Psychiatric Nursing Practice

1. Which of the following groups are considered to be at highest risk for suicide?

Adolescents, men over age 45, and persons who have made previous suicide attempts

Teachers, divorced persons, and substance abusers

Alcohol abusers, widows, and young married men

Depressed persons, physicians, and persons living in rural areas

Rationale: Studies of those who commit suicide reveal the following high-risk groups: adolescents; men over age 45; persons who have made previous suicide attempts; divorced, widowed, and separated persons; professionals, such as physicians, dentists, and attorneys; students; unemployed persons; persons who are depressed, delusional, or hallucinating; alcohol or substance abusers; and persons who live in urban areas. Although more women attempt suicide than
men, they typically choose less lethal means and therefore are less likely to succeed in their attempts

Explanation

Rationale: Studies of those who commit suicide reveal the following high-risk groups: adolescents; men over age 45; persons who have made previous suicide attempts; divorced, widowed, and separated persons; professionals, such as physicians, dentists, and attorneys; students; unemployed persons; persons who are depressed, delusional, or hallucinating; alcohol or substance abusers; and persons who live in urban areas. Although more women attempt suicide than
men, they typically choose less lethal means and therefore are less likely to succeed in their attempts

2. A client who's at high risk for suicide needs close supervision. To best ensure the client's safety, the nurse should:

Check the client frequently at irregular intervals throughout the night

Assure the client that the nurse will hold in confidence anything the client says

Repeatedly discuss previous suicide attempts with the client

Disregard decreased communication by the client because this is common in suicidal clients

Checking the client frequently but at irregular intervals prevents the client from predicting when observation will take place and altering behavior in a misleading way at these times. Option B may encourage the client to try to manipulate the nurse or seek attention for having a secret suicide plan. Option C may reinforce suicidal ideas. Decreased communication is a sign of withdrawal that may indicate the client has decided to commit suicide; the nurse
shouldn't disregard it (option D )

Explanation

Checking the client frequently but at irregular intervals prevents the client from predicting when observation will take place and altering behavior in a misleading way at these times. Option B may encourage the client to try to manipulate the nurse or seek attention for having a secret suicide plan. Option C may reinforce suicidal ideas. Decreased communication is a sign of withdrawal that may indicate the client has decided to commit suicide; the nurse
shouldn't disregard it (option D )

3. Eighteen hours after undergoing an emergency appendectomy, a client with a reported history of social drinking displays these vital signs: temperature, 101.6° F (38.7° C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm Hg. The client exhibits gross hand tremors and is screaming for someone to kill the bugs in the bed. The nurse should suspect:

A postoperative infection.

Alcohol withdrawal

Acute sepsis

Pneumonia

The client's vital signs and hallucinations suggest delirium tremens or alcohol withdrawal syndrome. Although infection, acute sepsis, and pneumonia may arise as postoperative complications, they wouldn't cause this client's signs and symptoms and typically would occur later in the postoperative course.

Explanation

The client's vital signs and hallucinations suggest delirium tremens or alcohol withdrawal syndrome. Although infection, acute sepsis, and pneumonia may arise as postoperative complications, they wouldn't cause this client's signs and symptoms and typically would occur later in the postoperative course.

4. The nurse is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan?

Restrict visits with the family until the client begins to eat.

Provide privacy during meals.

Set up a strict eating plan for the client.

Encourage the client to exercise, which will reduce her anxiety.

Establishing a consistent eating plan and monitoring the client's weight are important for this disorder. The family should be included in the client's care. The client should be monitored during meals — not given privacy. Exercise must be limited and supervised.

Explanation

Establishing a consistent eating plan and monitoring the client's weight are important for this disorder. The family should be included in the client's care. The client should be monitored during meals — not given privacy. Exercise must be limited and supervised.

5. The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:

Avoid shopping for large amounts of food.

Control eating impulses.

Identify anxiety-causing situations.

Eat only three meals per day.

Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping for large amounts of food isn't a goal early in treatment. Managing eating impulses and replacing them with adaptive coping mechanisms can be integrated into the plan of care after initially addressing stress and underlying issues. Eating three meals per day isn't a realistic goal early in treatment.

Explanation

Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping for large amounts of food isn't a goal early in treatment. Managing eating impulses and replacing them with adaptive coping mechanisms can be integrated into the plan of care after initially addressing stress and underlying issues. Eating three meals per day isn't a realistic goal early in treatment.

6. One of the goals for a client with anorexia nervosa is that the client will demonstrate increased individual coping by responding to stress in constructive ways. Which of the following actions is the best indicator that the client is working toward meeting the goal?

The client drinks 4 L of fluid per day.

The client paces around the unit most of the day

The client keeps a journal and discusses it with the nurse.

The client talks almost constantly with friends by telephone

The client is moving toward meeting the goal because recording and discussing feelings is a constructive way to manage stress. Although physical activity can reduce stress, the anorexic client is more likely to use pacing to burn calories and lose weight. Although talks with friends can decrease stress, constant talking is more likely a way of avoiding dealing with problems. Increased fluid intake may be an attempt by the client to curb her appetite and artificially increase her weight.

Explanation

The client is moving toward meeting the goal because recording and discussing feelings is a constructive way to manage stress. Although physical activity can reduce stress, the anorexic client is more likely to use pacing to burn calories and lose weight. Although talks with friends can decrease stress, constant talking is more likely a way of avoiding dealing with problems. Increased fluid intake may be an attempt by the client to curb her appetite and artificially increase her weight.

7. The nurse is caring for an adolescent female who reports amenorrhea, weight loss, and depression. Which additional assessment finding would suggest that the woman has an eating disorder?

Wearing tight-fitting clothing

Increased blood pressure

Oily skin

Excessive and ritualized exercise

A client with an eating disorder will normally exercise to excess in an effort to burn as many calories as possible. The client will usually wear loose-fitting clothing to hide what she considers to be a fat body. Skin and nails become dry and brittle and blood pressure and body temperature drop from excessive weight loss

Explanation

A client with an eating disorder will normally exercise to excess in an effort to burn as many calories as possible. The client will usually wear loose-fitting clothing to hide what she considers to be a fat body. Skin and nails become dry and brittle and blood pressure and body temperature drop from excessive weight loss

8. A client is admitted to the psychiatric unit with a diagnosis of borderline personality disorder. The nurse expects the assessment to
reveal:

Unpredictable behavior and intense interpersonal relationships.

Inability to function as a responsible parent.

Somatic symptoms.

Coldness, detachment, and lack of tender feelings.

Rationale: A client with borderline personality disorder displays a pervasive pattern of unpredictable behavior, mood, and self-image. Interpersonal relationships may be intense and unstable and behavior may be inappropriate and impulsive. Although the client's impaired ability to form relationships may affect parenting skills, inability to function as a responsible parent is more typical of antisocial personality disorder. Somatic symptoms characterize avoidant personality disorder. Coldness, detachment, and lack of tender feelings typify schizoid and schizotypal personality disorders.

Explanation

Rationale: A client with borderline personality disorder displays a pervasive pattern of unpredictable behavior, mood, and self-image. Interpersonal relationships may be intense and unstable and behavior may be inappropriate and impulsive. Although the client's impaired ability to form relationships may affect parenting skills, inability to function as a responsible parent is more typical of antisocial personality disorder. Somatic symptoms characterize avoidant personality disorder. Coldness, detachment, and lack of tender feelings typify schizoid and schizotypal personality disorders.

9. A client with anorexia nervosa tells the nurse, "When I look in the mirror, I hate what I see. I look so fat and ugly." Which strategy should the nurse use to deal with the client's distorted perceptions and feelings?

Avoid discussing the client's perceptions and feelings.

Focus discussions on food and weight.

Avoid discussing unrealistic cultural standards regarding weight.

Provide objective data and feedback regarding the client's weight and attractiveness.

By focusing on reality, this strategy may help the client develop a more realistic body image and gain self-esteem. Option A is inappropriate because discussing the client's perceptions and feeling wouldn't help her to identify, accept, and work through them. Focusing discussions on food and weight would give the client attention for not eating, making option B incorrect. Option C is inappropriate because recognizing unrealistic cultural standards wouldn't help the client establish more realistic weight goals.

Explanation

By focusing on reality, this strategy may help the client develop a more realistic body image and gain self-esteem. Option A is inappropriate because discussing the client's perceptions and feeling wouldn't help her to identify, accept, and work through them. Focusing discussions on food and weight would give the client attention for not eating, making option B incorrect. Option C is inappropriate because recognizing unrealistic cultural standards wouldn't help the client establish more realistic weight goals.

10. When planning care for a client who has ingested phencyclidine (PCP), which of the following is the highest priority?

Client's physical needs

Client's safety needs

Client's psychosocial needs

Client's medical needs

The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as the staff. Drug effects are unpredictable and prolonged, and the client may lose control easily. After safety needs have been met, the client's physical, psychosocial, and medical needs can be met.

Explanation

The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as the staff. Drug effects are unpredictable and prolonged, and the client may lose control easily. After safety needs have been met, the client's physical, psychosocial, and medical needs can be met.

11. A client is found sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at her bleeding wrists while staff members call for an ambulance. How should the nurse approach her initially?

Enter the room quietly and move beside her to assess her injuries.

Call for staff back-up before entering the room and restraining her

Move as much glass away from her as possible and sit next to her quietly

Ensuring the safety of the client and the nurse is the priority at this time. Therefore, the nurse should approach the client cautiously while calling her name and talking to her in a calm, confident manner. The nurse should keep in mind that the client shouldn't be startled or overwhelmed. After explaining that the nurse is there to help, the nurse should observe the client's response carefully. If the client shows signs of agitation or confusion or poses a threat, the nurse should retreat and request assistance. The nurse shouldn't attempt to sit next to the client or examine injuries without first announcing the
nurse's presence and assessing the dangers of the situation.

Explanation

Ensuring the safety of the client and the nurse is the priority at this time. Therefore, the nurse should approach the client cautiously while calling her name and talking to her in a calm, confident manner. The nurse should keep in mind that the client shouldn't be startled or overwhelmed. After explaining that the nurse is there to help, the nurse should observe the client's response carefully. If the client shows signs of agitation or confusion or poses a threat, the nurse should retreat and request assistance. The nurse shouldn't attempt to sit next to the client or examine injuries without first announcing the
nurse's presence and assessing the dangers of the situation.

12. The nurse is caring for a client with bulimia. Strict management of dietary intake is necessary. Which intervention is also important?

Fill out the client's menu and make sure she eats at least half of what is on her tray.

Allowing the client to select her own food from the menu will help her feel some sense of control. She must then eat 100% of what she selected. Remaining with the client for at least 1 hour after eating will prevent purging. Bulimic clients should only be allowed to eat food provided by the dietary department.

Explanation

Allowing the client to select her own food from the menu will help her feel some sense of control. She must then eat 100% of what she selected. Remaining with the client for at least 1 hour after eating will prevent purging. Bulimic clients should only be allowed to eat food provided by the dietary department.

13. A client is admitted to the psychiatric unit with a diagnosis of anorexia nervosa. Although she is 5′ 8" (1.7 m) tall and weighs only 103 lb (46.7 kg), she talks incessantly about how fat she is. Which
measure should the nurse take first when caring for this client?

Teach the client about nutrition, calories, and a balanced diet.

Establish a trusting relationship with the client.

Discuss cultural stereotypes regarding thinness and attractiveness.

Explore the reasons why the client doesn't eat.

Rationale: A client with an eating disorder may be secretive and unwilling to admit that a problem exists. Therefore, the nurse first must establish a trusting relationship to elicit the client's feelings and thoughts. The anorexic client may spend long hours discussing nutrition or handling and preparing food in an effort to stall or avoid eating food; the nurse shouldn't reinforce her preoccupation with food, as in option A. Although cultural stereotypes may play a prominent
role in anorexia nervosa, discussing these factors isn't the first action the nurse should take. Exploring the reasons why the client doesn't eat would increase her emotional investment in food and eating.

Explanation

Rationale: A client with an eating disorder may be secretive and unwilling to admit that a problem exists. Therefore, the nurse first must establish a trusting relationship to elicit the client's feelings and thoughts. The anorexic client may spend long hours discussing nutrition or handling and preparing food in an effort to stall or avoid eating food; the nurse shouldn't reinforce her preoccupation with food, as in option A. Although cultural stereotypes may play a prominent
role in anorexia nervosa, discussing these factors isn't the first action the nurse should take. Exploring the reasons why the client doesn't eat would increase her emotional investment in food and eating.

14. During postprandial monitoring, a client with bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting your time. After you sat with me yesterday, I was still able to purge. Today, my goal is to do it twice." What is the nurse's best response?

"I trust you not to purge."

"How are you purging and when do you do it?"

"Don't worry. I won't allow you to purge today."

"I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat."

This response acknowledges that the client is testing limits and that the nurse is setting them by performing postprandial monitoring to prevent self-induced emesis. Clients with bulimia nervosa need to feel in control of the diet because they feel they lack control over all other aspects of their lives. Because their therapeutic relationships with caregivers are less important than their need to purge, they don't fear betraying the nurse's trust by engaging in the activity. They commonly plot purging and rarely share their secrets about it. An authoritarian or challenging response may trigger a power struggle between the nurse and client.

Explanation

This response acknowledges that the client is testing limits and that the nurse is setting them by performing postprandial monitoring to prevent self-induced emesis. Clients with bulimia nervosa need to feel in control of the diet because they feel they lack control over all other aspects of their lives. Because their therapeutic relationships with caregivers are less important than their need to purge, they don't fear betraying the nurse's trust by engaging in the activity. They commonly plot purging and rarely share their secrets about it. An authoritarian or challenging response may trigger a power struggle between the nurse and client.

15. The nurse in the substance abuse unit is trying to encourage a client to attend Alcoholics Anonymous meetings. When the client asks the nurse what he must do to become a member, the nurse should respond:

"You must first stop drinking."

"Your physician must refer you to this program."

"Admit you're powerless over alcohol and that you need help."

"You must bring along a friend who will support you."

The first of the "Twelve Steps of Alcoholics Anonymous" is admitting that an individual is powerless over alcohol and that life has become unmanageable. Although Alcoholics Anonymous promotes total abstinence, a client will still be accepted if he drinks. A physician referral isn't necessary to join. New members are assigned a support person who may be called upon when the client has the urge to drink.

Explanation

The first of the "Twelve Steps of Alcoholics Anonymous" is admitting that an individual is powerless over alcohol and that life has become unmanageable. Although Alcoholics Anonymous promotes total abstinence, a client will still be accepted if he drinks. A physician referral isn't necessary to join. New members are assigned a support person who may be called upon when the client has the urge to drink.

16. A client receiving haloperidol (Haldol) complains of a stiff jaw and difficulty swallowing. The nurse's first action is to:

Reassure the client and administer as needed lorazepam (Ativan) I.M.

Administer as needed dose of benztropine (Cogentin) I.M. as ordered

Administer as needed dose of benztropine (Cogentin) by mouth as ordered

Administer as needed dose of haloperidol (Haldol) by mouth

Rationale: The client is most likely suffering from muscle rigidity due to haloperidol. I.M. benztropine should be administered to prevent asphyxia or aspiration. Lorazepam treats anxiety, not extrapyramidal effects. Another dose of haloperidol would increase the severity of the reaction.

Explanation

Rationale: The client is most likely suffering from muscle rigidity due to haloperidol. I.M. benztropine should be administered to prevent asphyxia or aspiration. Lorazepam treats anxiety, not extrapyramidal effects. Another dose of haloperidol would increase the severity of the reaction.

17. A client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Police suspect the client was intoxicated at the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dl). The client later admits to drinking heavily for years. During hospitalization, the client periodically complains of tingling and numbness in the hands and feet. The nurse realizes that these symptoms probably result from:

Acetate accumulation.

Thiamine deficiency.

Triglyceride buildup.

A below-normal serum potassium level

Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis, which results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake. Treatment includes reducing alcohol intake, correcting nutritional deficiencies through diet and vitamin supplements, and preventing such residual disabilities as foot and wrist drop. Acetate accumulation, triglyceride buildup, and a below-normal serum
potassium level are unrelated to the client's symptoms.

Explanation

Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis, which results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake. Treatment includes reducing alcohol intake, correcting nutritional deficiencies through diet and vitamin supplements, and preventing such residual disabilities as foot and wrist drop. Acetate accumulation, triglyceride buildup, and a below-normal serum
potassium level are unrelated to the client's symptoms.

18. A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see:

Tension and irritability.

Slow pulse.

Hypotension

Constipation.

Rationale: An amphetamine is a nervous system stimulant that is subject to abuse because of its ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Options B and C are incorrect because amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea is a common adverse effect, so option D is incorrect.

Explanation

Rationale: An amphetamine is a nervous system stimulant that is subject to abuse because of its ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Options B and C are incorrect because amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea is a common adverse effect, so option D is incorrect.

19. Which of the following drugs may be abused because of tolerance and physiologic dependence.

Lithium (Lithobid) and divalproex (Depakote).

Verapamil (Calan) and chlorpromazine (Thorazine)

Alprazolam (Xanax) and phenobarbital (Luminal)

Clozapine (Clozaril) and amitriptyline (Elavil)

Rationale: Both benzodiazepines, such as alprazolam, and barbiturates, such as phenobarbital, are addictive, controlled substances. All the other drugs listed aren't addictive substances.

Explanation

Rationale: Both benzodiazepines, such as alprazolam, and barbiturates, such as phenobarbital, are addictive, controlled substances. All the other drugs listed aren't addictive substances.

20. While pacing in the hall, a client with paranoid schizophrenia runs to the nurse and says, "Why are you poisoning me? I know you work for central thought control! You can keep my thoughts. Give me back my soul!" How should the nurse respond during the early stage of the therapeutic process?

"I'm a nurse. I'm not poisoning you. It's against the nursing code of ethics."

"I'm a nurse, and you're a client in the hospital. I'm not going to harm you."

"I'm not poisoning you. And how could I possibly steal your soul?"

"I sense anger. Are you feeling angry today?"

Rationale: The nurse should directly orient a delusional client to reality, especially to place and person. Options A and C may encourage further delusions by denying poisoning and offering information related to the delusion. Validating the client's feelings, as in option D, occurs during a later stage in the therapeutic process.

Explanation

Rationale: The nurse should directly orient a delusional client to reality, especially to place and person. Options A and C may encourage further delusions by denying poisoning and offering information related to the delusion. Validating the client's feelings, as in option D, occurs during a later stage in the therapeutic process.

21. A 38-year-old client is admitted for alcohol withdrawal. The most common early sign or symptom that this client is likely to experience is:

Impending coma.

Manipulating behavior

Suppression

Perceptual disorders

Rationale: Perceptual disorders, especially frightening visual hallucinations, are very common with alcohol withdrawal. Coma isn't an immediate consequence. Manipulative behaviors are part of the alcoholic client's personality but aren't signs of alcohol withdrawal. Suppression is a conscious effort to conceal unacceptable thoughts, feelings, impulses, or acts and serves as a coping mechanism for most alcoholics.

Explanation

Rationale: Perceptual disorders, especially frightening visual hallucinations, are very common with alcohol withdrawal. Coma isn't an immediate consequence. Manipulative behaviors are part of the alcoholic client's personality but aren't signs of alcohol withdrawal. Suppression is a conscious effort to conceal unacceptable thoughts, feelings, impulses, or acts and serves as a coping mechanism for most alcoholics.

22. A dystonic reaction can be caused by which of the following medications?

Diazepam (Valium)

Haloperidol (Haldol)

Amitriptyline (Elavil)

Clonazepam (Klonopin)

Rationale: Haloperidol is a phenothiazine and is capable of causing dystonic reactions. Diazepam and clonazepam are benzodiazepines, and amitriptyline is a tricyclic antidepressant. Benzodiazepines don't cause dystonic reactions; however, they can cause drowsiness, lethargy, and hypotension. Tricyclic antidepressants rarely cause severe dystonic reactions; however, they can cause a decreased level of consciousness, tachycardia, dry mouth, and dilated pupils.

Explanation

Rationale: Haloperidol is a phenothiazine and is capable of causing dystonic reactions. Diazepam and clonazepam are benzodiazepines, and amitriptyline is a tricyclic antidepressant. Benzodiazepines don't cause dystonic reactions; however, they can cause drowsiness, lethargy, and hypotension. Tricyclic antidepressants rarely cause severe dystonic reactions; however, they can cause a decreased level of consciousness, tachycardia, dry mouth, and dilated pupils.

23. Which medication can control the extrapyramidal effects associated with antipsychotic agents?

Perphenazine (Trilafon)

Doxepin (Sinequan)

Amantadine (Symmetrel)

Clorazepate (Tranxene)

Rationale: Amantadine is an anticholinergic drug used to relieve drug-induced extrapyramidal adverse effects, such as muscle weakness, involuntary muscle movement, pseudoparkinsonism, and tardive dyskinesia. Other anticholinergic agents used to control extrapyramidal reactions include benztropine mesylate (Cogentin), trihexyphenidyl (Artane), biperiden (Akineton), and diphenhydramine (Benadryl). Perphenazine is an antipsychotic agent; doxepin, an antidepressant; and chlorazepate, an antianxiety agent. Because these medications have no anticholinergic or neurotransmitter effects, they don't alleviate
extrapyramidal reactions.

Explanation

Rationale: Amantadine is an anticholinergic drug used to relieve drug-induced extrapyramidal adverse effects, such as muscle weakness, involuntary muscle movement, pseudoparkinsonism, and tardive dyskinesia. Other anticholinergic agents used to control extrapyramidal reactions include benztropine mesylate (Cogentin), trihexyphenidyl (Artane), biperiden (Akineton), and diphenhydramine (Benadryl). Perphenazine is an antipsychotic agent; doxepin, an antidepressant; and chlorazepate, an antianxiety agent. Because these medications have no anticholinergic or neurotransmitter effects, they don't alleviate
extrapyramidal reactions.

24. Which of the following drugs should the nurse prepare to administer to a client with a toxic acetaminophen (Tylenol) level?

Deferoxamine mesylate (Desferal)

Succimer (Chemet)

Flumazenil (Romazicon)

Acetylcysteine (Mucomyst)

The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion of toxic metabolites to nontoxic metabolites. Deferoxamine mesylate is the antidote for iron intoxication. Succimer is an antidote for lead poisoning. Flumazenil reverses the sedative effects of benzodiazepines.

Explanation

The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion of toxic metabolites to nontoxic metabolites. Deferoxamine mesylate is the antidote for iron intoxication. Succimer is an antidote for lead poisoning. Flumazenil reverses the sedative effects of benzodiazepines.

25. A client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is the nurse most likely to administer to reduce the symptoms of alcohol withdrawal?

Naloxone (Narcan)

Haloperidol (Haldol)

Magnesium sulfate

Chlordiazepoxide (Librium)

Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of alcohol withdrawal. Haloperidol (Haldol) may be given to treat clients with psychosis, severe agitation, or delirium. Naloxone (Narcan) is administered for narcotic overdose. Magnesium sulfate and other anticonvulsant medications are only administered to treat seizures if they occur during withdrawal.

Explanation

Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of alcohol withdrawal. Haloperidol (Haldol) may be given to treat clients with psychosis, severe agitation, or delirium. Naloxone (Narcan) is administered for narcotic overdose. Magnesium sulfate and other anticonvulsant medications are only administered to treat seizures if they occur during withdrawal.

26. For a client with anorexia nervosa, which goal takes the highest priority?

The client will establish adequate daily nutritional intake

The client will make a contract with the nurse that sets a target weight

The client will identify self-perceptions about body size as unrealistic

The client will verbalize the possible physiological consequences of self-starvation

According to Maslow's hierarchy of needs, all humans need to meet basic physiological needs first. Because a client with anorexia nervosa eats little or nothing, the nurse must first plan to help the client meet this basic, immediate physiological need. The nurse may give lesser priority to goals that address long-term plans (as in option B), self-perception (as in option C), and potential complications (as in option D).

Explanation

According to Maslow's hierarchy of needs, all humans need to meet basic physiological needs first. Because a client with anorexia nervosa eats little or nothing, the nurse must first plan to help the client meet this basic, immediate physiological need. The nurse may give lesser priority to goals that address long-term plans (as in option B), self-perception (as in option C), and potential complications (as in option D).

27. In the emergency department, a client with facial lacerations states that her husband beat her with a shoe. After the health care team repairs her lacerations, she waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the client's husband arrives, shouting that he wants to "finish the job." What is the first priority of the health care worker who witnesses this scene?

Remaining with the client and staying calm

Calling a security guard and another staff member for assistance

Telling the client's husband that he must leave at once

Determining why the husband feels so angry

The health care worker who witnesses this scene must take precautions to ensure personal as well as client safety, but shouldn't attempt to manage a physically aggressive person alone. Therefore, the first priority is to call a security guard and another staff member. After doing this, the health care worker should inform the husband what is expected, speaking in concise statements and maintaining a firm but calm demeanor. This approach makes it clear that the health care worker is in control and may diffuse the situation until the security guard arrives. Telling the husband to leave would probably be
ineffective because of his agitated and irrational state. Exploring his anger doesn't take precedence over safeguarding the client and staff.

Explanation

The health care worker who witnesses this scene must take precautions to ensure personal as well as client safety, but shouldn't attempt to manage a physically aggressive person alone. Therefore, the first priority is to call a security guard and another staff member. After doing this, the health care worker should inform the husband what is expected, speaking in concise statements and maintaining a firm but calm demeanor. This approach makes it clear that the health care worker is in control and may diffuse the situation until the security guard arrives. Telling the husband to leave would probably be
ineffective because of his agitated and irrational state. Exploring his anger doesn't take precedence over safeguarding the client and staff.

28. A client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He's shouting that the government of France is trying to assassinate him. Which of the
following responses is most appropriate?

"You're wrong. Nobody is trying to kill you."

"A foreign government is trying to kill you? Please tell me more about it."

Rationale: Responses should focus on reality while acknowledging the client's feelings. Arguing with the client or denying his belief isn't therapeutic. Arguing can also inhibit development of a trusting relationship. Continuing to talk about delusions may aggravate the psychosis. Asking the client if a foreign government is trying to kill him may increase his anxiety level and can reinforce his delusions.

Explanation

Rationale: Responses should focus on reality while acknowledging the client's feelings. Arguing with the client or denying his belief isn't therapeutic. Arguing can also inhibit development of a trusting relationship. Continuing to talk about delusions may aggravate the psychosis. Asking the client if a foreign government is trying to kill him may increase his anxiety level and can reinforce his delusions.

29. A client with paranoid schizophrenia has been experiencing auditory hallucinations for many years. One approach that has proven to be effective for hallucinating clients is to:

Take an as-needed dose of psychotropic medication whenever they hear voices.

Practice saying "Go away" or "Stop" when they hear voices.

Sing loudly to drown out the voices and provide a distraction.

Go to their room until the voices go away.

Rationale: Researchers have found that some clients can learn to control bothersome hallucinations by telling the voices to go away or stop. Taking an as needed dose of psychotropic medication whenever the voices arise may lead to overmedication and put the client at risk for adverse effects. Because the voices aren't likely to go away permanently, the client must learn to deal with the hallucinations without relying on drugs. Although distraction is helpful, singing loudly may upset other clients and would be socially unacceptable after the client is discharged. Hallucinations are most bothersome in a quiet
environment when the client is alone, so sending the client to his room would increase, rather than decrease, the hallucinations.

Explanation

Rationale: Researchers have found that some clients can learn to control bothersome hallucinations by telling the voices to go away or stop. Taking an as needed dose of psychotropic medication whenever the voices arise may lead to overmedication and put the client at risk for adverse effects. Because the voices aren't likely to go away permanently, the client must learn to deal with the hallucinations without relying on drugs. Although distraction is helpful, singing loudly may upset other clients and would be socially unacceptable after the client is discharged. Hallucinations are most bothersome in a quiet
environment when the client is alone, so sending the client to his room would increase, rather than decrease, the hallucinations.

30. After completing chemical detoxification and a 12-step program to treat crack addiction, a client is being prepared for discharge. Which remark by the client indicates a realistic view of the future?

"I'm never going to use crack again."

"I know what I have to do. I have to limit my crack use."

"I'm going to take 1 day at a time. I'm not making any promises."

"I will substitue crack for something else"

Twelve-step programs focus on recovery 1 day at a time.Such programs discourage people from claiming that they will never again use a substance, because relapse is common. The belief that one may use a limited amount of an abused substance indicates denial. Substituting one abused substance for another predisposes the client to cross-addiction.

Explanation

Twelve-step programs focus on recovery 1 day at a time.Such programs discourage people from claiming that they will never again use a substance, because relapse is common. The belief that one may use a limited amount of an abused substance indicates denial. Substituting one abused substance for another predisposes the client to cross-addiction.

31. For a client with anorexia nervosa, the nurse plans to include the parents in therapy sessions along with the client. What fact should the nurse remember to be typical of parents of clients with anorexia nervosa?

They tend to overprotect their children.

They usually have a history of substance abuse.

They maintain emotional distance from their children

They alternate between loving and rejecting their children

Clients with anorexia nervosa typically come from a family with parents who are controlling and overprotective. These clients use eating to gain control of an aspect of their lives. The characteristics described in options B, C, and D aren't typical of parents of children with anorexia

Explanation

Clients with anorexia nervosa typically come from a family with parents who are controlling and overprotective. These clients use eating to gain control of an aspect of their lives. The characteristics described in options B, C, and D aren't typical of parents of children with anorexia

32. Flumazenil (Romazicon) has been ordered for a client who has overdosed on oxazepam (Serax). Before administering the medication, the nurse should be prepared for which common adverse effect?

Seizures

Shivering

Anxiety

Chest pain

Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. Less common adverse effects include shivering, anxiety, and chest pain.

Explanation

Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. Less common adverse effects include shivering, anxiety, and chest pain.

33. He nurse is providing care for a female client with a history of schizophrenia who's experiencing hallucinations. The physician orders 200 mg of haloperidol (Haldol) orally or I.M. every 4 hours as needed.
What is the nurse's best action?

Administer the haloperidol orally if the client agrees to take it.

Call the physician to clarify whether the haloperidol should be given orally or I.M

Call the physician to clarify the order because the dosage is too high.

Withhold haloperidol because it may worsen hallucinations.

Rationale: The dosage is too high (normal dosage ranges from 5 to 10 mg daily). Options A and B may lead to an overdose. Option D is incorrect because haloperidol helps with symptoms of hallucinations.

Explanation

Rationale: The dosage is too high (normal dosage ranges from 5 to 10 mg daily). Options A and B may lead to an overdose. Option D is incorrect because haloperidol helps with symptoms of hallucinations.

34. A client with disorganized type schizophrenia has been hospitalized for the past 2 years on a unit for chronic mentally ill clients. The client's behavior is labile and fluctuates from childishness
and incoherence to loud yelling to slow but appropriate interaction. The client needs assistance with all activities of daily living. Which behavior is characteristic of disorganized type schizophrenia?

Extreme social impairment

Suspicious delusions

Waxy flexibility

Elevated affect

Rationale: Disorganized type schizophrenia (formerly called hebephrenia) is characterized by extreme social impairment, marked inappropriate affect, silliness, grimacing, posturing, and fragmented delusions and hallucinations. A client with a paranoid disorder typically exhibits suspicious delusions, such as a belief that evil forces are after him. Waxy flexibility, a condition in which the client's limbs remain fixed in uncomfortable positions for long periods, characterizes
catatonic schizophrenia. Elevated affect is associated withschizoaffective disorder

Explanation

Rationale: Disorganized type schizophrenia (formerly called hebephrenia) is characterized by extreme social impairment, marked inappropriate affect, silliness, grimacing, posturing, and fragmented delusions and hallucinations. A client with a paranoid disorder typically exhibits suspicious delusions, such as a belief that evil forces are after him. Waxy flexibility, a condition in which the client's limbs remain fixed in uncomfortable positions for long periods, characterizes
catatonic schizophrenia. Elevated affect is associated withschizoaffective disorder

35. The nurse is assessing a client on admission to the chemical dependency unit for alcohol detoxification. When the nurse asks about alcohol use, this client is most likely to:

Accurately describe the amount consumed.

Underestimate the amount consumed.

Overestimate the amount consumed.

Deny any consumption of alcohol.

Most people who abuse substances underestimate their consumption in an attempt to conform to social norms or protect themselves. Few accurately describe or overestimate consumption; some may deny it. Therefore, on admission, quantitative and qualitative toxicology screens are done to validate information obtained from the client.

Explanation

Most people who abuse substances underestimate their consumption in an attempt to conform to social norms or protect themselves. Few accurately describe or overestimate consumption; some may deny it. Therefore, on admission, quantitative and qualitative toxicology screens are done to validate information obtained from the client.

36. The nurse is assigned to care for a suicidal client. Initially, which is the nurse's highest care priority?

Assessing the client's home environment and relationships outside the hospital

Exploring the nurse's own feelings about suicide

Discussing the future with the client

Referring the client to a clergyperson to discuss the moral implications of suicide

The nurse's values, beliefs, and attitudes toward self-destructive behavior influence responses to a suicidal client; such responses set the overall mood for the nurse-client relationship. Therefore, the nurse initially must explore personal feelings about suicide to avoid conveying negative feelings to the client. Assessment of the client's home environment and relationships may reveal the need for family therapy; however, conducting such an assessment isn't
a nursing priority. Discussing the future and providing anticipatory guidance can help the client prepare for future stress, but this isn't a priority. Referring the client to a clergyperson may increase the client's trust or alleviate guilt; however, it isn't the highest priority.

Explanation

The nurse's values, beliefs, and attitudes toward self-destructive behavior influence responses to a suicidal client; such responses set the overall mood for the nurse-client relationship. Therefore, the nurse initially must explore personal feelings about suicide to avoid conveying negative feelings to the client. Assessment of the client's home environment and relationships may reveal the need for family therapy; however, conducting such an assessment isn't
a nursing priority. Discussing the future and providing anticipatory guidance can help the client prepare for future stress, but this isn't a priority. Referring the client to a clergyperson may increase the client's trust or alleviate guilt; however, it isn't the highest priority.

37. The nurse is caring for a client being treated for alcoholism. Before initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of the following products?

Carbonated beverages

Aftershave lotion

Toothpaste

Cheese

Disulfiram may be given to clients with chronic alcohol abuse who wish to curb impulse drinking. Disulfiram works by blocking the oxidation of alcohol, inhibiting the conversion of acetaldehyde to acetate. As acetaldehyde builds up in the blood, the client experiences noxious and uncomfortable symptoms. Even alcohol rubbed onto the skin can produce a reaction. The client receiving disulfiram must be taught to read ingredient labels carefully to avoid products containing alcohol such as aftershave lotions. Carbonated beverages, toothpaste, and cheese don't contain alcohol and don't need to be avoided by the
client.

Explanation

Disulfiram may be given to clients with chronic alcohol abuse who wish to curb impulse drinking. Disulfiram works by blocking the oxidation of alcohol, inhibiting the conversion of acetaldehyde to acetate. As acetaldehyde builds up in the blood, the client experiences noxious and uncomfortable symptoms. Even alcohol rubbed onto the skin can produce a reaction. The client receiving disulfiram must be taught to read ingredient labels carefully to avoid products containing alcohol such as aftershave lotions. Carbonated beverages, toothpaste, and cheese don't contain alcohol and don't need to be avoided by the
client.

38. A client with anorexia nervosa describes herself as "a whale." However, the nurse's assessment reveals that the client is 5′ 8" (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should be included in the plan of care?

Asking the client to compare her figure with magazine photographs of women her age

Assigning the client to group therapy in which participants provide realistic feedback about her weight

Confronting the client about her actual appearance during one-on-one sessions, scheduled during each shift

A client with anorexia nervosa has an unrealistic body image that causes consumption of little or no food. Therefore, the client needs assistance with making decisions about health. Instead of protecting the client's health, options A, B, and C may serve to make the client defensive and more entrenched in her unrealistic body image.

Explanation

A client with anorexia nervosa has an unrealistic body image that causes consumption of little or no food. Therefore, the client needs assistance with making decisions about health. Instead of protecting the client's health, options A, B, and C may serve to make the client defensive and more entrenched in her unrealistic body image.

39. A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect that the child was abused?

The child cries uncontrollably throughout the examination.

The child pulls away from contact with the physician.

The child doesn't cry when the shoulder is examined

The child doesn't make eye contact with the nurse.

A characteristic behavior of abused children is lack of crying when they undergo a painful procedure or are examined by a health care professional. Therefore, the nurse should suspect child abuse. Crying throughout the examination, pulling away from the physician, and not making eye contact with the nurse are normal behaviors for preschoolers

Explanation

A characteristic behavior of abused children is lack of crying when they undergo a painful procedure or are examined by a health care professional. Therefore, the nurse should suspect child abuse. Crying throughout the examination, pulling away from the physician, and not making eye contact with the nurse are normal behaviors for preschoolers

40. Victims of domestic violence should be assessed for what important information?

Reasons they stay in the abusive relationship (for example, lack of financial autonomy and isolation)

Readiness to leave the perpetrator and knowledge of resources

Use of drugs or alcohol

History of previous victimization

Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of the resources available to them. Nurses can then provide the victims with information and options to enable them to leave when they are ready. The reasons they stay in the relationship are complex and can be explored at a later time. The use of drugs or alcohol is irrelevant. There is no evidence to suggest that previous victimization results in a
person's seeking or causing abusive relationships.

Explanation

Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of the resources available to them. Nurses can then provide the victims with information and options to enable them to leave when they are ready. The reasons they stay in the relationship are complex and can be explored at a later time. The use of drugs or alcohol is irrelevant. There is no evidence to suggest that previous victimization results in a
person's seeking or causing abusive relationships.

41. A client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, "It felt so wonderful to get high." Which of the following is the most appropriate response?

"If you continue to talk like that, I'm going to stop speaking to you."

"You told me you got fired from your last job for missing too many days after taking drugs all night."

"Tell me more about how it felt to get high."

"Don't you know it's illegal to use drugs?"

Confronting the client with the consequences of substance abuse helps to break through denial. Making threats (option A) isn't an effective way to promote self-disclosure or establish a rapport with the client. Although the nurse should encourage the client to discuss feelings, the discussion should focus on how the client felt before, not during, an episode of substance abuse (option C). Encouraging elaboration about his experience while getting high may reinforce the abusive behavior. The client undoubtedly is aware that drug use is illegal; a reminder to this effect (option D) is unlikely to alter behavior.

Explanation

Confronting the client with the consequences of substance abuse helps to break through denial. Making threats (option A) isn't an effective way to promote self-disclosure or establish a rapport with the client. Although the nurse should encourage the client to discuss feelings, the discussion should focus on how the client felt before, not during, an episode of substance abuse (option C). Encouraging elaboration about his experience while getting high may reinforce the abusive behavior. The client undoubtedly is aware that drug use is illegal; a reminder to this effect (option D) is unlikely to alter behavior.

42. When interviewing the parents of an injured child, which of the following is the strongest indicator that child abuse may be a problem?

The injury isn't consistent with the history or the child's age

The mother and father tell different stories regarding what happened.

The family is poor.

The parents are argumentative and demanding with emergency department personnel.

When the child's injuries are inconsistent with the history given or impossible because of the child's age and developmental stage, the emergency department nurse should be suspicious that child abuse is occurring. The parents may tell different stories because their perception may be different regarding what happened. If they change their story when different health care workers ask the same question, this is a clue that child abuse may be a problem. Child abuse occurs in all socioeconomic groups. Parents may argue and be demanding because of the stress of having an injured child.

Explanation

When the child's injuries are inconsistent with the history given or impossible because of the child's age and developmental stage, the emergency department nurse should be suspicious that child abuse is occurring. The parents may tell different stories because their perception may be different regarding what happened. If they change their story when different health care workers ask the same question, this is a clue that child abuse may be a problem. Child abuse occurs in all socioeconomic groups. Parents may argue and be demanding because of the stress of having an injured child.

43. A 24-year-old client is experiencing an acute schizophrenic episode. He has vivid hallucinations that are making him agitated. The nurse's best response at this time would be to:

Take the client's vital signs.

Explore the content of the hallucinations

Tell him his fear is unrealistic

Engage the client in reality-oriented activities

Rationale: Exploring the content of the hallucinations will help the nurse understand the client's perspective on the situation. The client shouldn't be touched, such as in taking vital signs, without telling him exactly what is going to happen. Debating with the client about his emotions isn't therapeutic. When the client is calm, engage him in reality-based activities

Explanation

Rationale: Exploring the content of the hallucinations will help the nurse understand the client's perspective on the situation. The client shouldn't be touched, such as in taking vital signs, without telling him exactly what is going to happen. Debating with the client about his emotions isn't therapeutic. When the client is calm, engage him in reality-based activities

44. A client with a history of polysubstance abuse is admitted to the facility. She complains of nausea and vomiting 24 hours after admission. The nurse assesses the client and notes piloerection,
pupillary dilation, and lacrimation. The nurse suspects that the client is going through which of the following withdrawals?

Alcohol withdrawal

Cannibis withdrawal

Cocaine withdrawal

Opioid withdrawal

Rationale: The symptoms listed are specific to opioid withdrawal. Alcohol withdrawal would show elevated vital signs. There is no real withdrawal from cannibis. Symptoms of cocaine withdrawal include depression, anxiety, and agitation.

Explanation

Rationale: The symptoms listed are specific to opioid withdrawal. Alcohol withdrawal would show elevated vital signs. There is no real withdrawal from cannibis. Symptoms of cocaine withdrawal include depression, anxiety, and agitation.

45. Clonidine (Catapres) can be used to treat conditions other than hypertension. For which of the following conditions might the drug be administered?

Phencyclidine (PCP) intoxication

Alcohol withdrawal

Opiate withdrawal

Cocaine withdrawal

Clonidine is used as adjunctive therapy in opiate withdrawal. Benzodiazepines, such as chlordiazepoxide (Librium), and neuropleptic agents, such as haloperidol, are used to treat alcohol withdrawal. Benzodiazepines and neuropleptic agents are typically used to treat PCP intoxication. Antidepressants and medications with dopaminergic activity in the brain, such as fluoxotine (Prozac), are used to treat cocaine withdrawal.

Explanation

Clonidine is used as adjunctive therapy in opiate withdrawal. Benzodiazepines, such as chlordiazepoxide (Librium), and neuropleptic agents, such as haloperidol, are used to treat alcohol withdrawal. Benzodiazepines and neuropleptic agents are typically used to treat PCP intoxication. Antidepressants and medications with dopaminergic activity in the brain, such as fluoxotine (Prozac), are used to treat cocaine withdrawal.

46. An attorney who throws books and furniture around the office after losing a case is referred to the psychiatric nurse in the law firm's employee assistance program. The nurse knows that the client's behavior most likely represents the use of which defense mechanism?

Regression

Projection

Reaction-formation

Intellectualization

An adult who throws temper tantrums, such as this one, is displaying regressive behavior, or behavior that is appropriate at a younger age. In projection, the client blames someone or something other than the source. In reaction formation, the client acts in opposition to his feelings. In intellectualization, the client overuses rational explanations or abstract thinking to decrease the significance of a feeling or event.

Explanation

An adult who throws temper tantrums, such as this one, is displaying regressive behavior, or behavior that is appropriate at a younger age. In projection, the client blames someone or something other than the source. In reaction formation, the client acts in opposition to his feelings. In intellectualization, the client overuses rational explanations or abstract thinking to decrease the significance of a feeling or event.

47. The nurse is assessing a 15-year-old female who's being admitted for treatment of anorexia nervosa. Which clinical manifestation is the nurse most likely to find?

Tachycardia

Warm, flushed extremities

Parotid gland tenderness

Coarse hair growth

Frequent vomiting causes tenderness and swelling of the parotid glands. The reduced metabolism that occurs with severe weight loss produces bradycardia and cold extremities. Soft, downlike hair (called lanugo) may cover the extremities, shoulders, and face of an anorexic client.

Explanation

Frequent vomiting causes tenderness and swelling of the parotid glands. The reduced metabolism that occurs with severe weight loss produces bradycardia and cold extremities. Soft, downlike hair (called lanugo) may cover the extremities, shoulders, and face of an anorexic client.

48. Which outcome criteria would be appropriate for a child diagnosed with oppositional defiant disorder?

Accept responsibility for own behaviors

Be able to verbalize own needs and assert rights.

Set firm and consistent limits with the client

Allow the child to establish his own limits and boundaries.

Children with oppositional defiant disorder frequently violate the rights of others. They are defiant, disobedient, and blame others for their actions. Accountability for their actions would demonstrate progress for the oppositional child. Options C and D aren't outcome criteria but interventions. Option B is incorrect as the oppositional child usually focuses on his own needs.

Explanation

Children with oppositional defiant disorder frequently violate the rights of others. They are defiant, disobedient, and blame others for their actions. Accountability for their actions would demonstrate progress for the oppositional child. Options C and D aren't outcome criteria but interventions. Option B is incorrect as the oppositional child usually focuses on his own needs.

49. Tourette syndrome is characterized by the presence of multiple motor and vocal tics. A vocal tic that involves repeating one's own sounds or words is known as:

Echolalia

Palilalia

Apraxia

Aphonia

Rationale: Palilalia is defined as the repetition of sounds and words. Echolalia is the act of repeating the words of others. Apraxia is the inability to carry out motor activities, and aphonia is the inability to speak

Explanation

Rationale: Palilalia is defined as the repetition of sounds and words. Echolalia is the act of repeating the words of others. Apraxia is the inability to carry out motor activities, and aphonia is the inability to speak