PSY NSG

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Flumazenil (Romazicon) has been ordered for a male client who has overdosed on oxazepam (Serax). Before administering the medication, the nurse should be prepared for which common adverse effect? A. Seizures B. Shivering C. Anxiety D. Chest pain

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1

Flumazenil (Romazicon) has been ordered for a male client who has overdosed on oxazepam (Serax). Before administering the medication, the nurse should be prepared for which common adverse effect? A. Seizures B. Shivering C. Anxiety D. Chest pain

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

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2

The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to: A. Avoid shopping for large amounts of food B. Control eating impulses C. Identify anxiety-causing situations D. Eat only three meals per day

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

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3

A female client who's at high risk for suicide needs close supervision. To best ensure the client's safety, the nurse should: A. Check on the client frequently at irregular intervals throughout the night B. Assure the client that the nurse will hold in confidence anything the client says C. Repeatedly discuss previous suicide attempts with the client D. Disregard decreased communication by the client because this is common in suicidal clients

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

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4

Which of the following drugs should the nurse prepare to administer to a client with a toxic acetaminophen (Tylenol) level? A. deferoxamine mesylate B. succimer (Chemet) C. flumazenil (Romazicon) D. acetylcysteine (Mucomyst)

D. acetylcysteine (Mucomyth) Rationale: The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion of toxic metabolites to nontoxic metabolites. Deferoxamine meslyate is the antidote for iron intoxication. Succimer is an antidote for lead poisoning. Flumazenil reverses the sedative effects of benzodiazepines.

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A male client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is the nurse likely to administer to reduce the symptoms of alcohol withdrawal? A. naloxone (Narcan) B. haloperidol (Haldol) C. magnesium sulfate D. chlordiazepoxide (Librium)

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

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During postprandial monitor, a female client with bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting your time. After you sat with me yesterday, I was still able to purge. Today, my goal is to do it twice." What is the nurse's BEST responses? A. "I trust you not to purge." B. "How are you purging and when do you do it?" C. "Don't worry. I won't allow you to purge today." D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat."

D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat." Rationale: This response acknowledges that the clients is testing limits and that the nurse is setting them by performing postprandial monitoring to prevent self-induced eyes is. Clients with bulimia nervosa need to feel in control of the diet because they feel they lack control over all other aspects of their lives. Because their therapeutic relationships with caregivers are less important than their need to purge, they don't fear betraying the nurse's trust by engaging in the activity. They commonly plot purging and rarely share their secrets about it. An authoritarian or challenging response may trigger a power struggle between the nurse and client.

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A male client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, "It felt so wonderful to get high." Which of the following is the most appropriate response? A. "If you continue to talk like that, I'm going to stop speaking to you." B. "You told me you got fired from your past job for missing too may days after taking drugs all night." C. "Tell me more about how it felt to get high." D. "Don't you know it's illegal to use drugs?"

B. "You told me you got fired from your past job for missing too many days after taking drugs all night." Rationale: Confronting the client with the consequences of substance abuse helps to break through denial. Making threats (option A) isn't an effective way to promote self-disclosure or establish a rapport with the client. Although the nurse should encourage the client to discuss feelings, the discussing should focus on how the client felt before, not during, an episode of substance abuse (option C). Encouraging elaboration about his experience while getting high may reinforce the abusive behavior. The client undoubtedly is aware that drug use is illegal; a reminder to this effect (option D) is unlikely to alter behavior.

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For a female client with anorexia nervosa, the nurse is aware that which goal takes the highest priority? A. The client will establish adequate daily nutritional intake B. The client will make a contract with the nurse that sets a target weight C. The client will identify self-perceptions about body size as unrealistic D. The client will verbalize the possible psychological consequences of self-starvation

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

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When interviewing the parents of an injured child, which of the following is the strongest indicator that child abuse may be a problem? A. The injury isn't consistent with the history or the child's age B. The mother and father tell different stories regarding what happened C. The family is poor D. The parents are argumentative and demanding with emergency department personnel

A. The injury isn't consistent with the history or the child's age Rationale: When the child's injuries are inconsistent with the history given or impossible because of the child's age and developmental stage, the emergency department nurse should be suspicious that child abuse is occurring. The parents may tell different stories because their perception may be different regarding what happened. If they change their story with different health care workers ask the same question, this is a clue that child abuse may be a problem. Child abuse occurs in all socioeconomic groups. Parents may argue and be demanding because of the stress of having an injured child.

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For a female client with anorexia nervosa, the nurse plans to include the parents in therapy sessions along with the client. What fact should the nurse remember to be typical of parents of clients with anorexia nervosa? A. They tend to overprotects their children B. They usually have a history of substance abuse C. They maintain emotional distance from their children D. They alternate between loving and rejecting their children

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

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In the emergency department, a client with a facial lacerations states that her husband beat her with a shoe. After the health care team repairs her lacerations, she waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the client's husband arrives, shouting that he wants to "finish the job." What is the first priority of the health care worker who witnesses this scene? A. Remaining with the client and staying calm B. Calling a security guard and another staff member for assistance C. Telling the client's husband that he must leave at once D. Determining why the husband feels so angry

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

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The nurse is caring for a client with bulimia. Strict management of dietary intake is necessary. Which intervention is also important? A. Fill out the client's menu and make sure she eats at least half of what is on her tray B. Let the client eat her meals in private. Then engage her in social activities for at least 2 hours after each meal C. Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal D. Let the client eat food brought in by the family if she chooses, but she should keep a strict calorie count

C. Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal Rationale: Allowing the client to select her own food from the menu will help her feel some sense of control. She must then eat 100% of what she selected. Remaining with the client for at least 1 hour after eating will prevent purging. Bulimic clients should only be allowed to eat food provided by the dietary department.

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The nurse is assigned to care for a suicidal client. Which is the nurse's highest care priority? A. Assessing the client's home environment and relationships outside the hospital B. Exploring the nurse's own feelings about suicide C. Discussing the future with the client D. Referring the client to a clergy person to discuss the moral implications of suicide

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

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A 24-year-old client with anorexia nervosa tells the nurse, "When I look in the mirror, I hate what I see. I look so fat and ugly." Which strategy should the nurse use to deal with the client's distorted perceptions and feelings? A. Avoid discussing the client's perceptions and feelings B. Focus discussions on food and weight C. Avoid discussing unrealistic cultural standards regarding weight D. Provide objective data and feedback regarding the client's weight and attractiveness

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

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The nurse is caring for a client being treated for alcoholism. Before initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of the following products? A. Carbonated beverages B. Aftershave lotion C. Toothpaste D. Cheese

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

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The nurse is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan? A. Restrict visits with the family until the client begins to eat B. Provide privacy during meals C. Set up a strict eating plan for the client D. Encourage the client to exercise, which will reduce her anxiety

C. Set up a strict eating plan for the client Rationale: Establishing a consistent eating plan and monitoring the client's weight are important for this disorder. The family should be included in the client's care. The client should be monitored during meals - not given privacy. Exercise should be limited and supervised.

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The nurse is aware that the victims of domestic violence should be assessed for what important information? A. Reasons they stay in the abusive relationships (for example, lack of financial autonomy and isolation) B. Readiness to leave the perpetrator and knowledge of resources C. Use of drugs or alcohol D. History of previous victimization

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

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A male client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Police suspect the client was intoxicated at the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dL). The client later admits to drinking heavily for years. During hospitalization, the client periodically complains of tingling and numbness in the hands and feet. The nurse realizes that these symptoms probably result from: A. Acetate accumulation B. Thiamine deficiency C. Triglyceride buildup D. A below-normal serum potassium level

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

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A parents brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect that the child was abused? A. The child cries uncontrollably thoughout the examination B. The child pulls away from contact with the physician C. The child doesn't cry when the shoulder is examined D. The child doesn't make eye contact with the nurse

C. The child doesn't cry when the shoulder is examined Rationale: A characteristic behavior of abused children is lack of crying when they undergo a painful procedure or are examined by the healthcare professional. Therefore, the nurse should suspect child abuse. Crying throughout the examination, pulling away from the physician, and not making eye contact with the nurse are normal behaviors for preschoolers.

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When planning care for a client who has ingested phencyclidine (PCP), the nurse is aware that the following is the highest priority? A. Client's physical needs B. Client's safety needs C. Clients psychosocial needs D. Client's medical needs

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

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The nurse is aware that which outcome criteria would be appropriate for a child diagnosed with oppositional defiance disorder? A. Accept the responsibility for own behaviors B. Be able to verbalize own needs and assert rights C. Set firm and consistent limits with the client D. Allow the client to establish his own limits and boundaries

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

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A male client is found, sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at her bleeding wrists while staff members call for an ambulance. How should the nurse approach her initially? A. Enter the room quietly and move beside her to assess her injuries B. Call for staff back-up before entering the room and restraining her C. Move as much glass away from her and possible and sit next to her quietly D. Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her

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

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A female client with anorexia nervosa describes herself as "a whale". However, the nurse's assessment reveals that the client is 5'8" (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should the nurse include in the plan of care? A. Asking the client to compare her figure with magazine photographs of women her age B. Assigning the client to group therapy in which participants provide realistic feedback about her weight C. Confronting the client about her actual appearance during one-on-one sessions, schedule during each shift D. Telling the client of the nurse's concern for her health and desire to keep her making decisions to keep her healthy

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

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Eighteen hours after undoing an emergency appendectomy, a client with a reported history of social drinking displays these vital signs: temperature, 101.6 F (38.7 C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mmHg. The client exhibits gross hand tremors and is screening for someone to kill the bugs in the bed. The nurse should suspect: A. A postoperative infection B. Alcohol withdrawal C. Acute sepsis D. Pneumonia

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

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Clonidine (Catapres) can used to treat conditions other than hypertension. The nurse is aware that the following conditions might the drug be administered? A. Phencyclidine (PCP) intoxication B. Alcohol withdrawal C. Opiate withdrawal D. Cocaine withdrawal

C. Opiate withdrawal Rationale: Clonidine is used as adjective therapy in opiate withdrawal. Benzodiazepines, such as chlordiazepoxide (Librium), and neuroleptic agents, such as haloperidol, are used to treat alcohol withdrawal. Benzodiazepines and neuroleptic agents are typically used to treat PCP intoxication. Antidepressants and medications with dopaminergic activity in the brain, such as fluoxetine (Prozac), are used to treat cocaine withdrawal.

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A male client with a history of cocaine addiction is admitted to the coronary care unit for evaluation of substernal cheats pain. The electrocardiography (ECG) shows a 1-mm ST-segment elevation in the anteroseptal leads and T-wave inversion in leads V3 to V5. Considering the client's history of drug abuse, the nurse expects the physician to prescribe: A. Lidocaine (Xylocaine) B. Procainamide (Pronestyl) C. Nitroglycerin (Nitro-Bid IV) D. Epinephrine

C. Nitroglycerin (Nitro-Bid IV) Rationale: The elevated ST segments in this client's ECG indicate myocardial ischemia. To reverse this problem, the physician is most likely to prescribe an infusion of nitroglycerin to dilate the coronary arteries. Lidocaine and procainamide are cardiac drugs that may be indicated for this client at some point but aren't used for coronary artery dilation. If a cocaine user experiences ventricular fibrillation or a systole, the physician may prescribe epinephrine. However, this drug must be used with caution because cocaine may potential even its adrenergic effects.

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A 14-year-old client is brought to the clinic by her mother. Her mother expresses concern about her daughter's weight loss and constant dieting. The nurse conducts health history interview. Which of the following comments indicates that the client may be suffering from anorexia nervosa? A. "I like the way I look. I just need to keep my weight down because I'nm a cheerleader." B. "I don't like the food my mother cooks. I eat plenty of fast food when I'm out with my friends." C. "I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls." D. "I do diet around my periods; otherwise, I just get so bloated."

C. "I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls." Rationale: Low self-esteem is the highest risk factor for anorexia nervosa. Constant dieting to get down to a "desirable weight" is characteristic of the disorder. Feeling inadequate when compared to peers indicates poor self-esteem. Most clients with anorexia nervosa don't like the way they look, and their self-perception may be distorted. A girl with cachexia may perceive herself to be other weight when she looks in the mirror. Proffering fast food over health food is common in this age-group. Because of the absence of body fat necessary for proper hormone production, amenorrhea is common in this client with anorexia nervosa.

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The nurse is aware that drug of choice for treating Tourette syndrome? A. Fluoxetine (Prozac) B. Fluvoxamine (Luvox) C. Haloperidol (Haldol) D. Paroxetine (Paxil)

C. Haloperidol (Haldol) Rationale: Haloperidol is the drug of choice for treating Tourette syndrome. Prozac, Luvox, and Paxil are antidepressants and aren't used to treat Tourette syndrome.

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A male client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from the nurse? A. "Why didn't you get someone else to drive?" B. "Tell me how you feel about the accident." C. "You should know better than to drink and drive." D. "I recommend that you attend an Alcoholics Anonymous meeting."

B. "Tell me how you feel about the accident." Rationale: An open-ended statement or question is the most therapeutic response. It encourages the widest range of client responses, makes the client an active participant in the conversation, and shows the client that the nurse is interested in his feelings. Asking the client why he drove while intoxicated can make him feel defensive and intimidated. A judgmental approach isn't therapeutic. By giving advice, the nurse suggests that client isn't capable of making decision, thus fostering dependency.

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A male client voluntarily admits himself to the substance abuse unit. He confesses that he drinks 1 qt or more of vodka each day and uses container occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition? A. Vomiting, diarrhea, and bradycardia B. Dehydration, temperature above 101 F (38.3 C), and pruritis C. Hypertension, diaphoresis, and seizures D. Diaphoresis, tremors, and nervousness

D. Diaphoresis, tremors, and nervousness Rationale: Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic hallucinosis, and alcohol withdrawal delirium (formerly delirium tremens). Signs of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pulse rate, sleep disturbances, and irritability. Although diarrhea may be an early sign of alcohol withdrawal, tachycardia - not - bradycardia - is associated with alcohol withdrawal. Dehydration and an elevated temperature may be expected, but a temperature above 101 F indicates an infection rather than alcohol withdrawal. Pruritus rarely occurs in alcohol withdrawal. If withdrawal symptoms remain untreated, seizures may arise later.

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When monitoring a female client recently admitted for treatment of cocaine addiction, the nurse notes sudden increases in the arterial blood pressure and heart rate. To correct these problems, the nurse expects the physician to prescribe: A. Norepinephrine (Levophed) and lidocaine (Xylocaine) B. Nifedipine (Procardia) and lidocaine (Xylocaine) C. Nitroglycerin (Nitro-Bid IV) and esmolol (Brevibloc) D. Nifedipine (Procardia) and esmolol (Brevibloc)

D. Nifedipine (Procardia) and esmolol (Brevibloc) Rationale: This client requires a vasodilator, such as nifedipine to treat hypertension, and a beta-adrenergic blocker, such as esmolol, to reduce the heart rate. Lidocaine, an anti arrhythmic, isn't indicated because the client doesn't have an arrhythmia. Although nitroglycerin may be used to treat coronary vasospasm, it isn't the drug of choice in hypertension.

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A 25-year-old client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority? A. The client will commit to a drug-free lifestyle B. The client will work with the nurse to remain safe C. The client will drink plenty of fluids daily D. The client will make a personal inventory of strengths

B. The client will work with the nurse to remain safe Rationale: The priority goal in alcohol withdrawal is maintaining the client' safety. Committing to a drug-free lifestyle, drinking plenty of fluids, and identifying personal strengths are important goals, but ensure the client's safety is the nurse's top priority.

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A male client is admitted to a psychiatric facility by court order for evaluation for antisocial personality disorder. This client has a long history of initiating fights and abusing animals and recently was arrested for setting the neighbor's dog on fire. When evaluating this client for the potential for violence, the nurse should assess for which behavioral clues? A. A rigid posture, restlessness, and glaring B. Depression and physical withdrawal C. Silence and noncompliance D. Hyper vigilance and talk of past violent acts

A. A rigid posture, restlessness, and glaring Rationale: Behavior clues that suggest the potential for violence include a rigid posture, restlessness, glaring, a change in usual behavior, clenched hands, overtly aggressive actions, physical withdrawal, noncompliance, overreaction, hostile threats, recent alcohol ingestion or drug use, talk of past violent acts, inability to express feelings, repetitive demands and complaints, argumentative ness, profanity, disorientation, inability to focus attention, hallucinations or delusions, paranoid ideas or suspicions, and somatic complaints. Violent clients rarely exhibit depression, silence, or hypervigilance.

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Client is brought to the psychiatric clinic by family members, who tell the admitting nurse that the client repeatedly drives while intoxicated despite their pleas to stop. During an interview with the nurse, which statement by the client most strongly supports a diagnosis of psychoactive substance abuse? A. "I'm not addicted to alcohol. In fact, I can drink more than I used to without being affected." B. "I only spend half of my paycheck at the bar." C. "I just drink to relax after work." D. "I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me."

D. "I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me." Rationale: According the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, diagnostic criteria for psychoactive substance abuse include a maladaptive pattern of such use, indicated either by continued use despite knowledge or having a persistent or recurrent social, occupational, psychological, or physical problem caused or exacerbated by substance abuse or recurrent use in dangerous situations (for example, while driving). For this client, psychoactive substance dependence must be ruled out; criteria for this disorder include a need for increasing amounts of the substance to achieve intoxication (option A), increased time and money spent on the substance (option B), inability to fulfill role obligations (option C), and typical withdrawal symptoms.

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A female client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client's wrists are scratched from a recent suicide attempt. Based on this finding, the nurse should formulate a nursing diagnosis of: A. Ineffective individual coping related to feelings of guilt B. Situational low self-esteem related to feelings of loss of control C. Risk for violence: Self-directed related to impulsive mutilating acts D. Risk for violence: Directed toward other related to verbal threats

C. Risk for violence: Self-directed related to impulsive mutilating acts Rationale: The predominant behavior characteristic of the client with borderline personal out disorder is impulsiveness, especially of a physically self-destructive sort. The observation that the client has scratched wrists doesn't substantiate the other options.

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A male client recently admitted to the hospital with sharp, substernal chest pain suddenly complains of palpitations. The nurse notes a rise in the client's arterial blood pressure and a heart rate of 144 beats/minute. On further questioning, the client admits to having used cocaine recently after previously denying use of the drug. The nurse concludes that the client is at high risk for which complication of cocaine use? A. Coronary artery spasm B. Bradyarrhythmias C. Neuribehavioral deficits D. Panic disorder

A. Coronary artery spasm Rationale: Cocaine use may cause such cardiac complications as coronary artery spasm, myocardial infarction, dilated cardiomyopathy, acute heart failure, endocarditis, and sudden death. Cocaine blocks reuptake of norepinephrine, epinephrine, and dopamine, causing an excess of these neurotransmitters at postsynaptic receptor sites. Consequently, the drug is more likely to cause tachyarrhythmias than bradyarrhythmias. Although neurobehavioral deficits are common in neonates born to cocaine users, they are rare in adults. As craving for the drug increases, a person who's addicted to cocaine typically experiences euphoria followed by depression, not panic disorder.

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A male client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to: A. Begin after 7 days B. Not occur at all because the time period for their occurrence has passed C. Begin anytime within the next 1-2 days D. Begin within 2-7 days

C. Begin anytime within the next 1-2 days Rationale: Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1-2 days later. Delirium tremens may occur 2-4 days - even up to 7 days - after the last drink.

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The nurse is assigned to care for a client with anorexia nervosa. Initially, which nursing intervention is most appropriate for this client? A. Providing one-on-one supervision during meals and for 1 hour afterward B. Letting the client ears with other clients to create a normal mealtime atmosphere C. Trying to persuade the client to eat and thus restore nutritional balance D. Giving the client as much time to eat as desired

A. Providing one-on-one supervision during meals and for 1 hour afterward Rationale: Because the client with anorexia nervosa, may discard food or induce vomiting in the bathroom, the nurse should provide one-on-one supervision during meals and for 1 hour afterward. Option B wouldn't be therapeutic because other clients may urge the client to eat and give attention for not eating. Option C would reinforce control issues, which are central to this client's underlying psychological problem. Instead of giving the client unlimited time to eat, as in option D, the nurse should set limits and let the client know what is expected.

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39

A female client begins to experience alcoholic hallucinosis. The nurse is aware that the best nursing intervention at this time is: A. Keeping the client restrained in bed B. Checking the client's blood pressure every 15 minutes and offering juices C. Providing a quiet environment and administering medications as needed and prescribed D. Restraining the client and measuring blood pressure every 30 minutes

C. Providing a quiet environment and administering medications as needed and prescribed Rationale: Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment to reduce stimulation and administering prescribed central nervous system depressants in dosages that control symptom without causing oversedation. Although bed rest is indicated, restraints are unnecessary unless the client poses a danger to himself or others. Also, restrains may increase agitation and make the client feel trapped and helpless when hallucinating. Offering juices is appropriate but measuring blood pressure every 15 minutes would interrupt the client's rest. To avoid overstimulating the client, the nurse should check blood pressure every 2 hours.

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40

The nurse is aware that which assessment finding is most consistent with early alcohol withdrawal? A. Heart rate of 120-140 beats/minute B. Heart rate of 50-60 beats/minute C. Blood pressure of 100/70 mmHg D. Blood pressure of 140/80 mmHg

A. Heart rate of 120-140 beats/minute Rationale: Tachycardia, a heart rate of 120-140 beats/minute, is a common sign of alcohol withdrawal. Blood pressure may be labeled throughout withdrawal, fluctuating at different stages. Hypertension typically occurs in early withdrawal. Hypotension, although rare during the early withdrawal stages, may occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don't receive treatment. The nurse should monitor the client's vital signs carefully throughout the entire alcohol withdrawal process.

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41

The nurse is aware that which client is at highest risk for suicide? A. One who appears depressed, frequently thinks of dying, and gives away all personal possessions B. One who plans a violence death and has the means readily available C. One who tells others that he or she might do something if life doesn't get better soon D. One who talks about wanting to die

B. One who plans a violent death and has the means readily available Rationale: The client at highest risks for suicide is one who plans a violent death (for example, by gunshot, jumping off a bridge, or hanging), has a specific plan (for example, after the spouse leaves for work), and has the means readily available (for example, a rifle hidden in the garage). A client who gives away possessions, thinks about death, or talks about wanting to die or attempt suicide is considered at a lower risk for suicide because this behavior typically serves to alert others that this client is contemplating suicide and wishes to be helped.

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42

The nurse is aware that which of the following medical conditions is commonly found in clients with bulimia nervosa? A. Allergies B. Cancer C. Diabetes mellitus D. Hepatitis A

C. Diabetes mellitus Rationale: Bulimia nervosa can lead to many complications, including diabetes, heart disease, and hypertension. The eating disorder isn't typically associated with allergies, cancer, or hepatitis A.

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43

Kellan, a high school student, is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome? A. The student discusses conflicts over drug use B. The student accepts a referral to a substance abuse counselor C. The student agrees to inform his parents of the problem D. The student reports increased comfort with making choices

B. The student accepts a referral to a substance abuse counselor Rationale: All of the outcomes stated are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional substance abuse counselor.

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44

A male client who reportedly consumes 1 qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, Dr. Smith is most likely to prescribe which drug? A. Clozapine (Clozaril) B. Thiothixene (Navane) C. Lorazepam (Ativan) D. Lithium carbonate (Eskalith)

C. Lorazepam (Ativan) Rationale: The best choice for preventing or treating alcohol withdrawal symptoms is lorazepam, a benzodiazepine. Clozapine and thiothixene are antipsychotic agents, and lithium carbonate is an anti manic agent; these drugs aren't used to manage alcohol withdrawal syndrome.

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45

A male client is being treated for alcoholism. After a family meetings, the client's spouse asks the nurse about ways to help the family deal with the effects of alcoholism. The nurse should suggest that the family join with organization? A. Al-Anon B. Make Today Count C. Emotions Anonymous D. Alcoholics Anonymous

A. Al-Anon Rationale: Al-Anon is an organization that assists family members to share common experiences and increase their understanding of alcoholism. Make Today Count is a support group for people with life-threatening or chronic illnesses. Emotions Anonymous is a support group for people experiencing depression, anxiety, or similar conditions. Alcoholics Anonymous is an organization that helps alcoholics recover by using a 12-step program.

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46

A female client is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the client's physical health, the nurse should plan to: A. Severely restrict the client's physical activities B. Weigh the client daily, after the evening meal C. Monitor vital signs, serum electrolytes levels, and acid-base balance D. Instruct the client to keep an accurate record of food and fluid intake

C. Monitor vital signs, serum electrolyte levels, and acid-base balance Rationale: An anorexic client who requires hospitalization is in poor physical condition from starvation and may die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalances. Therefore, monitoring the client's vital signs, serum electrolyte levels, and acid-base balance is crucial. Option A may worsen anxiety. Option B is incorrect because a weight obtained after breakfast is more accurate than one obtained after the evening meal. Option D would reward the client with attention for not eating and reinforce the control issues that are central to the underlying psychological problem; also, the client may record food and fluid intake inaccurately.

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47

Kevin is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since. His history suggests maladaptive coping, which is associated with: A. Antisocial personality disorder B. Borderline personality disorder C. Obsessive-compulsive personality disorder D. Narcissistic personality disorder

A. Antisocial personality disorder Rationale: The client's history of delinquency, running away from home, vandalism, and dropping out of school are characteristic of antisocial personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others. In borderline personality disorder, the client exhibits mood instability, poor self-image, identity disturbance, and labile affect. Obsessive-compulsive personality disorder is characterized by a preoccupation with impulses and thoughts that the client realizes are senseless but can't control. Narcissistic personality disorder is marked by a pattern of self-involvement, grandiosity, and demand for constant attention.

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48

Macoy and Helen seek emergency crisis intervention because he slapped her repeatedly the night before. The husband indicates that his childhood was marred by an abusive relationship with his father. When intervening with this couple, the nurse knows they are at risk for repeated violence because the husband: A. Only has moderate impulse control B. Denies feelings of jealousy or possessiveness C. Has learned violence as an acceptable behavior D. Feels secure in his relationship with his wife

C. Has learned violence as an acceptable behavior Rationale: Family violence usually is a learned behavior, and violence typically leads to further violence, putting this couple at risk. Repeated slapping may indicate poor, not moderate, impulse control. Violent people commonly are jealous and possessive and feel insecure in their relationships.

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49

A client whose husband just left her has a recurrence of anorexia nervosa. The nurse caring for her realizes that this exacerbation of anorexia nervosa results from the client's effort to: A. Manipulate her husband B. Gain control of one part of her life C. Commit suicide D. Live up to her mother's expectations

B. Gain control of one part of her life Rationale: By refusing to eat, a client with anorexia nervosa is unconsciously attempting to gain control over the only part of her life she feels she can control. This eating disorder doesn't represent an attempt to manipulate others or live up to their expectations (although anorexia nervosa has a high incidence in families that emphasizes achievement). The client isn't attempting to commit suicide through starvation; rather, by refusing to eat, she is expressing feelings or despair, worthlessness,s and hopelessness.

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50

A male client has approached the nurse asking for advice on how to derail with his alcohol addiction. The nurse should tell the client that the only effective treatment for alcoholism is: A. Psychotherapy B. Total abstinence C. Alcoholics Anonymous (AA) D. Aversion therapy

B. Total abstinence Rationale: Total abstinence is the only effective treatment for alcoholism. Psychotherapy, attendance at AA meetings, and aversion therapy are all adjunctive therapies than can support the client in his efforts to abstain.

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51

A 48-year-old Hispanic woman is seen by a psychiatric clinical nurse specialist after receiving a call by her son. According to the son, since his father's death 7 months ago, his mother has lost 30 pounds and can't sleep. During her initial visit, the patient states, 'My husband talks to me in his visits, but his words make no sense to me. I don't understand what he wants me to do.' What is an appropriate nursing diagnosis? A. Ineffective denial. B. Bipolar mood disorder. C. Hyper-religiosity. D. Grieving.

D. Grieving.

Reason: Grieving may be characterized by weight loss, sleep disturbances, and messages from beyond.

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52

Your neighbor's husband comes to talk to you. He says his wife has not left the house in 2 weeks, has a flat mood, and has lost interest in her usual activities. You recognize these as the primary symptoms of A. Depression. B. Schizophrenia. C. Suicidal ideation. D. Bipolar manic episodes.

A. Depression.

Reason: Depressed mood and anhedonia (loss of interest or pleasure in activities) are the primary symptoms of major depression.

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53

Your patient is ready for discharge after a 30-day hospitalization for manic depression. About 30 minutes before his discharge, his roommate comes to you and says, 'He is talking crazy.' When you ask your patient how he is feeling, he states, 'I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator.' Which type of mania-related symptoms is this patient exhibiting? A. Social. B. Cognitive. C. Behavioral. D. Perceptual.

B. Cognitive.

Reason: Cognitive symptoms include inflated self-esteem and grandiosity.

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54

You need to assess whether a patient who has a mood disorder is ready for discharge. Which statement would indicate readiness for discharge? A. Right now, I can't bathe myself or dress myself, but I feel good about that. B. Going home will be fun, but if it isn't fun, I can always make my mother help me or tell her to do so. She better help me. C. I will take my medicines as I should and know to call the number you gave me if I have bad thoughts. D. Taking care of myself is important, but it's okay if I don't want to do anything.

C. I will take my medicines as I should and know to call the number you gave me if I have bad thoughts.

Reason: Verbalization of a plan for help and demonstration of care are realistic discharge criteria.

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55

An angry patient is in the community room. She picks up a chair and uses it to hit another patient on the head. When you come into the community room, what should your first response to the patient holding the chair be? A. Are you crazy? Hitting people can hurt them! B. Hitting others is unacceptable. Please put the chair completely down on the floor. C. How would you like it if I hit you over the head with a chair? D. You're in big trouble now. It's probably prison you are looking at!

B. Hitting others is unacceptable. Please put the chair completely down on the floor.

Reason: Use words to indicate your lack of acceptance of the patient's behavior in a nonthreatening voice or tone.

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56

A 22-year-old female is admitted to the unit following a suicide attempt. She has a 2-week history of depression as well as a history of abusing multiple substances and anorexia nervosa. What is your first nursing priority? A. Socialization. B. Contracting for eating behavior. C. Safety. D. Administering the Beck depression scale.

C. Safety.

Reason: Safety is the major principle underlying psychiatric nursing.

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57

Gerald was admitted to the psychiatric acute care unit because he stood in the center of a main two-way street in his underwear and a T-shirt, shouting, 'I am being held against my will. I have personal rights.' Gerald was diagnosed with bipolar disorder, manic type. Which of the following interventions will add to everyone's safety in the acute care environment? A. Have hectic surroundings. B. Have consistent unit routines. C. Minimize staff interventions. D. Medicate the patient only if he has private health insurance.

B. Have consistent unit routines.

Reason: Quiet environments with consistent routines will help calm patients and add to safety.

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58

Your patient has just been physically cleaned up after slicing his left arm 8 times. To show an appropriate evaluative response, which of the following would be your best statement? A. I could care less if you cut yourself. It doesn't hurt me. B. If you wouldn't cut yourself, you would have a much happier life. C. You are lucky someone found you in time. Now you can help us make you better. D. The behavior of cutting is not acceptable.

D. The behavior of cutting is not acceptable.

Reason: Focus on the behavior, not the person. Be neutral, but not indifferent.

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59

A 22-year-old female was admitted to the mental health unit with major depression and suicidal ideation. She has a history of cutting her wrists intermittently throughout the last 2 years. On days 1 and 2, the patient stays in her room and eats only 20% of her meals. On day 3, she eats 80% of her meals and is talking to others in group. The nurse should consider that the patient is A. Showing improvement. B. Highly suicidal. C. Exhibiting mood swings. D. In need of electroshock therapy.

A. Showing improvement.

Reason: The patient improvement is based on increased socialization and increased appetite.

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60

A 21-year-old patient has a diagnosis of schizophrenia and is stuporous, yet exhibits sudden, excessive motor activity with repetitive sit-ups. What is this behavior called? A. Delusional. B. Hallucinogenic. C. Paranoid. D. Catatonic.

D. Catatonic.

Reason: Catatonic schizophrenia occurs suddenly and includes motor immobility or excessive motor activity.

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61

A 16-year-old girl is admitted for her first psychotic break. Her parents feel very guilty. What is your best nursing response? A. No one really knows the cause of schizophrenia. It is not your fault and is not due to anything you did in the past. It is important to understand this, to support your daughter, and to find support for yourselves. B. Does anyone in your family have schizophrenia, as this disease is known to be genetic? C. You may feel bad now, but there are so many other bad things out there, such as cancer and paralysis. D. Let me share with you some websites to help you deal with your guilt.

A. No one really knows the cause of schizophrenia. It is not your fault and is not due to anything you did in the past. It is important to understand this, to support your daughter, and to find support for yourselves.

Reason: Schizophrenia has a multifocal origin and its cause may include a genetic component. Support is needed for both patients and caregivers.

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62

A physical indicator of possible abuse in a battered woman would be a fracture of the distal bones, such as the skull, face, or extremities. A. TRUE B. FALSE

A. TRUE

Reason: Musculoskeletal fractures and sprains, especially of distal versus proximal bones, are indications of battering. Also assess for dislocated shoulders and old fractures.

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63

Which of the following statements indicates that your patient, who has schizophrenia, is ready to manage a relapse? A. I will think of a plan of action before I get these racing thoughts again. B. I will not drink alcohol and will exercise daily. This will help me stay well. C. If I start feeling badly and don't sleep very much, then I will tell my friend Sandy and talk to her. She or I will call my therapist. D. When I feel stressed, I will sit near my bed and wait to feel better.

C. If I start feeling badly and don't sleep very much, then I will tell my friend Sandy and talk to her. She or I will call my therapist.

Reason: Managing a relapse includes a plan of action, involvement of a friend or family member, and, after identification of signs, notification of a therapist.

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64

Your patient has a diagnosis of schizophrenia and believes that his thoughts are broadcast from his head. What is the most appropriate nursing diagnosis? A. Risk for self-directed violence. B. Disturbed sensory perception. C. Impaired verbal communication. D. Disturbed thought processes.

D. Disturbed thought processes.

Reason: Thought broadcasting and thought withdrawal are disturbed thought processes.

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65

As a nurse, you wish to reinforce functional behavior in your schizophrenic patient. Which intervention will accomplish reinforcement? A. Praise the patient for reality-based perceptions and cessation of acting-out behaviors. B. Educate the patient about the symptoms of schizophrenia. C. Facilitate learning about the importance of medication compliance using written materials for reinforcing medication use. D. Focus on the feelings of delusion to reinforce reality and decrease false beliefs by talking to the patient.

A. Praise the patient for reality-based perceptions and cessation of acting-out behaviors.

Reason: Reinforcement by praise increases functional behavior.

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66

Your patient is preoccupied with perfection and control, has difficulty relaxing, exhibits rule-conscious behavior, and cannot discard anything. What type of personality disorder does this behavior reflect? A. Antisocial personality. B. Obsessive-compulsive personality. C. Manic behavior. D. Anxiety disorder.

B. Obsessive-compulsive personality.

Reason: Obsessive-compulsive disorder is a personality disorder that includes perfection, control, procrastination, excessive devotion to work, difficulty relaxing, rule-conscious behavior, and inability to discard anything.

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67

Which of the following questions is appropriate to assess for disturbances in a patient's relationships? A. What are your main worries? B. Have you ever used alcohol or illegal drugs? C. How has your appetite been in the past month? D. What do you talk about with friends?

D. What do you talk about with friends?

Reason: Asking what the patient talks about with family or friends and what types of activities he or she engages in can help assess relationships.

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68

Which type of therapy helps patients with personality disorders explore ways to enjoy themselves and increase their socialization skills? A. Occupational therapy. B. Recreational therapy. C. Music therapy. D. Medication therapy.

B. Recreational therapy.

Reason: Recreational therapy helps patients explore ways to enjoy themselves without using alcohol or drugs and strengthens social skills.

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69

Which of the following symptoms of alcohol detoxification would you be most concerned about? A. Vitamin and mineral depletion. B. Diaphoresis. C. Increased heart rate. D. Hallucinations and delusions.

D. Hallucinations and delusions.

Reason: Hallucinations and delusions can result in problems with safety and possibly lead to suicide.

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70

What is the priority nursing intervention to help orient a patient who has Alzheimer's disease? A. Post a schedule in the dining room of daily activities. B. Use an overhead loudspeaker to announce upcoming events. C. Provide a daily routine and easy-to-read clocks. D. Have the patient live alone in a private room.

C. Provide a daily routine and easy-to-read clocks.

Reason: Daily routines and large clocks help patients' functional status.

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71

You are caring for a patient and pour out his evening risperidone (Risperdal) 2 mg tablet. The pill falls on the countertop. What is your next intervention? A. Pick the pill up from the counter and place it in a cup. B. Wash the pill off with alcohol and place it in a cup. C. Discard the pill and repour the medication. D. Call the patient up to the pill line to receive his medication.

C. Discard the pill and repour the medication.

Reason: The pill is contaminated once dropped, so for infection control purposes you discard it and repour the medication.

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72

Your patient has just shown you some fresh, self-inflicted, superficial cuts-eight of them going up and down his right arm. What is your initial intervention based on infection control principles? A. Send the patient back to his room as part of behavioral modification. B. Suture the cuts using a large-bore needle and nondissolving sutures. C. Cleanse the wounds with soap and water. D. Administer tetanus toxoid injection intramuscularly.

C. Cleanse the wounds with soap and water.

Reason: Cleansing the wound with soap and water is the initial intervention.

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73

A hypomanic patient tells you that she has been 'picking up energy from my car engine and car CD player' while driving and has received five speeding tickets in the past 6 months. What would be one effective intervention to avoid fast driving? A. Make a contract not to drive more than 55 miles per hour and drive with the CD played turned off. B. Call the local police and alert them to the patient's car license plate number and the make and model of her car. C. Ask the patient to "hand over the keys" to you, and tell her that now she must use a cab or other public transportation until your next session. D. Share with the patient that she cannot drink and drive.

A. Make a contract not to drive more than 55 miles per hour and drive with the CD played turned off.

Reason: Contracts can see a patient through period of hypomanic agitation.

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74

Patients who require close surveillance due to the potential for safety hazards give up the right of A. Continued confusion. B. Decision making. C. Social contact. D. Privacy.

D. Privacy.

Reason: Privacy and autonomy are often given up for the sake of safety.

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75

patient is extremely agitated and is throwing body fluids at anyone who comes near him. What is the best way to protect yourself as you and others physically restrain the patient? A. Wash your clothes within 30 minutes of becoming soiled with body fluids. B. Wear protective eyewear and a face shield. C. Check that your tetanus and hepatitis B titers are within normal limits. D. Wear a gown over your clothes and shoe covers.

B. Wear protective eyewear and a face shield.

Reason: Protective gear helps prevent infections that may gain entry through openings in the skin, the eyes, or the mouth.

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76

A patient who is psychotic has a formed bowel movement on the floor of his room. How should you clean up this excrement? A. Use a thick diaper or pad. B. Wear gloves and use some paper towels or toilet paper. C. Wear gloves, use toilet paper, and wash the area with a 1:10 bleach solution. D. Wear a gown, shoe covers, mask, and chemotherapy-impervious gloves, and wash the area with an ammonia with bleach 1:1 solution.

C. Wear gloves, use toilet paper, and wash the area with a 1:10 bleach solution.

Reason: Clean all body fluids with an appropriate disinfectant such as 1:10 bleach solution, using universal precautions.

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77

Your patient is scheduled for a one-on-one therapy session. Upon his entry into your office, you note that the patient has a cough, is sweating, is coughing up a small amount of blood, and has a fever. What is your initial intervention regarding infection control? A. Wash all of the patient's sheets and clothes. B. Place a mask on the patient and yourself. C. Take the patient's temperature. D. Place resuscitation equipment in the patient's room.

B. Place a mask on the patient and yourself.

Reason: The patient might have tuberculosis, so wear a mask, especially given that the patient is coughing.

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78

You have just given your patient an intramuscular injection of fluphenazine (Prolixin) with a syringe that does not have a safety lock. What is your next step? A. Recap the needle. B. Snap the needle off and place it in the needle box. C. Immediately place the syringe in a nearby impermeable container. D. Clip the needle off with a syringe needle cutter (SNC).

C. Immediately place the syringe in a nearby impermeable container.

Reason: Place the syringe in a nearby container specific for needles. Do not recap, bend, clip, or manipulate the needle in any way.

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79

In an inpatient acute psychiatric unit, it is important to shut and lock the unit door behind you. A. TRUE B. FALSE

A. TRUE

Reason: This behavior enhances safety.

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80

You drive up to the house of your patient, who is known to have schizophrenia with manic episodes. This is your fifth visit. On this occasion, the patient is sitting on his front porch in a rocking chair with a shotgun in his arms. What should your next intervention be? A. Beep your car horn to get your patient's attention. B. Yell your patient's name out your car window and wave at him to say hello. C. Keep driving in a path that is going away from the patient's house. D. Stop the car in the patient's driveway and call your boss on your cell phone.

C. Keep driving in a path that is going away from the patient's house.

Reason: Safety includes not placing yourself in vulnerable situations.

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81

Your patient, who is in a community psychiatric program, shows up at your home peeping through your kitchen window. You also noticed the patient yesterday when you went to the grocery story and the hairdresser. You believe he is stalking you. What should you do? A. Call the local police and report your suspicion of stalking. B. Call the patient's spouse and discuss his behavior. C. Invite the patient to have a cup of coffee with you at a local café to discuss his behavior. D. Wait until the patient's next group meeting to discuss his stalking behavior.

A. Call the local police and report your suspicion of stalking.

Reason: Stalking behavior needs to be dealt with by the police for your safety.

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82

Your patient's auditory, visual, and tactile hallucinations are controlled with bimonthly injections of haloperidol (Haldol) that the community health nurse administers during home visits. You are the new nurse on this case; the previous nurse has retired. The previous nurse has stated in her care plan that the patient will let the nurse in the house only if the nurse carries a public health-issued blue bag and wears black pants. You are scheduled to visit this patient tomorrow. What should you do? A. Call the patient and tell her that you are a new nurse and will be wearing white pants. B. Show up as scheduled carrying only a stethoscope, vial, alcohol wipe, and medication syringe. C. Show up as scheduled with a police officer. D. Telephone the patient, introduce yourself, and show up carrying a blue bag and wearing black pants.

D. Telephone the patient, introduce yourself, and show up carrying a blue bag and wearing black pants.

Reason: The patient needs her medication, and following the care plan is the optimal course of action.

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83

Your patient has an admitting diagnosis of alcohol withdrawal syndrome. You receive a phone call at the nurses' station from a person who says he is the patient's minister and wants to know if the patient 'fell off the wagon again' and when visitation hours are. What is your best response? A. Yes, the patient drank too much, but he should be fine in a few days. Visiting hours are 9 A.M. to 6 P.M. B. We do not give out any information. Visitation hours in the hospital are from 9 A.M. to 6 P.M. daily. C. Please pray for the patient; he is in bad shape. You can visit him anytime between 9 A.M. and 6 P.M. daily. D. Please contact the hospital's chief executive officer, who can give you the information you are requesting.

B. We do not give out any information. Visitation hours in the hospital are from 9 A.M. to 6 P.M. daily.

Reason: Patient confidentiality is required, and there is no way to verify the identity of the person calling.

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84

Your patient has been hospitalized for acute alcohol withdrawal. It is the fifth day, and he is having visual hallucinations followed by a seizure. What is the most likely source of the patient's problem? A. Autonomic dysreflexia (AD). B. A brain tumor. C. Sleep deprivation. D. Delirium tremens (DTs).

D. Delirium tremens (DTs).

Reason: Delirium tremens occurs as acute alcohol withdrawal progresses. It includes symptoms such as clouding of sensorium, hallucinations, seizures, and autonomic hyperactivity.

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85

Which of the following assessments is used to confirm alcohol intake? A. Pupil dilation. B. Serum sample. C. Hair shaft analysis. D. Sputum sample.

B. Serum sample.

Reason: Urine and serum samples are toxicology specimens used to assess and monitor alcohol withdrawal.

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86

Which of the following questions is most appropriate to ask in screening for a potential problem of high alcohol intake? A. Have you felt you should cut down on your alcohol consumption? B. Do you enjoy getting smashed? C. Have you ever thought about killing someone? D. In the last week, have you had a glass of wine?

A. Have you felt you should cut down on your alcohol consumption?

Reason: Screening requires questions associated with cutting down, feelings of guilt about drinking, and having a first drink in the morning.

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87

Your patient in the Emergency Department has a diagnosis of acute alcohol withdrawal syndrome (AWS). He is acting euphoric, yet shy. The APN has prescribed the following care: CAGE questionnaire, serum for toxicology, IV of D5 1/2 NS and 1 amp multivitamin (MVI) at 75 mL/h, neuro check q 1 h. What is your first priority? A. Administer the CAGE questionnaire. B. Start the IV. C. Do the neuro check. D. Obtain a serum blood sample.

D. Obtain a serum blood sample.

Reason: Obtain a toxicology sample, as the patient is too euphoric to answer the CAGE questionnaire. The IV and neuro checks can wait.

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88

Your patient sees you at a preplanned postoperative visit 4 weeks after being hospitalized for acute alcohol withdrawal. Upon questioning, she states that her husband is abusive, so she drinks to 'drown out his yelling.' The patient also complains of depression and severe pain in the epigastric region that radiates to her back and has been constant since yesterday. She has vomited twice in the past 12 hours. What is your first priority? A. Refer her immediately for treatment of depression. B. Call social services and report spousal abuse. C. Assess her for pancreatitis. D. Administer a test or scale that assesses alcohol withdrawal.

C. Assess her for pancreatitis.

Reason: Approximately 65% of cases of pancreatitis are related to alcohol. This patient is exhibiting the classic symptoms of this disease.

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89

Prolonged alcohol ingestion can cause disorders of the liver such as A. Pancreatitis. B. Hypomagnesemia. C. Cirrhosis. D. Colitis

D. Colitis

Reason: Cirrhosis is a liver disorder that can result from prolonged ingestion of alcohol.

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90

Adolescent suicide has increased over the past and is among the top five causes of death in U.S. adolescents. A. TRUE B. FALSE

A. TRUE

Reason: Adolescent suicides have quadrupled since 1950 and are the third leading cause of death in U.S. adolescents.

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91

Alcohol tolerance develops as a result of the central nervous system's adaptive mechanisms. A. TRUE B. FALSE

A. TRUE

Reason: The central nervous system adapts, so more alcohol is needed to obtain the initial effects of alcohol ingestion, especially euphoria.

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92

Your patient experienced alcohol withdrawal syndrome and now admits he 'needs help.' Which of the following is the most appropriate resource to which you should direct the patient? A. Reach to Recovery. B. Alcoholics Anonymous. C. Depression support group. D. Suicide support group.

B. Alcoholics Anonymous.

Reason: Alcoholics Anonymous is the most appropriate resource for alcoholism, although depression may or may not be involved in this case.

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93

Which of the following is a common symptom of a major depressive episode? A. Loss of hearing. B. Increased energy. C. Hopelessness. D. Recurrent thoughts of well-being.

C. Hopelessness.

Reason: Hopelessness, loss of pleasure, and a profound sense of sadness are symptoms of a major depressive episode.

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94

Which of the following statements would indicate a depressed mood? A. I can't wait to go to the ballgame today; it should be fun. B. I feel sad today, just like yesterday. C. I feel like going to the gym for a workout today, then maybe to a movie. D. Since it's raining outside, how about a game of chess?

B. I feel sad today, just like yesterday.

Reason: A subjective report of feeling sad or empty is a sign of depression.

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95

Which of the following medical conditions has similar signs and symptoms as those seen in a major depressive episode? A. Pancreatitis. B. Cholecystitis. C. Tuberculosis. D. Hypothyroidism.

D. Hypothyroidism.

Reason: Signs and symptoms of hypothyroidism include changes in weight, sleep disturbances, decreased energy, and difficulty in thinking—just like in depression.

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96

Once a patient is diagnosed with a major depressive episode, the primary nursing intervention should be associated with A. Safety. B. Pharmacology. C. Administration of gastric lavage. D. Hemodialysis.

A. Safety.

Reason: Safety is the primary focus for an intervention, as 25% to 30% of depressed patients are at risk for suicide.

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97

A 35-year-old male patient has been brought to your hospital unit after making a suicide attempt at his workplace. Which of the following interventions can you legally implement? A. Call the patient's girlfriend and inform her of his admission and visiting hours. B. Physically search the patient for weapons and harmful materials. C. Call the patient's boss at work and report him as in need of extended medical leave. D. Place the patient in four-point restraints and begin an IV for sedation.

B. Physically search the patient for weapons and harmful materials.

Reason: A suicide attempt is a serious and self-destructive behavior that demands searching for weapons and harmful materials to increase safety.

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98

Your patient has just received his sixth electroconvulsant therapy outpatient treatment. He tells you that he plans to drive himself home because his wife is working at her part-time job today. What is your best response? A. Be careful and drive slowly. B. You need to wait 30 minutes and then you will be safe to drive. C. Let me take your vital signs; if they are stable, then you can drive. D. You cannot drive. I can call you a cab, or would you prefer to call your wife or someone for a ride home?

D. You cannot drive. I can call you a cab, or would you prefer to call your wife or someone for a ride home?

Reason: Patients cannot drive after ECT, as its effects can include disorientation, muscle pain, central nervous system depression, and cardiac dysrhythmias.

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99

Which of the following patients is at risk for depression? A. A patient with history of diabetes mellitus. B. A patient with a depressive genetic predisposition. C. A patient who recently bought a puppy. D. A patient who had only 6 hours of sleep last night due to watching a TV movie.

B. A patient with a depressive genetic predisposition.

Reason: Risk factors include genetic predisposition, a recent loss or trauma, and a feeling of sadness or hopelessness.

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100

A patient has been admitted to your unit with a drug overdose, and you need to assess for acidosis and hypoxemia. Which test should you perform? A. Complete blood count (CBC). B. Serum electrolytes. C. Partial thromboplastin time (PTT). D. Arterial blood gases (ABG).

D. Arterial blood gases (ABG).

Reason: ABGs assess for acidosis [pH, bicarbonate, and hypoxemia (pO2)].

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