Chapter 22 Psychiatric/Mental Health Problems

1. Which patient is the most likely candidate for outpatient depot antipsychotic therapy?

1. Older man with psychosis secondary to dementia who lives with his daughter

2. Homeless veteran with schizophrenia who occasional sleeps in a nearby shelter

3. Housewife with bipolar disorder who has psychotic features during the manic phase

4. Student with recently diagnosed schizophrenia who lives at home with his parents

2. Homeless veteran with schizophrenia who occasional sleeps in a nearby shelter

Ans: 2 Depot antipsychotic therapy uses long-acting injectable medications. These medications are used for long-term maintenance for schizophrenia for patients who may have some difficulties with adherence to taking medications. The homeless veteran has the least amount of social support and stability, which are factors in medication adherence. For the older adult patient with dementia and psychosis, identifying underlying factors and then behavioral therapies would be recommended first. Psychotic features in the manic phase of bipolar disorder would be treated as an acute episode. The student has the support of family, and the health care team will try to work with the patient and the family to build behaviors that support lifetime adherence to therapy

2. What is the nurse's most important role in helping patients, who have schizophrenia, to benefit from a comprehensive approach that includes medication and multidisciplinary nondrug therapies?

1. Help identify patients who would benefit from conventional psychotherapy. 2. Refer patients to a psychiatric nurse specialist for education about the disease.

3. Suggest that patients talk to vocational specialists for additional training.

4. Establish a therapeutic relationship with patients and encourage participation.

4. Establish a therapeutic relationship with patients and encourage participation.

Ans: 4 The nurse and the psychiatric nursing assistant spend more time with the patients than any of the other members of the health care team; thus establishing a good therapeutic relationship is essential to building trust; increasing social skills; encouraging medication adherence; and suggesting participation in educational, socialization, and vocational opportunities. Conventional psychotherapy is generally not used with patients with schizophrenia

3. A patient with a mental health disorder is brought to the emergency department by the police. In determining hospitalization versus discharge back into the community, which consideration is given the highest priority?

1. Willingness of person to follow the treatment plan

2. Potential for harm to self or others

3. Availability of family or social support

4. Ability of person to meet own basic physical needs

2. Potential for harm to self or others

Ans: 2 Potential for harm to self or others would be the priority; however, the other options are also important in planning for long-term outcomes

4. A patient who was recently diagnosed with conversion disorder is experiencing a sudden loss of vision after witnessing a violent fight between her husband and adult- age son. What is the priority therapeutic approach to use with this patient?

1. Reassure her that her blindness is temporary and will resolve with time.

2. Gently point out that she can see well enough to function independently.

3. Encourage expression of feelings and link emotional trauma to the blindness.

4. Teach ways to cope with blindness, such as methodically arranging personal items.

4. Teach ways to cope with blindness, such as methodically arranging personal items.

Ans: 4 Patients with conversion disorders are experiencing symptoms, even though there is no identifiable organic cause; therefore the patient should be assisted in learning ways to cope and live with the disability. The patient may physically be able to see, but pointing this out is not helpful. Encouraging the expression of feelings is okay, but it is premature to expect the patient to link the fight to her blindness. It is likely that the sudden onset of blindness will resolve, but the priority therapeutic approach is teaching her ways to cope in the meantime

5. The charge nurse is reviewing the assignment sheet for an acute psychiatric unit. Which experienced team member should be reassigned?

1. Male LVN assigned to an older male patient with chronic depression and excessive rumination

2. Young male psychiatric nursing assistant assigned to a female adolescent with anorexia nervosa

3. Female RN assigned to a newly admitted female patient who has command hallucinations and delusions of persecution

4. Older female RN with medical-surgical experience assigned to a male patient with Alzheimer disease

2. Young male psychiatric nursing assistant assigned to a female adolescent with anorexia nervosa

Ans: 2 Adolescents, in general, are self-conscious in the presence of members of the opposite sex, and teenagers with anorexia are overly concerned with their appearance; therefore it would be better to assign this patient to a mature female staff member. An experienced LVN is able to set boundaries and to assist patients with chronic health problems. An experienced RN should be assigned to new admissions and to patients with acute safety issues. An RN with medical-surgical experience would be well acquainted with care issues related to dementia

6. The nurse arrives home and finds that a neighbor's (Jane's) house is on fire. A fireman is physically restraining Jane as she screams and thrashes around to get free to run back into the house. What is the nurse's best action?

1. Make eye contact and encourage Jane to verbalize feelings.

2. Physically restrain Jane so that the fireman can resume his job.

3. Use a firm tone of voice and give Jane simple commands.

4. Use a gentle persuading tone and ask Jane to be calm.

3. Use a firm tone of voice and give Jane simple commands.

Ans: 3 Jane is experiencing a panic level of anxiety, and initially she needs firm, simple, and direct instructions. It may be very difficult for the nurse to safely restrain Jane. Speaking softly and gently and encouraging her to express feelings are appropriate when her anxiety is more under control.

7. There is a patient on the rehabilitation unit who has been there for several months. He is hostile, rude, and belligerent, and no one likes to interact with him. How should the charge nurse handle the assignment?

1. Rotate the assignment schedule so that no one has to care for him more than once or twice a week.

2. Pair a float nurse and a nursing student and assign this team to care for the patient; they will have a fresh perspective.

3. Identify several experienced nurses as primary caregivers and develop a plan that includes psychosocial interventions.

4. Assign self as primary caregiver and role-model how patients should be treated.

3. Identify several experienced nurses as primary caregivers and develop a plan that includes psychosocial interventions.

Ans: 3 This patient has trouble with interpersonal interactions, so consistent caregivers who use psychosocial interventions have the best chance of developing a functional nurse-patient relationship. Rotating the assignment sheet to give the staff a break and using float staff are frequent strategies that are used, but these are not necessarily the best for the patient. Taking the patient may seem like the easiest solution for the charge nurse, but in the long run, strengthening and supporting the staff are better strategies

8. After reviewing medication prescriptions on an acute psychiatric unit, which prescription is the nurse most likely to question?

1. Fluoxetine for a middle-aged patient with depression

2. Chlorpromazine for a young patient with schizophrenia

3. Loxapine for an older adult patient with dementia and psychosis

4. Lorazepam for a young patient with generalized anxiety disorder

3. Loxapine for an older adult patient with dementia and psychosis

Ans: 3 Conventional (first-generation) antipsychotics are usually not prescribed for older adult patients with psychosis secondary to dementia because of the increased incidence of death, usually from cardiac problems or infection. Fluoxetine for depression, chlorpromazine for schizophrenia, and lorazepam for generalized anxiety disorder are viable options.

Test-Taking Tip: In general, older adults patients have more complex issues related to medications. While studying for the NCLEX® Examination, pay attention to information that highlights the care of older adults

9. A patient diagnosed with paranoid schizophrenia says, "Dr. Smith has killed several other patients, and now he is trying to kill me." What is the best response?

1. "I have worked here a long time. No one has died. You are safe here."

2. "What has Dr. Smith done to make you think he would like to kill you?"

3. "All of the staff, including Dr. Smith, are here to ensure your safety."

4. "Whenever you are concerned or nervous, talk to me or any of the nurses."

4. "Whenever you are concerned or nervous, talk to me or any of the nurses."

Ans: 4 The nurse can acknowledge the patient's fears without agreeing or disagreeing with his accusation. Directing him to talk to the nursing staff provides a source of emotional support and an action that he can use to decrease his anxiety. Telling the patient that no one has died and that the staff will ensure safety is presenting reality; however, he has a delusional belief and arguments should be avoided. Asking him to explain his rationale for his beliefs encourages him to elaborate on his delusion.

10. Which patient needs assessment first?

1. A patient who is having command hallucinations

2. A patient who is demonstrating clang associations

3. A patient who is verbalizing ideas of reference

4. A patient who is using neologisms

1. A patient who is having command hallucinations

Ans: 1 During command hallucinations, the patient may be getting a command to harm self or others; content must be assessed. Ideas of reference occur when an ordinary thing or event (e.g., a song on the radio) has personal significance (e.g., belief that the lyrics were written for him or her). Ideas of reference could escalate into aggression, if delusions of persecution are present; content must be assessed. Clang association is a meaningless rhyming of words, and neologisms are new words created by patients. These communication patterns create frustration for staff and patients, but there is no need for immediate intervention.

Test-Taking Tip: Safety is a priority concern for all patients. In identifying safety issues for patients with active psychosis, the potential concern is frequently harm to self or to

11. The nurse is talking to the primary caregiver of Martha, who was diagnosed 8 years ago with Alzheimer disease. The caregiver says, "We love Martha, but my daughter needs help with her kids, and my husband's health is poor.

I really need help." Which member of the health care team should the nurse consult first?

1. Health care provider to review long-term prognosis and new treatments for Alzheimer disease

2. Psychiatric clinical nurse specialist to design behavioral modification therapies for Martha

3. Clinical psychologist to assess caregiver for major depression and need for treatment

4. Social worker to identify and arrange placement for Martha in an acceptable nursing home

4. Social worker to identify and arrange placement for Martha in an acceptable nursing home

Ans: 4 The caregiver needs assistance to identify and locate an alternative care situation for Martha. The family has been coping and caring for Martha for a long time, but family circumstances and a patient's condition will change over time. The nurse may do additional assessment to see if the caregiver needs to be referred for depression, guilt, or anxiety related to having to make this change for Martha. New treatments and behavioral modification can be attempted, but currently there are no therapies that reverse the gradual decline.

12. The patient has a panic disorder and is having difficulty controlling his anxiety. Which symptoms are cause for greatest concern?

1. His heart rate is increased, and he reports chest tightness.

2. He demonstrates tachypnea and carpopedal spasms.

3. He is pacing to and fro and pounding his fists together.

4. He is muttering to himself and is easily startled.

3. He is pacing to and fro and pounding his fists together.

Ans: 3 All of these symptoms signal an increase of anxiety; however, physically aggressive behavior signals a danger to others and to self. Verbal intervention is still possible, but the pacing and fist pounding are a step above the other symptoms. Tachycardia and chest tightness are assessed, but should abate as the patient becomes less anxious. Carpopedal spasms occur during hyperventilation; assisting the patient to breathe in a paper bag will help. Muttering to self can be interrupted by using a normal conversational tone and topic

13. The nurse is interviewing a patient with suicidal ideations and a history of major depression. Which comment is cause for greatest concern?

1. "I have had problems with depression most of my adult life."

2. "My father and my brother both committed suicide."

3. "My wife is having health problems, and she relies on me."

4. "I am afraid to kill myself, and I wish I had more courage."

2. "My father and my brother both committed suicide."

Ans: 2 The patient has a strong family history of completed suicide, which is an increased risk factor. The patient may believe that other family members have successfully used suicide to solve their problems. A long history of depression suggests that the problem is chronic; assess for treatment history, risk factors, and coping strategies. Having a feeling of responsibility toward others and feeling fear are protective factors that can be used in the treatment plan.

14. A patient comes into the walk-in clinic and tells the nurse that he would like to be admitted to an alcohol rehabilitation program. Which question is the most important to ask?

1. "What made you decide to enter a program at this time?"

2. "How much alcohol do you usually consume in a day?"

3. "When was the last time you had a drink?"

4. "Have you been in a rehabilitation program before?"

3. "When was the last time you had a drink?"

Ans: 3 Before someone enters an alcohol rehabilitation program, there should be a medically supervised detoxification. This patient has walked in off the street; therefore the nurse must determine whether he is at risk for withdrawal symptoms. Withdrawal from alcohol can be life threatening. The other questions are relevant and are likely to be included in the interview

15. The nurse is working with a health care provider (HCP) who recently started treating patients with depression. Which action by the HCP would prompt the nurse to intervene?

1. Tells the patient and family that it may take 4 to 8 weeks before the antidepressant medication begins to relieve symptoms

2. Prescribes 3 months of antidepressants for a patient newly diagnosed with depression and gives a 3 month follow-up appointment

3. Instructs the patient that the initial dose is low but will gradually be increased to reach a maintenance dosage

4. Tells the patient and the family to watch for and immediately report anxiety, agitation, irritability, or suicidal thoughts

2. Prescribes 3 months of antidepressants for a patient newly diagnosed with depression and gives a 3 month follow-up appointment

Ans: 2 Patients with depression are at high risk for suicide, and antidepressants can be used to commit suicide. For the patient who was recently diagnosed with depression and prescribed antidepressants, the nurse intervenes because a small number of doses should be prescribed and dispensed, and follow-up should be weekly to allow for close monitoring and assessment. The other options are correct information to share with patients and family members

16. A patient on the acute psychiatric unit develops neuroleptic malignant syndrome. Which task would be delegated to the psychiatric nursing assistant (PNA)?

1. Wiping the patient's body with cool moist towels

2. Monitoring and interpreting vital signs every 15 minutes

3. Attaching the patient to the electrocardiogram (ECG) monitor

4. Transporting the patient to the medical intensive care unit (ICU)

1. Wiping the patient's body with cool moist towels

Ans: 1 A PNA can perform this simple cooling measure with minimal instruction. Neuroleptic malignant syndrome is a rare but potentially fatal reaction to antipsychotic medication. Symptoms include fever, altered mental status, muscle rigidity, and autonomic instability. The RN should continuously interpret vital signs, although taking vital signs can be delegated. Assistive personnel in the ICU and emergency department will be familiar with how to attach ECG leads, but PNAs will rarely have occasion to use this equipment; therefore the RN should perform this task. The RN (or health care provider) should accompany the patient to the ICU, although the PNA could assist.

Test-Taking Tip: In assigning, delegating, or supervising tasks to ancillary personnel, be familiar with state laws that relate to the scope of practice for these individuals. Because it is impossible to list every task and every circumstance, you must learn to analyze the situation and the skills of available personnel. This will help you to determine if the task is within their scope of practice.

17. A newly graduated nurse has just started working at the acute psychiatric unit. Which patient would be the best to assign to this nurse?

1. Patient who is frequently admitted for borderline personality disorder and suicidal gestures

2. Patient admitted yesterday for disorganized schizophrenia and psychosis

3. Patient newly admitted to determine differential diagnosis of depression, dementia, or delirium

4. Patient newly diagnosed with major depression and rumination about loss and suicide

4. Patient newly diagnosed with major depression and rumination about loss and suicide

Ans: 4 Although the patient is ruminating about suicide, in the early phase of major depression the patient has minimal energy to act. The danger for suicide will increase as the medication and therapy begin to help. A new nurse lacks experience with therapeutic boundary setting that is necessary for patients with borderline personality disorder. Psychotic patients can seem very threatening to new nurses and it takes experience to interpret psychotic behavior. Depression, dementia, and delirium have some behavior and symptom overlap; this patient should be assigned to an experienced nurse until the delirium is treated or ruled out

18. Which task can be delegated to a medical-surgical assistive personnel (AP) who has been temporarily floated to the acute psychiatric unit to help?

1. Performing one-to-one observation of a patient who is suicidal

2. Assisting the occupational therapist to conduct a craft class

3. Accompanying an older adult patient who wanders on a walk outside

4. Assisting the medication nurse who is having problems with a patient

3. Accompanying an older adult patient who wanders on a walk outside

Ans: 3 Medical-surgical APs assist patients to ambulate, and they frequently care for older confused patients. Performing one-to-one suicide watch requires experience to recognize behaviors and to immediately alert the nurse and intervene. Assisting the occupational therapist or medication nurse may be possible, but the medical-surgical AP is unlikely to be familiar with the behavioral interventions required in these situations

19. The nurse has identified a patient who may be a candidate for substance addiction treatment. Which health care team member should the nurse contact to increase the likelihood of a successful long-term outcome?

1. Call a social worker who can locate an immediately available treatment program.

2. Call admissions to obtain the patient's voluntary consent to enter a treatment program.

3. Consult a pharmacist about medication therapy to counter addiction.

4. Contact the health care provider to initiate admission to a medical detoxification unit

1. Call a social worker who can locate an immediately available treatment program.

Ans: 1 Early treatment contributes to success; however, one of the greatest barriers in addiction treatment is locating a treatment program that can immediately accept a patient. Limited finances and lack of comprehensive programs make locating a program even more difficult. Medication therapy is one important aspect. Medical detoxification is also important, but it is only one step in a long treatment process. Patients' voluntary participation and consent are ideal, but pressure and support from family, friends, or employers can increase the likelihood of success

20. The team must apply restraints to a combative patient to prevent harm to others or to self. Which action requires the charge nurse's intervention?

1. Psychiatric nursing assistant uses a quick-release knot to tie restraints.

2. Health care provider (HCP) secures the restraint to the side rail.

3. RN checks the pulses distal to the restraints.

4. LPN/LVN explains to the patient why he is being restrained.

2. Health care provider (HCP) secures the restraint to the side rail.

Ans: 2 The restraints must be tied to a stationary portion of the bed. HCPs are usually less familiar with how the beds function. Quick-release knots are for safety in case the restraints need to be quickly removed. Distal pulses should be checked. The HCP or RN is usually responsible for explaining the restraint procedure; however, restraining a combative patient is rarely a planned event, and the caregiver who has the best relationship with the patient may be the best spokesperson.

21. A well-known celebrity is admitted to the psychiatric unit. Several RNs from other units drop by and express an interest in seeing the patient. What is the best response?

1. "Please be discreet and do not interrupt the workflow."

2. "How did you find out that the patient was admitted to this unit?"

3. "Please wait. I need to call the nursing supervisor about this request."

4. "I'm sorry; the patient has asked that only family be allowed to visit."

2. "How did you find out that the patient was admitted to this unit?"

Ans: 2 Determine how the nurses found out about the patient's admission. This is a serious Health Insurance Portability and Accountability Act violation, and information disclosure must be immediately stopped. Unfortunately for these RNs, administration will have to be notified, but as a professional courtesy, it would be better if they went directly to the supervisor and admitted the error rather than immediately calling the supervisor and reporting them

22. An LPN/LVN complains to the charge nurse that she is always assigned to the same patient with chronic depression. What should the charge nurse do?

1. Look at the assignment sheet and see if there is any way to switch assignments with another LPN/LVN.

2. Tell her to care for the patient today but that her request will be considered for future assignments.

3. Remind her that continuity of care and patient-centered care are the primary goals.

4. Explain that patients with chronic conditions are more likely to fall under the LPN/LVN scope of practice.

2. Tell her to care for the patient today but that her request will be considered for future assignments.

Ans: 2 Switching the assignments at shift change or midshift creates delays for everyone, so politely ask her to continue for the day. Nevertheless, her request is not unreasonable; dealing with depressed patients can be very exhausting, so consider her request for future assignments. Although many patients benefit from having the same caregiver, a chronically depressed patient might benefit from stimulation by various caregivers. Explaining scope of practice and continuity of care is probably not necessary and may seem condescending

23. Which person is displaying behaviors that most strongly suggest the need for additional screening for possible substance abuse?

1. Person with cancer progressively needs more pain medication to achieve relief

2. College student reports occasionally smoking marijuana during semester break

3. Stay-at-home mom reports drinking when her kids are in school or in bed asleep

4. Person with a fractured leg reports taking opioids and tapering off when pain subsides

3. Stay-at-home mom reports drinking when her kids are in school or in bed asleep

Ans: 3 A woman who is drinking when her children are out of sight is displaying substance use that is not based on medical needs or social norms. The college student is using an illegal substance, but at this point, the frequency does not suggest that it is a compulsive problem. The person with cancer and person with a fracture are using medications for pain as indicated

24. The emergency department (ED) nurse is calling to report on a patient who will be admitted to the acute psychiatric unit. He has a history of bipolar disorder and was in an altercation that resulted in the death of another. He has contusions, abrasions, and minor lacerations. What is the priority question that the receiving nurse should ask?

1. "When will the patient be transferred?"

2. "Will a police officer be with him while he is on the unit?"

3. "Why isn't the patient being admitted to the trauma unit?"

4. "What is the patient's current mood and behavior?"

4. "What is the patient's current mood and behavior?"

Ans: 4 Knowing the current mood and behavior is the priority so that the nurse can prepare for physical or chemical restraints, isolation or a private room, and allocation and assignment of staff members. The other questions are also relevant; however, the nurse should be aware that challenging the appropriateness of the psychiatric unit versus the trauma unit requires contacting the nursing supervisor because the ED nurse will not be able to resolve this issue

25. An adolescent girl is juuling all of the time with her friends. Her mother is distraught, because, "She won't stop and I know it's harming her." Which substance abuse problem will the nurse assess for?

1. Opioid abuse

2. Nicotine addiction

3. Alcohol abuse

4. Cannabinoid hyperemesis syndrome

2. Nicotine addiction

Ans: 2 The nurse would assess for signs/symptoms of nicotine addiction. Juul is a type of e-cigarette that is popular among children and teenagers. It comes in flavors (e.g., fruity or minty). The device may look like a pen or a USB flash drive. It is easy to use and produces no odor. There is a higher concentration of nicotine compared with other electronic nicotine device systems.

26. A 23-year-old man with no known health problems says, "Well, I was a little nervous, so I smoked four or five cigarettes right before I came into the clinic." Which vital signs would be consistent with the patient's use of cigarettes?

1. Blood pressure of 90/60 mm Hg; pulse of 60 beats/min

2. Temperature of 100.6°F (38.1°C); respirations of 40 breaths/min

3. Blood pressure of 140/90 mm Hg; pulse of 120 beats/min

4. Temperature of 97.4°F (36.3°C); respirations of 30 breaths/min

3. Blood pressure of 140/90 mm Hg; pulse of 120 beats/min

Ans: 3 Nicotine promotes the release of norepinephrine and epinephrine. This can result in vasoconstriction, which elevates the pulse rate and the blood pressure

27. A patient is displaying muscle spasms of the tongue, face, and neck, and his eyes are locked in an upward gaze. He has been prescribed haloperidol. Which action will the nurse take first?

1. Maintain eye contact and stay with him until the spasms pass.

2. Place the patient on aspiration precautions until the spasms subside.

3. Obtain a prescription for intramuscular or IV diphenhydramine.

4. Obtain a prescription for and administer an antiseizure medication

3. Obtain a prescription for intramuscular or IV diphenhydramine.

Ans: 3 IV administration of diphenhydramine will rapidly alleviate the symptoms. The patient is experiencing medication side effects. This condition is frightening and uncomfortable for the patient, but it is not usually harmful. Swallow precautions will not harm the patient, but waiting for the spasms to pass delays the most appropriate intervention

28. Several patients are taking antipsychotic medications and are having medication side effects. Place the following patients in priority order for additional assessment and appropriate interventions, with 1 being the most critical and 4 being the least.

1. A patient who is taking trifluoperazine and has a temperature of 103.6°F (39.8°C) with tachycardia, muscular rigidity, and dysphagia

2. A patient who is taking fluphenazine and has dry mouth and dry eyes, urinary hesitancy, constipation, and photosensitivity

3. A patient who is taking loxapine and has a protruding tongue with lip smacking and spastic facial distortions

4. A patient who is taking clozapine and reports a sore throat, fever, malaise, and flulike symptoms that began about 6 weeks ago after starting the new antipsychotic medication; white blood cell count is 2000/mm3 (2.0 × 10 9 /L)

1. A patient who is taking trifluoperazine and has a temperature of 103.6°F (39.8°C) with tachycardia, muscular rigidity, and dysphagia

4. A patient who is taking clozapine and reports a sore throat, fever, malaise, and flulike symptoms that began about 6 weeks ago after starting the new antipsychotic medication; white blood cell count is 2000/mm3 (2.0 × 10 9 /L)

3. A patient who is taking loxapine and has a protruding tongue with lip smacking and spastic facial distortions

2. A patient who is taking fluphenazine and has dry mouth and dry eyes, urinary hesitancy, constipation, and photosensitivity

Ans: 1, 4, 3, 2 The highest priority is patient 1, who has symptoms of neuroleptic malignant syndrome, which is rare but potentially fatal. This patient should be transferred to a medical unit. Patient 4 may have agranulocytosis. The mortality rate is high, and interventions include discontinuing the medication, aggressively treating the infection, and ensuring that the patient is not exposed to others with infections. Patient 3 has symptoms of tardive dyskinesia, which should be reported to the health care provider. A new medication, valbenazine (Ingrezza) was recently approved for the treatment of tardive dyskinesia. Side effects include somnolence and possible QT prolongation. Patient 2 is showing anticholinergic effects, which can be treated symptomatically (i.e., provide sips of water or hard candy, encourage use of artificial tears, place a warm towel on the abdomen, give stool softeners, and encourage the use of sunglasses).

29. The patient tells the nurse that he drinks three or four servings of alcohol every day. He also reports frequently taking acetaminophen for stress-related headaches. Based on this information, which laboratory test results are the most important to follow up on?

1. Renal function tests

2. Liver function tests

3. Cardiac enzymes

4. Serum electrolytes

2. Liver function tests

Ans: 2 Regular, even moderate, consumption of alcohol and excessive use of acetaminophen (maximum dose is 4000 mg/day) can cause fatal liver damage. Some authorities recommend that people who drink moderately should limit the total daily dose of acetaminophen to 2 g/day.

30. The nurse is caring for a young patient with type 1 diabetes who has sustained injuries when she tried to commit suicide by crashing her car. Her blood glucose (BG) level is 700 mg/dL (38.8 mmol/L), but she refuses insulin; however, she wants the pain medication. What is the best action?

1. Notify the charge nurse and make arrangements to transfer to intensive care.

2. Explain the significance of BG and insulin and call the health care provider (HCP).

3. Withhold the pain medication until she agrees to accept the insulin.

4. Give her the pain medication and document the refusal of the insulin.

2. Explain the significance of BG and insulin and call the health care provider (HCP).

Ans: 2 Explain that insulin is a priority because life-threatening ketoacidosis may already be in progress. If she is already aware of the dangers of an elevated BG level, then her refusal suggests ongoing suicidal intent and the HCP should be notified so that steps can be taken to override her refusal (potentially a court order). A BG level of over 600 mg/dL (33.3 mmol/L) can be criterion for transfer to intensive care, but making arrangements for transfer is time consuming, and treatment of the elevated BG should begin as soon as possible. Withholding pain medication is unethical, and merely documenting refusal of insulin is inappropriate because of the elevated BG and possible ongoing suicidal intent.

31. The health care provider recently prescribed rivastigmine twice daily for a 62-yearold patient who lives at home with his wife. Based on this information, which additional assessment would the home health nurse plan to perform first?

1. Assess for psychotic features, such as hallucinations.

2. Perform a comprehensive pain assessment.

3. Assess for cognitive deficits and memory loss.

4. Observe for fine and gross motor deficits.

3. Assess for cognitive deficits and memory loss.

Ans: 3 Rivastigmine is prescribed for mild to moderate cognitive impairment that occurs in Alzheimer disease. The medication does not improve cognition but may slow the decline. It is likely that the nurse will also assess the other areas to establish baseline information. Severe Alzheimer disease will eventually affect motor activity. Psychosis can occur in patients who have dementia. Later in the disease course, the patient may not be able to verbally express pain.

32. Which behavior would be the most problematic and require vigilance to prevent danger to self or others?

1. Avolition

2. Echolalia

3. Motor agitation

4. Stupor

3. Motor agitation

Ans: 3 All unusual behavior requires ongoing assessment, intervention, and documentation; however, motor agitation presents the greatest safety issue because excessive physical activity such as running about or flailing the arms and legs creates a risk for injury to self and others or exhaustion (to the point of death). Avolition is a lack of energy in initiating activities. Echolalia is pathologically repeating other people's words or phrases. Stupor is a state in which the patient may remain motionless for a prolonged period.

33. A patient frequently comes to the clinic with repeated complaints of nausea, constipation, and "excruciating stomach pain." Multiple diagnostic tests have consistently yielded negative results. What is the priority nursing intervention for this patient?

1. Advocate for the patient to have a psychiatric consultation.

2. Make an appointment as soon as possible with the same health care provider (HCP) for continuity of care.

3. Perform a physical assessment to identify any physical abnormalities.

4. Assess for concurrent symptoms of depression or anxiety

3. Perform a physical assessment to identify any physical abnormalities.

Ans: 3 The health care team must always be vigilant for actual physical disease; however, the patient most likely has an undiagnosed somatoform disorder, which is a chronic and severe psychological condition in which the patient experiences physical symptoms but without apparent organic cause. Depression and anxiety are common among patients with somatoform disorders. After physical disease has been ruled out, the diagnosis of somatoform disorder should be verified. Having emotional support from a consistent HCP is often the most effective approach for somatoform disorders. Thus all of the options would be included in the care plan

34. An older man was admitted for palliative care of terminal pancreatic cancer. His wife stated, "We don't want hospice; he wants treatment." The patient requested discharge and home health visits. Several hours after discharge, the man committed suicide with a gun. Which people should participate in a root cause analysis of this sentinel event? Select all that apply. 1. The wife and all immediate family members

2. Only the health care provider (HCP) who discharged the patient

3. Any nurse who cared for the patient during hospitalization

4. The case manager who arranged home visits for the patient

5. Only the nurse who discharged the patient

6. All HCPs who were involved in the care of the patient

3. Any nurse who cared for the patient during hospitalization

4. The case manager who arranged home visits for the patient

6. All HCPs who were involved in the care of the patient

Ans: 3, 4, 6 Everyone who was involved in the direct care of the patient should be invited to participate. The purpose of this root cause analysis is to review the event to identify behaviors, signs, or signals of risk for suicide. This information would be used to increase the staff's awareness to prevent future similar events. Inviting the wife and family is not appropriate because the performance of the staff is internally reviewed to improve performance. The purpose is not to fix blame or to create a situation that engenders guilt or conflict for the wife or family (or the staff). Likewise, the purpose of the analysis is not to provide psychotherapy or emotional support for the wife or family. (Referrals should be made for this.)

35. An adolescent girl is admitted to the medical-surgical unit for diagnostic evaluation and nutritional support related to anorexia nervosa. She is mildly dehydrated, her potassium level is 3.5 mEq/L (3.5 mmol/L), and she has experienced weight loss of more than 25% within the past 3 months. What is the primary collaborative goal?

1. Assist her to increase feelings of control.

2. Decrease power struggles over eating.

3. Resolve dysfunctional family roles.

4. Restore normal nutrition and weight.

4. Restore normal nutrition and weight.

Ans: 4 If the patient meets the criteria for admission to a medical-surgical unit, nutritional restoration is the primary concern. Concurrently, the health care team will assist the patient to achieve success in the other areas.

36. In caring for a patient who is admitted to a medical surgical unit for treatment of anorexia nervosa, which task can be delegated to assistive personnel (AP)?

1. Sitting with the patient during meals and for 1 to 1½ hours after meals

2. Observing for and reporting ritualistic behaviors related to food

3. Obtaining special food for the patient when she requests it

4. Weighing the patient daily and reinforcing that she is underweight

1. Sitting with the patient during meals and for 1 to 1½ hours after meals

Ans: 1 The AP should be instructed to observe the amount of food eaten and ensure that the patient is not throwing out the food. After meals, observation is necessary to ensure that the patient does not induce vomiting. Ritualistic behaviors can be subtle or difficult to define. Observation for these behaviors cannot be delegated. Requests for special foods could be delaying tactics or attempts to manipulate the staff. The AP should not be responsible for deciding if food requests are appropriate. Daily weights may not be ordered, because this could increase the patient's emotional focus on weight. In addition, repeatedly telling the patient that she is underweight is counterproductive because she does not believe she is underweight.

37. Nurse B frequently asks to be assigned to care for patients who require opioids for pain; drug counts involving Nurse B frequently show discrepancies. Nurse A suspects that Nurse B may have a substance abuse problem. Based on the ethical principle of negligence, what should Nurse A do first?

1. Talk to Nurse B and give counsel about the ethical issues of taking patients' medications.

2. Continue to assess Nurse B's behavior for other signs and symptoms of abuse.

3. Work closely with Nurse B to give support and help to reduce stress of workload.

4. Report facts (e.g., date, time, circumstance) about Nurse B's behavior to the nursing supervisor.

4. Report facts (e.g., date, time, circumstance) about Nurse B's behavior to the nursing supervisor.

Ans: 4 Nurse A should report factual events to the nursing supervisor. The other actions may be well intended, but they serve to enable Nurse B's behavior by delaying confrontation and resolution of the suspected substance abuse. Negligence is failure to meet the standard of care. Intentional or unintentional actions that increase risk or harm to patients are considered negligence. Reporting suspicious behaviors is for the safety of patients and coworkers

38. A male-to-female transgender patient (transwoman) is admitted to an acute care psychiatric unit for depression and suicidal ideations. On her arrival, several other patients display suspicion and contempt and verbal harassment is directed toward the woman. What should the charge nurse do first?

1. Isolate the patient and explain that the action is meant for her safety and privacy.

2. Make a general announcement to patients and staff that bullying is not tolerated.

3. Assess the patient's reaction to the comments and nonverbal behaviors.

4. Gently suggest that the patient could temporarily adopt natal gender appearance.

3. Assess the patient's reaction to the comments and nonverbal behaviors.

Ans: 3 The charge nurse would first assess the patient's reaction to what is happening. The patient is in a fragile state and should be encouraged to verbalize feelings and preferences. Based on the assessment findings, the nurse can plan interventions to help the patient feel safe and comfortable.

39. For several years, a patient diagnosed with hypochondriasis has undergone multiple diagnostic tests for "cancer," with no evidence of organic disease. Today he declares, "I know I have a brain tumor. My appointment is tomorrow, but I can't wait!" What is the most therapeutic response?

1. Present reality: "Sir, you have been seen many times in this clinic and had many diagnostic tests. The results have always been negative."

2. Encourage expression of feelings: "Let me spend some time with you. Tell me about what you are feeling and why you think you have a brain tumor."

3. Set boundaries: "Sir, I will take your vital signs, but then I am going to call your case manager so that you can discuss the scheduled appointment."

4. Respect the patient's wishes: "Sir, sit down and I will make sure that you see the health care provider right away. Don't worry; we will take care of you."

3. Set boundaries: "Sir, I will take your vital signs, but then I am going to call your case manager so that you can discuss the scheduled appointment."

Ans: 3 The case manager has a relationship with the patient, knows the specific details of agreements made with the patient, and is the most capable of helping him to decrease anxiety and preoccupation with physical symptoms. In general, presenting reality does not have an impact on patients with hypochondriasis. Encouraging expression of feelings and following the patient's wishes contribute to secondary gains of maintaining the sick role

Scenario: Two patients had to be restrained and isolated for an episode of physical aggression. The patients and staff were upset by the incident. The disruption of the milieu prompted the charge nurse to conduct a staff inservice that included, the principles of “least restrictive” interventions to be used when patients are in danger of harming self or others. Based on the principles of “least restrictive”, what is the correct order for interventions that are designed to prevent patients from harming self or others?

Instructions: Place the interventions in the correct order from the least restrictive to the most restrictive. In the left column are interventions that the staff can use. In the right column, write the number (1-9) to indicate the correct order: 1 being the least restrictive and 9 being the most restrictive.

Ans: 1e, 2j, 3c, 4h, 5i, 6d, 7a, 8g, 9f, 10b, 11k

The least restrictive method starts with the quick identification of escalating aggression to initiate early intervention. Addressing the person by name is the best way to make a therapeutic connection with a confused, agitated, or highly anxious patient. Clear and concise directions are given to stop the undesirable behavior and then the person is directed to independently do an alternative and acceptable behavior. Distraction is a step up from independent behavior because a staff member is selecting and guiding the patient’s actions. The patient should be allowed to stay in public areas if possible, and then progressively moved to more isolated spaces. After exhausting less restrictive methods, the patient can be physically (or chemically) restrained for safety. All interventions and patient responses should be carefully documented to validate progression from least restrictive to most restrictive.

Enhanced Hot Spot _________________________________________________

Scenario: A parent reports that her 19-year-old son started to have episodes of frustration and anxiety about 1 year ago. His grades declined and he withdrew from school activities and socializing with friends. After high school graduation, he had no interest in going to college or getting a job. Lately, he wants to go to the Antarctic, to get away from the voices that are always telling him what to do. He believes that eating pure Antarctic snow/foods will make him feel better. He has lost weight, because he rejects “unpure” food that his mother offers him.

Instructions: Underline or highlight the factors that indicate the patient may have a thought disorder, such as schizophrenia

Ans: A parent reports that her 19-year-old son started to have episodes of frustration and anxiety about 1 year ago. His grades declined and he withdrew from school activities and socializing with friends. After high school graduation, he had no interest in going to college or getting a job. Lately, he wants to go to the Antarctic to get away from the voices that are always telling him what to do. He believes that eating pure Antarctic snow/foods will make him feel better. His mother reports, he has lost weight, because he rejects the “unpure” food that his mother offers him. Vital signs: T 98.7° F (37°C), P 80, R 14, BP 115/78 mmHg. Assessment: Height: 5’ 9” (1.75 meters), Weight: 125 lbs (56.7 kg). Clothes are dirty and disheveled. Affect is flat. Displays poverty of speech and thought. Schizophrenia often starts in adolescence or young adulthood. For this patient, the nurse considers the onset and gradual progression of the symptoms. Early signs/symptoms are frustration and anxiety that worsen to a progressive loss of function in school, work or social activities. There is a gradual decline of hygiene and ability to meet basic needs. The negative symptoms of avolition, flat affect, poverty of thought and speech and decreased emotional expression further contribute to the person’s ability to interact with his/her environment. Positive symptoms include hallucinations (auditory being the most common) and delusions (fixed false belief ). There are other thought disorders that have similar symptoms, such as, delusional disorder, schizoaffective disorders, chizophreniform disorder and brief psychotic disorder

Scenario: A patient needs clonazepam 0.25 mg PO. The pharmacy delivers lorazepam 2-mg tablets. A nursing student asks the supervising nurse if clonazepam and lorazepam are interchangeable or if they are the same drug. What is the correct sequence of the steps that the nurse will teach the student to help decrease or prevent medication errors?

Instructions: Steps are listed in the left column. In the right column write in the number to indicate the correct sequence of steps to prevent medication errors; 1 being the first step and 9 being the last step

Ans: 1b, 2d, 3c, 4g, 5f, 6h, 7a, 8i, 9e

The first step is to maintain an awareness of the ways that medication errors can occur. Check the original prescription for legibility and clarification. (If the prescription is handwritten, these two drugs could easily be mistaken if the handwriting is not legible.) Consult a drug reference to determine the purpose of the prescribed medication; check to see if clonazepam and lorazepam are interchangeable or different names for the same drug. (Note: Medications become familiar with clinical practice and experience. Experienced nurses will recognize that clonazepam and lorazepam are not the same drug and therefore may not consult a reference; however, all nurses should continue to look up any new or unfamiliar drugs.) The patient should have a condition that warrants the prescribed medication (if unsure the student would be directed to go and look at the patient’s medical records). The HCP is notified if the prescription is not clear or if the medication does not seem appropriate for the patient’s condition. (HCPs can also mistake drug names.) If the HCP gives a new prescription, this is immediately entered onto the order sheet as a phone prescription. Advise the pharmacy about any errors or changes so that the correct medication is delivered. Documentation in the nurses’ notes would include a brief explanation about HCP and pharmacy notification (e.g., Dr. S contacted for clarification of clonazepam; pharmacy notified about prescription change). An incident report is submitted to evaluate circumstances and prevent system errors in the future.