupation gradually decreases

Recovery (Engel stage of grief)

Client moves past the preoccupation and forward with life

Worden: Four Tasks of Mourning

Task I: accepting the reality of the loss Task II: processing the pain of grief Task III: adjusting to a world without the lost entity Task IV: finding an enduring connection with the lost entity in the midst of embarking on a new life

Delayed or inhibited grief

Client does not demonstrate the expected behaviors of the normal grief process

Distorted or exaggerated grief response

Client experiences the feelings and somatic manifestations associated with normal grief but to an exaggerated level

Chronic or prolonged grief

Difficult to identify due to varying lengths or time required by clients to work through the stages/tasks of grief; can remain in the denial stage and remain unable to accept the reality of the loss; can result in the client’s inability to perform activities of daily living

A nurse is caring for a client following the loss of her partner due to a terminal illness. Identify the sequence of Engel’s five stages of grief that the nurse should expect the client to experience. (Select the stages of grief in the order of occurrence. All steps must be used.)

A. Developing awareness
B. Restitution
C. Shock and disbelief
D. Recovery
E. Resolution of the loss

Step 1: C. Shock and disbelief Step 2: A. Developing awareness Step 3: B. Restitution Step 4: E. Resolution Step 5: D. Recovery

A charge nurse is reviewing Kugler-Ross: Five Stages of Grief with a group of newly licensed nurses. Which of the following stages should the charge nurse include in the teaching? (Select all that apply)

A. Disequilibrium
B. Denial
C. Bargaining
D. Anger
E. Depression

B, C, D, & E. Denial, bargaining, anger, and depression are stages of the Kulber-Ross five stages of grief. Disequilibrium is the second stage of Bowlby’s four stages of grief.

A nurse is working with a client who has recently lost his mother. The nurse recognizes that which of the following factors influence a client’s grief and coping ability? (Select all that apply)

A. Interpersonal relationships
B. Culture
C. Birth order
D. Religious beliefs
E. Prior experience with loss

A, B, D, & E. Interpersonal relationships, culture, religious beliefs, and prior experience with loss influence a client’s grief and coping ability. Birth order does not influence a client’s grief and coping ability.

A nurse is discussing normal grief with a client who recently lost a child. Which of the following statements made by the client indicates understanding? (Select all that apply)

A. "I may experience feelings of resentment."
B. "I will probably withdraw from others."
C. "I can expect to experience changes in sleep."
D. "It is possible that I will experience suicidal thoughts."
E. "It is expected that I will have a loss of self-esteem."

A, B, & C. Resentment, withdrawal, and somatic manifestations are associated with normal grief. Suicidal ideations and loss of self-esteem are associated with maladaptive grief.

A nurse is caring for a client who lost his mother to cancer last month. The client states, "I’d still have my mother if the doctor would have diagnosed her sooner." Which of the following responses should the nurse make?

A. "You sound angry. Anger is a normal feeling associated with loss."
B. "I think you would feel better if you talked about your feelings with a support group."
C. "I understand just how you feel. I felt the same when my mother died."
D. "Do other members of your family also feel this way?"

A. This response acknowledges the client’s emotion and provides education on the normal grief response. B offers advice. C minimizes the client’s feelings. D takes the focus away from the client.

Oppositional defiant disorder

Characterized by a recurrent pattern of the following antisocial behaviors: negativity, disobedience, hostility, defiant behaviors (especially toward authority figures), stubbornness, argumentativeness, limit testing, unwillingness to communicate, and refusal to accept responsibility for misbehavior

Disruptive mood dysregulation disorder

Onset is between ages 6-28; clients who have this disorder exhibit recurrent temper outbursts that are severe and do not correlate with the situation; temper outbursts are manifested verbally and/or physically and can include aggression, are not appropriate for the client’s developmental level, are present 3 or more times per week, and are observable by others

Intermittent explosive disorder

Occurs in clients 18 years and older; clients who have this disorder exhibit recurrent episodic violent and aggressive behavior with the possibility of hurting people, property, or animals

Conduct disorder

Clients who have this disorder demonstrate a persistent pattern of behavior that violates the rights of others or rule and norms of society; categories of conduct disorder include aggression to people and animals, destruction of property, deceitfulness or theft, and serious violations of rules; child onset occurs before 10 years, adolescent onset occurs after 10 years

A nurse is assisting the parents of a school-age child who has oppositional defiant disorder in identifying strategies to promote positive behavior. Which of the following is an appropriate strategy for the nurse to recommend? (Select all that apply)

A. Allow the child to choose consequences for negative behavior
B. Use role-playing to act out unacceptable behavior
C. Develop a reward system for acceptable behavior
D. Encourage the child to participate in school sports
E. Be consistent when addressing unacceptable behavior

C, D, & E. The parents should have a method to reward the child for acceptable, encourage physical activity, and set clear limits on unacceptable behavior.

A nurse is performing an admission assessment on an adolescent client who has depression. Which of the following manifestations should the nurse expect (Select all that apply)

A. Fear of being alone
B. Substance use
C. Weight gain
D. Irritability
E. Aggressiveness

B, D, & E. Substance, irritability, and aggressiveness are expected findings associated with depression. Solitary play and weight loss are expected findings of depression.

A nurse is obtaining a health history from the parents of a 12 year old client who has conduct disorder. Which of the following findings should the nurse expect? (Select all that apply)

A. Bullying of others
B. Threats of suicide
C. Law-breaking activities
D. Narcissistic behavior
E. Flat affect

A, B, & C. Bullying behavior, suicidal ideation, and law and/or rule breaking are expected findings of conduct disorder. Low self-esteem and irritability/temper outbursts are expected findings of conduct disorder.

A nurse in a pediatric clinic is caring for a preschool-age child who has a new diagnosis of ADHD. When teaching the parent about this disorder, which of the following statements should the nurse include in the teaching?

A. "Behaviors associated with ADHD are present prior to age 3."
B. "This disorder is characterized by argumentativeness."
C. "Below-average intellectual functioning is associated with ADHD."
D. "Because of this disorder, your child is at increased risk for injury."

D. Inattentive or impulse behavior increases the risk for injury in a child who has ADHD. Behaviors associated with ADHD are present before the age of 12. Argumentativeness is associated with oppositional defiant disorder. Below-average intellectual functioning is associated with intellectual development disorder.

A nurse is assessing a 4-year-old child for indications of autism spectrum disorder. For which of the following manifestations should the nurse assess?

A. Impulsive behavior
B. Repetitive counting
C. Destructiveness
D. Somatic problems

B. Repetitive actions and strict routine are an indication of autism spectrum disorder. Impulsive behavior is an indication of ADHD. Destructiveness is an indication of conduct disorder. Somatic problems are an indication of PTSD.

Situational/external crisis

Often unanticipated loss or change experienced in every day, often unanticipated, life events

Maturational/internal crisis

Achieving new developmental stages, which requires learning additional coping mechanisms

Adventitious crisis

The occurrence of natural disaster or crimes; people in communities with large scale psychological trauma caused by natural disasters

Phase 1 of a crisis

Escalating anxiety from a threat activates increased defense responses

Phase 2 of a crisis

Anxiety continues escalating as defense responses fail, functioning becomes disorganized, and the client resorts to trial-and-error attempts to resolve anxiety

Phase 3 of a crisis

Trial-and-error methods of resolution fail, and the client’s anxiety escalates to severe or panic levels, leading to flight or withdrawal behaviors

Phase 4 of a crisis

The client experiences overwhelming anxiety that can lead to anguish and apprehension, feelings of powerlessness and being overwhelmed, dissociative symptoms (depersonalization, detachment from reality), depression, confusion, and/or violence against others or self

Primary care of a crisis

Collaborate with client to identify potential problems; instruct on coping mechanisms; and assist in lifestyle changes

Secondary care of a crisis

Collaborate with client to identify interventions while in an acute crisis that promote safety

Tertiary care of a crisis

Collaborate with client to provide support during recovery from a severe crisis that include outpatient clinics, rehab centers, and workshops

A nurse is conducting chart reviews of multiple clients at a community mental health facility. Which of the following events is an example of client experiencing a maturational crisis?

A. Rape
B. Marriage
C. Severe physical illness
D. Job loss

B. Marriage is an example of a maturational crisis, which is a naturally occurring event during the life span. Rape is an example of an adventitious crisis. Severe physical illness and job loss are examples of situational crises.

A nurse is caring for a client who is experiencing a crisis. Which of the following medications might the provider prescribe? (Select all that apply)

A. Lithium carbonate
B. Paroxetine
C. Risperidone
D. Haloperidol
E. Lorazepam

B & E. SSRIs and benzodiazepines may be prescribed to decrease the anxiety of a client experiencing a crisis. Mood stabilizers and antipsychotics are not useful in treating the anxiety of a client experiencing a crisis.

Primary interventions for suicide

Focus on suicide prevention through the use of community education and screenings to identify individuals at risk

Secondary interventions for suicide

Focus on suicide prevention for an individual client who is having an acute suicidal crisis; suicide precautions are included in this level

Tertiary interventions for suicide

Focus on providing support and assistance to survivors of a client who completed suicide

A nurse is assessing a client who has major depressive disorder. The nurse should identify which of the following client statements as an overt comment about suicide? (Select all that apply)

A. "My family will be better off if I’m dead."
B. "The stress in my life is too much to handle."
C. "I wish my life was over."
D. "I don’t feel like I can ever be happy again."
E. "If I kill myself then my problems will go away."

A, C, & E. Overt statements talk directly about the client’s perception of suicide and their wish to no longer be alive. B & D are covert statements.

A nurse is caring for a client who states, "I plan to commit suicide." Which of the following assessments should the nurse identify as the priority?

A. Client’s educational and economic background
B. Lethality of the method and availability of means
C. Quality of the client’s social support
D. Client’s insight into the reasons for the decision

B. The greatest risk to the client is self-harm as a result of carrying out a suicide plan. The priority assessment is to determine how lethal the method is, how available the method is, and how detailed the plan is.

A nurse is assisting with the development of protocols to address the increasing number of suicide attempts in the community. Which of the following interventions should the nurse include as a primary intervention? (Select all that apply)

A. Conducting a suicide risk screening on all new clients
B. Creating a support group for family members of clients who completed suicide
C. Educating high school teens about suicide prevention
D. Initiating one-on-one observation for a client who has suicidal ideation
E. Teaching middle-school educators about warning indicators of suicide

A, C, & E. Primary interventions include suicide prevention through the use of screenings to identify individuals at risk and community education. B is tertiary intervention. D is secondary intervention.

A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care?

A. Assign the client to a private room
B. Document the client’s behavior every hour
C. Allow the client to keep perfume in her room
D. Ensure that the client swallows medication

D. Ensure that the client swallows medication to prevent hoarding of medication for an attempted overdose. Clients who are suicidal should not be assigned to a private room. Their behavior should be documented every 15 min. Perfume should be removed from the client’s room.

A nurse is conducting a class for a group of newly licensed nurses on caring for clients who at risk for suicide. Which of the following information should the nurse include in the teaching?

A. A client’s verbal threat of suicide is attention-seeking behavior
B. Interventions are ineffective for clients who really want to commit suicide
C. Using the term suicide increases the client’s risk for a suicide attempt
D. A no-suicide contract decreases the client’s risk for a suicide attempt

D. The use of a no-suicide contract decreases the client’s risk for suicide by promoting and maintaining trust between the nurse and the client. However, it should not replace other suicide prevention strategies. A, B, & C are myths.

Steps to handle aggressive behavior

Respond quickly, remain calm and in control, encourage the client to express feelings verbally, allow the client as much personal space as possible, maintain eye contact, sit or stand at the same level of the client, avoid accusatory or threatening statements, describe options clearly and offer choices, reassure the client that staff members are present to help prevent loss of control, set limits for the client

Medications to control aggressive and impulsive behaviors

Olanzapine and ziprasidone (atypical antipsychotics; haloperidol (antipsychotic); may also use SSRIs, mood stabilizers, and benzodiazepines

A nurse is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication?

A. "I wish you could not make me angry."
B. "I feel angry when you leave me."
C. "It makes me angry when you interrupt me."
D. "You’d better listen to me."

D. This implies a threat and a lack of respect for another individual. A, B, & C do not imply threats or indicate a lack of respect.

A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take?

A. Insist that the client stop yelling
B. Request that other staff members remain close by
C. Move as close to the client as possible
D. Walk away from the client

B. The nurse should request that other staff members remain close by to assist if necessary. The nurse should not make demands of the client or walk away from an angry client. Clients who are angry need large personal space.

A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is in the preassaultive stage of violence? (Select all that apply)

A. Lethargy
B. Defensive responses to questions
C. Disorientation
D. Facial grimacing
E. Agitation

B, D, & E. Defensive responses, facial grimacing, and agitation are assessment findings that indicate a client is in the preassaultive stage. A is more likely to be observed in a client who has depression. C is more likely to be assessed in a client who has a cognitive disorder.

A nurse is caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the day room. Which of the following is the priority nursing action?

A. Encourage the client to express her feelings
B. Maintain eye contact with the client
C. Move the client away from others
D. Tell the client that the behavior is not acceptable

C. The client’s behavior indicates that he is at greatest risk for harming others. The priority acton for the nurse is to move the client away from others.

A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse to the client?

A. "Stop screaming, and walk with me outside."
B. "Why are you so angry and screaming at everyone?"
C. "You will not get your way by screaming."
D. "What was going through your mind when you started screaming?"

A. This sets limits and the use of physical activity, such as walking, to deescalate anger. B is a "why" question. C is a close-ended statement, which is nontherapeutic. The client is not ready to discuss this issue.

Characteristics of abusers

Possible use of threats and intimidation to control the vulnerable person, usually an extreme disciplinarian who believes in physical punishment, poor impulse control, perceives the child as bad, violent outbursts, poor coping skills, low self-esteem, feelings of worthlessness, possible of history of substance use disorder, difficulty assuming typical adult roles, likely to have experienced family violence as a child

A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates an understanding of the teaching?

A. "Children older than 3 are at greater risk for abuse."
B. "Substance use disorder does not increase the risk for violence."
C. "Entering an intimate relationship increases the risk for violence."
D. "Pregnancy increases the risk for violence toward the intimate partner."

D. Pregnancy tends to increase the likelihood of violence toward the intimate partner. Children younger than 3 are at an increased risk for abuse. Substance use disorder increases the risk for violence. Vulnerable persons are at an increased risk for violence when they try to leave the relationship.

A nurse is preparing to assess an infant who has shaken baby syndrome. Which of the following is an expected finding? (Select all that apply)

A. Sunken fontanels
B. Respiratory distress
C. Retinal hemorrhage
D. Altered LOC
E. Increase in head circumference

B, C, D, & E. Respiratory distress, retinal hemorrhage, altered LOS, and increased head circumference are expected findings of shaken baby syndrome. Bulging, rather than sunken, fontanels are an expected finding of shaken baby syndrome.

A nurse working in an emergency department is assessing a preschool-age child who reports abdominal pain. When conducting a head-to-toe assessment, which of the following findings should alert the nurse to possible abuse?

A. Abrasions on knees
B. Round burn marks on forearms
C. Mismatched clothing
D. Abdominal rebound tenderness
E. Areas of ecchymosis on torso

B & E. Round burn marks anywhere on the child’s body can indicate cigarette burns and should alert the nurse to possible abuse. Areas of ecchymosis on the torso, back, or buttocks should alert the nurse to possible abuse. Minor injuries on the arms and legs and mismatched clothing are common in this age group. Abdominal rebound tenderness is a possible indication or appendicitis rather than abuse.

A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following?

A. Refusing to pay bills for a dependent, even when funds are available, is neglect.
B. Intentionally causing an older adult to fall is an example of physical violence.
C. Striking an intimate partner is an example of sexual violence.
D. Failure to provide a stimulating environment for normal development is emotional abuse.

B. Physical violence occurs when physical pain or harm is directed toward another individual. A is economic maltreatment. C is physical violence. D is neglect.

A nurse is caring for an adult client who has injuries resulting from intimate partner abuse. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is the highest priority?

A. Advise the client about the location of women’s shelters
B. Encourage the client to participate in a support group for survivors of abuse
C. Implement case management to coordinate community and social services
D. Educate the client about the use of stress management techniques

A. The greatest risk to this client is injury from intimate partner abuse. Therefore, the priority action the nurse should take is to assist the client with the development of a safety plan that includes the identification of safe places to live.

Rape trauma syndrome

Sustained and maladaptive response to a forced, violent sexual penetration against the individual’s will and consent, similar to PTSD; expressed reaction is overt and consists of emotional outbursts (crying, laughing, hysteria, anger, incoherence); controlled reaction is ambiguous; somatic reaction can occur later

Compound rape reaction

Some survivors of rape can experience additional disorders as a result of the sexual assault; mental health disorders (depression, substance use); physical disorders (manifestations of a prior physical illness)

Silent rape reaction

The survivor does not report or tell anyone of the sexual assault; abrupt changes in relationships with partners, nightmares, increased anxiety during interview, marked changes in sexual behavior, sudden onset of phobic reactions, no verbalization of the occurrence of sexual assault

A nurse is discussing silent rape reaction with a newly licensed nurse. The nurse should identify which of the following characteristics as expected for this type of reaction? (Select all that apply)

A. Sudden development of phobias
B. Development of substance use disorder
C. Increased level of anxiety during interview
D. Reactivation of a prior physical disorder
E. Unwillingness to discuss the sexual assault

A, C, & E. Sudden onset of phobic reactions, increased anxiety during interview, and not verbalizing the sexual assault are characteristics of a silent rape reaction. B and D are characteristics of a compound rape reaction.

A nurse is assessing a client who experienced sexual assault. Which of the following findings indicate the client is experiencing an emotional reaction of rape-trauma syndrome? (Select all that apply)

A. Genitourinary soreness
B. Difficulties with low self-esteem
C. Sleep disturbances
D. Emotional outburst
E. Difficulty making decisions

D & E. Emotional outbursts indicate an expressed initial reaction of rape-trauma syndrome. Difficulty making decisions indicates a controlled initial reaction of rape-trauma syndrome. A and C are somatic reactions. B is a sustained and maladaptive emotional response beyond the initial reaction.

A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A. "I will administer prophylactic treatment for sexually transmitted infections."
B. "I am not required to obtain informed consent before the sexual assault nurse examiner collects forensic evidence."
C. "I can expect manifestations of rape-trauma syndrome to be similar to bipolar disorder."
D. "I should use narrative documentation when documenting subjective data."

A. The nurse should administer prophylactic treatment for STIs. Informed consent is required before collecting forensic evidence. Manifestations of rape-trauma syndrome are similar to PTSD. The nurse should document subjective data using the client’s verbatim statements.

A nurse is caring for a client who was recently raped. The client states, "I never should have been out on the street alone at night." Which of the following responses should the nurse make?

A. "Your actions had nothing to do with what happened."
B. "You should focus on recovery rather than blaming yourself for what happened."
C. "You believe this wouldn’t have happened if you hadn’t been out alone?"
D. "Why do you feel that you should not have been alone on the street at night?"

C. This response uses the therapeutic communication technique restating, which promotes reflection and verbalization of feelings. A offers opinion. B indicates disapproval. D is a "why" question.

A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates an understanding of the teaching?

A. "Rape is a crime of passion."
B. "Acquaintance rape often involves alcohol."
C. "Young adults are the typical victims of sexual assault."
D. "The majority of rapists are unknown to the victims."

B. Alcohol and other substances are often associated with date or acquaintance rape. Rape is a crime of violence, aggression, anger, and power. Individuals of all ages are affected by sexual assault and can be male or female. The majority of perpetrators are known to the vulnerable persons.

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