mentalhealth exam 3.0

Ans: Alarm reaction stage
B) Resistance stage

Exhaustion stage

Feedback:
The stages in Selye's general adaptation syndrome include the alarm reaction stage, the resistance stage, and the exhaustion stage. Selye did not identify either a coping stage or a panic stage.

1. The nurse knows that which of the following are stages in Selye's general adaptation syndrome? Select all that apply.
A) Alarm reaction stage
B) Resistance stage
C) Coping stage
D) Exhaustion stage
E) Panic stage

Ans: Stress is the wear and tear that life causes on the body.

Feedback:
Stress is the wear and tear that life causes on the body. It occurs when a person has difficulty dealing with life situations, problems, and goals. Each person handles stress differently. Anxiety is a vague feeling of dread or apprehension; it is a response to external or internal stimuli that can have behavioral, emotional, cognitive, and physical symptoms. Anxiety is a response to stress.

2. The nurse knows that which one of the following statements is true about stress and anxiety?
A) All people handle stress in the same way.
B) Stress is a person's reaction to anxiety.
C) Anxiety occurs when a person has trouble dealing with life situations, problems,
and goals.
D) Stress is the wear and tear that life causes on the body.

Ans: Anxiety is unavoidable.
Feedback:
Anxiety is distinguished from fear, which is feeling afraid or threatened by a clearly identifiable external stimulus that represents danger to the person. Anxiety is unavoidable in life and can serve many positive functions such as motivating the person to take action to solve a problem or to resolve a crisis.

3. The nursing student answers the test item correctly when identifying which one of the following statements is true?
A) Anxiety and fear are the same.
B) Anxiety is unavoidable.
C) Anxiety is always harmful.
D) Fear is feeling threatened by an unknown entity.

Ans: It is activated during the resistance stage.

Feedback:
In the alarm reaction stage, stress stimulates the body to send messages to the hypothalamus to the glands, which stimulates the sympathetic nervous system. Sympathetic nerve fibers ìcharge upî the vital signs at any hint of danger to prepare the body's defensesófight, flight, or freeze. The adrenal glands release adrenaline (epinephrine), which causes the body to take in more oxygen, dilate the pupils, and increase arterial pressure and heart rate while constricting the peripheral vessels and shunting blood from the gastrointestinal and reproductive systems and increasing glycogenolysis to release free glucose for the heart, muscles, and central nervous system. When the danger has passed, parasympathetic nerve fibers reverse this process and return the body to normal operating conditions until the next sign of threat reactivates the sympathetic nervous system. During the resistance stage of the generalized anxiety syndrome, if the threat has ended, the parasympathetic nervous system is stimulated and the body responses relax. If the threat persists, the body will eventually enter the exhaustion stage when the body stores are depleted as a result of the continual arousal of the physiologic responses and little reserve capacity.

4. The student nurse correctly identifies that which one of the following statements applies to the parasympathetic nervous system?
A) It is activated during the alarm reaction stage.
B) It is activated during the resistance stage.
C) It is activated during the exhaustion stage.
D) It is commonly referred to as the fight, flight, or freeze response.

Ans: Heightened focus

Feedback:
Mild anxiety is associated with increased learning ability. It involves a sensation that something is different and warrants special attention. Sensory stimulation increases and helps the person focus attention to learn, solve problems, think, act, feel, and protect himself or herself. Mild anxiety often motivates people to make changes or to engage in goal-directed activity. Focusing only on immediate task, a faster rate of speech, and a narrowed perceptual field are associated with moderate levels of anxiety.

5. The nurse plans to teach a client about dietary modifications to manage diabetes. Teaching would be most effective if the client displayed which one of the following characteristics?
A) Focusing only on immediate task
B) Faster rate of speech
C) Narrowed perceptual field
D) Heightened focus

Ans: Severe

Feedback:
Physiologic responses to severe anxiety include headache, nausea, vomiting, diarrhea, trembling, rigid stance, vertigo, pale, tachycardia, and chest pain

6. A client says to the nurse, ìI just can't talk in front of the group. I feel like I'm going to pass out.î The nurse assesses the client's anxiety to be at which level?
A) Mild
B) Moderate
C) Severe
D) Panic

Ans: Moderate

Feedback:
Moderate anxiety is the disturbing feeling that something is definitely wrong; the person becomes nervous or agitated. In moderate anxiety, the person can still process information, solve problems, and learn new things with assistance from others. He or she has difficulty concentrating independently but can be redirected to the topic. Mild anxiety is a sensation that something is different and warrants special attention. Sensory stimulation increases and helps the person focus attention to learn, solve problems, think, act, feel, and protect himself or herself. As the person progresses to severe anxiety and panic, more primitive survival skills take over, defensive responses ensue, and cognitive skills decrease significantly. A person with severe anxiety has trouble thinking and reasoning.

7. A student is preparing to give a class presentation. A few minutes before the presentation is to begin, the student seems nervous and distracted. The student is looking at and listening to the peer speaker and occasionally looking at note cards. When the peer speaker asks a question of the group, the student is able to answer correctly. The professor understands that the student is likely experiencing which level of stress?
A) Mild
B) Moderate
C) Severe
D) Panic

Ans: depersonalization.

Feedback:
During a panic attack, the client may describe feelings of being disconnected from himself or herself (depersonalization) or sensing that things are not real (derealization). Denial is not admitting reality. Hallucinations involve sensing something that is not there.

8. A client who suffers from frequent panic attacks describes the attack as feeling disconnected from himself. The nurse notes in the client's chart that the client reports experiencing
A) hallucinations.
B) depersonalization.
C) derealization.
D) denial

Ans: Defense mechanisms are a human's attempt to reduce anxiety.

Defense mechanisms can be harmful when overused.
D) Defense mechanisms are cognitive distortions

Defense mechanisms can control the awareness of anxiety.
Feedback:
Freud described defense mechanisms as the human's attempt to control awareness of and to reduce anxiety. Defense mechanisms are cognitive distortions that a person uses unconsciously to maintain a sense of being in control of a situation, to lessen discomfort, and to deal with stress. Because defense mechanisms arise from the unconscious, the person is unaware of using them. Some people overuse defense mechanisms, which stops them from learning a variety of appropriate methods to resolve anxiety-producing situations. The dependence on one or two defense mechanisms also can inhibit emotional growth, lead to poor problem-solving skills, and create difficulty with relationships.

9. Which of the following statements about the use of defense mechanisms in persons with anxiety disorders are accurate? Select all that apply.
A) Defense mechanisms are a human's attempt to reduce anxiety.
B) Persons are usually aware when they are using defense mechanisms.
C) Defense mechanisms can be harmful when overused.
D) Defense mechanisms are cognitive distortions.
E) The use of defense mechanisms should be avoided.
F) Defense mechanisms can control the awareness of anxiety.

Ans: Defense mechanisms can help a person to reduce anxiety.

Feedback:
Defense mechanisms can help a person to reduce anxiety. This is the only positive outcome of using defense mechanisms. The dependence on defense mechanisms can inhibit emotional growth, lead to poor problem-solving skills, and create difficulty with relationships. These are all negative outcomes of using defense mechanisms.

10. Which one of the following can be a positive outcome of using defense mechanisms?
A) Defense mechanisms can inhibit emotional growth.
B) Defense mechanisms can lead to poor problem-solving skills.
C) Defense mechanisms can create difficulty with relationships.
D) Defense mechanisms can help a person to reduce anxiety.

Ans: Anxiety is learned in childhood through interactions with caregivers.

Feedback:
Interpersonal theory proposes that caregivers can communicate anxiety to infants or children through inadequate nurturing, agitation when holding or handling the child, and distorted messages. In adults, anxiety arises from the person's need to conform to the norms and values of his or her cultural group. Psychoanalytic theories describe reducing anxiety through the use of defense mechanisms. Defense mechanisms are cognitive distortions that a person uses unconsciously to maintain a sense of being in control of a situation, to lessen discomfort, and to deal with stress.

11. Which of the following best explains the etiology of anxiety disorders from an interpersonal perspective?
A) Anxiety is learned in childhood through interactions with caregivers.
B) Anxiety is learned throughout life as a response to life experiences.
C) Anxiety stems from an unconscious attempt to control awareness.
D) Anxiety results from conforming to the norms of a cultural group.

Ans: A person's innate anxiety is the stimulus for behavior.
Feedback:
Theories of anxiety can be classified as intrapsychic/psychoanalytic theories, interpersonal theories, and behavioral theories. Freud's intrapsychic theory views a person's innate anxiety as the stimulus for behavior. Interpersonal theories include Sullivan's theory that anxiety is generated from problems in interpersonal relationships and Peplau's belief that humans exist in interpersonal and physiologic realms. Behavioral theorists view anxiety as being learned through experiences.

12. Which of the following theories about anxiety is based upon intrapsychic theories?
A) A person's innate anxiety is the stimulus for behavior.
B) Anxiety is generated from problems in interpersonal relationships.
C) A nurse can help the client to achieve health by attending to interpersonal and
physiologic needs.
D) Anxiety is learned through experiences.

Ans: Henry Stack Sullivan's theory
C) Hildegard Peplau's theory

Feedback:
Theories of anxiety can be classified as intrapsychic/psychoanalytic theories, interpersonal theories, and behavioral theories. Freud's intrapsychic theory views a person's innate anxiety as the stimulus for behavior. Interpersonal theories include Sullivan's theory that anxiety is generated from problems in interpersonal relationships and Peplau's belief that humans exist in interpersonal and physiologic realms. Behavioral theorists view anxiety as being learned through experiences.

13. Which of the following are interpersonal theories regarding the etiologies of major anxiety disorders? Select all that apply.
A) Sigmund Freud's theory
B) Henry Stack Sullivan's theory
C) Hildegard Peplau's theory
D) Pavlov's theory

Ans: Alarm reaction
Feedback:
In the alarm reaction stage, stress stimulates the body to send messages from the hypothalamus to the glands and organs to prepare for potential defense needs. In the resistance stage, the digestive system reduces function to shunt blood to areas needed for defense. The exhaustion stage occurs when the person has responded negatively to anxiety and stress. There is no autonomic stage.

14. The student nurse correctly identifies that according to Selye (1956, 1974), which stage of reaction to stress stimulates the body to send messages from the hypothalamus to the glands and organs to prepare for potential defense needs?
A) Resistance
B) Exhaustion
C) Alarm reaction
D) Autonomic

Ans: ìI feel upset when you interrupt me.î
Feedback:
Assertiveness training helps the person take more control over life situations. Techniques help the person negotiate interpersonal situations and foster self- assurance. They involve using ìIî statements to identify feelings and to communicate concerns or needs to others.

15. A nurse is working with a client to develop assertive communication skills. The nurse documents achievement of treatment outcomes when the client makes a statement such as,
A) ìI'm sorry. I'm not picking this up very quickly.î
B) ìI feel upset when you interrupt me.î
C) ìYou are pushing me too hard.î
D) ìI'm not going to let people push me around anymore.î

Ans: systematic desensitization.
Feedback:
One behavioral therapy often used to treat phobias is systematic (serial) desensitization, in which the therapist progressively exposes the client to the threatening object in a safe setting until the client's anxiety decreases. Flooding is a form of rapid desensitization in which a behavioral therapist confronts the client with the phobic object (either a picture or the actual object) until it no longer produces anxiety. Cognitive restructuring involves challenging the client's irrational beliefs. Exposure therapy is similar to flooding.

16. A client experiences panic attacks when confronted with riding in elevators. The therapist is teaching the client ways to relax while incrementally exposing the client to getting on an elevator. This technique is called
A) systematic desensitization.
B) flooding.
C) cognitive restructuring.
D) exposure therapy.

Ans: Flooding, Systematic desensitization
Feedback:
Systematic desensitization is when the therapist progressively exposes the client to a threatening object in a safe setting until the client's anxiety decreases. Flooding is a form of rapid desensitization in which the behavior therapist confronts the client with the phobic object until it no longer produces anxiety. Systematic desensitization and flooding are behavioral therapies used in the treatment of phobias. Assertiveness training would help the person to take more control over life situations. Decatastrophizing helps the client to realistically appraise the situation. These are both used for general anxiety. When a person is exposed to a phobic object, the person is not likely in control. Reminding a person to calm down is not at all an effective way to manage anxiety.

17. Which techniques would be most effective for a client who has situational phobias? Select all that apply.
A) Flooding
B) Reminding the person to calm down
C) Systematic desensitization
D) Assertiveness training
E) Decatastrophizing

Ans: You are safe. Take a deep breath.î

Feedback:
Nursing interventions for panic disorder include providing a safe environment and ensuring the client's privacy during a panic attack, remaining with the client during a panic attack, helping the client to focus on deep breathing, talking to the client in a calm, reassuring voice, teaching the client to use relaxation techniques, helping the client to use cognitive restructuring techniques, and the engaging client to explore how to decrease stressors and anxiety-provoking situations.

18. A client is currently experiencing a panic attack. Which of the following is the most appropriate response by the nurse?
A) ìJust try to relax.î
B) ìThere is nothing here to harm you.î
C) ìYou are safe. Take a deep breath.î
D) ìWhat are you feeling right now?î

Ans: appraise his situation more realistically.
Feedback:
Decatastrophizing involves the therapist's use of questions to more realistically appraise the situation. The therapist may ask, ìWhat is the worst that could happen? Is that likely? Could you survive that? Is that as bad as you imagine?î

19. A client states, ìI will just die if I don't get this job.î The nurse then asks the client, ìWhat will be the worst that will happen if you don't get the job?î The nurse is using this response to
A) appraise his situation more realistically.
B) assist the client to make alternative plans for the future.
C) assess if the client has health problems compounded by stress.
D) clarify the client's meaning.

Ans: When an elder person has an onset of anxiety for the first time in his or her life, it
is possible that the anxiety is associated with another condition.

Feedback:
Anxiety that starts for the first time in late life is frequently associated with another condition such as depression, dementia, physical illness, or medication toxicity or withdrawal. Phobias, particularly agoraphobia, and GAD are the most common late-life anxiety disorders. Most people with late-onset agoraphobia attribute the start of the disorder to the abrupt onset of a physical illness or as a response to a traumatic event such as a fall or mugging. Ruminative thoughts are common in late-life depression and can take the form of obsessions such as contamination fears, pathologic doubt, or fear of harming others.

20. Which of the following statements about the assessment of persons with anxiety and anxiety disorders is most accurate?
A) When an elder person has an onset of anxiety for the first time in his or her life, it
is possible that the anxiety is associated with another condition.
B) Panic attacks are the most common late-life anxiety disorders.
C) An elder person with anxiety may be experiencing ruminative thoughts.
D) Agoraphobia that occurs in late life may be related to trauma experienced or
anticipated.

Ans: stand at the doorway and say, ìYou seem upset.î

Feedback:
Staying with the client while allowing personal space is an important and safe intervention; this therapeutic communication technique is designed to get the client to communicate feelings. It may not be safe for the nurse to approach the client. Help is not needed at this time, and saying, ìCalm down,î is not effective. Turning and walking away from the client may seem like rejection and may worsen the client's anxiety as well as damage the nurseñclient relationship.

21. The nurse enters the client's room and finds the client anxiously pacing the floor. The client begins shouting at the nurse, ìGet out of my room!î The best intervention by the nurse would be to
A) approach the client and ask, ìWhat's wrong?î
B) call for help and say, ìCalm down.î
C) turn and walk away from the room without saying anything.
D) stand at the doorway and say, ìYou seem upset.î

Ans: Positive reframing
B) Decatastrophizing
C) Assertiveness training

Unlearning

Feedback:
Positive reframing means turning negative messages into positive messages. Decatastrophizing involves the therapist's use of questions to more realistically appraise the situation. Assertiveness training helps the person take more control over life situations. Positive reframing, decatastrophizing, and assertiveness training are cognitiveñbehavioral therapy techniques. Humor is not a cognitiveñbehavioral therapy technique. Unlearning is the theory underlying behavioral therapy.

22. Which of the following are cognitiveñbehavioral therapy techniques that may be used effectively with anxious clients? Select all that apply.
A) Positive reframing
B) Decatastrophizing
C) Assertiveness training
D) Humor
E) Unlearning

Ans: Replace the dressing on the wound.

Feedback:
The client has severe anxiety; the priority is to lower the client's anxiety level. The first action should be to replace the dressing on the wound to decrease the client's level of anxiety and to prevent contamination of the wound before a new dressing can be applied. The other choices could be done after replacing the dressing on the wound.

23. The nurse is teaching about postoperative wound care. As the wound is uncovered, the client begins mumbling, breathing rapidly, and trying to get out of bed, and the client does not respond when the nurse calls his name. Which of the following should be the nurse's first action?
A) Ask the client to describe his feelings.
B) Proceed with wound care quickly.
C) Replace the dressing on the wound.
D) Get the assistance of another nurse.

Ans: The client will experience reduced anxiety and develop alternative responses to
anxiety-provoking situations.
Feedback:
A primary client outcome is improved adaptive coping skills.

24. The nursing student understands correctly when identifying which objective is appropriate for all clients with anxiety disorders?
A) The client will experience reduced anxiety and accept the fact that underlying
conflicts cannot be treated.
B) The client will experience reduced anxiety and develop alternative responses to
anxiety-provoking situations.
C) The client will experience reduced anxiety and learn to control primitive impulses.
D) The client will experience reduced anxiety and strive for insight through
psychoanalysis.

Ans: Provide a safe environment., Ensure the client's privacy.

Feedback:
During a panic attack, the nurse's first concern is to provide a safe environment and to ensure the client's privacy. If the environment is overstimulating, the client should move to a less stimulating place. Decreasing external stimuli will help lower the client's anxiety level. The client's safety is priority. Anxious behavior can be escalated by external stimuli. In a large area, the client can feel lost and panicked, but a smaller room can enhance a sense of security. An antianxiety agent may be helpful, but it is not the priority. It would likely be stimulating to engage the client in recreational activities.

25. When a client is experiencing a panic attack while in the recreation room, what interventions are the nurse's first priorities? Select all that apply.
A) Provide a safe environment.
B) Request a prescription for an antianxiety agent.
C) Offer the client therapy to calm down
D) Ensure the client's privacy.
E) Engage the client in recreational activities.

Ans: change reactions to stressors.
Feedback:
Stress and anxiety in life are unavoidable; managing the effects of stress is a reasonable goal for treatment. It is not possible or desirable to avoid anxiety at all costs as anxiety is a warning that the client is not dealing with stress effectively. Learning to heed this warning and to make needed changes is a healthy way to deal with the stress of daily events.

26. A client is learning to cope with anxiety and stress. The expected outcome is that the client will
A) change reactions to stressors.
B) ignore situations that cause stress.
C) limit major stressors in his or her life.
D) avoid anxiety at all costs.

Ans: ìMedications combined with therapy help you change how well you function.î

Feedback:
Treatment for anxiety disorders usually involves medication and therapy. This combination produces better results than either one alone.

27. A client asks the nurse, ìWhy do I have to go to counseling? Why can't I just take medications?î The best response by the nurse would be,
A) ìBoth therapies are effective. You can eventually choose one or the other.î
B) ìYou cannot get the full effect of your medications without cognitive therapy as
well.î
C) ìAs soon as your medications reach therapeutic level, you can omit the therapy.î
D) ìMedications combined with therapy help you change how well you function.î

Ans: GABA

Feedback:
Gamma-aminobutyric acid (GABA) is the amino acid neurotransmitter believed to be dysfunctional in anxiety disorders. GABA reduces anxiety, and norepinephrine increases it; researchers believe that a problem with the regulation of these neurotransmitters occurs in anxiety disorders. Serotonin is usually implicated in psychosis and mood disorders. Dopamine is indicated in psychosis.

28. A client asks how his prescribed alprazolam (Xanax) helps his anxiety disorder. The nurse explains that antianxiety medications such as alprazolam affect the function of which neurotransmitter that is believed to be dysfunctional in anxiety disorders?
A) Serotonin
B) Norepinephrine
C) GABA
D) Dopamine

Ans: Practice the techniques when relatively calm

Feedback:
The nurse can teach the client relaxation techniques to use when he or she is experiencing stress or anxiety, including deep breathing, guided imagery and progressive relaxation, and cognitive restructuring techniques. For any of these techniques, it is important for the client to learn and to practice them when he or she is relatively calm.

29. The nurse is teaching a client with an anxiety disorder ways to manage anxiety. The nurse suggests which of the following schedules for practicing stress management techniques?
A) Practice the techniques each morning and night as part of a daily routine.
B) Use the techniques as needed when experiencing severe anxiety.
C) Practice the techniques when relatively calm.
D) Expect to practice the techniques when meeting with a therapist.

Ans: Continued development of positive coping skills,

Continued practice of relaxation techniques

Development of a regular exercise program
Feedback:
Client/family education for panic disorder includes reviewing breathing control and relaxation techniques, discussing positive coping strategies, encouraging regular exercise, emphasizing the importance of maintaining prescribed medication regimen and regular follow-up, describing time management techniques such as creating ìto doî lists with realistic estimated deadlines for each activity, crossing off completed items for a sense of accomplishment, saying ìno,î and stressing the importance of maintaining contact with community and participating in supportive organizations. Medication should be adhered to as prescribed. Daily responsibilities cannot be avoided, rather should be successfully accomplished.

30. The nurse is educating a client and family about managing panic attacks after discharge from treatment. The nurse includes which of the following in the discharge teaching? Select all that apply.
A) Continued development of positive coping skills
B) Weaning off of medications as necessary
C) Lessening the amount of daily responsibilities
D) Continued practice of relaxation techniques
E) Development of a regular exercise program

Ans: Caffeine Feedback:
The effects of caffeine are similar to some anxiety symptoms, and, therefore, caffeine ingestion will worsen anxiety. The other types of foods are also potentially harmful to physical as well as psychological health, but the worst offender is caffeine.

31. When teaching a client with generalized anxiety disorder, which is the highest priority for the nurse to teach the client to avoid?
A) Caffeine
B) High-fat foods
C) Refined sugars
D) Sodium

Ans: This medication will relax me, so I can focus on problem solving.î
Feedback:
Anxiolytics are designed for short-term use to relieve anxiety. These drugs are designed to relieve anxiety so that the person can deal more effectively with whatever crisis or situation is causing stress. Benzodiazepines have a tendency to cause dependence. Clients need to know that antianxiety agents are aimed at relieving symptoms such as anxiety but do not treat the underlying problems that cause the anxiety.

32. An anxiolytic agent, lorazepam (Ativan), has been prescribed for the client. Which of the following statements by the client would indicate to the nurse that client education about this medication has been effective?
A) ìMy anxiety will be eliminated if I take this medication as prescribed.î
B) ìThis medication presents no risk of addiction or dependence.î
C) ìI will probably always need to take this medication for my anxiety.î
D) ìThis medication will relax me, so I can focus on problem solving.î

Ans: Remember to practice techniques to manage stress and anxiety in your own life.
Feedback:
It is critical for the nurse to remember to practice techniques to manage stress and anxiety in his or her own life. Remember that everyone occasionally suffers from stress and anxiety that can interfere with daily life and work. It is important for the nurse to avoid falling into the pitfall of trying to ìfixî the client's problems. It is important that the nurse should discuss any uncomfortable feelings with a more experienced nurse for suggestions on how to deal with his or her feelings toward these clients.

33. Which of the following would be key points for the nurse to remember when working with persons who are suffering from anxiety disorders?
A) It is important for the nurse to ìfixî the client's problems.
B) Remember to practice techniques to manage stress and anxiety in your own life.
C) If you have any uncomfortable feelings, do not tell anyone about them.
D) Remember that only people who suffer from anxiety disorders have stress that can interfere with daily life and work.

Ans: To provide better care for the client
B) To help understand the role anxiety plays in performing nursing responsibilities,

To help nurses to function at a high level
Feedback:
Nurses must understand why and how anxiety behaviors work, not just for client care but to help understand the role anxiety plays in performing nursing responsibilities. Nurses are expected to function at a high level and to avoid allowing their own feelings and needs to hinder the care of their clients, but as emotional beings, nurses are just as vulnerable to stress and anxiety as others, and they have needs of their own.

34. Which of the following are reasons that the nurse must understand why and how anxiety behaviors work? Select all that apply.
A) To provide better care for the client
B) To help understand the role anxiety plays in performing nursing responsibilities
C) To help the nurse to mask his or her own feelings of anxiety
D) So the nurse can identify that his or her own needs are more important than the clients
E) To help nurses to function at a high level

Ans: Decreased brain tissue in the frontal and temporal regions of the brain
Feedback:
Decreased brain tissue in the frontal and temporal regions of the brain is the most commonly supported neuroanatomic theory that suggests the etiology of schizophrenia. The other theories are neurochemical.

1. The most commonly supported neuroanatomic theory of schizophrenia suggests which etiology?
A) Excessive amounts of dopamine and serotonin in the brain
B) Ineffective ability of the brain to use dopamine and serotonin
C) Insufficient amounts of dopamine in the brain
D) Decreased brain tissue in the frontal and temporal regions of the brain

Ans: That genetics is the cause of schizophrenia.

Persons with schizophrenia have decreased brain volume and abnormal brain

The brain activity of persons with schizophrenia differs from people who do not
have schizophrenia.

That the etiology of schizophrenia may be related to the body's response to
exposure of a virus.
Feedback:
In the first half of the 20th century, studies focused on trying to find a particular pathologic structure associated with the disease, largely through autopsy. Such a site was not discovered. The biologic theories of schizophrenia focus on genetic factors, neuroanatomic and neurochemical factors (structure and function of the brain), and immunovirology (the body's response to exposure to a virus).

2. The nurse reviews current literature and identifies that which of the following are included in current studies of biologic theories regarding the etiology of schizophrenia? Select all that apply.
A) That there is a particular pathologic structure associated with the disease.
B) That genetics is the cause of schizophrenia.
C) Persons with schizophrenia have decreased brain volume and abnormal brain
function in the frontal and temporal areas of persons with schizophrenia.
D) The brain activity of persons with schizophrenia differs from people who do not
have schizophrenia.
E) That the etiology of schizophrenia may be related to the body's response to
exposure of a virus.

Ans: D) That schizophrenia is at least partially inherited.

Feedback:
The most important studies have centered on twins; these findings have demonstrated that if one identical twin has schizophrenia, the other twin has a 50% chance of developing it as well. Fraternal twins have only a 15% risk. This finding indicates that schizophrenia is at least partially inherited.

3. The student nurse correctly recognizes that which one of the following findings is best supported by genetic studies in the etiology of schizophrenia?
A) If a person has schizophrenia, distant relatives are also at risk.
B) That there is no relationship at all between schizophrenia and genetics.
C) That there is a weak correlation between genetics and schizophrenia.
D) That schizophrenia is at least partially inherited.

Ans: Hesitant to answer the nurse's questions during the assessment interview

Feedback:
A negative symptom of schizophrenia is alogia, or the tendency to speak very little or to convey little substance of meaning (poverty of content). Associative looseness (fragmented or poorly related thoughts and ideas), delusions (fixed false beliefs that have no basis in reality), and echopraxia (imitation of the movements and gestures of another person whom the client is observing) are all positive symptoms.

4. The nurse is assessing for negative symptoms of schizophrenia in a newly admitted client. The nurse would note which behavior as indicative of a negative symptom?
A) Difficulty staying on subject when responding to assessment questions
B) Belief of owning a transportation device allowing for travel to the center of the
Earth
C) Hesitant to answer the nurse's questions during the assessment interview
D) Mimicking the postural changes made by the nurse during the assessment
interview

Ans: Delusions

Feedback:
Delusions are fixed false beliefs that have no basis in reality. Hallucinations are false sensory perceptions or perceptual experiences that do not exist in reality. Ideas of reference are false impressions that external events have special meaning for the person. Anhedonia is feeling no joy or pleasure from life or any activities or relationships.

5. The client with schizophrenia believes the student nurses are there to spy on the clients. The client is suffering from which of the following symptoms?
A) Hallucinations
B) Delusions
C) Anhedonia
D) Ideas of reference

Ans: associative looseness.

Feedback:
Associative looseness is demonstrated through fragmented or poorly related thoughts and ideas. The series of disconnected thoughts best exemplifies this concept. Some of the statements contain delusions, or fixed false beliefs that have no basis in reality. Flight of ideas refers to rapidly flowing thoughts that are more connected than the client's statement. Ideas of reference are false impressions that external events have special meaning for the person.

6. The client with schizophrenia makes the following statement, ìI just don't know how to count. The sky turned to fire. I have a ball in my head.î The nurse documents this entire statement as an example of
A) flight of ideas.
B) ideas of reference.
C) delusional thinking.
D) associative looseness.

Ans: Flat
B) Blunt

Feedback:
Clients with schizophrenia are often described as having blunted affect (few observable facial expressions) or flat affect (no facial expression). The client may exhibit an inappropriate expression or emotions incongruent with the context of the situation. It is not likely that the affect of a person with schizophrenia would be pleasant.

7. A person suffering from schizophrenia has little emotional expression when interacting with others. The nurse would document the client's affect as which of the following? Select all that apply.
A) Flat
B) Blunt
C) Bright
D) Inappropriate
E) Pleasant

Ans: Thought blocking

Feedback:
The nurse can assess thought content by evaluating what the client actually says. For example, clients may suddenly stop talking in the middle of a sentence and remain silent for several seconds to 1 minute (thought blocking). They also may state that they believe others can hear their thoughts (thought broadcasting), that others are taking their thoughts (thought withdrawal), or that others are placing thoughts in their mind against their will (thought insertion).

8. A client who has schizophrenia is having a conversation with the nurse suddenly stops talking in the middle of a sentence. The client is experiencing which type of thought disruption?
A) Thought withdrawal
B) Thought insertion
C) Thought blocking
D) Thought broadcasting

Ans: Auditory hallucinations

Feedback:
Auditory hallucinations, the most common type, involve hearing sounds, most often voices, talking to or about the client. Command hallucinations are voices demanding that the client take action, often to harm self or others, and are considered dangerous. Olfactory hallucinations involve smells or odors. Gustatory hallucinations involve a taste lingering in the mouth or the sense that food tastes like something else

9. During the nursing assessment, a client describes constantly hearing voices mumbling in the background. The client denies that the voices are telling him to do anything harmful. The nurse documents that the client is experiencing which of the following?
A) Command hallucinations
B) Auditory hallucinations
C) Olfactory hallucinations
D) Gustatory hallucinations

Ans: Referential delusion

Feedback:
Referential delusions or ideas of reference involve the client's belief that television broadcasts, music, or newspaper articles have special meaning for him or her. Grandiose delusions are characterized by the client's claim to association with famous people or celebrities, or the client's belief that he or she is famous or capable of great feats. Thought insertion is the belief that others are placing thoughts in their mind against their will. Personalization is not a psychotic characteristic of schizophrenia.

10. A client with schizophrenia reads the advice column in the newspaper daily. When asked why the client is so interested in the advice column, the client replies, ìThis person is my guide and tells me what I must do every day.î The nurse would best describe this type of thinking as which of the following?
A) Referential delusion
B) Grandiose delusion
C) Thought insertion
D) Personalization

Ans: ) insight.

Feedback:
Insight refers to the client's degree of self-awareness and realistic view of life. It can be severely impaired in schizophrenia. Over time, some clients can learn about the illness, anticipate problems, and seek appropriate assistance as needed. Judgment refers to appropriate decision-making ability and is based on the ability to interpret the environment correctly. At times, lack of judgment is so severe that clients cannot meet their needs for safety and protection and place themselves in harm's way.

11. The nurse is preparing a client with schizophrenia for discharge. The nurse asks the client, ìHow are you going to care for yourself at home?î The purpose of the nurse's question is to assess the client's
A) self concept.
B) judgment.
C) insight.
D) social support system.

Ans: Social isolation

Feedback:
NANDA diagnoses commonly established based on the assessment of psychotic symptoms or positive signs are as follows:
- Risk for other-directed violence
- Risk for suicide
- Disturbed thought processes
- Disturbed sensory perception
- Disturbed personal identity
- Impaired verbal communication
NANDA diagnoses based on the assessment of negative signs and functional abilities include the following:
- Self-care deficits
- Social isolation
- Deficient diversional activity
- Ineffective health maintenance
- Ineffective therapeutic regimen management

12. All of the following are nursing diagnoses identified for a client with schizophrenia. The student nurse correctly anticipates which diagnosis will resolve when the client's negative symptoms improve?
A) Impaired verbal communication
B) Risk for other-directed violence
C) Disturbed thought processes
D) Social isolation

Ans: Observe for signs of fear or agitation

Feedback:
Safety for both the client and the nurse is the priority when providing care for the client with schizophrenia. The nurse must observe for signs of building agitation or escalating behavior such as increased intensity of pacing, loud talking or yelling, and hitting or kicking objects. The nurse must then institute interventions to protect the client, nurse, and others in the environment.

13. All of the following are included in the plan of care for a client with schizophrenia. Which nursing intervention should the nurse perform first when caring for this client?
A) Observe for signs of fear or agitation
B) Maintain reality through frequent contact
C) Encourage to participate in the treatment milieu
D) Assess community support systems

Ans: ìI don't hear or see anyone else; what are you hearing and seeing?î

Feedback:
Intervening when the client experiences hallucinations requires the nurse to focus on what is real and to help shift the client's response toward reality. Initially, the nurse must determine what the client is experiencingóthat is, what the voices are saying or what the client is seeing. In command hallucinations, the client hears voices directing him or her to do something, often to hurt self or someone else. For this reason, the nurse must elicit a description of the content of the hallucination so that health-care personnel can take precautions to protect the client and others as necessary. The nurse might say, ìI don't hear any voices; what are you hearing?î ìHow long have you known the person you are talking to?î would reinforce the client's hallucination.

14. A client with schizophrenia is seen sitting alone and talking out loud. Suddenly, the client stops and turns as if listening to someone. The nurse approaches and sits down beside the client. Which of the following is the best initial response by the nurse?
A) ìYou must be pretty bored to be sitting here talking to an invisible person.î
B) ìI don't hear or see anyone else; what are you hearing and seeing?î
C) ìI can tell you are hearing voices, but they are not real.î
D) ìHow long have you known the person you are talking to?î

Ans:Show me what you did in art therapy this morning"

Feedback:
The client experiencing delusions utterly believes them and cannot be convinced they are false or untrue. It is the nurse's responsibility to present and maintain reality by making simple statements. The nurse must avoid openly confronting the delusion or arguing with the client about it. The nurse also must avoid reinforcing the delusional belief by ìplaying alongî with what the client says.

15. A client states, ìI am dead. I have come back from the dead.î An appropriate response by the nurse is,
A)"what is it like to feel dead"
B)"No you did not die. People don't come back from the dead."
C)"Show me what you did in art therapy this morning"
D)"Ill get your medicine and you'll feel better"

Ans: State, ìTell me what's happening.î

Feedback:
Having the client tell the nurse what is happening explores what the client is experiencing and engages the client in reality interaction. Answer choices A, B, and C are not appropriate responses by the nurse in this situation.

16. A client diagnosed with schizophrenia is laughing and talking while sitting alone. Which of the following is the best response by the nurse?
A) State, ìCan you share your joke with me?î
B) To sit with the client quietly until the client is ready to talk
C) State, ìTell me what's happening.î
D) State, ìYou look lonely here. Let's join the others in the day room.î

Ans: Assessing fluid intake and output

Feedback:
Physiologic homeostasis is a priority for this client. Completing an assessment of mental status, obtaining data about college experiences, and providing adequate rest are not the highest priority

17. A college freshman is admitted to the hospital with a diagnosis of schizophrenia. Friends reported that she had been in her room for 2 days in a trance-like state, not eating nor speaking to anyone. Which of the following is the highest priority for this client?
A) Assessing fluid intake and output
B) Completing an assessment of mental status
C) Obtaining more data about her college experiences
D) Providing for adequate rest

Ans: Have you discussed this with your physician?î

Feedback:
This sounds like a new symptom, so talking with the physician is important; the client may need to have his medication reevaluated. ìHow could that be possible,î puts the client on the defensive. ìYou cannot have rats in your brain,î refers to the response as being unbelievable. ìYou look OK to me,î is inappropriate and not therapeutic.

18. The client with schizophrenia tells the nurse that rats have started to eat his brain. The best response by the nurse would be,
A) ìHave you discussed this with your physician?î
B) ìHow could that be possible?î
C) ìYou cannot have rats in your brain.î
D) ìYou look OK to me.î

Ans: He is fearful of what his roommate might do to him while he sleeps.
Feedback:
Clients who have suspicion trust no one and believe others are going to harm them. Being fearful of his roommate, being a light sleeper and unaccustomed to a roommate, and worrying about family problems would not be the most likely reasons why this client has been awake for the past three nights. The other explanations are not as likely.

19. A client who has suspicion has been placed in a room with a roommate. The night nurse reports that this client has been awake for the past 3 nights. The likely explanation for his wakefulness is which of the following?
A) He is fearful of what his roommate might do to him while he sleeps.
B) He is a light sleeper and unaccustomed to a roommate.
C) He is watching for an opportunity to escape.
D) He is worrying about his family problems.

Ans: What is it about the medicine that you don't like?
Feedback:
Asking the client why he does not like his medication explores the client's reason for refusal, which is the first step in resolving the issue. The nurse must determine the barriers to compliance for each client. Threatening the client with an injection is assault. Waiting until tomorrow puts off the inevitable. Telling him it is for his own good is not the most therapeutic response in order to get the client to take his medication.

20. A client with schizophrenia is reluctant to take his prescribed oral medication. The most therapeutic response by the nurse to this refusal is,
A) ìI can see that you're uncomfortable now, so we can wait until tomorrow.î
B) ìIf you refuse these pills, you'll have to get an injection.î
C) ìWhat is it about the medicine that you don't like?î
D) ìYou know you have to take this medicine for your own good.

Ans: ìAre you hearing something?î
Feedback:
Asking the client if he is hearing something validates the nurse's assessment and focuses on the client's experience. The other choices do not address the situation of the client experiencing auditory hallucinations at the present time.

21. The nurse observes a client with schizophrenia sitting alone, laughing occasionally, and turning his head as if listening to another person. The nurse assesses this behavior to indicate that the client is experiencing auditory hallucinations and says,
A) ìAre you hearing something?î
B) ìIt's a beautiful day, isn't it?î
C) ìWould you like to go to your room to talk?î
D) ìWould you like to take some of your PRN medication?î

Ans: The client will increase his reality orientation
Feedback:
The client needs to be oriented to reality before he can participate in other therapeutic activities. The other choices would not be priority goals for this patient right now.

22. A client with schizophrenia is admitted to the inpatient unit. He does not speak when spoken to but has been observed talking to himself on occasion. What would be the priority objective at this time?
A) The client will begin talking with other clients
B) The client will express his feelings freely
C) The client will increase his socialization with others
D) The client will increase his reality orientation

Ans: You don't need to talk right now. I'll just sit here for a few minutes.î
Feedback:
This response indicates acceptance of the client and shows genuine interest in him, building rapport and trust. Initially, the client may tolerate only 5 or 10 minutes of contact at one time. Establishing a therapeutic relationship takes time, and the nurse must be patient. The nurse must maintain nonverbal communication with the client, especially when verbal communication is not very successful. This involves spending time with the client, perhaps through fairly length periods of silence. The presence of the nurse is a contact with reality for the client and also can demonstrate the nurse's genuine interest and caring to the client. The other choices are not consistent with what is therapeutic for the client.

23. The nurse enters the room of a client with schizophrenia the day after he has been admitted to an inpatient setting and says, ìI would like to spend some time talking with you.î The client stares straight ahead and remains silent. The best response by the nurse would be,
A) ìI can see you want to be alone. I'll come back another time.î
B) ìYou don't need to talk right now. I'll just sit here for a few minutes.î
C) ìI've got some other things I can do now. I hope you'll feel like talking later.î
D) ìYou would feel better if you would tell me what you're thinking.î

Ans: ìI understand you hear a voice. You and I are the only ones in the hall, and I don't
hear a voice.î
Feedback:
Acknowledging that the client hears a voice validates that the client's experience is real to him, while presenting reality. ìThe voices are part of your illness, and they will leave in time,î is not appropriate to the client's statement. ìThis guarding responsibility can make you tired. You rest for now, and I'll guard a while,î reinforces the client's delusion. ì'You are just imagining these things. Do not pay any attention to the voices,î does not deal with the patient in a serious manner.

24. One evening, a client with schizophrenia leaves his room and begins marching in the hall. When approached by the nurse, the client says, ìGod says I'm supposed to guard the area.î Which of the following responses would be best?
A) ìI understand you hear a voice. You and I are the only ones in the hall, and I don't
hear a voice.î
B) ìThe voices are part of your illness, and they will leave in time.î
C) ìThis guarding responsibility can make you tired. You rest for now, and I'll guard
a while.î
D) ìYou are just imagining these things. Do not pay any attention to the voices.î

Ans: Short-term memory intact,

Receives monthly disability checks

, States location of pharmacy nearest his residence
Feedback:
Sometimes clients intend to take their medications as prescribed but have difficulty remembering when and if they did so. They may find it difficult to adhere to a routine schedule for medications. Clients may have practical barriers to medication compliance, such as inadequate funds to obtain expensive medications, lack of transportation or knowledge about how to obtain refills for prescriptions, or inability to plan ahead to get new prescriptions before current supplies run out.

25. When performing discharge planning for a client who has schizophrenia, the nurse anticipates barriers to adhering to the medication regimen. The nurse assesses which of the following as improving the likelihood that the client will follow the prescribed medication regimen? Select all that apply.
A) Short-term memory intact
B) History of missing appointments
C) Receives monthly disability checks
D) Walking is primary mode of transportation
E) States location of pharmacy nearest his residence

Ans: ìIt is important for you to take an antipsychotic medication. You may need a different type that will be less likely to affect your sexual functioning. I would like to call your physician about this.î
Feedback:
Some side effects, such as those affecting sexual functioning, are embarrassing for the client to report, and the client may confirm these side effects only if the nurse directly inquires about them. This may require a call to the client's physician or primary provider to obtain a prescription for a different type of antipsychotic.

26. A client with schizophrenia is attending a follow-up appointment at the community mental health clinic. The client reports to the nurse, ìI stopped taking the antipsychotic medication because I can't get a hard-on with my girlfriend anymore.î Which of the following should the nurse recommend to enhance the client's well-being?
A) ìIt sounds like that is a problem for you. Don't you still find her to be sexy enough?î
B) ìSexual dysfunction is a temporary side effect and should get better once your body is used to the medication.î
C) ìYou should avoid having sex with your girlfriend anyway. Do you really want her to get pregnant?î
D) ìIt is important for you to take an antipsychotic medication. You may need a different type that will be less likely to affect your sexual functioning. I would like to call your physician about this.î

Ans: Have the symptoms you were experiencing disappeared?
B) If the symptoms have not disappeared, are you able to carry out your daily life
despite the persistence of some psychotic symptoms?
C) Are you committed to taking the medication as prescribed?
D) Are you satisfied with your quality of life?

Feedback:
The client's perception of the success of treatment plays a part in evaluation. In a global sense, evaluation of the treatment of schizophrenia is based on the following:
ï Have the client's psychotic symptoms disappeared? If not, can the client carry out his or her daily life despite the persistence of some psychotic symptoms?
ï Does the client understand the prescribed medication regimen? Is he or she committed to adherence to the regimen?
ï Does the client believe that he or she has a satisfactory quality of life?
The question, ìDo you have access to community agencies that will help you to live successfully in this community?î is an appropriate question to ask to evaluate the plan of care but does not directly relate to antipsychotic medications.

27. Which of the following questions would best help the nurse to evaluate the effectiveness of antipsychotic medications for a client who has schizophrenia? Select all that apply.
A) Have the symptoms you were experiencing disappeared?
B) If the symptoms have not disappeared, are you able to carry out your daily life
despite the persistence of some psychotic symptoms?
C) Are you committed to taking the medication as prescribed?
D) Are you satisfied with your quality of life?
E) Do you have access to community agencies that will help you to live successfully
in this community?

Ans: Suck on hard candy as desired

Use stool softeners as needed

Maintain a balanced calorie-controlled diet
Feedback:
Unwanted side effects are frequently reported as the reason clients stop taking medications. Interventions, such as eating a proper diet and drinking enough fluids, using a stool softener to avoid constipation, sucking on hard candy to minimize dry mouth, or using sunscreen to avoid sunburn, can help to control some of these uncomfortable side effects.

28. A client with schizophrenia has returned to the clinic because of an increase in symptoms. The client reports he stopped taking his meds because he did not like the side effects. The nurse educates the client about managing uncomfortable side effects. Which of the following is included in the teaching plan? Select all that apply.
A) Suck on hard candy as desired
B) Spend at least 30 minutes outside in the sun daily
C) Use stool softeners as needed
D) Decrease the amount of daily fluid intake
E) Maintain a balanced calorie-controlled diet

Ans: ìIt's time to put your dress on now.î

Feedback:
Clients with schizophrenia may have significant self-care deficits. The client needs clear direction, with tasks broken into small steps, to begin to participate in her own self-care. The other choices do not support the client effectively. ìI'll expect you in the dining room in 20 minutes,î is authoritarian and does not allow the client dignity. ìStay right here, and I'll get your clothes for you,î is also authoritarian and does not allow the client dignity. ìWhy don't you stay here and I'll get your tray for you,î is kinder but it robs the client of the opportunity to do for himself or herself as much as possible.

29. The nurse is working with a client with schizophrenia, disorganized type. It is time for the client to get up and eat breakfast. Which of the following statements by the nurse would be most effective in helping the client prepare for breakfast?
A) ìI'll expect you in the dining room in 20 minutes.î
B) ìIt's time to put your dress on now.î
C) ìStay right there and I'll get your clothes for you.î
D) ìWhy don't you stay here and I'll get your tray for you.î

Ans: Fatigue
C) Irritability

,Negativity
Feedback:
Teaching the client and family members to prevent or manage relapse is an essential part of a comprehensive plan of care. This includes providing facts about schizophrenia, identifying the early signs of relapse, and teaching health practices to promote physical and psychological well-being. Early signs of relapse include impaired cause-and-effect reasoning, impaired information processing, poor nutrition, lack of sleep, lack of exercise, fatigue, poor social skills, social isolation, loneliness, interpersonal difficulties, lack of control, irritability, mood swings, ineffective medication management, low self- concept, looking and acting different, hopeless feelings, loss of motivation, anxiety and worry, disinhibition, increased negativity, neglecting appearance, and forgetfulness.

30. The parents of a young adult male who has schizophrenia ask how they can recognize when their son is beginning to relapse. The nurse teaches the family to look for which of the following? Select all that apply.
A) Excessive sleeping
B) Fatigue
C) Irritability
D) Increased inhibition
E) Negativity

Ans: If you remember within 3 to 4 hours later than it is due, take it then. If you
remember more than 4 hours after it was due, do not take that dose.î

Feedback:
If a client forgets a dose of antipsychotic medication, advise the client to take it if the dose is only 3 to 4 hours late. If the missed dose is more than 4 hours late or the next dose is due, ask the client to omit the forgotten dose.

31. A client asks the nurse upon discharge, ìWhat should I do if I forget to take my medicine?î The nurse should explain to the client which of the following?
A) ìJust double the dose next time it is scheduled.î
B) ìSkip that dose and resume your regular with the next dose.î
C) ìDon't miss doses, or you will not maintain therapeutic drug levels.î
D) ìIf you remember within 3 to 4 hours later than it is due, take it then. If you
remember more than 4 hours after it was due, do not take that dose.î

Ans: Working with clients to manage their own lives
C) Working with clients to make effective treatment decisions
D) Working with clients to have an improved quality of life according to his or her
point of view.

Feedback:
Psychiatric rehabilitation has the goal of recovery for clients with major mental illness that goes beyond symptom control and medication management. Working with clients to manage their own lives, make effective treatment decisions, and have an improved quality of lifeófrom the client's point of viewóare central components of such programs.

32. Which of the following are central components of a psychiatric rehabilitation and recovery program? Select all that apply.
A) Working with clients to have an improved quality of life according to society's
point of view
B) Working with clients to manage their own lives
C) Working with clients to make effective treatment decisions
D) Working with clients to have an improved quality of life according to his or her
point of view.
E) Working with clients to diagnose their problem early

Ans: Stay in an open area while talking with the clients

Feedback:
The nurse also may be genuinely frightened or threatened if the client's behavior is hostile or aggressive. The nurse must acknowledge these feelings and take measures to ensure his or her safety. This may involve talking to the client in an open area rather than in a more isolated location or having an additional staff person present rather than being alone with the client. If the nurse pretends to be unafraid, the client may sense the fear anyway and feel less secure, leading to a greater potential for the client to lose personal control. It is not possible for the instructor to accompany the student at all times.

33. A student nurse is having a first experience in an inpatient psychiatric unit and is frightened by the behaviors of the clients with schizophrenia. The student should take which of the following actions to deal with fear?
A) Express fear to the psychiatrist during rounds
B) Pretend to not be afraid
C) Stay in an open area while talking with the clients
D) Insist that the instructor accompanies the student at all times.

Ans: That the client's behavior is a part of the illness
Feedback:
Suspicious or paranoid behavior on the client's part may make the nurse feel as though he or she is not trustworthy or that his or her integrity is being questioned. The nurse must recognize this type of behavior as part of the illness and not interpret or respond to it as a personal affront. The nurse must not take responsibility for the success or failure of treatment efforts or view the client's status as a personal success or failure.

34. Which of the following attitudes would be best for the nurse when the client who has schizophrenia acts as though the nurse is not trustworthy or that his or her integrity is being questioned?
A) That the client is correct and the nurse is not trustworthy
B) That the client wants to insult the nurse
C) That the client's behavior is a part of the illness
D) That the nurse's actions have failed

Ans: Decreased serotonin and norepinephrine activity
Feedback:
Deficits of serotonin, its precursor tryptophan, or a metabolite (5-hydroxyindole acetic acid, or 5-HIAA) of serotonin found in the blood or cerebrospinal fluid occur in people with depression. Norepinephrine levels may be deficient in depression and increased in mania. Elevated glucocorticoid activity is associated with the stress response, and evidence of increased cortisol secretion is apparent in about 40% of clients with depression. Kindling is the process by which seizure activity in a specific area of the brain is initially stimulated.

1. Which best explains the neurochemical processes responsible for depression?
A) Increased activity of dopamine
B) Decreased glucocorticoid activity
C) Decreased serotonin and norepinephrine activity
D) Potentiating of the kindling process

Ans: ) Depression is anger turned inward.

Feedback:
Freud looked at the self-depreciation of people with depression and attributed that self- reproach to anger turned inward related to either a real or perceived loss. Meyer viewed depression as a reaction to a distressing life experience such as an event with psychic causality. Horney believed that children raised by rejecting or unloving parents were prone to feelings of insecurity and loneliness. Beck saw depression as resulting from specific cognitive distortions in susceptible people.

2. Which is a freudian explanation of the etiology of depression?
A) Depression is a reaction to a distressing life experience.
B) Depression results from being raised by rejecting or unloving parents.
C) Depression results from cognitive distortions.
D) Depression is anger turned inward.

Ans: Manic episodes are a ìdefenseî against underlying depression.

The id takes over the ego and acts as an undisciplined hedonistic being (child).
Feedback:
Most psychoanalytic theories of mania view manic episodes as a ìdefenseî against underlying depression, with the id taking over the ego and acting as an undisciplined hedonistic being (child). Norepinephrine levels may be increased in mania, and acetylcholine seems to be implicated in mania, but these are neurochemical theories.

3. Which statements about the etiology of bipolar disorder do most psychoanalytical theories subscribe to? Select all that apply.
A) Norepinephrine levels may be increased in mania.
B) Manic episodes are a ìdefenseî against underlying depression.
C) Acetylcholine seems to be implicated in mania.
D) The id takes over the ego and acts as an undisciplined hedonistic being (child).

Ans: Mood disorder in first-degree relatives, Divorced

Feedback:
Major depression is twice as common in women and has a 1.5 to 3 times greater incidence in first-degree relatives than in the general population. Incidence of depression decreases with age in women and increases with age in men. Single and divorced people have the highest incidence. Depression in prepubertal boys and girls occurs at an equal rate.

4. Which variables represent the highest risk for developing major depressive disorder? Select all that apply.
A) Male gender
B) Mood disorder in first-degree relatives
C) Substance abuse
D) Divorced
E) Older adult

Ans: Taking unnecessary risks
Feedback:
The diagnosis of a manic episode or mania requires at least 1 week of unusual and incessantly heightened, grandiose, or agitated mood in addition to three or more of the following symptoms: exaggerated self-esteem; sleeplessness; pressured speech; flight of ideas; reduced ability to filter extraneous stimuli; distractibility; increased activities with increased energy; and multiple, grandiose, high-risk activities involving poor judgment and severe consequences, such as spending sprees, sex with strangers, and impulsive investments.

5. A concerned family member tells the nurse, ìI am concerned about my brother. He has been acting very different lately.î Knowing the family has a history of bipolar disorder, the nurse inquires further about this. Which behavior during the past week might indicate that the brother has bipolar disorder?
A) Taking unnecessary risks
B) Sleeping more
C) Intense focus
D) Showing low self-esteem

Ans: Anhedonia, feelings of worthlessness, and difficulty focusing
Feedback:
Symptoms of major depressive disorder include depressed mood; anhedonism (decreased attention to and enjoyment from previously pleasurable activities); unintentional weight change of 5% or more in a month; change in sleep pattern; agitation or psychomotor retardation; tiredness; worthlessness or guilt inappropriate to the situation (possibly delusional); difficulty thinking, focusing, or making decisions; or hopelessness, helplessness, and/or suicidal ideation. Grandiose mood, pressured speech, and flight of ideas are associated with mania.

6. A client is admitted for major depression. What should the nurse expect to find during assessment?
A) Anhedonia, feelings of worthlessness, and difficulty focusing
B) Depressed mood, guilt, and pressured speech
C) Changes in sleep pattern, tired, and grandiose mood
D) Difficulty focusing, feelings of helplessness, and flight of ideas

Ans: Approximately 2 weeks after starting antidepressant medication
Feedback:
Observe the client closely for suicide potential, especially after antidepressant medication begins to raise the client's mood. Risk for suicide increases as the client's energy level is increased by medication. The other choices are not significantly associated with increased risk for suicide

7. A client has just been diagnosed as having major depression. At which time would the nurse expect the client to be at highest risk for self-harm?
A) Immediately after a family visit
B) On the anniversary of significant life events in the client's life
C) During the first few days after admission
D) Approximately 2 weeks after starting antidepressant medication

Ans: The client will independently carry out activities of daily living.

Feedback:
Expected outcomes for the depressed client include the following:
ï The client will not injure himself or herself.
ï The client will independently carry out activities of daily living (showering, changing clothing, grooming).
ï The client will establish a balance of rest, sleep, and activity.
ï The client will establish a balance of adequate nutrition, hydration, and elimination.
ï The client will evaluate self-attributes realistically.
ï The client will socialize with staff, peers, and family/friends.
ï The client will return to occupation or school activities.
ï The client will comply with the antidepressant regimen.
ï The client will verbalize symptoms of a recurrence.
Avoiding agitation and harm to others are outcomes more appropriate for a client with mania. It is unrealistic to be completely free from stress.

8. The nurse is planning care for a client with major depression. Which is an appropriate expected outcome?
A) The client will avoid causing harm to others.
B) The client will be free from stress.
C) The client will independently carry out activities of daily living.
D) The client will not experience agitation.

Ans: You are feeling really sad right now. It's a hard time.î
Feedback:
Do not cut off interactions with cheerful remarks or platitudes. Do not belittle the client's feelings. Accept the client's verbalizations of feelings as real, and give support for expressions of emotions, especially those that may be difficult for the client (like anger). Allow (and encourage) the client to cry. It is important that the nurse does not attempt to ìfixî the client's difficulties

9. A client who is depressed begins to cry and states, ìI'm just really sick of feeling this way. Nothing ever seems to go right in my life.î Which would be the most appropriate response by the nurse?
A) ìDon't cry. Try to look at the positive side of things.î
B) ìYou are feeling really sad right now. It's a hard time.î
C) ìHang in there. Your medication will start helping in a few days.î
D) ìNothing ever goes right?î

Ans: Setting limits on aggressive and intimidating behavior
Feedback:
Because of the safety risks that clients in the manic phase take, safety plays a primary role in care, followed by issues related to self-esteem and socialization. It is necessary to set limits when they cannot set limits on themselves. Giving the client the opportunity to exercise self-control is most therapeutic. If the client cannot control his or her behavior, then more restrictive measures can be taken, such as room restriction or sedation. Clearing the area is not necessary during limit setting and may cause excessive panic on the part of other clients. When setting limits, it is important to clearly identify the unacceptable behavior and the expected, appropriate behavior. All staff must consistently set and enforce limits for those limits to be effective.

10. A client who is manic threatens others on the unit. Which would be the initial nursing action in response to this behavior?
A) Administering a sedative that has been prescribed to be used PRN.
B) Insisting the client take a ìtime-outî in his room
C) Clearing the area of all other clients
D) Setting limits on aggressive and intimidating behavior

Ans: Ham sandwich, cheese slices, milk
Feedback:
Finger foods, or things clients can eat while moving around, are the best options to improve nutrition. Such foods should be as high in calories and protein as possible.

11. Which meal would the nurse provide to best meet the nutritional needs of a client who is manic?
A) Peanut butter sandwich, chips, cola
B) Fried chicken, mashed potatoes, milk
C) Ham sandwich, cheese slices, milk
D) Spaghetti, garlic bread, salad, tea

Ans: ìPlease slow down. I'm not sure what you need first.î
Feedback:
The speech of manic clients may be pressured: rapid, circumstantial, rhyming, noisy, or intrusive with flights of ideas. The nurse must keep channels of communication open with clients, regardless of speech patterns. The nurse can say, ìPlease speak more slowly. I'm having trouble following you.î This puts the responsibility for the communication difficulty on the nurse rather than on the client.

12. A client who is manic states, ìWhat time is it? I have to see the doctor. Is breakfast here yet? I've got to see the doctor first. Can I get my cereal out of the kitchen?î Which would be the most appropriate response by the nurse?
A) ìPlease slow down. I'm not sure what you need first.î
B) ìYou will have to be quiet and have breakfast after the doctor comes.î
C) ìAre you hungry?î
D) ìYour thoughts seem to be racing this morning.î

Ans: Accompany the client to his or her room to get dressed.
Feedback:
Redirecting the client to appropriate behavior without confrontation is most effective. Seclusion is not an appropriate intervention for this situation. Ignoring the behavior is not indicated. The client is in the manic phase; telling him or her to stop the behavior may make the behaviors escalate.

13. A client with mania is demonstrating hypersexual behavior by blowing kisses to other clients, making suggestive remarks, and removing some articles of clothing. Which nursing intervention would be most appropriate at this time?
A) Accompany the client to his or her room to get dressed.
B) Put the client in seclusion for his or her own protection.
C) Tell other clients to ignore the behavior because it is harmless.
D) Tell the client that the behaviors have to stop right now.

Ans: Do not swing at me again. If you cannot control yourself, we will help you.î
Feedback:
This response firmly states behavioral expectations and lets the client know his behavior will be safely controlled if he is unable to do so. The other choices are not appropriate responses to this situation.

14. The client with mania attempts to hit the nurse. Which is the best response by the nurse?
A) ìDo not swing at me again. If you cannot control yourself, we will help you.î
B) ìIf you do that one more time, you will be put in seclusion immediately.î
C) ìStop that. I didn't do anything to provoke an attack.î
D) ìWhy do you continue that kind of behavior? You know I won't let you do it.î

Ans: C
Feedback:
Redirecting the client to a quieter, smaller room will decrease external stimuli and promote calmness, so the client will eventually rest and sleep.

15. During report, the nurse learns that a client with mania has not slept since admission 2 days ago. On entering the day room, the nurse finds this client dancing to loud music. Which would be the most appropriate statement by the nurse?
A) ìDo you think you could sit still for a few minutes so we can talk?î
B) ìHow are you ever going to get any rest if you keep that music on?î
C) ìLet's go to the conference room and talk for a while.î
D) ìTurn the radio down so we can hear ourselves talk.î

Ans:ìI can't call the psychiatrist now, but you and I can talk about your request for a pass.î
Feedback:
This response states a limit on an unreasonable request while providing the opportunity to discuss the request. Answer choices A, B, and D are not therapeutic.

16. At 1 AM, the client with mania rushes to the nurses' station and demands that the psychiatrist come to the unit now to write an order for a pass to go home. What would be the nurse's most therapeutic response?
A) ìGo to the day room and wait while I call your psychiatrist.î
B) ìDon't be unreasonable. I can't call the psychiatrist at this time of night.î
C) ìI can't call the psychiatrist now, but you and I can talk about your request for a pass.î
D) ìYou must really be upset to want a pass immediately; I'll give you some medication.î

Ans: ) Other clients need to be protected from the intrusive behavior.

Feedback:
The nurse must set limits on this intrusive behavior because other clients have the right to be protected. The client is in the manic phase; the client may not calm down after lunch. The behavior could be an imminent threat to individual safety for many reasons, infection control included. The client's need for food and fluids does not supersede any of the other clients' needs for food and fluids.

17. A client with mania is in the dining room at lunchtime and is observed taking food from other clients' trays. The nurse's intervention should be based on which rationale?
A) As soon as lunch is over, the client will calm down.
B) Other clients need to be protected from the intrusive behavior.
C) The client's behavior is not an imminent threat to anyone's physical safety.
D) The client needs food and fluids in any way possible.

Ans: Decrease the client's environmental stimuli.
Feedback:
When the client is agitated, decreasing stimuli is the priority. Answer choices D, B, and C are not priority interventions.

18. A client with bipolar disorder is admitted to the psychiatric unit. The client is talking loudly, walking back and forth rapidly, and exhibiting a short attention span. Which nursing intervention should occur first?
A) Decrease the client's environmental stimuli.
B) Give the client feedback about his behavior.
C) Introduce the client to other staff on the unit.
D) Tell the client about hospital rules and policies.

Ans: Move to a chair a little further away and say, ìWe can just sit together quietly.î
Feedback:
Moving away gives the client more personal space; staying with the client indicates acceptance and genuine interest. It is not necessary for the nurse to talk to the client the entire time; rather, silence can convey that clients are worthwhile even if they are not interacting.

19. The nurse observes a client sitting alone at a table, looking sad and preoccupied. The nurse sits down and says, ìI saw you sitting alone and thought I might keep you company.î The client turns away from the nurse. Which would be the most therapeutic nursing intervention?
A) Move to another chair closer to the client and say, ìThe staff is here to help you.î
B) Move to a chair a little further away and say, ìWe can just sit together quietly.î
C) Remain in place and say, ìHow are you feeling today?î
D) Say, ìI'll visit with you a little later,î and leave the client alone for a while.

Ans: Structuring the activity to facilitate completion of one specific task
Feedback:
The client needs to experience success in the group but is unlikely to do that independently. The other choices would not be appropriate actions for the client who is lethargic and apathetic.

20. A client with depression appears lethargic and apathetic but agrees to participate in a leisure activity group. Which nursing intervention is most likely to help the client successfully participate?
A) Allowing the client to direct her participation at her own pace
B) Giving the client several choices of projects, so she can choose her favorite
C) Staying away from the client during the session to encourage free expression
D) Structuring the activity to facilitate completion of one specific task

Ans: Stating, ìMedications help your brain function better, but the therapy helps you
achieve lasting behavior change.î
Feedback:
Clients and family should know that treatment outcomes are best when psychotherapy and antidepressants are combined. Psychotherapy helps clients to explore anger, dependence, guilt, hopelessness, helplessness, object loss, interpersonal issues, and irrational beliefs. The goal is to reverse negative views of the future, improve self- image, and help clients gain competence and self-mastery.

21. A client asks the nurse why he has to go to therapy and cannot just take his prescribed antidepressant medication. Which would be the most therapeutic nursing intervention?
A) Stating, ìThe effects of medications will not last forever. You will need to
eventually learn to function without them.î
B) Stating, ìMedications help your brain function better, but the therapy helps you
achieve lasting behavior change.î
C) Stating, ìBoth are recommended. Since your insurance covers both, that is the best
plan for you.î
D) Asking, ìDo you have reservations about going to therapy?î

Ans: ) Take the medication at night
Feedback:
Citalopram (Celexa) causes drowsiness, sedation, insomnia, nausea, vomiting, weight gain, constipation, and diarrhea. Nursing implications for drowsiness and sedation include instructing the client to administer the dose at 6 PM or later.

22. A client who has been discharged home on Celexa (citalopram) calls the nurse complaining that the medication causes her to feel too drowsy. The nurse should make which of the following suggestions?
A) Make an appointment to change to a different medication.
B) Take the medication at night.
C) Be patient while this early side effect subsides.
D) Skip a dose if drowsiness is excessive.

Ans: appropriate; the wife needs support in setting boundaries.
Feedback:
Family members often say they know clients have stopped taking their medication when, for example, clients become more argumentative, talk about buying expensive items that they cannot afford, hotly deny anything is wrong, or demonstrate any other signs of escalating mania. People sometimes need permission to act on their observations.

23. The wife of a client with bipolar disorder calls the nurse expressing distress about recent spending patterns of her husband. The nurse suggests the wife implement the limit- setting skills she has learned in family therapy. In this instance, the nurse's action would be considered
A) inappropriate; the nurse should not give advice to the wife.
B) inappropriate; the husband has the legal right to spend personal money.
C) appropriate; the wife is responsible for the husband's actions since he has a mental illness.
D) appropriate; the wife needs support in setting boundaries.

Ans: Drink a 2-L bottle of decaffeinated fluid daily.
C) Do not alter dietary salt intake.
D) See the doctor if you get the flu.
Feedback:
Clients should drink adequate water (approximately 2 L/day) and continue with the usual amount of dietary table salt. Having too much salt in the diet because of unusually salty foods or the ingestion of salt-containing antacids can reduce receptor availability for lithium and increase lithium excretion, so the lithium level will be too low. If there is too much water, lithium is diluted, and the lithium level will be too low to be therapeutic. Drinking too little water or losing fluid through excessive sweating, vomiting, or diarrhea increases the lithium level, which may result in toxicity. Monitoring daily weights and the balance between intake and output and checking for dependent edema can be helpful in monitoring fluid balance. The physician should be contacted if the client has diarrhea, fever, flu, or any condition that leads to dehydration.

24. A client is being discharged on lithium. The nurse encourages the client to follow which health maintenance recommendations? Select all that apply.
A) Weigh self weekly at the same time of day.
B) Drink a 2-L bottle of decaffeinated fluid daily.
C) Do not alter dietary salt intake.
D) See the doctor if you get the flu.
E) Restrict involvement in intense exercise.

Ans: ìI never knew depression could just happen for no specific reason.î

Feedback:
Depression can be endogenous, with no external cause or event. Clients must understand that depression is an illness, not a lack of willpower or motivation. Major depression typically involves 2 or more weeks of a sad mood or lack of interest in life activities with at least four other symptoms of depression.

25. The nurse is teaching a 70-year-old man about his depression. Which statement by the client would indicate that teaching has been effective?
A) ìAll old people get depressed at times.î
B) ìI'm glad I'll feel better in 2 or 3 days.î
C) ìI never knew depression could just happen for no specific reason.î
D) ìWhen I reduce the stress in my life, the depression will go away.î

Ans: A 71-year-old male, alcohol user, independent minded

Feedback:
In the United States, men commit approximately 72% of suicides, which is roughly three times the rate of women, although women are four times more likely than men to attempt suicide. Adults older than age 65 years compose 10% of the population but account for 25% of suicides. Suicide is the second leading cause of death (after accidents) among people 15 to 24 years of age. Clients with psychiatric disorders, especially depression, bipolar disorder, schizophrenia, substance abuse, posttraumatic stress disorder, and borderline personality disorder, are at increased risk for suicide. Chronic medical illnesses associated with increased risk for suicide include cancer, HIV or AIDS, diabetes, cerebrovascular accidents, and head and spinal cord injury. Environmental factors that increase suicide risk include isolation, recent loss, lack of social support, unemployment, critical life events, and family history of depression or suicide.

26. Which individual is at highest risk for committing suicide?
A) A 71-year-old male, alcohol user, independent minded
B) A 16-year-old female, diabetic, two best friends
C) A 47-year-old male, schizophrenic, unemployed
D) A 57-year-old female, depression, active in church

Ans: The relative's suicide offers a sense of ìpermissionî or acceptance of suicide as a method of escaping a difficult situation.

Feedback:
Those with a relative who committed suicide are at increased risk for suicide: the closer the relationship, the greater the risk. One possible explanation is that the relative's suicide offers a sense of ìpermissionî or acceptance of suicide as a method of escaping a difficult situation. Treatment with antidepressants and spring increase in sunlight and energy may give a person with suicidal ideation the energy to act on it. If a relative commits suicide, the family members may recognize that suicide is emotionally harmful to the ones left behind and vow not to consider suicideóthis does not increase the risk of suicide.

27. Which is a possible explanation for the increased risk of suicide in persons who have
had a relative who committed suicide?
A) The relative's suicide offers a sense of ìpermissionî or acceptance of suicide as a method of escaping a difficult situation.
B)Many people with depression who have suicidal ideation lack the energy to implement suicide plans, but antidepressant treatment can actually give clients with depression the energy to act on suicidal ideation.
C) Suicide is more likely to occur in April when natural energy from increased sunlight may give the client the energy to act on suicidal ideation.
D) The relative's suicide caused the family members to realize that suicide is emotionally harmful to the ones left behind and vow not to consider suicide.

Ans: After starting antidepressant therapy but not having reached the therapeutic level

If the client has made a choice to discontinue antidepressant therapy without
medical supervision and is becoming gradually more depressed

If the client does not adhere to the medication regimen and takes antidepressant
medications irregularly

Prior to initiating antidepressant therapy but before the depression results in lack
of energy

,Feedback:
After starting antidepressant therapy but not having reached the therapeutic level, the client is still troubled with depression and may have the energy to execute any suicide ideation. If the client has made the choice to discontinue antidepressant therapy without medical supervision and is becoming gradually more depressed does not adhere to the medication regimen and takes antidepressant medications irregularly, or prior to initiating antidepressant therapy but before the depression results in lack of energy, the client may be motivated to commit suicide because of the depression that is not effectively treated by a therapeutic level of antidepressant medications and yet still have enough energy to execute any suicide ideation. After having reached the therapeutic level of antidepressant medications and having maintained it for several years, the client is not likely at an increased risk for suicide.

28. Which time periods during antidepressant therapy are persons most likely to commit suicide? Select all that apply.
A) After starting antidepressant therapy but not having reached the therapeutic level
B) After having reached the therapeutic level of antidepressants and maintained it for
several years
C) If the client has made a choice to discontinue antidepressant therapy without
medical supervision and is becoming gradually more depressed
D) If the client does not adhere to the medication regimen and takes antidepressant
medications irregularly
E) Prior to initiating antidepressant therapy but before the depression results in lack
of energy

Ans: A client who has a private gun collection.
Feedback:
When a client admits to having suicidal thoughts, the next step is to determine potential lethality, including a specific plan and lethality of means. Specific and positive answers to lethality assessment questions increase the client's likelihood of committing suicide.

29. Which client is at highest risk for carrying out a suicide plan?
A) A client who plans to take a bottle of sleeping pills.
B) A client who says, ìMy life is over.î
C) A client who has a private gun collection.
D) A client who says, ìI'm going to jump off the next bridge I see.î

Ans: Are you planning to commit suicide?î
Feedback:
The nurse never ignores any hint of suicidal ideation regardless of how trivial or subtle it seems and the client's intent or emotional status. Asking clients directly about thoughts of suicide is important.

30. A client who is depressed states, ìI think my family would be better off without me. They don't need to worry.î Which would be the most appropriate response by the nurse?
A) ìAre you planning to commit suicide?î
B) ìWhat do you think they are worried about?î
C) ìWhere are you going?î
D) ìYou don't mean that. Your family loves you.î

Ans: Pour the soda into a plastic cup.
Feedback:
For clients who are suicidal, staff members remove any item they can use to commit suicide, such as sharp objects, shoelaces, belts, lighters, matches, pencils, pens, and even clothing with drawstrings. The client could access the soda can and commit self-harm.

31. A visitor comes to see a client who is suicidal. Upon entering the unit, the nurse notices that the visitor has brought the client a can of his favorite soda. Which action should the nurse take at his time?
A) Confiscate the soda can as a restricted item.
B) Pour the soda into a plastic cup.
C) Ask the visitor to place the soda can at the nurse's desk until he or she leaves.
D) Ask the visitor not to bring outside items on the unit in the future.

Ans: Risk for suicide related to a highly lethal plan
Feedback:
Safety is the priority. The overall goal for the client who is suicidal is to first keep the client safe and later to help him or her to develop new coping skills that do not involve self-harm. The other choices would not be the highest priority diagnosis for this client.

32. A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is involuntarily admitted to the psychiatric unit. Which nursing diagnosis has the highest priority?
A) Hopelessness related to recent divorce
B) Ineffective coping related to inadequate stress management
C) Spiritual distress related to conflicting thoughts about suicide and sin
D) Risk for suicide related to a highly lethal plan