Psychiatric Nursing | NCLEX Quiz 192 - Quiz, Flashcards & Trivia

1. The nurse enters the room of a client with a cognitive impairment disorder and asks what day of the week it is: what the date. month. and year are; and where the client is. The nurse is attempting to assess:

Confabulation

Delirium

Orientation

Perseveration

The initial. most basic assessment of a client with cognitive impairment involves determining his level of orientation (awareness of time. place. and person).Options A and D: The nurse may also assess for confabulation and perseveration in a client with cognitive impairment. but the questions in this situation would not elicit the symptom response.Option B: Delirium is a type of cognitive impairment; however. other symptoms are necessary to establish this diagnosis.

Explanation

The initial. most basic assessment of a client with cognitive impairment involves determining his level of orientation (awareness of time. place. and person).Options A and D: The nurse may also assess for confabulation and perseveration in a client with cognitive impairment. but the questions in this situation would not elicit the symptom response.Option B: Delirium is a type of cognitive impairment; however. other symptoms are necessary to establish this diagnosis.

2. The doctor has prescribed haloperidol (Haldol) 2.5 mg. I.M. for an agitated client. The medication is labeled haloperidol 10 mg/2 ml. The nurse prepares the correct dose by drawing up how many milliliters in the syringe?

0.3

0.4

0.5

0.6

Set up the problem as follows: 2.5mg/10mg = Xml/2ml X=0.5ml

Explanation

Set up the problem as follows: 2.5mg/10mg = Xml/2ml X=0.5ml

3. Which of the following will the nurse use when communicating with a client who has a cognitive impairment?

Complete explanations with multiple details

Picture or gestures instead of words

Stimulating words and phrases to capture the client’s attention

Short words and simple sentences

Short words and simple sentence minimize client confusion and enhance communication.Options A and C: Complete explanations with multiple details and stimulating words and phrases would increase confusion in a client with short attention span and difficulty with comprehension.Option B: Although pictures and gestures may be helpful. they would not substitute for verbal communication.

Explanation

Short words and simple sentence minimize client confusion and enhance communication.Options A and C: Complete explanations with multiple details and stimulating words and phrases would increase confusion in a client with short attention span and difficulty with comprehension.Option B: Although pictures and gestures may be helpful. they would not substitute for verbal communication.

4. The nurse correctly teaches a client taking the Benzodiazepine Oxazepam (Serax) to avoid excessive intake of:

Cheese

Coffee

Sugar

Shellfish

Coffee contains caffeine. which has a stimulating effect on the central nervous system that will counteract the effect of the antianxiety medication oxazepam. None of the remaining foods is contraindicated.

Explanation

Coffee contains caffeine. which has a stimulating effect on the central nervous system that will counteract the effect of the antianxiety medication oxazepam. None of the remaining foods is contraindicated.

5. The nurse is administering a psychotropic drug to an elderly client who has a history of benign prostatic hypertrophy. It is most important for the nurse to teach this client to:

Add fiber to his diet.

Exercise on a regular basis.

Report incomplete bladder emptying

Take the prescribed dose at bedtime.

Urinary retention is a common anticholinergic side effect of psychotic medications. and the client with benign prostatic hypertrophy would have increased risk for this problem.Options A and B: Adding fiber to one’s diet and exercising regularly are measures to counteract another anticholinergic effect. constipation.Option D: Depending on the specific medication and how it is prescribed. taking the medication at night may or may not be important. However. it would have nothing to do with urinary retention in this client.

Explanation

Urinary retention is a common anticholinergic side effect of psychotic medications. and the client with benign prostatic hypertrophy would have increased risk for this problem.Options A and B: Adding fiber to one’s diet and exercising regularly are measures to counteract another anticholinergic effect. constipation.Option D: Depending on the specific medication and how it is prescribed. taking the medication at night may or may not be important. However. it would have nothing to do with urinary retention in this client.

6. The nurse understands that electroconvulsive therapy is primary used in psychiatric care for the treatment of:

Anxiety disorders.

Depression.

ManiA.

Schizophrenia.

The onset of action of the SSRI antidepressant paroxetine occurs around 3 to 4 weeks after drug therapy begins. Therefore. a client will seldom notice improvement before this time. Continuing to take the drug is important for this client.

Explanation

The onset of action of the SSRI antidepressant paroxetine occurs around 3 to 4 weeks after drug therapy begins. Therefore. a client will seldom notice improvement before this time. Continuing to take the drug is important for this client.

7. Which client outcome is most appropriately achieved in a community approach setting in psychiatric nursing?

The client performs activities of daily living and learns about crafts.

The client is able to prevent aggressive behavior and monitors his use of medications.

The client demonstrates self-reliance and social adaptation.

The client experience experiences anxiety relief and learns about his symptoms.

A therapeutic community is designed to help individuals assume responsibility for themselves. to learn how to respect and communicate with others. and to interact in a positive manner.Options A. B. and D: The remaining answer choices may be outcomes of psychiatric treatment. but the use of a therapeutic community approach is concerned with the promotion of self-reliance and cooperative adaptation to being with others.

Explanation

A therapeutic community is designed to help individuals assume responsibility for themselves. to learn how to respect and communicate with others. and to interact in a positive manner.Options A. B. and D: The remaining answer choices may be outcomes of psychiatric treatment. but the use of a therapeutic community approach is concerned with the promotion of self-reliance and cooperative adaptation to being with others.

8. A client taking the MAOI phenelzine (Nardil) tells the nurse that he routinely takes all of the medications listed below. Which medication would cause the nurse to express concern and therefore initiate further teaching?

Acetaminophen (Tylenol)

Diphenhydramine (Benadryl)

Furosemide (Lasix)

Isosorbide dinitrate (Isordil)

Over-the-counter medications used for allergies and cold symptoms are contraindicated because they will increase the sympathomimetic effects of MAOIs. possibly causing a hypertensive crisis.Options A. C. and D: None of the remaining medications will increase the sympathomimetic response and. therefore. are not contraindicated.

Explanation

Over-the-counter medications used for allergies and cold symptoms are contraindicated because they will increase the sympathomimetic effects of MAOIs. possibly causing a hypertensive crisis.Options A. C. and D: None of the remaining medications will increase the sympathomimetic response and. therefore. are not contraindicated.

9. The nurse provides a referral to Alcoholics Anonymous to a client who describes a 20-year history of alcohol abuse. The primary function of this group is to:

Encourage the use of a 12-step program.

Help members maintain sobriety.

Provide fellowship among members.

Teach positive coping mechanisms.

The primary purpose of Alcoholics Anonymous is to help members achieve and maintain sobriety.Options A. C. and D: Although each of the remaining answer choices may be an outcome of attendance at Alcoholics Anonymous. the primary purpose is directed toward sobriety of members.

Explanation

The primary purpose of Alcoholics Anonymous is to help members achieve and maintain sobriety.Options A. C. and D: Although each of the remaining answer choices may be an outcome of attendance at Alcoholics Anonymous. the primary purpose is directed toward sobriety of members.

10. A client with panic disorder experiences an acute attack while the nurse is completing an admission assessment. List the following interventions according to their level of priority.

Remain with the client.

Encourage physical activity.

Encourage low, deep breathing.

Reduce external stimuli.

Teach coping measures.

The nurse should remain with the client to provide support and promote safety. Reducing external stimuli. including dimming lights and avoiding crowded areas. will help decrease anxiety. Encouraging the client to use slow. deep breathing will help promote the body’s relaxation response. thereby interrupting stimulation from the autonomic nervous system. Encouraging physical activity will help him to release energy resulting from the heightened anxiety state; this should be done only after the client has brought his breathing under control. Teaching coping measures will help the client learn to handle anxiety; however. this can only be accomplished when the client’s panic has dissipated and he is better able to focus.

Explanation

The nurse should remain with the client to provide support and promote safety. Reducing external stimuli. including dimming lights and avoiding crowded areas. will help decrease anxiety. Encouraging the client to use slow. deep breathing will help promote the body’s relaxation response. thereby interrupting stimulation from the autonomic nervous system. Encouraging physical activity will help him to release energy resulting from the heightened anxiety state; this should be done only after the client has brought his breathing under control. Teaching coping measures will help the client learn to handle anxiety; however. this can only be accomplished when the client’s panic has dissipated and he is better able to focus.

Submit