TEST BANK for Stahl's Essential Psychopharmacology 5th Edition

COMPLETE TEST BANK Stahl's Essential Psychopharmacology 5th Edition Test bank Neuroscientific Basis and Practical Applications TESTBANK/STUDY GUIDE

Stahl's Essential Psychopharmacology Neuroscientific Basis and Practical Applications TESTBANK/STUDY GUIDE

Chapter 1 Chemical neurotransmission MULTIPLE CHOICE 1.

A patient with depression mentions to the nurse, My mother says depression is a chemical disorder. What does she mean? The nurses response is based on the theory that depression primarily involves which of the following neurotransmitters? a.

Cortisol and GABA

b.

COMT and glutamate

c.

Monamine and glycine

d.

Serotonin and norepinephrine

ANS: D One possible cause of depression is thought to involve one or more neurotransmitters.

Serotonin and norepinephrine have been found to be important in the regulation of depression. There is no research to support that the other options play a significant role in the development of depression.

2.

A patient has experienced a stroke (cerebral vascular accident) that has resulted in damage to the Broca area. Which evaluation does the nurse conduct to reinforce this diagnosis? a.

Observing the patient pick up a spoon

b.

Asking the patient to recite the alphabet

c.

Monitoring the patients blood pressure

d.

Comparing the patients grip strength in both hands

ANS: B Accidents or strokes that damage Brocas area may result in the inability to speak (i.e., motor aphasia). Fine motor skills, blood pressure control, and muscle strength are not controlled by the Broca area of the left frontal lobe.

3.

The patient diagnosed with schizophrenia asks why psychotropic medications are always prescribed by the doctor. The nurses answer will be based on information that the therapeutic action of psychotropic drugs is the result of their effect on: a.

The temporal lobe; especially Wernickes area

b.

Dendrites and their ability to transmit electrical impulses

c.

The regulation of neurotransmitters especially dopamine

d.

The peripheral nervous system sensitivity to the psychotropic medications

ANS: C Medications used to treat psychiatric disorders operate in and around the synaptic cleft and have action at the neurotransmitter level, especially in the case of schizophrenia, on dopamine. The Wernickes area, dendrite function, or the sensitivity of the peripheral nervous system are not relevant to either schizophrenia or psychotropic medications.

4.

A student nurse mutters that it seems entirely unnecessary to have to struggle with understanding the anatomy and physiology of the neurologic system. The mentor would base a response on the understanding that it is:

a.

Necessary but generally for psychiatric nurses who focus primarily on behavioral interventions

b.

A complex undertaking that advance practice psychiatric nurses frequently use in their practice

c.

Important primarily for the nursing assessment of patients with brain traumacaused cognitive symptoms

d.

Necessary for planning psychiatric care for all patients especially those experiencing psychiatric disorders ANS: D

Nurses must understand that many symptoms of psychiatric disorders have a neurologic basis, although the symptoms are manifested behaviorally. This understanding facilitates effective care planning. The foundation of knowledge is not used exclusively by advanced practice psychiatric nurses nor is it relevant for only behavior therapies or brain trauma since dealing with the results of normal and abnormal brain function is a responsibility of all nurses providing all types of care to the psychiatric patient.

5.

A patient asks the nurse, My wife has breast cancer. Could it be caused by her chronic depression? Which response is supported by research data? a.

Too much stress has been proven to cause all kinds of cancer.

b.

There have been no research studies done on stress and disease yet.

c.

Stress does cause the release of factors that suppress the immune system.

d.

There appears to be little connection between stress and diseases of the body

ANS: C Research indicates that stress causes a release of corticotropin-releasing factors that suppress the immune system. Studies indicate that psychiatric disorders such as mood disorders are sometimes associated with decreased functioning of the immune system.

Research does not support a connection between many cancers and stress. There is a significant amount of research about stress and the body. Research has shown that there are some connections between stress and physical disease.

6.

A patient who has a parietal lobe injury is being evaluated for psychiatric rehabilitation needs. Of the aspects of functioning listed, which will the nurse identify as a focus of nursing intervention? a.

Expression of emotion

b.

Detecting auditory stimuli

c.

Receiving visual images

d.

Processing associations

ANS: D The parietal lobe is responsible for associating and processing sensory information that allows for functions such as following directions on a map, reading a clock, dressing self, keeping appointments, and distinguishing right from left. Emotional

expression is associated with frontal lobe function. Detecting auditory stimuli is a temporal lobe function. Receiving visual images is related to occipital lobe function.

7.

At admission, the nurse learns that some time ago the patient had an infarct in the right cerebral cortex. During assessment, the nurse would expect to find that the patient: a.

Demonstrates major deficiencies in speech

b.

Is unable to effectively hold a spoon in the left hand

c.

Has difficulty explaining how to go about using the telephone

d.

Cannot use his right hand to shave himself or comb his own hair

ANS: B The cerebral hemispheres are responsible for functions such as control of muscles.

The right hemisphere mainly controls the motor and sensory functions on the left side of the body. Damage to the right side would result in impaired function on the left side of the body. The motor cortex controls voluntary motor activity. Brocas area controls motor speech. Cognitive functions are attributed to the association cortex.

The right side of the bodys motor activity is controlled by the left cerebral cortex.

8.

A patient with chronic schizophrenia had a stroke involving the hippocampus.

The patient will be discharged on low doses of haloperidol. The nurse will need to individualize the patients medication teaching by: a.

Including the patients caregiver in the education

b.

Being careful to stress the importance of taking the medication as prescribed

c.

Providing the education at a time when the patient is emotionally calm and relaxed

d.

Encouraging the patient to crush or dissolve the medication to help with swallowing ANS: A

The hippocampus plays a major role in short-term memory and, hence, in learning.

Taking the medication as prescribed and providing the education at a time when the

patient is calm and relaxed is information or considerations that all patients should be given. The medication does not necessarily need to be crushed or dissolved since the stroke would not have caused difficulty with swallowing.

9.

The physician tells the nurse, The medication Im prescribing for the patient enhances the g-aminobutyric acid (GABA) system. Which patient behavior will provide evidence that the medication therapy is successful? a.

The patient is actively involved in playing cards with other patients.

b.

The patient reports that, I dont feel as anxious as I did a couple of days ago.

c.

The patient reports that both auditory and visual hallucinations have decreased.

d.

The patient says that, I am much happier than before I came to the hospital.

ANS: B GABA is the principle inhibitory neurotransmitter. The medication should provide an antianxiety effect. Alertness, psychotic behaviors, and mood elevation are not generally affected by g-aminobutyric acid.

10.

The patients family asks whether a diagnosis of Parkinsons disease creates an increased risk for any mental health issues. What question would the nurse ask to assess for such a comorbid condition? a.

Has your father exhibited any signs of depression?

b.

Does your father seem to experience mood swings?

c.

Have you noticed your father talking about seeing things you cant see?

d.

Is your dad preoccupied with behaviors that he needs to repeat over and over?

ANS: A Serotonin and its close chemical relatives, dopamine and norepinephrine, are the neurotransmitters that are most widely involved in various forms of depression. Most researchers agree that the immediate cause of parkinsonism is a deficiency of dopamine and so a patient with Parkinsons disease should be monitored for depression, The other mental health disorders (bipolar disorder, hallucinations, and obsessive compulsive disorder) have not been connected to Parkinsons disease.

11.

Which explanation for the prescription of donepezil (Aricept) would the nurse provide for a patient in the early stage of Alzheimers disease? a.

It will increase the metabolism of excess GABA.

b.

Excess dopamine will be prevented from attaching to receptor sites.

c.

Serotonin deficiency will be managed through a prolonged reuptake period.

d.

The acetylcholine deficiency will be managed by inhibiting cholinesterase.

ANS: D

Decreased levels of acetylcholine are thought to produce many of the behavioral symptoms of Alzheimers disease. The inhibiting action the drug has on cholinesterase will slow down the breakdown of acetylcholine and so delay the onset of symptoms.

The other neurotransmitters (GABA, dopamine, and serotonin) are not currently believed to play a role in Alzheimers disease.

12.

There remains a stigma attached to psychiatric illnesses. The psychiatric nurse makes the greatest impact on this sociological problem when: a.

Providing educational programming for patients and the public

b.

Arranging for adequate and appropriate social support for the patient

c.

Assisting the patient to achieve the maximum level of independent functioning

d.

Regularly praising the patient for seeking and complying with appropriate treatment ANS: A Much of the stigma attached to psychiatric illness is due to a lack of understanding of the biologic basis of these disorders. Therefore, effective patient, family, and public teaching is an important function of the role of the psychiatric mental health nurse.

While the remaining options are appropriate, they are not directed towards eliminating social stigma but rather empowering the patient.

13.

The wife of a patient with paranoid schizophrenia tells the nurse, Ive learned that my husband has several close relatives with the same disorder. Does this problem run in families? The response based on recent discoveries in the field of genetics would be: a.

Your children should be monitored closely for the disorder.

b.

Research tends to support a familiar tendency to schizophrenia.

c.

There is no concrete evidence; it is just as likely a coincidence.

d.

Only bipolar disorder has been identified to have a genetic component.

ANS: B Familial tendencies appear with several psychiatric disorders including schizophrenia.

To insinuate that the children are at such risk would not be supported by research.

14.

A patient whose symptoms of mild depression have been managed with antidepressants is concerned about the affect of accepting a promotion that will require working the night shift. What will be the basis of the response the nurse gives to address the patients concern? a.

The connection between a new job and possible depression does exist.

b.

The medication can be adjusted to manage any increase in depression.

c.

The interruption in normal wake-sleep patterns can influence mood disorders.

d.

The change in sleep routine can be managed with a healthy sleep hygiene routine.

ANS: C Many psychiatric and medical disorders occur more frequently or are exacerbated when sleep patterns and biologic rhythms are disrupted. While the remaining options contain true information regarding the management of depression that is a result of sleep disruption, they do not effectively address the patients concern.

15.

The nurse is discouraged because the patient exhibiting negative symptoms of schizophrenia has shown no improvement with the planned interventions to reduce the symptoms. The mentors remark that helps place the problem in perspective is: a.

You arent responsible for the behavior of any other person.

b.

Patients can be perverse and cling to symptoms despite our efforts.

c.

Negative symptoms have been associated with genetic pathology.

d.

It will take several trail and error attempts to get the right combination care.

ANS: C A complex disorder, such as schizophrenia, most likely has multiple contributing factors, including genetic predisposition, prenatal development, and the environment.

Nurse frustration can be alleviated by helping the nurse realize that negative symptoms may be the result of actual brain dysfunction, rather than psychologically

determined behaviors; thus the remaining options are not appropriate since they do not address the complexity of the problem.

MULTIPLE RESPONSE 1.

What assessment data would reinforce the diagnosis of temporal lobe injury in patient who experienced head trauma? Select all that apply. a.

Inability to balance a checkbook

b.

Uncharacteristically aggressive

c.

Affect fluctuates dramatically

d.

Increased interest in sexual behaviors

e.

Difficulty remembering the names of family members

ANS: C, D, E The temporal lobe is involved with memory as well as increased sexual focus and altered emotional responses. Personality and intellectual function is not centered in the temporal lobe.

2.

A patient has begun experiencing dysfunction of the hypothalamus. What nursing interventions will the nurse include in the patients plan of care? Select all that apply. a.

Reinforcing clear physical boundaries

b.

Assisting the patient with completing daily menus

c.

Learning about healthy sleep hygiene habits

d.

Monitoring and recording temperature every 4 hours

e.

Monitoring and recording blood pressure every 4 hours

ANS: B, C, D The hypothalamus is responsible for regulation of sleep-rest patterns, body temperature, and physical drives of hunger. Social appropriateness and blood pressure is not controlled by the hypothalamus.

3.

The nurse is preparing a patient for a positron emission tomography (PET) scan.

Which instructions will the nurse include? Select all that apply.

a.

There will likely be a 30 to 45 minute wait between the injection and the beginning of the scan.

b.

A blindfold and earplugs may be used to help decrease reaction to the environment during the scan.

c.

Make every attempt to lie still during the scan because movement will affect the imaging produced.

d.

No food or fluids are to be ingested for at least 8 full hours before the scan and none during the scan.

e.

Staying awake during the scan is important since the results are altered when the patient is in any phase of the sleep state.

ANS: A, B, C, E Appropriate patient preparation for a PET scan would include information regarding the time interval between injection of the isotope and the actual scan, the fact that steps will be taken to minimize the effects of sights and sounds during the scan, lying still is critical to achieving a quality image, and that being asleep during the scan will alter the results. It is not necessary to fast before or during the scan.

4.

A patient with schizophrenia is described as having difficulty with executive functions. What patient dysfunction can the nurse expect to assess behaviorally? Select all that apply. a.

Invades the personal space of others frequently

b.

Consistently fails to bring money when going to buy snacks

c.

Cannot remember the names of staff who often provide care

d.

Requires repeated reinforcement on how to make a sandwich

e.

Frequently speaks of hurting himself or of hurting other patients

ANS: A, B, D

Executive functions include reasoning, planning, prioritizing, sequencing behavior, insight, flexibility, judgment, focusing on tasks, responding to social cues, and attending in appropriate ways to incoming stimuli. Memory is not considered an

executive function and risk for harm to self and others is not generally a diagnosis appropriate for such a patient.

5.

The unit physicians have ordered magnetic resonance imaging (MRI) tests for the following patients. For which patients would the nurse decline to make test arrangements without further discussion with the physician? Select all that apply. a.

A patient who is claustrophobic

b.

A patient who is breastfeeding

c.

A patient who has an allergy to iodine

d.

A patient who had a total knee replacement

e.

A patient who is taking a neuroleptic medication

ANS: A, D Patients with claustrophobia are often unable to complete this type of study, because the MRI machine is enclosed, and patients are required to remain motionless. Metal implants are contraindications for MRIs since metal affects the scan. Breastfeeding, iodine sensitivity, and neuroleptic medication therapy are not contraindications for an MRI.

Chapter 2 Transporters, receptors, and enzymes as targets of psychopharmacological drug action 1.

The somatic nervous system provides sensory and motor innervation for:

A)

peripheral nerves.

B)

abdominal viscera.

C)

secretory glands.

D)

smooth muscle.

2.

ANS.A

The proteins and other materials used by the axon are synthesized and then flow down the axon through its cytoplasm.

A)

in the cell body

B)

by Nissl bodies

C)

through dendrites

D)

across synapses

3.

ANS.A

Supporting cells of the nervous system, such as Schwann cells, satellite cells, and types of glial cells, function to provide neurons with: A)

local protection.

B)

control functions.

C)

membrane permeability.

D)

integrative metabolism.

4.

ANS.A

Neurons are characterized by the ability to communicate with other neurons and body cells through: A)

astrocytes.

B)

axon hillocks.

C)

nodes of Ranvier.

D)

action potentials.

ANS.D

5. Chemical synapses rely on neurons.

A)

diffusion

B)

gap junctions

C)

satellite cells

D)

transmitter molecules

6.

ANS.D

in order to provide communication between

The blood-brain and CSF-brain barriers control the chemical environment of the brain by allowing easy entrance to only a few chemicals that include: A)

oxygen.

B)

protein.

C)

glutamate.

D)

potassium.

7.

ANS.A

The perception of where a stimulus is in space and in relation to body parts is a function of the: A)

occipital lobe.

B)

parietal lobe.

C)

hypothalamus.

D)

prefrontal cortex.

8.

ANS.B

The pia mater is a connective tissue sheath that covers the spinal cord and also contains: A)

spinal fluid.

B)

fibrocartilage.

C)

blood vessels.

D)

segmental nerves.

ANS.B

9. Which of the following is the neurotransmitter for most postganglion sympathetic neurons?

A)

Enkephalin

B)

Glutamic acid

C)

Catecholamines

D)

Acetylcholine

10.

ANS.C

In contrast to the sympathetic nervous system, the functions of the parasympathetic nervous system include: A)

sweating.

B)

anabolism.

C)

pupil dilation.

D)

vasoconstriction.

11.

ANS.B

Which of the following substances provides the majority of the fuel needs of the neurologic system?

A)

Glycogen

B)

Glucose

C)

Amino acids

D)

Triglycerides

12.

ANS.B

A 60-year-old woman has been recently diagnosed with multiple sclerosis, a disease in which the oligodendrocytes of the patients central nervous system (CNS) are progressively destroyed. Which physiologic process within the neurologic system is most likely be affected by this disease process?

A)

Oxygen metabolism

B)

Neurotransmitter synthesis

C)

Nerve conduction

D)

Production of cerebrospinal fluid

ANS.C

13.A neuron has been hyperpolarized. How will this affect the excitability of the neuron?

A)

The neuron will have a membrane potential farther from the threshold.

B)

The neuron will be more difficult to repolarize after firing.

C)

The membrane potential of the neuron will be closer to the threshold.

D)

The neurons excitability will be significantly increased.

14.

ANS.A

A pregnant womans most recent ultrasound is suggestive of spina bifida, and her primary care provider has subsequently order further diagnostic testing. The pathophysiologic effects of this disease are due to: A)

malformation of the mesoderm.

B)

abnormal closure of the neural tube.

C)

lesions in the dorsal root ganglia.

D)

hypertrophy of the primary vesicles.

15.

ANS.B

Which of the following messages is most likely to be carried by general somatic afferent (GSA) neurons?

A)

The sensation of cold when touching ice

B)

The message to move a finger and thumb

C)

The message to move the larynx during speech

D)

Information about the position of a joint

16.

ANS.A

Which of the following processes is most likely to occur as a result of a spinal reflex?

A)

Peristalsis of the small and large bowel

B)

Control of oculomotor function in changing light levels

C)

Pain sensation from a potentially damaging knee movement

D)

Withdrawal of a hand from a hot stove element

ANS.D

17. A patient has required mechanical ventilation following a traumatic head injury sustained in a motorcycle crash, during which he sustained damage to his respiratory center. Which of the patients brain structures has been injured?

A)

Brain stem

B)

Midbrain

C)

Diencephalon

D)

Frontal lobe

18.

ANS.A

A patient with a diagnosis of epilepsy has required surgical removal of part of her prefrontal cortex. Which of the following effects should her family and care team anticipate?

A)

Lapses in balance and coordination

B)

Deficits in regulation of the endocrine system

C)

Sensory losses

D)

Changes in behavior and judgment

19.

ANS.D

A patients primary care provider has prescribed a b-adrenergic receptor blocker. Which of the following therapeutic effects do the patient and care provider likely seek?

A)

Reduction in heart rate and blood pressure

B)

Slowing of gastrointestinal motility

C)

Increase in mental acuity

D)

Decreased production of gastric acid

20.

ANS.A

Neurotrophic factors contribute to the maintenance of homeostasis in which of the following ways?

A)

By catalyzing the effects of neurotransmitters

B)

By increasing the sensitivity of receptors on postsynaptic cells

C)

By promoting the growth and survival of neurons

D)

By selectively increasing or decreasing the release of neurotransmitters

ANS. C

Chapter 3 Ion channels as targets of psychopharmacological drug action

1.

A nurse is teaching a medication class to a group of psychiatric patients. One of them asks the nurse why he has so much more trouble learning now when hes in his

60s than he did when he was younger. Which of the following concepts would the nurse integrate into the response?

A)

The extrapyramidal motor system

B)

The amygdala

C)

Neuroplasticity

D)

Psychoneuroimmunology

2.

ANS.C

Which of the following would a nursing instructor identify when describing the area of the brain involved with verbal language function, including areas for both receptive and expressive speech?

A)

Right hemisphere

B)

Parietal lobe

C)

Occipital lobe

D)

Left hemisphere

3.

ANS.D

A nurse is developing a plan of care for a patient experiencing expressive aphasia. The nurse incorporates knowledge that the patient most likely has sustained damage to which of the following?

A)

The postcentral gyrus

B)

Brocas area

C)

Basal ganglia

D)

The hippocampus

4.

ANS.B

The nurse is caring for an older adult who has experienced damage to the frontal lobe after an automobile accident. The nurse anticipates that the patient will have difficulty with which of the following?

A)

Smell

B)

Concept formation

C)

Receptive speech

D)

Hearing

5.

ANS.B

The nurse is caring for a patient who has experienced damage to the parietal lobes of the brain. The nurse anticipates that the patient with have difficulty with which of the following?

A)

Perceiving sensory input

B)

Calculating a math problem

C)

Seeing objects in front of him

D)

Speaking fluently

6.

ANS.B

A patient has been diagnosed with memory dysfunction associated with Alzheimers disease. The nurse determines that damage to the patients brain includes deterioration of temporal lobe structures and the nerves of which of the following?

A)

Basal ganglia

B)

Limbic system

C)

Frontal lobe

D)

Hippocampus

7.

ANS.D

The nurse is caring for a hospitalized patient who has a disorder of the hypothalamus.

When developing the patients plan of care, in which of the following areas would the nurse anticipate a problem?

A)

Sleep

B)

Constipation

C)

Speech

D)

Motor activity

8.

ANS.A

A patient who is scheduled to undergo a sleep deprivation electroencephalogram (EEG) in the morning is experiencing moderate anxiety about the procedure. Based on an understanding of this test, which of the following would the nurse avoid?

A)

Explaining in depth what to expect during the upcoming procedure

B)

Administering a benzodiazepine medication prescribed for anxiety

C)

Taking a thorough history of her use of prescribed and illicit drugs

D)

Giving her a noncaffeinated beverage of her choice

9.

ANS.B

A nursing instructor asks a student to explain the influence of chronobiology on depression. Which of the following would the student include when responding?

A) The exact location of genes leads to identifying the gene responsible for causing depression.

B) A break in the corpus coliseum blocks information exchange between the right and left hemispheres.

C) Damage to the posterior areas of the parietal lobe leads to altered discriminative sensory function.

D) Internal and external triggers can elicit biologic rhythm changes indicative of clinical depression.

10.

ANS.D

When describing the various neurotransmitters, which of the following would the nurse identify as the primary cholinergic neurotransmitter?

A)

Dopamine

B)

Acetylcholine

C)

Norepinephrine

D)

Serotonin

11.

ANS.B

A group of nursing students are reviewing the various neurotransmitters. The students demonstrate understanding when they identify which of the following as a neuropeptide?

A)

Melatonin

B)

Serotonin

C)

Glutamate

D)

Gamma-aminobutyric acid

12.

ANS.A

The nurse is assessing a patient experiencing anxiety and observes increased sweating and gooseflesh. The nurse understands that these are the result of which substance?

A)

Acetylcholine

B)

Norepinephrine

C)

Serotonin

D)

Histamine

13.

ANS.B

A nurse is developing a plan of care for a patient diagnosed with schizophrenia. The nurse integrates knowledge of this disorder, identifying which neurotransmitter as being primarily involved?

A)

Acetylcholine

B)

Dopamine

C)

Norepinephrine

D)

Serotonin ANS.B

14.A group of students are reviewing information about neurotransmitter subtypes.

The group demonstrates understanding of the information when they identify which neurotransmitter as having muscarinic and nicotinic receptors?

A)

Serotonin

B)

Gamma-aminobutyric acid (GABA)

C)

Dopamine

D)

Acetylcholine

15.

ANS.D

A nurse is involved in gathering information about the inheritance of mental disorders using population genetics. Which of the following would the nurse be least likely to be evaluating?

A)

Concordance rates

B)

Occurrence in first-degree relatives

C)

Risk factor analysis

D)

Adoptions studies

16.

ANS.C

A nurse is reading a journal article about psychoneuroimmunology. Which information would the nurse most likely find? Select all that apply.

A)

Neurotoxins role in receptor site damage

B)

Hypothalamicpituitarythyroid axis disruption

C)

Static activity of natural killer cells in response to stress

D)

Hypothalamic damage leading to immune dysfunction

E)

Interruption in the typical circadian rhythm cycle

17.

ANS.A,B,D

A patient is scheduled for a challenge test. Which of the following would the nurse include when explaining this test to the patient?

A)

Intravenous administration of a substance to induce symptoms

B)

Application of electrodes to the scalp for monitoring

C)

Evaluation electrical impulses recorded on graph paper

D)

Exposure to a flashing strobe light to elicit abnormal activity

18.

ANS.A

A patient with depression tells the nurse that he is to have a test that involves the recording of an electroencephalogram (EEG) throughout the night. The nurse most likely identifies this testing as which of the following?

A)

Sleep deprivation EEG

B)

Polysomnography

C)

Evoked potentials

D)

Functional magnetic resonance imaging

19.

ANS.B

A group of nursing students are reviewing the role of serotonin in psychiatric disorders. The students demonstrate a need for additional study when they identify which disorder as being associated with its dysfunction?

A)

Depression

B)

Obsessive-compulsive disorder

C)

Panic disorder

D)

Schizophrenia

20.

ANS.D

When describing neuronal transmission, an instructor describes the area where the electrical intracellular signal becomes a chemical one. The instructor is describing which of the following?

A)

Soma

B)

Synaptic cleft

C)

Terminal

D)

Receptor site

ANS.B

Chapter 4 Psychosis and schizophrenia

MULTIPLE CHOICE 1.

A newly admitted patient has the diagnosis of catatonic schizophrenia. Which behavior observed in the patient supports that diagnosis? a.

Uses a rhyming form of speech

b.

Refuses to eat any unwrapped foods

c.

Laughs when watching a sad movie

d.

Maintains an immobilized state for hours

ANS: D Catatonic schizophrenia is characterized by extremes of psychomotor activity ranging from frenzied behavior to immobilization and may include echopraxia and posturing.

Paranoid thinking is characteristic of paranoid schizophrenia. Inappropriate affect and clanging are seen in disorganized schizophrenia.

2.

What would be an appropriate short-term outcome for a patient diagnosed with residual schizophrenia who exhibits ambivalence? a.

Decide their own daily schedule.

b.

Decide which unit groups they will attend.

c.

Choose which clinic staff member to work with.

d.

Choose between two outfits to wear each morning.

ANS: D An early step would be to make choices about nonthreatening matters when presented with limited alternatives. The remaining options represent decisions that are too complicated for the patient to make initially.

3.

What is the priority nursing diagnosis for a catatonic patient?

a.

Ineffective coping

b.

Impaired physical mobility

c.

Impaired social interaction

d.

Risk for deficient fluid volume

ANS: D The highest priority for the patient is maintenance of basic physiologic needs, such as hydration. Mobility is of lesser physiological importance than fluid volume. The remaining options do not have priority over a physiological need.

4.

Which nursing diagnosis is appropriate for a patient who insists being called Your Highness and demonstrates loosely associated thoughts? a.

Risk for violence

b.

Defensive coping

c.

Impaired memory

d.

Disturbed thought processes

ANS: D Delusions and loose associations suggest disturbed thought processes. The other options are not supported by data in the scenario.

5.

Which initial short-term outcome would be appropriate for a patient who was admitted expressing delusional thoughts? a.

Accept that delusion is illogical.

b.

Distinguish external boundaries.

c.

Explain the basis for the delusions.

d.

Engage in reality-oriented conversation.

ANS: D Delusions are not reality oriented; thus an appropriate outcome would be that patient will engage in reality-oriented conversation rather than discussing delusional beliefs.

Delusions are fixed, false beliefs. Patients rarely accept anyone using logic to dispute them. Data are not present to suggest boundary disturbance. Explaining the delusion is not progress; it suggests the patient still holds to the belief.

6.

Which of the following interventions should the nurse plan to use to reduce patient focus on delusional thinking? a.

Confronting the delusion

b.

Refuting the delusion with logic

c.

Exploring reasons the patient has the delusion

d.

Focusing on feelings suggested by the delusion

ANS: D Focusing on feelings suggested by the delusion will help meet patient needs and help the patient stay based in reality. This technique fosters rapport and trust while discouraging the belief without challenging or refuting it.

7.

Which assessment observation supports a patients diagnosis of disorganized schizophrenia? a.

Reports suicidal ideations

b.

Last relapse was 6 years ago

c.

Consistent inappropriate laughing

d.

Believes that the government is out to get me

ANS: C The presence of disorganization and inappropriate affect identifies this disorder as disorganized schizophrenia. The symptoms of residual schizophrenia have long periods of remission. Schizoaffective disorder presents with severe mood disorders

along with symptoms of schizophrenia. Paranoid schizophrenia is characterized by persecutory or grandiose delusions.

8.

A patient tried to gouge out his eye in response to auditory hallucinations commanding, If thine eye offends thee, pluck it out. The nurse would analyze this behavior as indicating: a.

Derealization

b.

Inappropriate affect

c.

Impaired impulse control

d.

Inability to manage anger

ANS: C Command hallucinations may be so intense that the patient cannot control the impulse to do what the hallucination tells him to do; thus the patient has impaired impulse control. This is not an anger management problem. Derealization is a feeling that the environment is distorted or unreal and not suggested in the scenario. No evidence of inappropriate affect is given.

9.

An appropriate intervention for a patient with an identified nursing diagnosis of situational low self-esteem would be: a.

Providing large muscle activities to relieve stress

b.

Attempting to determine triggers to hallucinations

c.

Engaging patient in activities designed to permit success

d.

Encouraging verbalization of feelings in a safe environment

ANS: C All are useful interventions for a patient with schizophrenia; however, engaging the patient in specifically designed activities is the only option that addresses improving self-esteem.

10.

A 19-year-old patient is admitted for the second time in 9 months and is acutely psychotic with a diagnosis of undifferentiated schizophrenia. The patient sits alone rubbing her arms and smiling. She tells the nurse her thoughts cause earthquakes and that the world is burning. The nurse assesses the primary deficit associated with the patients condition as: a.

Social isolation

b.

Disturbed thinking

c.

Altered mood states

d.

Poor impulse control

ANS: B

The nurse interprets the patients statements that were not reality-based as indicating disturbed thought processes. Social isolation is not the primary patient problem. No data exist to support the other options.

11.

A patient has been admitted with disorganized type schizophrenia. The nurse observes blunted affect and social isolation. He occasionally curses or calls another

patient a jerk without provocation. The nurse asks the patient how he is feeling, and he responds, Everybody picks on me. They frobitz me. The patients communication exhibits: a.

A neologism

b.

Loose associations

c.

Delusional thinking

d.

Circumstantial speech

ANS: A A newly coined word having meaning only for the patient is called a neologism (meaning, new word). It is associated with autistic thinking. The patients speech does not show associative looseness or circumstantiality. The use of a neologism is not delusional in and of itself, but it suggests delusional thinking may be present.

12.

A patient has been admitted with disorganized type schizophrenia. The nurse asks the patient how he is feeling, and he responds, Everybody picks on me. They frobitz me. The best response for the nurse to make would be: a.

Thats really too bad that you are being treated that way.

b.

Who do you mean when you say everybody?

c.

What difference does frobitzing make?

d.

Why do they frobitz?

ANS: B This response will help clarify the patients thinking and change the focus from global to specific. In this situation, sympathizing with the patient is a nonproductive response. The remaining options appear to accept the neologism thus supporting the patients delusional thinking.

13.

Which patient behavior would support the diagnosis of residual schizophrenia with negative symptoms? a.

Communicating using only rhyming phases

b.

Claims that worms are crawling in my brain

c.

Maintaining both arms suspended awkwardly overhead

d.

Shows no emotion when telling the story of a sisters recent death

ANS: D

Blunted affect is considered a negative symptom. The other symptoms would be classified as positive symptoms.

14.

By discharge, which outcome is appropriate for a patient who hears voices telling him he is evil? a.

Respond verbally to the voices.

b.

Verbalize the reason the voices say he is evil.

c.

Identify events that increase anxiety and promote hallucinations.

d.

Integrate the voices into his personality structure in a positive manner.

ANS: C An appropriate outcome for a patient with hallucinations is recognition of events that precede the onset of hallucinations. Trigger events or situations usually cause increased feelings of anxiety. The remaining options are neither desirable nor appropriate.

15.

Which response by the nurse would best assist a patient in de-escalating aggressive behavior? a.

Tell me whats going on.

b.

Why are you getting so upset?

c.

If you throw something, you will be restrained.

d.

Its time for group therapy. You can talk there.

ANS: A Using how, what, and when to gather information is a nonthreatening approach. It will promote patient verbalization and explanation of events without causing the patient to become defensive. Mentioning restraints sounds threatening even though it may be meant to remind the patient of limits.Why questions are demanding and threatening to patients. Sending the patient into group therapy sidesteps the problem.

16.

A 34-year-old male admitted with catatonic schizophrenia has been mute and motionless for several days while at home prior to admission. He still appears stuporous in the hospital. Which nursing intervention would be an initial priority? a.

Orienting the patient to the unit

b.

Reinforcing reality with the patient

c.

Establishing a nonthreatening relationship

d.

Assessing the patient for physical problems

ANS: D Patients who are mute and motionless and inattentive to environmental stimuli are at risk for a number of physical problems. Further, they are unable to communicate existing problems. The nurse must make thorough and astute assessments before creating plans to meet the patients needs. A patient who is stuporous may not be able

to attend to information given about unit rules and protocols. While establishing a therapeutic nurse-patient relationship is an important intervention, it does not have priority according to Maslows hierarchy. Because the patient is mute, one can only suspect lack of reality orientation. While an appropriate intervention, it is not the priority according to Maslows hierarchy.

17.

Which response is appropriate when a patients mother expresses guilt over causing my child to be schizophrenic? a.

I can see how you would be upset over this turn of events.

b.

New findings suggest this disorder is biological in nature.

c.

Dont be so hard on yourself; your daughter needs you to be strong.

d.

Its difficult to see what produces stress for the child at the time its occurring.

ANS: B Many individuals in the mental health field attribute the development of schizophrenia to multiple causes centering on biological theories. The remaining options do little to provide the mother with new information.

18.

Which response demonstrates both empathy and understanding of the relationship genetics has to the development of schizophrenia in twins?

a.

In fraternal twins, the chance of the other twin developing the disorder is quite small.

b.

Studies show that 50% of twins develop schizophrenia when it is present in the other twin.

c.

No one can say what will happen, so we will hope for the best for you and both of your sons.

d.

You poor woman! I wish I could tell you that your other son he will be free of the disorder.

ANS: A Current research supports the correct option, whereas the remaining options are not factual and show expressed sympathy rather than empathy.

19.

The wife of a patient diagnosed with paranoid schizophrenia asks, Ive been told that my husbands illness is probably related to imbalanced brain chemicals. Can you be more specific? The response based on the dopamine hypothesis is:

a.

Breakdown of dopamine produces LSD, which in large amounts produces psychosis.

b.

An increase in the brain chemical dopamine explains the presence of delusions and hallucinations.

c.

Decreased amounts of the brain chemical dopamine explain the presence of delusions and hallucinations.

d.

An increase in the brain chemical dopamine explains the presence of lack of motivation and disordered affect.

ANS: B The statement is correctly based on the dopamine hypotheses while the remaining options are neither known to be true nor based on that theory

20.

What is the basis for the reduction in disturbed thought processes when a patient is administered haloperidol (Haldol)? a.

Reduction in the number of brain cells that crave dopamine

b.

Dopamine receptors are blocked, making dopamine less available

c.

Dopamine receptors are enhanced, making more dopamine available

d.

Medication causes an increased cellular production of dopamine

ANS: B Excess dopamine is responsible for symptoms of psychosis such as delusions and hallucinations. Blocking dopamine receptors will result in reduction of primary symptoms. The other options do not reflect the action of typical antipsychotic medications.

21.

During a treatment team meeting, the point is made that a patient with schizophrenia has recovered from the acute psychosis but continues to demonstrate apathy, avolition, and blunted affect. The nurse who relates these symptoms to serotonin (5HT2) excess will suggest that the patient receive: a.

Haloperidol (Haldol)

b.

Chlorpromazine (Thorazine)

c.

Olanzapine (Zyprexa)

d.

Phenelzine (Nardil)

ANS: C Olanzapine is an atypical antipsychotic. Atypical antipsychotic medications are more effective than typical antipsychotics in blocking serotonin receptors and reducing the negative symptoms of schizophrenia. Haloperidol (Haldol) and chlorpromazine (Thorazine) are typical antipsychotic medications while phenelzine (Nardil) is an MAOI antidepressant.

22.

What response would be anticipated when a patient who received chlorpromazine (Thorazine) for 15 years to treat schizophrenia is switched to Seroquel (quetiapine)? a.

Development of pseudoparkinsonism

b.

Development of dystonic reactions

c.

Improvement in tardive dyskinesia

d.

Worsening of anticholinergic symptoms

ANS: C

Atypical antipsychotics have been noted to block oral dyskinesia and improve tardive dyskinesia as well as improve both positive and negative symptoms of schizophrenia.

Pseudoparkinsonism and dystonic reactions are associated with typical antipsychotic medication. Anticholinergic symptoms are not intense with the use of atypical antipsychotic medication.

23.

A patient admitted with the diagnosis of schizophreniform disorder R/O organic pathology. Based on this information, the nurse can expect that the patient will: a.

Be scheduled for a magnetic resonance imaging (MRI) test

b.

See a mental health specialist for extensive psychological testing

c.

Have an immunologic assay performed within 2 days of the admission

d.

Participate in a dexamethasone suppression test (DST) administered by the staff

ANS: A The MRI will reveal structural changes in the brain that might be responsible for symptoms of psychosis (e.g., abscess, tumor). Psychologic testing may be performed but will be less definitive in ruling out organic pathology. Immunologic studies are not indicated. The DST is related to depression.

24.

In planning aftercare for a patient with schizophrenia and whose insurance benefits have been exhausted, the nurse who is concerned about overcoming negative symptoms will make provisions for the patient to have stimulation, structure, socialization, and support. Which option would best incorporate these factors? a.

Day hospitalization

b.

Attending a psychosocial club

c.

Living with his elderly mother

d.

Spending free time in the mall

ANS: B

A psychosocial club is organized to provide the 4 Ss and is not costly to patients. Day hospitalization would not be possible because of the lack of insurance benefits. Living with his mother might fall short of stimulation and support. Spending time in the mall lacks structure, socialization, and support.

25.

A patient with catatonic schizophrenia has been standing with his left arm upraised and his right foot off the floor for the majority of the last 20 hours, eating only when allowed to eat standing up. Which nursing intervention has priority for this patient? a.

Providing high-calorie drinks hourly

b.

Assessing for lower extremity edema bid

c.

Taking the patient to activities therapy once daily

d.

Encouraging the patient to sit or lie down for 30 minutes hourly

ANS: B Patients who maintain one position for long periods of time should be assessed for dependent edema. In this case, the nurse would look for edema of the lower extremities and would be concerned about the pressure exerted by standing on one foot for long periods of time. Such encouragement would probably be met with resistance by the patient. High-calorie drinks would be necessary if the patient failed to eat at meals. The patient probably would not be able to cognitively process what is required to participate in activities.

26.

Which nursing action best addresses the needs of a paranoid patient who believes the food is poisoned? a.

Explaining that others eat the food and are not harmed

b.

Allowing the patient to select food from vending machines

c.

Encouraging the patient to discuss why someone would poison the food

d.

Taking steps to prevent the patient from verbalizing the delusional thoughts

ANS: B Patients who think hospital food is being poisoned will sometimes eat wrapped foods that have not been opened, and occasionally, they may eat food brought from the outside by a trusted person. Delusions are fixed, false beliefs that cannot be refuted by logic. The patient will probably state that the others have been given the antidote to the poison. Encouraging discussion about the delusion is not therapeutic. Although it

is wise to minimize the amount of discussion about delusions, refusing to allow the patient to speak about the delusions will not foster a therapeutic alliance.

27.

Prior to discharge, the nurse plans to teach the patient and family about relapse.

Which items will the nurse include in the teaching? a.

Recognizing warning signs of relapse

b.

Using street drugs judiciously and only in small amounts

c.

Lowering medication dosage to manage emerging side effects

d.

Notifying the nurse of warning signs present for more than one month

ANS: A The patient and family must be aware of signs of impending relapse. These signs are usually similar to those that the patient experienced prior to hospitalization and will be patient-specific. The nurse should be notified ASAP, rather than waiting two weeks.

Patients should never adjust medication dosage. Street drug use often precipitates relapse since many street drugs are dopaminergic.

28.

Because of the cognitive disturbances associated with schizophrenia, which technique will be useful as the nurse teaches a patient about self-management? a.

Use only verbal instruction.

b.

Teach material in small segments.

c.

Offer opportunities for making numerous choices.

d.

Plan the teaching for a time when the patient has been recently medicated.

ANS: B Patients with cognitive disturbances should be taught small blocks of information at a time and given frequent reinforcement. Both verbal and visual materials should be used since processing of verbal stimuli may be more impaired. Teaching should be scheduled when the patient is most alert. A large number of choices may be confusing for the person, but a few simple choices may be included.

29.

The wife of a patient newly diagnosed with paranoid schizophrenia is concerned that her husband will be this sick for the rest of his life. What information can the nurse provide to the wife? a.

This disorder generally responds well with treatment and follow-up.

b.

All types of schizophrenia by their nature are chronic relapsing disorders.

c.

Outcomes are related to the patients pre-hospital symptoms of disorganization.

d.

The typical outcome for this diagnosis is that total remission is not achievable.

ANS: A The prognosis for paranoid schizophrenia is good with appropriate treatment and effective follow-up. The remaining options are not correct when considering this type of schizophrenia 30.

A patient is exhibiting auditory hallucinations in addition to being forgetful and easily confused. Which diagnosis does the nurse base this patients interventions on? a.

Social isolation

b.

Deficient knowledge

c.

Situational low self-esteem

d.

Impaired cognitive functioning

ANS: D Schizophrenia may alter cognitive functioning, including memory, retention, attention, and the processing of incoming information. Altered cognition accounts for many of the symptoms mentioned in the scenario. Knowing that cognition is altered, the nurse can adjust plans to take the deficits into account. The patient is not exhibiting symptoms that would warrant any of the other options.

31.

A patient experiences intrusive, insulting auditory hallucinations. Which independent behavioral technique can the nurse teach the patient to employ when the voices are troublesome? a.

Introduce a distraction like reading.

b.

Use positive talk to offset the insults.

c.

Sing or whistle to compete with the voices.

d.

Increase the daily dose of an antipsychotic medication.

ANS: C This action provides an alternative to listening to the voices and gives the patient a sense of control. The patient should not adjust medication independently. Reading will

not be particularly effective, because the voices are uncontested in a quiet atmosphere.

Positive talk is generally used to positively affect self-esteem.

32.

A patient with schizophrenia tells the nurse as they sit in the day room, I hear voices telling me bad things. The most therapeutic response the nurse can make is: a.

Tell me what the voices are saying.

b.

I believe you hear voices, but I dont hear them myself.

c.

The voices are not real. Theyre a product of your imagination.

d.

Do you think the voices would go away if we went into your room to talk?

ANS: B By voicing his or her own reality related to the voices, the nurse does not deny the patients experiences but helps the patient distinguish actual voices from those resulting from internal stimulation. Discussing what the voices are saying serves only to validate the reality of the voices. Challenging the voices will cause the patient to defend his perceptions and thereby reinforce the importance of the hallucination.

Asking to move validates the reality of the voices and is not a helpful action since the voices go where the patient goes.

33.

A patient tells the nurse, When Im in the day room, I hear people whispering about me, and that makes me want to punch them. What direction will the nurse provide the staff regarding interacting with this patient? a.

To minimize the need to whisper, utilize nonverbal techniques when possible.

b.

Stay physically close to this patient and use touch as a tool to interact with him.

c.

Treat this patient matter-of-factly. Be direct; dont talk about him or others in his presence.

d.

Interact with this patient only when necessary. The fewer interactions, the fewer misinterpretations there will be.

ANS: C This approach is important when providing care for a patient who is misinterpreting reality and is suspicious of the motives of others. Ostracizing the patient is non-

therapeutic. Patients often misinterpret touch as threatening. This might promote loss of control. Using nonverbal communication techniques would be nontherapeutic as it would increase patient anxiety and promote loss of control.

34.

A patient with schizophrenia is medication compliant and has well-controlled symptoms. He has, however, never been successful in holding a job because of poor social skills and lack of understanding of basic job skills. The nurse case manager should consider referring the patient: a.

For cognitive therapy

b.

To assertiveness training

c.

To a day hospital program

d.

For psychosocial rehabilitation

ANS: D Psychosocial rehabilitation helps patients readjust to community living by promoting development of necessary skills. Social skills training and job skills training programs are usually available. The patient does not need the more intensive services found in a day hospital. Cognitive therapy will not offer the needed community living skills training. Assertiveness training is only a small portion of the community living skills the patient needs.

35.

A patient prescribed an antipsychotic medication develops a high fever, unstable blood pressure, and muscle rigidity. Her next dose of medication is due. The nurse should: a.

Administer the medication and monitor the vital signs every 4 hours.

b.

Give a lower dose of the medication for 24 hours and monitor the blood pressure.

c.

Prepare to administer a prn dose of the anticholinergic drug benztropine (Cogentin).

d.

Hold the medication and immediately describe the patients symptoms to the doctor.

ANS: D These symptoms could be related to a possibly fatal disorder called neuroleptic malignant syndrome (NMS), and the nurse should hold the medication and contact the doctor immediately. The other options are inappropriate in light of the seriousness of the situation.

MULTIPLE RESPONSE 1.

Which interventions will the nurse implement to preserve milieu safety when a patient becomes agitated? Select all that apply. a.

Project confidence and control.

b.

Provide a show of force when appropriate.

c.

Ask the agitated patient why they are feeling so aggressive.

d.

Move to within 5 feet of the patient to help contain their movement.

e.

Provide the patient with several options as means of de-escalating the crisis.

ANS: A, B, E The correct options demonstrate that the staff is in control without unnecessarily challenging the patient. Asking why is often interpreted as being challenging and often serves to future agitate the patient. Eight feet is considered to be the therapeutic distance between patient and staff in this type of situation.

2.

Which interventions will the nurse implement to assure effective staff crises management skills? Select all that apply. a.

Schedule regular staff crises simulations.

b.

Encourage the staff to discuss the details of unit crises.

c.

Attempt to identify staff who are ineffective during crises.

d.

Review documentation that describe the details of unit crises.

e.

Review unit crises management policies for needed updates.

ANS: A, B, D, E The correct options empower the staff while improving/maintaining their crises management skills. The failures of the process should be identified without blaming staff for ineffective crises management.

Chapter 5 Antipsychotic agents MULTIPLE CHOICE 1.

The nurse is assessing a patient who is complaining of hearing voices. What is this patient experiencing? a.

Delusions

b.

Flight of ideas

c.

Disorganized thinking

d.

Hallucinations

ANS: D Hallucinations are false sensory perceptions that are experienced without an external stimulus but seem real to the patient. Auditory hallucinations are prominent in a schizophrenic patient. Additional sensory hallucinations include those of touch, sight, smell, and body sensation. Delusions are false beliefs that persist despite evidence to the contrary. Flight of ideas is characterized by rapid changes in thought from one topic to another. Disorganized thinking is commonly associated with psychoses and consists of a flight of ideas during which the individual jumps from one idea or topic to another one.

2.

A patient with schizophrenia has been nonadherent with his home medication regimen. He requires frequent admissions to the intensive psychiatric unit for treatment of acute psychotic episodes. Which medication regimen would be appropriate for this patient? a.

Daily home nursing visits to administer the prescribed oral medication

b.

Continuous inpatient hospitalization for medication therapy

c.

Administration of depot antipsychotic medication

d.

Subcutaneous medication administration

ANS: C

Depot antipsychotic medications are long acting injections that may be used with noncompliant patients and may assist in avoiding repeated hospital admissions. Daily home nursing visits are not an efficient way to ensure medication compliance.

Continuous inpatient hospitalization is not an efficient way to ensure medication compliance. Subcutaneous medication administration is not an option for this patient.

3.

What is the most common cause of nonadherence to antipsychotic pharmacologic treatment? a.

Expense

b.

Increased symptoms of chemical dependency

c.

Extrapyramidal effects

d.

Inability of the patient to understand the need to take medications

ANS: C Extrapyramidal effects are the most common reason for nonadherence to antipsychotic therapy. The four categories of extrapyramidal effects are dystonic reactions, pseudoparkinsonism, akathisia, and tardive dyskinesia. Although expense may be a concern, it is not the most common reason for noncompliance. Chemical dependency is not a feature of therapy with antipsychotic drugs. Although knowledge deficit is a concern, it is not the most common reason for noncompliance.

4.

Which type of adverse effects is present when a patient displays prolonged tonic contractions of the tongue, oculogyric crisis, and torticollis? a.

Dystonic reactions

b.

Pseudoparkinsonism

c.

Akathisia

d.

Tardive dyskinesia

ANS: A Dystonic reactions are the first extrapyramidal symptoms to occur when a patient is taking antipsychotic agents. Dystonias are spasmodic movements of muscle groups such as tongue protrusion, rolling back of the eyes (oculogyric crisis), jaw spasms (trismus), or neck torsion (torticollis). Pseudoparkinsonism is characterized by tremor and rigidity. Akathisia is characterized by subjective feelings of anxiety and restlessness, accompanied by pacing and the inability to remain in one place for

extended periods. Tardive dyskinesia is characterized by persistent involuntary hyperkinetic movements.

5.

The nurse is teaching a patient who is taking clozapine (Clozaril) to have weekly blood tests for the first 6 months of treatment to monitor for which potential complication? a.

Agranulocytosis

b.

Vitamin deficiencies

c.

Clotting abnormalities

d.

Polycythemia

ANS: A The use of clozapine requires a baseline and weekly white blood cell (WBC) counts because of the high incidence of agranulocytosis. Clozapine does not cause vitamin deficiencies. Clozapine does not interfere with clotting abilities. Clozapine does not affect red blood cell volume.

6.

A male patient becomes verbally aggressive and insists the nurse is poisoning him as she attempts to administer haloperidol (Haldol). Which action will the nurse take?

a.

Support the patients decision to refuse the medication.

b.

Discreetly ask an assistant to put the medication in the patients food.

c.

Firmly redirect the patient to take the medication.

d.

Speak privately with the patient and reinforce medication action.

ANS: C During episodes of acute psychosis, the patient is out of touch with reality and often does not understand the need for medication in stabilizing his or her condition. Target symptoms such as agitation, suspicion, and paranoia are common. Health care providers must be supportive yet firm in their expectations. An open and direct manner in handling patients who are highly suspicious is critical. Delusions should not be supported. The patient is not competent to determine his need for medication. It is dishonest to hide medication in a patients food and destroys a trusting relationship.

Reasoning with the patient is unlikely to change his mind; he needs external structure for making decisions when he is aggressive and paranoid.

7.

Which statement is true regarding the adverse effects associated with antipsychotic medications? a.

Tardive dyskinesia is a common, reversible condition.

b.

Painful dystonic reactions can occur in the first 72 hours of initiation of therapy. c.

Neuroleptic malignant syndrome (NMS) is a common adverse effect.

d.

Pseudoparkinsonian symptoms can cause Parkinsons disease.

ANS: B Approximately 90% of all dystonic reactions occur in the first 72 hours of antipsychotic therapy. These symptoms are often frightening and painful. Tardive dyskinesia is present in 20% to 25% of patients and may become irreversible. NMS is not a common adverse effect. Pseudoparkinsonism is not related to Parkinsons disease.

8.

To what does potency of an antipsychotic medication refer?

a.

Severity of adverse effects associated with the drug

b.

Length of time that it takes to reach a therapeutic blood level of the drug

c.

Milligram doses used for the medication

d.

Effectiveness of the drug in alleviating psychotic behavior

ANS: C Low and high potency refers only to the milligram doses used for the medications and does not suggest any difference in effectiveness. Potency is not related to severity of adverse effects or onset of action. Potency does not refer to effectiveness.

9.

Dystonic reactions, pseudoparkinsonism, akathisia, and tardive dyskinesia are types of which effect? a.

Extrapyramidal symptoms

b.

Allergic reactions

c.

Idiosyncratic reactions

d.

Therapeutic responses

ANS: A There are four categories of extrapyramidal symptoms: dystonic reactions, pseudoparkinsonism, akathisia, and tardive dyskinesia. These are not allergic reactions, idiosyncratic reactions, or therapeutic responses.

10.

Which is an appropriate nursing intervention for a patient who has recently been prescribed clozapine (Clozaril)? a.

Assess for signs and symptoms of hypoglycemia.

b.

Encourage a low fiber diet.

c.

Measure the patients waist circumference.

d.

Monitor for insomnia.

ANS: C Waist circumference baseline measurement is appropriate because of the weight gain and onset of diabetes with use of these medications. Hypoglycemia and insomnia do not occur with this medication. A low fiber diet is not appropriate.

11.

A young male patient taking an antipsychotic is experiencing an oculogyric crisis. The nurse prepares to administer: a.

diphenhydramine.

b.

haloperidol.

c.

aripiprazole.

d.

risperidone.

ANS: A Acute dystonic reactions may be controlled by intramuscular injections of diphenhydramine. Haloperidol, aripiprazole, and risperidone are not used for dystonic reactions.

MULTIPLE RESPONSE 12.

A patient admitted to the hospital is exhibiting psychotic behavior. Which sign(s) and/or symptom(s) would support the diagnosis of psychosis? (Select all that apply.) a.

Constant eye contact during the admission history

b.

Deterioration of social functioning

c.

Reporting that the FBI has solicited important secret information from his phone conversations d.

Confirmation of hearing voices in his head

e.

Changing the topic of conversation inappropriately

ANS: B, C, D, E Social deterioration, disordered thinking (including delusions), disordered perception, (including hallucinations), and flight of ideas are symptoms of psychotic behavior. It is uncommon for a psychotic patient to maintain eye contact.

13.

Why is a combination of antipsychotic agents with benzodiazepines useful in initial treatment of the agitated patient? (Select all that apply.) a.

Antipsychotics are not effective for 2 days.

b.

Benzodiazepines allow for lower dosages of antipsychotic agents to be used, thereby decreasing serious adverse effects seen with high dose therapy. c.

It assists in calming the psychotic patient.

d.

It allows for rapid increase in dosing of the antipsychotic agents to expedite treatment of hallucinations.

e.

It effectively treats extrapyramidal adverse effects associated with antipsychotic agents.

ANS: B, C The use of benzodiazepines allows lower dosages of antipsychotic agents to be used.

Benzodiazepines assist in calming the agitated psychotic patient. Antipsychotic medications can be effective in a matter of minutes when injected. Benzodiazepines do not facilitate the increase of antipsychotic medications or treat extrapyramidal adverse effects associated with antipsychotic agents.

14.

Which is/are extrapyramidal adverse effect(s) of antipsychotic agents? (Select all that apply.)

a.

Spasmodic movements of muscle groups

b.

Masklike expression

c.

Lip smacking

d.

Inability to sit in one place for an extended period

e.

Weight gain

ANS: A, B, C, D Dystonic reactions, pseudoparkinsonism, tardive dyskinesia, and akathisia are extrapyramidal symptoms of antipsychotic agents. Antipsychotic drug therapy often causes substantial weight gain, but this is not classified as a extrapyramidal adverse effect.

15.

Which sign(s) and symptom(s) may occur in neuroleptic malignant syndrome?

(Select all that apply.) a.

Fever

b.

Hypertension

c.

Severe extrapyramidal symptoms

d.

Alterations in consciousness

e.

Bradycardia

ANS: A, B, C, D Fever, severe extrapyramidal symptoms, hypertension, and alterations in consciousness (such as stupor, mutism, and coma) are characteristic of neuroleptic malignant syndrome. Bradycardia is not a sign of neuroleptic malignant syndrome.

16.

Which adverse effect(s) may occur as a result of antipsychotic drug therapy?

(Select all that apply.) a.

Acute dystonia

b.

Akathisia

c.

Weight loss

d.

Neuroleptic malignant syndrome

e.

Hypoglycemia

f.

Tardive dyskinesia

ANS: A, B, D, F Antipsychotic drugs can cause neuroleptic malignant syndrome and motor dysfunctions such as dystonia, akathisia, and tardive dyskinesia. Antipsychotic drugs may cause weight gain and hyperglycemia.

17.

A patient admitted to a psychiatric facility is hallucinating, pacing, and acting highly suspicious. Based on this information, the nurse will take which action(s)? (Select all that apply.) a.

Use the most restrictive restraints available to subdue the patient.

b.

Be open and direct when handling the patient.

c.

Encourage a variety of interactions with others.

d.

Provide high-protein, high-calorie foods.

e.

Reinforce hallucinations.

ANS: B, D Nursing interventions for patients with psychosis must be individualized and based on patient assessment data. The nurse should be open and direct when handling patients who are highly suspicious. High-protein, high-calorie foods are appropriate for the individual to eat while pacing or highly active. If physical restraints are necessary,

they should be the least restrictive possible for the circumstances. Interactions should be minimized when perceptions are altered. Hallucinations should not be reinforced.

18.

The psychiatric nurse is educating an elderly patient and family about antipsychotic drug therapy. When providing this education, the nurse will include which statement(s)? (Select all that apply.) a.

Hallucinations may be reduced within 1 week of starting.

b.

Rapid increase in dosages will increase frequency of adverse effects.

c.

Older patients should be observed for hypertension.

d.

Tardive dyskinesia may be reversible in early stages

e.

Full therapeutic response may require 6 to 8 weeks to be achieved.

ANS: B, D, E

Rapid increases in dosages of antipsychotic medication will not reduce the antipsychotic response time but will increase the frequency of adverse effects. Tardive dyskinesia may be reversible in early stages, but it becomes irreversible with continued use of the antipsychotic medication. Reduction in hallucinations, delusions, and thought disorders often requires 6 to 8 weeks for a full therapeutic response to be achieved. Older patients should be observed for hypotension.

Chapter 6 Mood disorders MULTIPLE CHOICE 1.

What occurs with mania associated with bipolar disorder?

a.

Varying degrees of sadness

b.

Distinct episodes of elation

c.

Suicide

d.

Psychomotor retardation

ANS: B Mania is characterized by distinct episodes of euphoria and elation. Sadness is characteristic of depression. Suicide is not generally associated with mania; it is more commonly associated with depression. Psychomotor retardation is not associated with mania.

2.

Which postoperative narcotic analgesic will most likely be prescribed to a patient whose current medications include a monoamine oxidase inhibitor (MAOI), a thyroid hormone, and a multivitamin? a.

Meperidine (Demerol)

b.

Morphine

c.

Ibuprofen (Advil)

d.

Acetaminophen (Tylenol)

ANS: B

Morphine is the narcotic analgesic of choice because it will not interact with the patients MAOI. Meperidine will interact with the patients medication. Ibuprofen and acetaminophen are not narcotic analgesics.

3.

What is the major advantage of selective serotonin reuptake inhibitors (SSRIs) over other types of antidepressant therapy? a.

They are less expensive than the other classes of antidepressants.

b.

They cure major depressive illnesses.

c.

They do not cause the anticholinergic and cardiovascular adverse effects.

d.

Therapeutic relief is immediate.

ANS: C SSRIs are the most widely used class of antidepressants. Although they are as effective in treating depression as the tricyclic antidepressants, they do not cause the anticholinergic and cardiovascular adverse effects that often limit the use of tricyclic antidepressants. SSRIs tend to be more expensive than other available antidepressants.

SSRIs do not cure major depressive illnesses. As with other antidepressants, it takes 2 to 4 weeks to obtain the full therapeutic benefit when taking SSRIs. 4.

Lithium (Eskalith) is the drug of choice for which of the following disorders?

a.

Psychotic episodes

b.

Obsessive compulsive disorders (OCDs)

c.

Bipolar disorders

d.

Depressive disorders

ANS: C Lithium is used to treat acute mania and for prophylactic treatment of recurrent manic and depressive episodes in bipolar disorders. Psychotic episodes are treated with major tranquilizers that have an antipsychotic effect. The drugs of choice for treating OCD are SSRIs. Depressive disorders are not primarily treated with lithium.

5.

Which psychological manifestation of depression will improve in response to antidepressant therapy? a.

Loss of energy

b.

Palpitations

c.

Sleep disturbances

d.

Social withdrawal

ANS: D Social withdrawal and lack of interest in surroundings are psychological responses that will improve within 2 to 4 weeks of the patient receiving an effective dosage of antidepressant therapy. An increase in energy, decreased palpitations, and improvement in sleep patterns are physiological responses.

6.

On what is the choice of tricyclic antidepressants based?

a.

The need to decrease the action of norepinephrine, dopamine, or serotonin

b.

Patient age and gender

c.

An absence of adverse effects, such as orthostatic hypotension

d.

The need for stimulation and increased mental alertness

ANS: B The choice of tricyclic antidepressants is based on their individual therapeutic characteristics. Tricyclics prolong the action of norepinephrine, dopamine, and serotonin. All tricyclics produce orthostatic hypotension to some degree. All tricyclics produce sedation, not stimulation.

7.

The nurse is teaching a patient about medication treatment for depression. The patient asks how long it will take before sleep and appetite will begin to improve.

Which response by the nurse is most accurate? a.

3 days

b.

1 week

c.

4 weeks

d.

2 months

ANS: B The physiological manifestations of depression (sleep disturbance, change in appetite, loss of energy, fatigue, palpitations) begin to be alleviated within the first week of

therapy. It takes longer than 3 days for the symptoms to improve. Four weeks and 2 months are longer than it takes for the symptoms to improve.

8.

What is the action of MAOIs on neurotransmitters?

a.

Blocking their reuptake

b.

Increasing their production

c.

Blocking their destruction

d.

Increasing their reuptake

ANS: C MAOIs act by blocking the metabolic destruction of epinephrine, norepinephrine, dopamine, and serotonin neurotransmitters by the enzyme monoamine oxidase in the presynaptic neurons of the brain. They prevent the degradation of these central nervous system (CNS) neurotransmitters so that their concentration is increased.

MAOIs do not block or increase the reuptake of neurotransmitters. MAOIs do not increase production of neurotransmitters.

9.

A patient who is taking an MAOI to treat depression admits to eating pickled herring and cheese and drinking red wine. Which assessment finding alerts the nurse to a potential complication? a.

Constipation

b.

Hypotension

c.

Neck stiffness

d.

Urinary retention

ANS: C Hypertensive crisis is a major potential complication. Common prodromal symptoms of hypertensive crisis include severe occipital headache, stiff neck, sweating, nausea, vomiting, and sharply elevated blood pressure. Constipation, hypotension, and urinary retention are not indicative of a major potential complication when patients consume foods high in tyramine.

10.

Which assessment would the nurse expect to observe in a patient who has been prescribed trazodone for treatment anxiety? a.

Excessive thirst

b.

Hand tremor

c.

Drowsiness

d.

Diarrhea

ANS: C Drowsiness is a common adverse effect, and people who work with machinery, drive a car, administer medicines, or perform other duties in which they must remain mentally alert should not take trazodone while working. Excessive thirst, hand tremors, and diarrhea are not an adverse effect associated with trazodone.

11.

The nurse is caring for a patient who is taking a newly prescribed drug, nefazodone, for treatment of depression. Which physical assessment finding is most important for the nurse to report to the health care provider immediately? a.

Bradycardia

b.

Dizziness

c.

Drowsiness

d.

Urinary retention

ANS: A Bradycardia with a drop in 15 beats/min is to be reported to the health care provider immediately; withholding the dose is warranted until approved. Dizziness, drowsiness, and urinary retention are common adverse effects that would not need to be reported to the health care provider.

12.

The nurse is providing education to a patient who has been prescribed bupropion (Wellbutrin) for smoking cessation. Which statement by the patient would indicate the need for further teaching? a.

My dose will increase after 3 days.

b.

I should swallow this medication whole.

c.

If I have the urge to smoke, I will take more medication.

d.

I do not need to taper my dose when the drug is discontinued.

ANS: C Dosage will begin at 150 mg/day for the first 3 days and then, for most patients, be increased to 300 mg/day. The patient is maintained on doses of 300 mg/day for 7 to 12 weeks and dosage is not based on a desire to smoke. Bupropion should be

swallowed whole, not crushed, divided, or chewed. Dose tapering is not required when discontinuing bupropion.

13.

Which nursing action is most important when providing care to a patient diagnosed with a mood disorder? a.

Assess the patient for thoughts of suicide.

b.

Provide supplemental feedings as needed.

c.

Assist with activities of daily living.

d.

Offer opportunities for interaction with other patients.

ANS: A Determining if there is a risk for suicide, monitoring at specified intervals, and providing patient safety and supervision are the highest priorities with severe mood disorders. Providing supplemental feedings, assisting with activities of daily living, and offering opportunities for interaction with other patients are not priorities of care.

14.

A patient is admitted to a long term psychiatric setting. The MAOI medication previously prescribed is discontinued by the physician. New orders are obtained to initiate imipramine therapy. The nurse will provide the first dose of imipramine to the patient the MAOI drug. a.

immediately following the last dose of

b.

in 1 week following the last dose of

c.

in 14 days following the last dose of

d.

before discontinuing

ANS: C MAOIs and TCAs, especially imipramine and desipramine, should not be administered concurrently. It is recommended that at least 14 days lapse between discontinuing an MAOI and starting SSRI/SNRI therapy.

15.

A patient taking vilazodone has been vomiting persistently for 12 hours. The priority nursing diagnosis for this patient is: a.

nausea.

b.

imbalanced nutrition (less than body requirements).

c.

fluid volume deficit.

d.

altered peripheral tissue perfusion.

ANS: C Nausea and vomiting are common adverse effects of vilazodone. Persistent vomiting should be evaluated for other causes, as well as for the development of electrolyte imbalance. Fluid volume deficit can lead to life threatening cardiac arrhythmias and therefore is the priority nursing diagnosis. The nursing diagnosis nausea is appropriate, but is not the priority. Imbalanced nutrition is an appropriate nursing diagnosis but is not the priority at this time. Altered peripheral tissue perfusion does MULTIPLE RESPONSE 16.

Which area(s) should be addressed by the nurse when obtaining a history of a patient admitted with depression? (Select all that apply.) a.

Current medications and medical history

b.

Recent stressors and support system

c.

Family history of mood disorder

d.

Dietary patterns

e.

Insurance coverage

ANS: A, B, C, D It is important to obtain a thorough history when assessing the patient with depression, including current medical status and medications, recent stressors, support system, family history of mood disorders, and nutritional patterns. Financial matters should not be part of the nursing assessment.

17.

Which instruction(s) is/are most pertinent to include in the discharge teaching of a patient on lithium (Eskalith) who is being discharged? (Select all that apply.)

a.

Persistent vomiting and profuse diarrhea are signs of toxicity and must be reported to the health care provider immediately.

b.

It is important to comply with schedules for blood tests to assess therapeutic levels.

c.

You should avoid foods such as Chianti wine and aged cheeses.

d.

The common adverse effects to expect, which are excessive nausea, anorexia, and abdominal cramps, tend to resolve. e.

You will be gradually weaned off this medication.

f.

Take the medication with food or milk.

ANS: A, B, D, F Patients should be informed of the importance of toxic symptoms to report and monitoring therapeutic lithium levels. Nausea, vomiting, and abdominal cramps are common adverse effects and tend to resolve. Lithium should be administered with food or milk. Chianti wine and aged cheeses are to be avoided during MAOI therapy.

The bipolar patient may be on lithium treatment for the rest of his or her life and will not be weaned from the medication.

18.

What will the nurse include in a teaching plan for a patient with depression being treated with amitriptyline (Elavil)? (Select all that apply.)

a.

Dryness of the mouth is normal; sucking on sugar free hard candy and ice chips or chewing gum may help alleviate this problem.

b.

Rise slowly from a supine or sitting position to avoid dizziness and orthostatic hypotension. c.

Avoid alcohol and barbiturates.

d.

If adverse effects occur, discontinue the medication.

e.

An immediate elevation in mood will be noted.

ANS: A, B, C Common adverse effects associated with tricyclic antidepressants are dry mouth and orthostatic hypotension. Alcohol and barbiturates should be avoided while taking

tricyclic antidepressants because they enhance sedation.Adverse effects are likely to occur, and the medication should not be discontinued without the direction of the

health care provider. Tricyclic antidepressants typically take several weeks to produce a therapeutic effect.

19.

Which food(s) containing significant amounts of tyramine will be contraindicated when a patient is on MAOI therapy? (Select all that apply.) a.

Beer

b.

Red meat

c.

Aged cheeses

d.

Green vegetables

e.

Bananas

ANS: A, C, E Beer, red wines, well ripened cheeses (such as camembert, edam, roquefort, parmesan, mozzarella, and cheddar), and overripe bananas contain tyramine. Red meat and green vegetables do not contain tyramine.

20.

Which nursing assessment(s) is/are important before the initiation of antidepressant therapy?(Select all that apply.) a.

Compliance with medication therapy within the last 2 months

b.

Nonverbal interactions among patient and significant others present

c.

Evaluation of the coherency, relevancy, and organization of thoughts in responses d.

Appearance and posture

e.

Elimination pattern

ANS: A, B, C, D Compliancy with prescribed medications over the last 2 months provides the health care provider with information regarding the patients state of mind and ability to follow through with medication administration independently. Patients with altered thought processes often display inconsistencies between statements of feelings and behavior norms in social settings. Coherency, relevancy, and organization of thoughts are often affected by thought disorders. This assessment also provides information regarding the accuracy of other information that the patient has offered. Note general appearance and appropriateness of attire and posture because these are often affected by mood disorders. Elimination pattern is not a priority premedication assessment.

21.

Which statement(s) is/are true regarding the pharmacologic actions of certain antidepressant drugs? (Select all that apply.) a.

MAOIs block the effects of dopamine in the CNS.

b.

SSRIs inhibit the destruction and reuptake of serotonin at the synaptic cleft.

c.

Tricyclic antidepressants block the action of norepinephrine and epinephrine in the SNS.

d.

Monocyclic antidepressants such as bupropion (Wellbutrin) have an unknown mechanism of action.

e.

SNRIs prolong the action of neurotransmitters by decreasing the destruction of serotonin and norepinephrine.

ANS: B, D, E SSRIs block the destruction and storage of serotonin at the synaptic cleft, therefore increasing the amount of serotonin available. Monocyclic antidepressants have an unknown mechanism of action. They are weaker inhibitors of the reuptake and inactivation of the neurotransmitters serotonin norepinephrine and dopamine. SNRIs act by inhibiting the reuptake and destruction of serotonin and norepinephrine and, to a lesser extent, dopamine, from the synaptic cleft, thereby prolonging the action of the neurotransmitters. MAOIs act by blocking the metabolic destruction of dopamine, so concentration is increased. Tricyclics block the reuptake of neurotransmitters, not their effects.

22.

Which drug(s) interact(s) with SSRI agents? (Select all that apply.)

a.

Tranylcypromine (Parnate)

b.

Lithium (Eskalith)

c.

Warfarin (Coumadin)

d.

Furosemide (Lasix)

e.

Propranolol (Inderal)

ANS: A, B, C, E

A 14-day lapse is recommended between MAOIs, such as Parnate, and SSRI agents. The incidence of lithium toxicity is increased with SSRI agents. The anticoagulant effects of warfarin may be enhanced with SSRIs. The SSRIs fluvoxamine and citalopram inhibit the metabolism of beta adrenergic blocking agents such as propranolol. Lasix does not interact with SSRI agents.

23.

The nurse must be sure to instruct the patient about which potential adverse effect(s) of tricyclic antidepressants? (Select all that apply.) a.

Diarrhea

b.

Dryness of mouth, nose, and throat

c.

Constipation

d.

Nocturia

e.

Urinary retention

f.

Blurred vision

ANS: B, C, E, F The patient may experience difficulty with dryness of the mouth, nose, and throat as well as smooth muscle contraction (resulting in constipation, urinary retention, and blurred vision). Diarrhea and nocturia are not adverse effects of tricyclic antidepressants.

24.

The nurse is preparing 0800 medications for a patient with the medical diagnosis of end stage renal disease. When reviewing the medication administration record (MAR), the nurse notices the patient is scheduled to receive an MAOI drug.

Which intervention(s) will the nurse perform before administering the drug? (Select all that apply.) a.

Assess temperature.

b.

Provide an alternative drug.

c.

Hold the MAOI drug.

d.

Consult with the prescribing health care provider.

e.

Assess urine output prior to administration.

ANS: C, D

If the patient prescribed an MAOI drug has a history of severe renal disease, the medication must not be given and the prescribing health care provider consulted. It is not necessary to assess temperature at this time. An alternative medication needs to be ordered by a health care provider licensed to prescribe. Assessing urine output does not apply to this situation.

Chapter 7 Antidepressants

Identify the choice that best completes the statement or answers the question.

1. You are admitting a new patient who is depressed. Your initial contact should do what?

A.

Address why he is depressed

B.

Keep communication open

C.

Lift his spirits

D.

Establish trust

2. In caring for a patient with major depression, the nurse knows that the patient needs: A.

Frequent changes in activities.

B.

Introduction to multiple new staff members.

C.

Behavior modification that restructures feelings.

D. 3.

Well-defined, structured interactions at the beginning of treatment. Patients with major depression commonly display signs of: A.

Energy.

B.

Repetitive, compulsive behaviors.

C.

Worthlessness.

D.

Visual hallucinations.

4. When your patient says I am depressed, what is the best response?

A.

We all feel that way now and then.

B.

Why do you feel that way?

C.

Everything will be OK once you snap out of it.

D.

Tell me more about what is going on with you.

5. Your patient takes tranylcypromine for depression. Which of the following is most likely to indicate dietary restrictions have not been followed?

A.

Hypertensive crisis

B.

Syncope

C.

Muscle spasms

D.

Increased depression

6. Your depressed patient who is taking a tricyclic antidepressant is advised of possible anticholinergic side effects. Which of the following is NOT an anticholinergic side effect?

A.

Blurred vision

B.

Difficulty starting urine stream

C.

Dry mouth

D.

Muscle rigidity

7. Helen, a 47-year-old client with a long history of severe depression, has not responded to antidepressant medications or psychotherapy. The nurse caring for the patient knows that the treatment of choice for depression unresponsive to conventional treatment would be: A.

Lithium.

B.

Electroconvulsive therapy (ECT).

C.

Light therapy.

D.

Neurolinguistic programming.

8. Your depressed patient is just started on duloxetine (Cymbalta). Which statement by the spouse tells you that family teaching has been effective?

A.

I cant wait for him to be back to his old self in the next day or so.

B.

I realize we cant expect big changes right away.

C.

I have to take him for weekly blood tests to monitor the drug dosage.

I will make sure he doesnt eat any aged cheese for the next 2 months until the D.

dose is stabilized.

9. Biological theories of depressive disorders include all of the following except:

A.

Chemical imbalances are responsible.

B.

The patient experiences maladaptive thought processes.

C.

There are genetic tendencies that run in families.

D. 10

Hormonal factors make women more susceptible than men.

. Light therapy has been shown to be effective in treating patients with:

A.

Bipolar disorder.

B.

Dysthymia.

C.

Major depression with seasonal pattern.

D.

Schizophrenia.

11. You are doing patient teaching for Margaret, who has been prescribed amitriptyline (Elavil) for treatment of depression. Which of the following statements suggests that Margaret needs further instruction?

A. I know I might not start feeling better for a few weeks, but Ill keep taking the medication just as the doctor prescribed.

B. Ill keep some hard candies in my purse in case my mouth gets dry from the medicine.

C. Once I start feeling better, Im looking forward to cutting down on this medication.

D. Im worried I may gain some weight, but thats a small price to pay for feeling better.

12. What is the main difference between major depression and dysthymic depression?

A.

Dysthymia is a short-term depression and major depression lasts for years.

B. Dysthymia is a chronic, low-level depression that lasts for years, while major depression is more severe.

C. Dysthymia is more likely to be caused by psychological factors and major depression is caused by neurological dysfunction.

D. Dysthymia is normally treated with psychotherapy only, while major depression is treated with antidepressants and psychotherapy.

13. Your depressed patient is starting a new medication called phenelzine (Nardil). Which teaching would be most important to emphasize?

A. Educate the patient to take this medication ongoing, even as symptoms improve.

B.

Instruct the patient and family about the many food-drug interactions.

C.

Instruct the patient about interventions to relieve dry mouth.

D. 14

Inform the patient that this medication takes 4 to 6 weeks to take full effect.

. Which of the following antidepressants is a tricyclic?

A.

Bupropion (Wellbutrin)

B.

Sertraline (Zoloft)

C.

Nortripyline (Pamelor)

D. 15

Venlafaxine (Effexor)

. Which statement is most true about depression?

A.

It is more common in women than men.

B.

It is rare to have more than one episode of major depression in ones lifetime.

C.

Young children do not suffer from depression.

D.

As one ages, there is reduced risk of depression.

16. A newly admitted client has been diagnosed with major depressive disorder.

Which nursing diagnosis takes priority?

A.

Impaired social interaction

B.

Self-esteem deficit

C.

Hopelessness

D.

Self-care deficit

17. The nurse knows that the two factors that often differentiate major depression from dysthymia depression are: A.

Amounts of mania and sadness.

B.

Presence or absence of anger and guilt.

C.

Severity and duration of symptoms.

D.

Patients gender and age.

18. You are caring for an older adult who is recently widowed. She says, No one cares if I die. Everyone I ever loved is dead. What is the best response?

A.

I am sure that you still have people who care about you.

B.

You sound like you are feeling all alone.

C.

Boy, that is depressing.

D.

I dont believe that.

19. Your patient with major depression tells you he suffers from urinary retention. Which medication would be most likely to cause this?

A.

Amitriptyline

B.

Duloxetine

C.

Carbamazepine

D. 20

Ritalin

. Which activity would be best for a depressed patient?

A.

A puzzle

B.

Drawing

C.

Crossword puzzles

D.

Television

21. Which of the following meal choices indicates the patient understands the diet restrictions when taking an MAOI?

A.

Pepperoni pizza and beer

B.

Roast chicken, baked potato, and beer

C.

Fried fish, rice, and cola

D.

Pickled herring, eggs, and coffee

22. Your patient with major depression sits in her room for hours staring out the window. Which of the following would be the most appropriate intervention?

A.

Sit with the patient and gently offer your availability to help.

B.

Keep encouraging the patient to go to exercise class.

C.

Offer the class once and then let the patient decide.

D. 23

Sit with the patient and ask her to list reasons for her depression.

. Which of the following drugs is a tricyclic antidepressant?

A.

Bupropion (Wellbutrin)

B.

Amitriptyline (Elavil)

C.

Fluoxetine (Prozac)

D.

Citalopram (Celexa)

24. Some medications such as tricyclics cause blurred vision. What is the cause of this effect?

A.

Hyperglycemia

B.

Anticholinergic effect

C.

Hypoxia

D.

Hypertension

25. Your patient has been taking a SSRI antidepressant for 6 weeks. On arrival at the clinic, which observation would indicate a positive outcome from the medication?

A.

Patient reports sleeping 12 hours a night.

B.

Patient reports sleeping 3 hours a night.

C.

Patient reports a weight loss of 10 pounds.

D.

Patient arrives neatly dressed.

26. Which response best describes how dysthymic disorder is different from major depression?

A.

More severe depression with psychotic features

B.

Chronic low level depression

C.

Mild depression with episodes of hypomania

D.

Depression with more anxiety symptoms

27. Which of the following would be the most effective intervention for a depressed patient?

A.

Establish one small goal to accomplish today.

B.

Help the patient develop a goal to complete in the next month.

C.

Encourage the patient to talk about recent failures in his or her life.

D.

Let the patient guide what is the next best action.

28. Which of the following is an important intervention for a patient taking nortriptyline?

A.

Make sure that CBC is ordered to monitor blood counts.

B.

Monitor for anticholinergic side effects.

C.

Ensure that the patients diet is gluten free.

D.

Push fluids to prevent dehydration.

29. A patient admitted to the mental unit has shown a deficit in providing selfcare and has a medical diagnosis of major depression. The nursing diagnosis for this would be: A.

Knowledge deficit related to personal choices.

B.

Self-care deficit related to impaired ability to provide personal hygiene.

C.

Risk for violence related to poor hygiene.

D.

Impaired social interaction related to poor hygiene.

Multiple Response Identify one or more choices that best complete the statement or answer the question.

30. Annie has been diagnosed as having dysthymic depression. The nurse knows that symptoms of this disorder include: (Select all that apply) A.

A depressed mood that lasts for most of each day over a 2-year period

B.

Low self-esteem

C.

Hallucinations

D.

Difficulty in making decisions

E.

Periods of euphoria

F.

Sleep pattern disturbances

31. Which of the following nursing interventions apply to all depressed patients? (Select all that apply) A.

Show patience

B.

Monitor lithium levels

C.

Monitor for suicidal ideation

D.

Communicate effectively

E.

Provide meaningful activities

F.

Include alternative therapies in the treatment plan

Chapter 7: Antidepressants/Depressive Disorders Answer Section MULTIPLE CHOICE 1.

ANS: D

Responses A and C are not helpful in just meeting the patient. Though response B is important, it begins with trust.

2.

ANS: D

The depressed patient may become overwhelmed if too much is offered too soon.

Structured, goal-directed activities are less stressful.

3.

ANS: C

Feelings of worthlessness are part of the common symptoms of sadness and low selfworth seen in major depression.

4.

ANS: D

This response gives the patient an opening to share feelings without being pressured to come up with reasons for these feelings. Responses A and C are not helpful for someone with depression because they minimize what the patient is experiencing.

5.

ANS: A

This medication is a MAOI (monoamine oxidase inhibitor). Eating foods with this enzyme can trigger a hypertensive crisis.

6.

ANS: D

Muscle rigidity is not an anticholinergic side effect.

7.

ANS: B

Though antidepressants are the treatment of choice for depression, electroconvulsive therapy is sometimes needed in cases of severe depression unresponsive to antidepressants. Lithium is generally not useful in depression. Light therapy and neurolinguistic programming may be adjuvants, not primary treatment in severe depression.

8.

ANS: B

This response tells you the spouse understands that antidepressants can take some time before seeing improvements. Response A tells you the spouse incorrectly thinks the drug will work immediately. There are no blood tests or food restrictions with this drug.

9.

ANS: B

Responses A, C, and D are all contributing biological factors to depression.

10.

ANS: C

Exposure to light has been shown to lift mood in this disorder.

11.

ANS: C

Antidepressants need to be taken consistently, including when the patient starts feeling better. Tricyclic antidepressants like amitriptyline can cause dry mouth.

12.

ANS: B

Dysthymia is depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years.

The level of depression is less than in major depression. Major depression is more severe and affects all areas of ones life.

13.

ANS: B

Though all the responses are correct, response B is most important. Nardil is a MAOI (monoamine oxidase inhibitor) with a potentially life-threatening side effect of hypertensive crisis in the presence of certain aged and/or processed foods.

14.

ANS: C

The other medications are examples of SSRIs and SSNIs. 15.

ANS: A

Nearly twice as many women as men are affected by depression. Men are more likely to mask depression in other ways, such as substance abuse. The elderly and children are also at risk for depression.

16.

ANS: C

While all of these diagnoses are important, the presence of hopelessness may be a sign of suicidal ideation and would take priority.

17.

ANS: C

Major depression and dysthymia are differentiated by severity and duration. The other responses are not factors.

18.

ANS: B

By translating words into feelings you are helping her focus on why she is feeling low.

Responses A and D disavow her reality, and response C expresses the nurses sense of being overwhelmed.

19.

ANS: A

Amitriptyline is a tricyclic antidepressant and is known to cause anticholinergic effects such as urinary retention.

20.

ANS: B

This response has no right or wrong answer and doesnt tax memory or concentration, which would occur in responses A and C. Television is passive and the patient can withdraw into his or her own world.

21.

ANS: C

The other responses contain dangerous foods, including pepperoni, beer, and pickled herring.

22.

ANS: A

This approach is the best one to establish trust without making too many demands on someone who has little energy to deal with demands. It is also important not to leave the patient alone too much, as that will send a message of not caring for her.

23.

ANS: B

The other choices are other categories of antidepressants.

24.

ANS: B

Anticholinergic effect can create blurred vision, urinary retention, and dry mouth caused by the blockage of acetylcholine.

25.

ANS: D

Attention to personal appearance is an important indicator of improved mood. The other responses are not indicative of improvements in depression. Abnormal sleep patterns indicate continued depression. Weight loss can occur with some antidepressants but would not be used as a measure of positive outcome for depression.

26.

ANS: B

The symptoms are less severe than major depressive disorder but have gone on for long periods.

27.

ANS: A

Small, achievable goals are the hallmark of helping a depressed person. One goal today is more concrete and achievable than one to be completed in a month. Talking about failures emphasizes negativity. The depressed patient may have no energy to identify the next best action.

28.

ANS: B

Anticholinergic effects from tricyclic antidepressants are a common initial side effect.

29.

ANS: B

Patient has the ability to provide own self-care, but cognitive ability to select the appropriate choice can be impaired by the depression.

MULTIPLE RESPONSE 30.

ANS: A, B, D, F

Dysthymic disorder includes symptoms of low level depression over a long period of time. It does not include hallucinations or periods of euphoria.

31.

ANS: A, D, E

Basic supportive interventions focus on communication and promoting self-esteem. All depressed patients do not need to be monitored for suicidal ideation. Lithium is usually not a medication for depression. Alternate therapies may not be appropriate for some patients.

Chapter 8 Mood stabilizers MULTIPLE CHOICE 1.

The nurse learns at report that a newly admitted manic patient is demonstrating grandiosity. Which statement would be most consistent with this symptom? a.

I cant do anything anymore.

b.

Im the worlds most astute financier.

c.

I can understand why my wife is upset that I overspend.

d.

I cant understand where all the money in our family goes.

ANS: B An individual who is demonstrating grandiosity has an exaggerated view of his abilities. The other options are more moderate statements and lack that element of exaggeration.

2.

The nurse will base a discussion of dysthymia on the fact that the condition:

a.

Typically has an acute onset

b.

Involves delusional thinking

c.

Is chronic low-level depression

d.

Does not include suicidal ideation

ANS: C

Dysthymia is identified as a chronic low-level depression frequently lasting over a period of several years without remitting. Dysthymia has a slow, insidious onset.

Delusional thinking is not a common manifestation of dysthymia. Suicidal thoughts are seen among dysthymic patients.

3.

What is the priority nursing diagnosis for a patient exhibiting signs of acute mania that include exaggerated physical activity, agitation, insomnia, and anorexia? a.

Risk for injury

b.

Chronic low self-esteem

c.

Noncompliance

d.

Insomnia

ANS: A Risk for injury is the priority diagnosis. Possible injuries include dehydration, which may result from not drinking and trauma, which may result from bumping into objects or from physical altercations. The other options are valid diagnoses, but not of highest priority.

4.

A patient has been admitted with a diagnosis of atypical depression. In planning interventions, the nurse would expect to consider the characteristic symptom of:

a.

Seasonal episodes

b.

Leaden paralysis

c.

Psychomotor agitation

d.

Increased depression in the morning

ANS: B Behavioral characteristics of atypical depression include the feeling that ones limbs are so heavy they cannot be lifted or moved (leaden paralysis). Seasonal mood changes are characteristic of seasonal affective disorder. Psychomotor agitation and depression that is greater in the morning than in the evening are characteristics more likely to be observed in patients with melancholic depression.

5.

An inappropriately dressed patient has not slept for 3 days while making excessive, expensive long-distance phone calls. When the patient can be heard singing loudly in the examining room, the nurse makes initial plans to focus on: a.

Assessing needs for food, liquids, and rest

b.

Setting strict limits on dress and behavior

c.

Conducting an in-depth suicide assessment

d.

Obtaining a complete psychosocial assessment

ANS: A Patients with mania frequently ignore their basic physiologic needs, as evidenced by not sleeping for 3 days, thus making these assessments the priority. Limits, although appropriate to consider, are not the priority. The manic state precludes a thorough assessment initially. Suicide assessment is not a priority at this time but reckless behavior could result in personal injury.

6.

Which statement by the patient would indicate the need for additional education regarding the prescribed lithium treatment regimen? a.

I will restrict my daily salt intake.

b.

I will take my medications with food.

c.

I will have my blood drawn on schedule.

d.

I will drink 8 to 12 glasses of liquids daily.

ANS: A Patients taking lithium must maintain a normal sodium intake or risk symptoms of lithium toxicity. The patient should have 2 to 3 liters of fluid daily. Taking lithium with food minimizes gastrointestinal side effects. Regular monitoring of lithium levels is important to prevent toxicity.

7.

The nurse would evaluate that patient education regarding lithium therapy for an individual with bipolar disorder as effective if the patient states: a.

I can stop my lithium when I feel better.

b.

I can continue with my diuretic and cardiac medications.

c.

I will probably need to take the lithium for the rest of my life.

d.

I will taper my lithium when a therapeutic serum level is achieved.

ANS: C Most patients with bipolar disorder require long-term maintenance on lithium or other antimanic medication. Patients should never stop medication without consulting the

physician. When a therapeutic level is achieved, the patient will continue on maintenance doses of lithium. Diuretics are contraindicated for the patient on lithium.

8.

A patient who has been taking lithium carbonate 300 mg tid comes to the Outpatient Department with a list of medications he is taking. Which of the medications on the list would require re-evaluation of lithium dosage? a.

HydroDIURIL daily

b.

Navane bid

c.

Ativan at bedtime

d.

Cefobid daily

ANS: A Diuretics alter fluid and electrolyte balance, increasing risk for lithium toxicity; therefore HydroDIURIL is correct. Antipsychotic medications are frequently prescribed concurrently with lithium to manage acute symptoms of mania, so no re- evaluation of lithium dose is necessary for Navane. Antianxiety drugs are not contraindicated with concurrent lithium use, so no lithium dose re-evaluation is necessary for Ativan.

Antibiotics do not alter fluid and electrolyte balance, so readjustment of lithium dosage is not required for Cefobid.

9.

Which outcomes would be appropriate to determine early favorable response to antidepressant medication? a.

The patient will complete own self-care activities.

b.

The patient will demonstrate assertive communication skills.

c.

The patient will describe signs and symptoms of major depression.

d.

The patient will make plans to attend one community social activity a week.

ANS: A Ability to manage basic ADLs demonstrates improvement in major depression.

Understanding the disorder may occur later when patient cognition has improved enough to be able to process information. Initiation of community social activity occurs when the patient has increased energy. Assertive communication is learned and practiced after the depression lifts.

10.

Prior to initiating medication therapy with phenelzine (Nardil), the nurse should plan to determine the patients:

a.

Mood and affect

b.

Activity level

c.

Cognitive ability to understand information about the medication

d.

Support network and its members willingness to participate in treatment

ANS: C Phenelzine (Nardil) administration requires strict adherence to a restricted diet. The patient must have the cognitive ability to understand the food and medication interactions that may cause a serious reaction.

11.

A patient who has a history of bipolar disorder recently underwent orthopedic surgery and was discharged to return home. When visited by the home care nurse, the nurse documented the following: slow and soft speech; sad facial expression; and patient crying when describing extreme fatigue, low mood, and the feeling that he will never get well. He has refused to bathe and perform ADLs for several days. Which nursing diagnosis would be appropriate? a.

Self-care deficit secondary to possible depression

b.

Situational low self-esteem related to immobility

c.

Deficient knowledge related to depression and surgery

d.

Disturbed thought processes related to bipolar disorder

ANS: A Refusal to perform tasks of bathing, grooming, and other ADLs provides evidence of a self-care deficit. The other symptoms documented by the nurse are characteristic of depression. No data are present to suggest the diagnoses given in the other options.

12.

The nurse caring for an extremely withdrawn patient with depression wants to assist her to become more interactive. The best approach would be to say: a.

I know youll feel better if you leave your room.

b.

You look so gloomy sitting here all by yourself.

c.

Lets explore how it feels to sit alone here all day and feel sad.

d.

I need another person for a card game and Id like you to be my partner.

ANS: D

This direct approach invites the patient to participate in a kind, but firm manner. The patient is not given an option to simply say yes or no. It is not therapeutic to give false reassurance. The remaining options focus too intensively on negative thoughts and feelings.

13.

Which nursing diagnosis would relate to the primary nursing concern related to a recently written prescription for amitriptyline (Elavil) 50 mg tid?

a.

Anxiety

b.

Ineffective coping

c.

Risk for self-injury

d.

Chronic low self-esteem

ANS: C Patients with depression are at increased risk for suicide when they have been on antidepressant medication for 2 weeks, because they are regaining some energy but may not have achieved full therapeutic effect with mood improvement. Poor coping is important but it is not the priority. Evidence of noncompliance is lacking. The medication is not prescribed for anxiety disorders.

14.

What information concerning amitriptyline (Elavil) 50 mg tid would the nurse give the patient regarding the expected outcome of this medication therapy? a.

Complying with this therapy will cure your depression.

b.

This medication is expected to improve brain chemical imbalance.

c.

Amitriptyline will help re-establish your ability to think clearly again.

d.

Elavil will be particularly effective at assisting you in regaining your independence.

ANS: B Antidepressant medication works by re-establishing the balance of neurotransmitters in the brain, particularly serotonin and norepinephrine. Antidepressants do not promise a cure for depression. Cognitive therapy, rather than antidepressants, addresses thinking issues. Learned helplessness is addressed by cognitive therapy.

15.

Which principle should the nurse apply when planning nursing care for a patient who was voluntarily admitted after a suicide attempt? a.

Patients who attempt suicide and fail will not try again.

b.

The more specific the plan, the greater the risk for suicide.

c.

Patients who talk about suicide are less likely to attempt it.

d.

Patients who attempt suicide and fail do not really want to die.

ANS: B Patients whose suicidal ideation includes a vague, diffuse plan or no plan at all are not at as high a risk for attempting suicide as an individual who has a well-developed plan and the means to carry it out. The nurse will need to continually reassess the patient.

None of the remaining options are true statements concerning suicide attempts.

16.

An appropriate nursing strategy to assist a patient who was involuntarily admitted after a suicide attempt is:: a.

Avoiding any focus on the topic of suicide

b.

Encouraging patient to verbalize personal feelings

c.

Supporting patient focus on others rather than self

d.

Discussing the impact of suicidal thoughts on the family

ANS: B Verbalization helps relieve pent-up feelings and emotional pain. Avoidance of the topic is nontherapeutic for a suicidal patient. The remaining options may serve to increase the patients feelings of guilt.

17.

Which principle should the nurse apply when planning care for a patient who is diagnosed with bipolar disorder and currently in the manic phase? a.

Manic patients respond well to peer pressure.

b.

Decreasing stimulation tends to diminish symptoms.

c.

Increasing stimulation tends to encourage the patient to focus.

d.

Detailed activities will facilitate the patients ability to self control behavior.

ANS: D

The only statement that is a valid principle is the option related to activity and its impact on controlling behavior. The other statements are inaccurate.

18.

Which nursing intervention is most therapeutic when the nurse is managing the aggressive, disruptive behaviors of a manic patient whose attempts to control the milieu has been rejected by the other patients? a.

Advising that the patient to accept the wishes of the group

b.

Suggesting that the patient either quiet down or leave the room

c.

Accompanying the patient to a quieter part of the unit

d.

Ignoring the patients outbursts because they are surly related to the mania

ANS: C Escorting the patient to a less stimulating environment will assist the patient to remain in control of behavior. It is unlikely that the patient would respond to verbal suggestions to leave the area unaccompanied or accept the groups wishes and would likely see the suggestions as a threat that would further escalate the impending loss of control. The behavior cannot be ignored since it will likely lead to an acceleration of the mania.

19.

What information would serve as the basis for the nurses reply when asked whether the cycling of moods from depressed to manic is a constant pattern seen in bipolar disorders? a.

Clinical observation tells us that mood disorders tend to remit and recur.

b.

Most cyclic behavior can be managed with the appropriate forms of therapy.

c.

Mood disorders generally see a decrease in cyclic affecting within 5 years of onset.

d.

Persons with higher cognitive abilities will generally exhibit fewer cyclic episodes.

ANS: A Mood disorders tend to remit and recur throughout the patients lifetime. There is no current research to support the other options.

20.

The individual who displays the history and symptoms most consistent with a medical diagnosis of seasonal affective disorder (SAD) is:

a.

26 years of age and complains of 3 consecutive years of depressed mood beginning in November and remitting in April

b.

64 years of age and complains of anhedonia, early morning awakening, psychomotor retardation, weight loss, and excessive feelings of guilt

c.

46 years of age and complains of dysphoric mood for 3 years, poor concentration, loss of interest in social activities, indecision, low energy, and low selfesteem

d.

38 years of age and complains of sadness, loss of ability to react to positive stimuli, weight gain, hypersomnia, leaden paralysis of limbs, and sensitivity to interpersonal rejection ANS: A Marked seasonal changes in mood typify seasonal affective disorder. Depression begins in October or November and lifts in March or April and must occur for at least 2 consecutive years. The other options are lacking in the identifying period of time when the symptoms are exhibited.

21.

A patient with suspected seasonal affective disorder asks the nurse, Ive been feeling down for 3 months. Will I ever feel like myself again? The response that builds on an understanding of this disorder is: a.

Spontaneous improvement usually comes in 6 months to a year.

b.

Can you tell me what you mean when you say feel like myself?

c.

People who have seasonal mood changes often feel better when spring comes.

d.

Usually patients with this disorder see improvement during the fall and winter.

ANS: C

Seasonal affective disorder is a condition in which the patient experiences depression beginning in the fall, lasting throughout the winter, and remitting in spring in the northern hemisphere. Fall and winter is not reflective of any diagnostic category of mood disorder. Spontaneous improvement occurs only with the change of seasons and available sunlight. Questioning is a response that does not address the point of understanding SAD.

22.

A Chinese-American patient comes to the mental health clinic after referral by her primary care physician. She complains of nervousness, headaches, fatigue, and vague GI symptoms for which no organic basis has been established. The symptoms began about 9 months ago when her favorite aunt died. The most appropriate independent nursing action would be to: a.

Prescribe a trial course of antianxiety medication.

b.

Plan strategies for cognitive behavioral therapy.

c.

Arrange admission to the inpatient unit for a complete workup and psychologic testing.

d.

Confer with the psychiatrist about the cultural association between depression and somatic symptoms.

ANS: D Expression of symptoms is influenced by ethnicity and culture. When depressed, Asian and Asian-American patients describe somatic symptoms, whereas patients of Western cultures may focus on mood and cognitive symptoms. Option d is an appropriate independent intervention the nurse should take. Options a, b, and c would be considered collaborative, rather than independent, interventions.

23.

A patient with melancholic depression paces and wrings her hands for hours at a time while repeating, Im a bad person. Staff members have been unsuccessful in their attempts to promote rest. Which intervention is most appropriate in promoting rest? a.

Instructing the patient to lie down for 15 minutes of every hour

b.

Asking the patient to fold and stack bath towels and washcloths

c.

Making the patient aware of the negative effects of fatigue on mood

d.

Reassuring the patient that she is accepted and not considered a bad person

ANS: B The psychomotor energy of agitation must be expended; it may be channeled into simple, repetitive activity. Standing in one place to fold towels is an improvement over pacing. This patient will be unable to comply with the request to lie down. A severely depressed patient will not be able to cognitively process this sort of information.

Reassurance will not appreciably affect the need for psychomotor activity.

24.

What measure will facilitate communication with a patient who is depressed and evidencing psychomotor retardation and withdrawal? a.

Ask the patient to indicate yes or no with finger signals.

b.

Arrange to spend time with the patient at prearranged intervals.

c.

Give concrete and concise directions rather than asking questions.

d.

Speak loudly and rapidly to the patient to focus his or her attention.

ANS: B This measure will promote the establishment of rapport and demonstrate respect and acceptance of the patient. It will facilitate patient willingness to communicate thoughts and feelings without making unnecessary demands on the patient; a headshake or nod would work as well. Patients should not simply be ordered about; they should be asked to respond without placing excessive demands. Patients with psychomotor retardation have the ability to hear, but their ability to process information may be slowed, requiring well-paced simple communication.

25.

Which measure consistent with the use of cognitive therapy could the nurse incorporate into the treatment plan of a chronically depressed patient? a.

Approach the patient with cheerful affect and optimistic remarks.

b.

Ignore the patients pessimistic statements; give attention for positive thinking.

c.

Identify negative evaluations and challenge pessimistic beliefs.

d.

Seek to uncover unconscious conflicts about significant relationships.

ANS: C Cognitive therapy addresses symptom removal by identifying and correcting distorted negative thinking. An overly cheerful mannerism is an insensitive nontherapeutic approach that will reinforce patient negative thinking about self. To ignore negative statements while reinforcing positive thinking is considered a behavioral approach.

Seeking to uncover unconscious conflicts is a psychodynamic approach.

26.

Which symptom related to thought-flow disturbance is the nurse most likely to assess in a newly admitted patient who is diagnosed with bipolar disorder, manic episode? a.

Slow, halting speech

b.

Flight of ideas

c.

Schemata

d.

Anhedonia

ANS: B Flight of ideas is a continuous rapid flow of speech marked by jumping from topic to topic. It is a manifestation of thought disorder associated with inability to filter stimuli causing increased distractibility. Slow speech would be seen in depression. Neither schemata or anhedonia are symptoms of a thought-flow disorder.

27.

Therapeutic interactions between the nurse and a manic patient will be facilitated when the nurse: a.

Uses a calm, matter-of-fact approach to structuring

b.

Focuses primarily on enforcing rigid limits on behaviors

c.

Implements a laissez-faire approach to the patients symptoms

d.

Encourages the patient to use humor and wit to redirect energy

ANS: A A calm, matter-of-fact approach minimizes patient need for defensiveness and minimizes power struggles. The use of rigid limit setting leads to power struggles and escalation of patient hyperactive, aggressive behavior. Structure and judicious limit setting are more therapeutic. A laissez-faire approach is nontherapeutic; manic patients usually need structure. Encouraging humor and wit is generally ineffective since patients with mania cannot maintain control of emotions and may shift from witty to angry in seconds.

28.

A patient who is experiencing a manic episode approaches the nurse and with pressured speech states, I hate oatmeal. Lets get everybody together to do exercises.

Im thirsty and Im burning up. Get out of my way; I have to see that guy. The priority nursing action is to:

a.

Measure the patients temperature and pulse.

b.

Offer to have the dietitian visit to discuss his diet.

c.

Tell the patient he can lead exercises at the community meeting.

d.

Show relief when the patient ends the interaction and walks away.

ANS: A During a manic episode, the patient may be inattentive to physical needs or illness.

The brief remark about burning up could suggest fever. Thirst may accompany fever, be a sign of dehydration, or be related to lithium administration. More information is needed. Because hyperactive patients have difficulty remaining still, taking the temperature and pulse will give priority information. If necessary, BP can be taken later. A nutritional consult is not a priority intervention. It is not appropriate to foster increased hyperactivity. To show relief would be disrespectful on the part of the nurse.

29.

A patient with bipolar disorder reveals to the clinic nurse that she may be 4 weeks pregnant. Which action will the nurse take?

a.

Confer with the physician about ordering a pregnancy test and discontinuing lithium.

b.

Educate the patient to the risk to the fetus as a result of exposure to the lithium in her blood.

c.

Suggest to the physician that the lithium dose should be increased for better symptom control.

d.

Remind the patient that barrier birth control methods should be used to prevent pregnancy during lithium therapy.

ANS: A

The first need is to learn whether the patient is pregnant. Lithium ingestion by the mother can cause fetal damage. Lithium should be discontinued, not increased, if pregnancy is confirmed. It is premature to discuss fetal malformations before the

pregnancy is confirmed. Options b and c are inappropriate and harmful. Birth control information has no value unless the pregnancy test is negative.

30.

Which nursing measure would be relevant to protecting the physiologic integrity of a patient during a manic episode when marked hyperactivity is present? a.

Provide appropriate attire for patient to wear.

b.

Set firm limits on behavior injurious to others.

c.

Monitor the patients weight at the same time daily.

d.

Use genuineness to develop a therapeutic alliance with the patient.

ANS: C Hyperactivity expends huge amounts of calories and interferes with caloric intake, thus resulting in rapid weight loss. Monitoring weight daily protects the patients physiologic integrity. The other options are concerned with psychosocial integrity.

31.

Care planned for a patient with adjustment disorder will be most effective if the nurse knows adjustment disorders are a group of disorders that: a.

Involve psychotic thinking in adolescents

b.

Address issues of anxiety and depression

c.

Include behaviors that are seen primarily in the child and adolescent population

d.

Manifest as transient episodes of dysfunction in response to specific stressors

ANS: D Adjustment disorders are short-term disturbances in mood or behavior resulting from identifiable stressors. Psychotic features are not present. Adjustment disorders can occur in any age group. Anxiety and depression may be present, but emphasis is on identifying and resolving the specific issue.

32.

The nurse manager, teaching a class to new staff members about working with patients with adjustment disorders, will specify that the intervention most helpful in working with patients with this diagnosis is: a.

Entering pertinent data in the patients medical record

b.

Including family members in the interdisciplinary treatment plan

c.

Identifying the precipitating stressful event and current problems

d.

Reducing the patients level of anxiety to prevent behavioral escalation

ANS: C

Identification of the precipitating stressful event and interpretation of the existing problem are fundamental to working with the patient to reduce symptoms. Including family in treatment planning is secondary to identification of the stressor and the problem. Anxiety will remain high until the problem and the stressor are identified.

Data entry is not directly related to the question posed.

33.

When a father states, I dont understand what the doctor means by saying my daughter has an adjustment disorder. The nurse explains that this disorder often results from: a.

Failure of existing coping skills

b.

Lack of stable emotional support

c.

Denial that a problem truly exists

d.

Overcompensation to present a controlled appearance

ANS: A When existing coping skills are not adequate to deal with a stressor, and new coping skills have not been developed, symptoms appear. These symptoms may fit the DSMIV-TR criteria for adjustment disorder. The lack of emotional support is not applicable to the situation. The disorder does not result from use of denial since patients usually recognize that a problem exists. Overcompensation is not related to the onset of adjustment disorder.

34.

Which question would be most effective in helping a patient with an adjustment disorder identify the event that triggered the maladaptive response? a.

Can you tell me about your support system?

b.

Have you ever been in psychotherapy before?

c.

Did you experience any stressful events recently?

d.

How do you usually handle problems in your life?

ANS: C

This question will determine whether the patient is able to identify a particular stressor that has affected her life recently. Asking about support systems will help gain information about important persons in the patients life. History of psychotherapy will provide information about mental health. Previous methods will provide information about use of coping strategies.

35.

A teenager is admitted to the adolescent unit with a diagnosis of adjustment disorder with depression. Which information collected from the assessment interview will be given highest priority when planning the patients care? a.

Patient frequently disregards curfew.

b.

Patients parents were divorced 8 years ago.

c.

Patient states she finds no pleasure in living.

d.

Patient is failing most of her high school classes.

ANS: C Finding no pleasure in living should suggest the need for further assessment of suicide potential. Safety needs take priority over problems suggested by other data collected.

36.

The nurse has been working with a patient who has adjustment disorder with depressed mood. Which finding would permit the nurse to accurately evaluate that the crisis has been resolved? a.

Absence of presenting symptoms

b.

Decreased need for medications

c.

Increased socialization with peers

d.

Significant increase in the patients appetite

ANS: A When the presenting symptoms are absent, the nurse can evaluate the problems as resolved. Most patients with adjustment disorders do not require medication, so this is not a good indicator. Data do not substantiate that the patient is experiencing problem socializing. This could indicate the patient is overeating as a means of dealing with stress.

37.

Which of the following statements would correctly serve as a basis for teaching a family the usual outcome of an adjustment disorder? a.

The symptoms will likely resolve completely.

b.

The patient may continue to be in danger of self-harm.

c.

Medications are frequently used to mask the symptoms.

d.

Relaxation is an effective tool to decrease and manage stress.

ANS: A The prognosis for most patients with adjustment disorders is good. In the majority of cases, identification of the stressor and use of effective coping strategies result in resolution. Continued self-harm is not a usual outcome for an adjustment disorder.

Medications are not used routinely to treat adjustment disorders. Relaxation techniques are interventions rather than outcomes.

38.

Which activity would be a constructive outlet for tension and anxiety while enhancing self-esteem for a patient with adjustment disorder with anxious mood? a.

Knitting scarves for a homeless shelter

b.

Painting a paint-by-number scenic picture

c.

Working on a large, colorful picture puzzle

d.

Engaging in regular, age-appropriate physical exercise

ANS: D

Physical exercise may assist in relieving tension and promoting feelings of well-being.

Knitting is tedious and requires steadiness, which the patient may not have if symptoms of anxiety include jitteriness. Painting requires fine motor coordination, not always present if a patient is anxious. Some patients find puzzles frustrating and become even more tense while working on one.

39.

The major rationale for careful ongoing assessment of a patient with adjustment disorder is: a.

Characteristic symptoms abate but take at least 6 months to do so.

b.

The disorder may be a precursor to a more serious mental health problem.

c.

Practitioners become less discerning as they become more familiar with the patient.

d.

Patients with adjustment disorders have a high risk for self-harm, especially suicide.

ANS: B Adjustment disorders usually improve with identification of the stressor and development of coping strategies to relieve stress. If symptoms worsen, new treatment strategies must be developed to treat the more serious mental health disorder that has become apparent. There is no research to support the remaining options.

MULTIPLE RESPONSE 1.

When assessing a patient diagnosed with a mood disorder, which abnormal diagnostic tests would be considered a possible factor in the manifestation of the disorder? Select all that apply a.

RBC (red blood cell)

b.

ECG (electrocardiogram)

c.

BUN ( blood urea nitrogen)

d.

TSH (thyroid stimulating hormone)

e.

Blood glucose

ANS: A, D, E Anemia, hyper- or hyperthyroidism, and diabetes mellitus are all medical conditions that can occur simultaneously with mood disorders. There is no research to support a strong connection between renal or cardiac disorders with mood disorders.

2.

Which statements regarding a hypomanic episode are true? Select all that apply.

a.

Behavior has been observed in the patient for at least 4 days.

b.

Patient appears unaware of potentially dangerous situations.

c.

Hospitalization is generally required to stabilize the behavior.

d.

Patient is engaging in behaviors that are normally uncharacteristic of them.

e.

Primary difference between mania and hypomania is the nature of the activity.

ANS: A, B, D

Manic and hypomanic episodes share symptom criteria, and they differ primarily with regard to their severity and duration but not the nature of the activity. Hypomanic episodes are not severe enough to cause significant impairment in social and occupational functioning or to require hospitalization. However, for diagnosis, it must be evident that the mood and behavioral disturbances of hypomaniarepresent a definite change in the persons usual functioning that lasts for at least 4 days. As judgment declines, patients sometimes fail to recognize the consequences of their actions and the presence of possible danger.

Chapter 9 Anxiety disorders and anxiolytics MULTIPLE CHOICE 1.

What is the recommended time over which antianxiety medications must be gradually tapered before discontinuation? a.

1 week

b.

1 month

c.

6 months

d.

1 year

ANS: B Withdrawal from medication should be done under a health care providers supervision. Withdrawal usually takes 4 weeks and requires a gradual reduction in dosage and greater intervals between medication administrations. One week is an inadequate interval for cessation of antianxiety medication therapy. Six months to 1 year is much longer than necessary for cessation of antianxiety medication therapy.

2.

Which is a benzodiazepine of choice when treating anxiety associated with alcohol withdrawal? a.

Chlordiazepoxide (Librium)

b.

Oxazepam (Serax)

c.

Diazepam (Valium)

d.

Clorazepate (Tranxene)

ANS: B

Oxazepam and lorazepam are the drugs of choice in treating anxiety disorders because they have no active metabolites. Chlordiazepoxide and clorazepate are not the drugs of choice when treating anxiety associated with alcohol withdrawal. Diazepam has not been studied as fully as oxazepam in treating patients who have hepatic function impairment.

3.

Which is the drug of choice to treat a patient with obsessive compulsive disorder (OCD)? a.

Lorazepam (Ativan)

b.

Buspirone (BuSpar)

c.

Fluvoxamine (Luvox)

d.

Hydroxyzine (Vistaril)

ANS: C Fluvoxamine inhibits the reuptake of serotonin at the nerve endings, thus prolonging serotonin activity. Fluvoxamine is used for the treatment of OCD when the obsessions

or compulsions cause marked distress or interfere substantially with social or occupational responsibilities. Fluvoxamine does not prevent the obsessions or compulsions; the therapeutic outcome of this drug is to assist the patient in their management. Lorazepam, buspirone, and hydroxyzine do not treat the symptoms of OCD. 4.

The outcome statement for a patient suffering from anxiety disorder reads, After 1 week on alprazolam (Xanax) therapy, patient will exhibit a manageable level of anxiety. Which assessment finding validates that this outcome is met? a.

Patient is unable to participate in group therapy conversations.

b.

Patient reports persistent fear about dying of a rare illness.

c.

Patient verifies that family reunions trigger anxiety and excessive drinking.

d.

Patient reports sleeping better and increased interest in activities.

ANS: D The primary therapeutic outcome expected from benzodiazepine antianxiety agents is a decrease in the level of anxiety to a manageable level. Physical signs of anxiety have decreased, and coping is improved. Being unable to participate in group therapy,

persistent fears, and choosing inappropriate coping mechanisms for noncatastrophic events indicate that the anxiety is not manageable.

5.

Which is true regarding psychological drug dependence?

a.

It is easier to treat than physiological dependence.

b.

It is not considered a true addiction.

c.

It is easily controlled by influencing the patients perceptions.

d.

It requires medical intervention to treat.

ANS: D Medical intervention is required to treat psychological drug dependence. Psychological addictions are often more difficult to overcome than physiological addictions.

Psychological drug dependence can be very difficult to treat.

6.

The nurse is preparing to educate a patient and significant other about antianxiety medications before the patients discharge. What is pertinent information to be included in the teaching plan?

a.

Discuss, review, and validate the behavior monitoring system and intervention flow sheet the patient and significant other will continue to use following discharge.

b.

Discuss the possible dependence associated with the medication at length to make sure the patient does not overuse the drug.

c.

Instruct the patient to educate family members about the medication therapy, based on recollection of discussions with the nurse.

d.

Provide all instructions verbally, with repetition as needed when requested by the patient.

ANS: A It is the responsibility of the nurse to educate patients about their therapy, monitoring for therapeutic benefit and adverse effects to expect and report, and

intervening whenever possible to optimize therapeutic outcomes. Making the patient fearful of the medication therapy defeats the purpose of using the drug to control anxiety. The topic should be mentioned because it is important, but it should not be emphasized. Family members or significant others should participate in discussions with the nurse whenever possible, and the patient should be given written instructions to refer to after discharge. Verbal instruction should be backed up with written documents for the patient to refer to after discharge.

7.

What will the nurse caution a patient about when providing information about the prescribed azaspirone antidepressant? a.

Risk for addiction

b.

Adverse effect of nausea

c.

Risk of injury when using machinery

d.

Additive effects of central nervous system (CNS) depression with alcohol

ANS: CThe most common adverse effects of azaspirone therapy include dizziness, nervousness, drowsiness, and lightheadedness. Azaspirones do not have a risk for abuse or addiction.

Nausea and vomiting are not common adverse effects of treatment with azaspirones.

Azaspirones do not have CNS depression, but it is recommended that they not be combined with alcohol or sedatives.

8.

Which patient is most likely to respond quickly to antianxiety therapy with benzodiazepines? a.

Patient with a history of long-term anxiety

b.

Patient with recent anxiety reactions

c.

Patient with severe depression in addition to being anxious

d.

Patient with incidents of auditory hallucinations

ANS: B Patients with anxiety reactions to recent events and those with a treatable medical illness that induces anxiety respond most readily to benzodiazepine therapy.

Long term anxiety is best treated with medications other than benzodiazepines (e.g., prescription medications such as Zoloft, Paxil, Prozac, Effexor, and Wellbutrin).

Severe depression does not improve with treatment of benzodiazepines. Patients who are having psychotic symptoms do not respond to benzodiazepines.

9.

What instruction is most important for the nurse to teach the patient who has recently been prescribed alprazolam (Xanax)?

a.

The medication needs to be taken on an empty stomach.

b.

You may feel dizzy or unsteady when rising to a standing position.

c.

Smoking will require a reduction in dosage of the medication.

d.

Over the counter medications are safe to take while on this medication.

ANS: B Patients may experience a transient episode of hypotension on arising. This medication does not need to be taken on an empty stomach. Smoking enhances the metabolism of benzodiazepines; larger doses may be necessary to maintain effects.

Over the counter medications are to be approved by the health care provider.

Antihistamines, for example, increase toxic effects.

10.

The nurse is developing a teaching plan for patients prescribed buspirone (BuSpar). Which information about this medication should be included? a.

There is minimal potential for abuse.

b.

Signs of improvement can be seen within 3 days.

c.

Sedation is increased compared with other antianxiety medications.

d.

It stimulates the action of gamma-aminobutyric acid (GABA).

ANS: A There is minimal potential for abuse with buspirone. It takes longer than 3 days to see signs of improvement. Buspirone has lower sedative properties and does not affect 11.

A newly admitted psychiatric patient repetitively states, I wish I were dead. I just want to kill myself. The priority nursing at this time is to: a.

establish a trusting relationship.

b.

encourage a nonstimulating environment.

c.

provide for patient safety.

d.

identify signs of increased anxiety.

ANS: C If the patient has suicidal ideas, intervention to provide patient safety is the priority nursing action. Although establishing a trusting relationship should occur, safety is the nursing priority. Once safety is established, support and reassurance may be provided. A nonstimulating environment should be encouraged once safety is established. Once patient safety is established signs of increased anxiety can be identified.

12.

The nurse transcribes an order for lorazepam for a patient experiencing nausea and vomiting as a result of alcohol withdrawal. The most appropriate route of administration for lorazepam with this patient would be: a.

by mouth.

b.

rectally.

c.

intramuscularly.

d.

subcutaneously.

ANS: C The use of lorazepam is somewhat limited for use with symptoms of alcohol withdrawal for those who cannot tolerate oral administration because of nausea and vomiting. The most appropriate route in this situation would be intramuscularly.

MULTIPLE RESPONSE 13.

A female patient is admitted to the adult psychiatric floor with a diagnosis of generalized anxiety disorder. Anxiolytic medications and group therapy have been prescribed. Evaluation of therapeutic outcomes related to her acute stay can be measured by which assessment(s)? (Select all that apply.) a.

She is able to sleep 5 hours during the night.

b.

The tremor and pacing she exhibited on admission are reduced.

c.

She is able to attend and actively participate in group sessions.

d.

She is eating only 10% of her meals.

e.

She complains of chest pain before group therapy.

ANS: A, B, C A primary therapeutic outcome expected from antianxiety therapy agents is a decreased level of anxiety to a manageable level with the ability to get adequate rest and nourishment, a decrease or elimination of somatic complaints, and active and appropriate participation in group therapy. Improved appetite would be a sign of decreased anxiety. Chest pain may be an example of somatization, especially when experienced during emotionally stressful times, such as group therapy.

14.

Which substance(s) may increase the toxic effects of benzodiazepines? (Select all that apply.) a.

Alcohol

b.

Antihistamines

c.

Analgesics

d.

Sedatives

e.

Vitamins

f.

Hypnotics

ANS: A, B, C, D, F Alcohol, antihistamines, analgesics, sedatives, and hypnotics may cause excessive sedation and impaired psychomotor function when taken concurrently with benzodiazepines. Vitamins do not cause excessive sedation and impaired psychomotor function when taken concurrently with benzodiazepines.

15.

In addition to the relief of mild to moderate anxiety, hydroxyzine (Vistaril) has which additional therapeutic outcome(s)? (Select all that apply.) a.

Reduced need for sedation and analgesia before and after surgery

b.

Elimination of psychotic thinking

c.

Control of itching in allergic reactions

d.

Control of vomiting

e.

Control of obsessive compulsive thoughts

f.

Prevention of extrapyramidal adverse effects and tardive dyskinesia

ANS: A, C, D Hydroxyzine has sedative, antihistamine, and antiemetic effects in addition to antianxiety activity. Hydroxyzine does not control psychotic thinking, obsessive compulsive thinking, or movement disorders caused by other medications.

16.

Which assessment(s) would be included in the evaluation of a patient with anxiety? (Select all that apply.) a.

Physical examination

b.

Psychological evaluation

c.

History of precipitation stressors

d.

Medication history

e.

Substance abuse history

f.

Blood glucose level

ANS: A, B, C, D, E Physical examination, psychological evaluation, history of precipitation stressors, medication history, and substance abuse history are important in evaluating a patient with anxiety to get a complete background on the patient. The blood glucose level is not included in evaluation of a patient with anxiety.

17.

The prenatal nurse is educating a woman regarding preconception care. The patient informs the nurse that she is currently taking a benzodiazepine drug for management of anxiety. Appropriate teaching for this patient will include that benzodiazepines: (Select all that apply.) a.

readily cross into breast milk.

b.

are safe to take throughout pregnancy.

c.

enter fetal circulation.

d.

are not associated with ill effects on the infant following birth.

e.

may increase newborn muscle tone.

ANS: A, C It is recommended that benzodiazepines not be administered during at least the first trimester of pregnancy. There may be an increased incidence of birth defects because these agents readily cross the placenta and enter fetal circulation. Mothers who are breast feeding should not receive benzodiazepines regularly. The benzodiazepines readily cross into breast milk and exert a pharmacologic effect on the infant. If benzodiazepines are taken regularly during pregnancy, the infant should be monitored closely after delivery for signs of withdrawal, including hypotonia.

Chapter 10 Chronic pain and its treatment MULTIPLE CHOICE 1.

The nurse is completing an assessment on a nonverbal adult patient. Which type of pain scale assessment tool is the most accurate to use? a.

TPPPS

b.

FLACC

c.

POCIS

d.

MOPS

ANS: B The Face, Legs, Activity, Cry, Consolability (FLACC) scale would be used to assess pain in the nonverbal patient. The Toddler Preschooler Postoperative Pain Scale (TPPPS), Pain Observation Scale for Young Children (POCIS), and Modified Objective Pain Scale (MOPS) would not be appropriate for this patient.

2.

Which action will the nurse take when a patient receiving morphine sulfate via percutaneous coronary angioplasty (PCA) has a shallow, irregular respiratory rate of 6 breaths/min? a.

Elevate the patients head of bed to facilitate lung expansion.

b.

Increase the patients primary intravenous (IV) flow rate.

c.

Complete the FLACC scale.

d.

Notify the health care provider and prepare to administer naloxone (Narcan).

ANS: D The patient is exhibiting signs of respiratory depression. Administration of the antidote naloxone would be the most appropriate nursing intervention. Lung expansion or increasing the primary IV infusion rate would not relieve respiratory depression. Assessing the patients pain at this point is a lesser priority than treating the respiratory depression.

3.

Which patient assessment would indicate to the nurse that salicylate toxicity is occurring? a.

Gastrointestinal (GI) bleeding

b.

Increased bleeding times

c.

Tinnitus

d.

Occasional nausea

ANS: C

Symptoms of salicylism include ringing in the ears (tinnitus), impaired hearing, dimming of vision, sweating, fever, lethargy, dizziness, mental confusion, nausea, and vomiting. Although salicylates may cause GI bleeding over time, it is not a symptom associated with toxicity. Increased bleeding time is an effect associated with the

treatment of clots. Occasional nausea is a common adverse effect of treatment with salicylates; it is not a sign of toxicity.

4.

What is the advantage of taking a nonsteroidal anti inflammatory drug (NSAID) that is a COX 2 inhibitor? a.

The medication is cheaper than aspirin.

b.

There are fewer GI adverse effects.

c.

They are more effective than COX 1 inhibitors.

d.

They have no known adverse effects.

ANS: B COX 2 inhibitor NSAIDs have fewer GI adverse effects than salicylates or COX 1 inhibitors. Aspirin is one of the least expensive analgesics available. The anti inflammatory actions of NSAIDs are caused by COX 2 inhibition; the unwanted adverse effects are caused by inhibition of COX 1. All these medications have adverse effects. ] 5.

An 86 year old patient who was admitted with GI bleeding as a result of salicylate therapy is being discharged. As the nurse reviews the discharge medication list, the patient states that she doesnt understand why Tylenol doesnt work as well as the aspirin she had been taking. What would be the nurses best response? a.

Tylenol and aspirin are chemically the same drug.

b.

Tylenol is appropriate for only minor pain.

c.

Tylenol does not help with inflammatory discomfort.

d.

A therapeutic blood level must be established with Tylenol.

ANS: C Acetaminophen (Tylenol) is effective as an analgesic or antipyretic. Tylenol does not possess any anti inflammatory activity and is therefore ineffective in relieving symptoms related to inflammation. Tylenol and aspirin are distinctly different drugs.

Tylenol can be useful in the relief of moderate pain. Tylenol can be effective in a single dose, without needing treatment over a period of time.

6.

What term is used to define an awareness of pain?

a.

Tolerance

b.

Threshold

c.

Perception

d.

Sensation

ANS: C Pain perception, also known as nociception, is an individuals awareness of the feeling of pain. Pain tolerance is an individuals ability to endure pain. Pain threshold is the point at which an individual first acknowledges or interprets a sensation as being painful. Pain is a sensation characterized by a group of unpleasant perceptual and emotional experiences that trigger autonomic, psychological, and somatomotor responses.

7.

Which statement is true about neuropathic pain?

a.

This pain is the result of a stimulus to pain receptors.

b.

Patients describe it as dull and aching.

c.

It commonly originates in the abdominal region.

d.

The pain is a result of nerve injury.

ANS: D Neuropathic pain results from injury to the peripheral or central nervous system, such as trigeminal neuralgia. Nociceptive pain is the result of a stimulus to pain receptors.

Nociceptive pain is usually described as dull and aching. Visceral pain originates from the abdominal and thoracic regions.

8.

How long after the administration of a parenteral pain medication will the nurse complete the next pain assessment to evaluate the effectiveness of the medication? a.

10 minutes

b.

30 minutes

c.

1 hour

d.

2 hours

ANS: B Evaluation of pain effectiveness of parenteral pain medications needs to occur within 15 to 30 minutes of administration. Ten minutes, 1 hour, and 2 hours are not accurate time frames to evaluate the effectiveness of parenteral medications.

9.

Which sign or symptom displayed by a patient would be indicative of opiate withdrawal? a.

Bradycardia

b.

Diarrhea

c.

Lethargy

d.

Hypothermia

ANS: B Symptoms of opiate withdrawal include muscular spasms; severe aches in the back, abdomen, and legs; abdominal and muscle cramps; hot and cold flashes; insomnia;

nausea, vomiting, and diarrhea; severe sneezing; and increases in body temperature, blood pressure, and respiratory and heart rates. Bradycardia is not a sign of opiate withdrawal; increased heart rate is a sign of opiate withdrawal. Lethargy is not a sign of opiate withdrawal; restlessness is a sign of opiate withdrawal. Hypothermia is not a sign of opiate withdrawal; fever is a sign of opiate withdrawal.

10.

Which medication is contraindicated when a patient is taking warfarin (Coumadin)? a.

Aspirin

b.

Acetaminophen (Tylenol)

c.

Propoxyphene (Darvon)

d.

Morphine (Roxanol)

ANS: A Salicylates enhance the anticoagulant effect of warfarin. Acetaminophen, propoxyphene, and morphine are not contraindicated with warfarin use. MSC: NCLEX Client Needs Category: Physiological Integrity 11.

What is the best way for the nurse to evaluate the effectiveness of the patients opiate agonist? a.

Ability of the patient to tolerate more activity

b.

Increased sleep time throughout the night

c.

Reduction of respiratory rate from 24 to 18 breaths/min

d.

Verbal report of 2 on a 1 to 10 scale

ANS: D A verbal report is the best indicator because pain is individually perceived and using a pain rating scale is a consistent manner of assessment. Toleration of activity and an increased sleep pattern are not the most accurate methods of pain evaluation.

Reduction of respiratory rate is not an appropriate measurement of pain control.

12.

Which medication would the nurse administer to a patient who is rating the pain at 8 on a 0 to 10 scale? a.

Acetaminophen (Tylenol)

b.

Morphine (Roxanol)

c.

Oxycodone (OxyContin)

d.

Oxycodone and aspirin (Percodan)

ANS: B Severe pain is treated with an opiate agonist (i.e., morphine). Severe pain is not treated with acetaminophen, oxycodone, or Percodan.

MSC: NCLEX Client Needs Category: Physiological Integrity 13.

In which case would the nurse be correct in withholding an opiate agonist?

a.

Evidence of postural hypotension

b.

Presence of constipation

c.

Pain rating of 7 on a 0 to 10 scale

d.

Respiratory rate of 10 breaths/min

ANS: D The nurse would withhold the medication if respirations are less than 12 breaths/min.

Postural hypotension is a common adverse effect that most frequently occurs when therapy is initiated. Providing for patient safety is important, but it does not warrant withholding the medication. Constipation is an expected adverse effect and does not warrant withholding an opiate agonist. A pain rating of 7 would not warrant holding an opiate agonist.

14.

What information is most accurate regarding the nurses understanding of pain management? a.

Older patients have difficulty describing their pain level.

b.

Encourage patients to report pain before the pain becomes too severe.

c.

Use the smallest dose of medication possible to control pain.

d.

Pain medication administration ordered PRN will maintain a constant blood level.

ANS: B Even though pain medicine administration may be scheduled, encourage the patient to request pain medication before the pain escalates and becomes severe. Although the smallest dose possible to control the pain is the goal of therapy, it is also important that the dose be sufficient to provide adequate relief. Older patients are able to describe pain; a variety of tools are available for a variety of patient populations.

Analgesics given on a scheduled basis every 3 to 4 hours will maintain a more constant plasma level.

15.

The nurse is assessing a patients pain. When the patient describes his pain as cramping and burning, which component of the pain history is being addressed? a.

Depth

b.

Location

c.

Quality

d.

Severity

ANS: C The actual sensation of the pain is often described as stabbing, dull, cramping, sore, burning, or a combination of these. Depth of pain, location of pain, and severity of pain are not described as cramping and burning.

16.

A patient experiencing chronic pain as a result of metastatic cancer has a new order for fentanyl (Duragesic) transdermal patch. The initial patch is applied at 8 AM on Monday. At 8 PM on Monday, the patient reports a pain level of 8. The nurses best response is to:

a.

immediately contact the physician.

b.

reassess pain level in 30 to 45 minutes.

c.

remove current patch and reapply a new patch.

d.

provide a PRN analgesic medication as ordered.

ANS: D The fentanyl (Duragesic) patch takes approximately 12 to 24 hours for the initial patch of medication to reach a steady blood level, so other analgesics must be used during this time. Therefore, it is not necessary to immediately contact the physician. The patient is reporting severe pain and requires immediate intervention to help relieve this discomfort.

17.

A patient is taking meperidine (Demerol) as needed for moderate to severe pain following an open appendectomy. The nurse assesses the following: current pain level 2, temperature 99 F, BP 130/76, respirations 10, lung sounds clear, abdomen soft and tender, bowel sounds present. Based on this assessment information, the priority nursing diagnosis is: a.

altered breathing pattern.

b.

risk for altered body temperature.

c.

risk for constipation.

d.

pain.

ANS: A Meperidine (Demerol) is an opiate agonist and can cause respiratory depression.

Respirations less than 12/min indicates altered breathing pattern and requires immediate intervention. Temperature of 99 F is not the priority concern. The abdomen is soft, so there is no indication of constipation. Pain level of 2 is considered mild; therefore, this is not the top priority.

MULTIPLE RESPONSE 18.

Which additional nursing intervention(s) would be effective with pain management in the pediatric population? (Select all that apply.) a.

Provide diversional activities such as coloring, puzzles, and games.

b.

Allow uninterrupted sleep and rest.

c.

Perform hygiene measures.

d.

Encourage parental participation with caregiving to diminish the childs anxiety.

e.

With the health care providers approval, encourage the child to drink eight to ten 8 ounce glasses of fluid daily.

ANS: A, B, C, D Diversional activities, adequate sleep, comfort measures (such as hygiene), and parental participation with care are alternative nursing interventions that may be used in pain management. Forcing fluids is not likely to assist with pain management in the child.

19.

Which common adverse effect(s) is/are associated with opiate agonists? (Select all that apply.) a.

Dizziness

b.

Orthostatic hypotension

c.

Respiratory depression

d.

Confusion

e.

Diarrhea

f.

Urinary urgency

ANS: A, B, C, D Dizziness, orthostatic hypotension, respiratory depression, and confusion are adverse effects associated with opiate agonists. Constipation, not diarrhea, is an adverse effect associated with opiate agonists. Urinary retention, not urgency, is an adverse effect associated with opiate agonists.

20.

Which condition(s) may be managed by salicylates? (Select all that apply.)

a.

Migraine headache

b.

Swollen joints

c.

Fever

d.

Muscle aches

e.

Myocardial infarction

ANS: B, C, D, E Salicylates inhibit prostaglandins that produce the signs and symptoms of inflammation, inhibit the synthesis and release of prostaglandins in the brain that cause the elevation of body temperature, inhibit the formation of prostaglandins that sensitize pain receptors (providing analgesia), and inhibit platelet aggregation and decrease the risk of clot development. Salicylates are not typically used for migraine headache.

21.

When teaching a patient who is starting therapy with NSAIDs, the nurse must be sure to mention drug interactions with which drug(s)? (Select all that apply.) a.

Warfarin (Coumadin)

b.

Lithium (Eskalith)

c.

Hydroxyzine (Vistaril)

d.

Insulin

e.

Diuretics

f.

Digitalis (Digoxin)

ANS: A, B, E NSAIDs may enhance the effects of warfarin, lithium, and diuretics. NSAIDs are not known to interact with hydroxyzine, insulin, or digitalis.

22.

When performing a baseline neurologic assessment prior to the administration of an NSAID medication, the nurse will assess which patient characteristic(s)? (Select all that apply.) a.

Vital signs

b.

Orientation to date, time, and place

c.

Mental alertness

d.

Bowel sounds

e.

Concurrent use of anticoagulant agents

ANS: B, C

Orientation to date, time, and place as well as assessment of mental alertness are components of a baseline neurologic assessment to be completed prior to medicating with an NSAID. Vital signs, bowel sounds, and assessment of concurrent use of anticoagulant drugs are not considered components of a neurologic assessment.

Chapter 11 Disorders of sleep and wakefulness and their treatment MULTIPLE CHOICE 1.

The nurse finds that a patient is extremely agitated, yells frequently, and is attempting to get out of bed without assistance. What is the nurses initial action? a.

Administer zolpidem after taking the patients vital signs.

b.

Close the patients door for privacy after administering Tylenol.

c.

Administer benzodiazepine before calling the health care provider.

d.

Spend uninterrupted time listening to the patient.

ANS: D Assessing the patients level of anxiety is important. The patient may only need someone to listen to what stressors he or she is facing. The nurse must assess the patient before medication can be administered.

2.

An older adult patient received a hypnotic agent at 9:00 PM. At 2:00 AM, the nurse discovers that the patient has removed her gown and is attempting to get out of bed without assistance. What type of medication effect is the patient exhibiting? a.

Allergic

b.

Hypersensitivity

c.

Paradoxical

d.

Therapeutic

ANS: C A paradoxical effect may occur in older adult patients. This includes periods of excitement, confusion, restlessness, and euphoria. Allergies to medications tend to manifest in skin or respiratory symptoms. A patient who is hypersensitive to a hypnotic would be difficult to rouse. A therapeutic effect for a hypnotic would be sedation.

3.

For what conditions are benzodiazepines prescribed?

a.

Chronic amnesia

b.

Chronic insomnia

c.

Preoperative sedation

d.

Psychotic episodes

ANS: C The sedative hypnotic effect of benzodiazepines facilitates surgical sedation. Short acting benzodiazepines are administered intramuscularly for preoperative sedation.

They are also given intravenously for conscious sedation before short diagnostic procedures or for the induction of general anesthesia. Benzodiazepines are not recommended for long term use and do not affect amnesia. Benzodiazepines are a

poor choice for the treatment of chronic insomnia because of their risk for habituation. Benzodiazepines do not have an antipsychotic effect.

4.

A patient receiving diazepam (Valium) is complaining of nausea and vomiting and is becoming jaundiced. Which type of blood work will be performed? a.

Renal function tests

b.

Liver function tests

c.

Clotting times

d.

Electrolyte panels

ANS: B Liver function tests will be performed because nausea, vomiting, and jaundice can be indicative of hepatotoxicity. Abnormal liver function test results (i.e., elevated bilirubin, aspartate transaminase [AST], alanine transaminase [ALT], gamma glutamyl transferase [GGT], and alkaline phosphatase levels, as well as prothrombin time) are indicative of hepatotoxicity. Benzodiazepines do not affect the kidneys, clotting times, and electrolytes.

5.

In addition to facilitating sleep, what is another benefit of sedatives?

a.

Increased pain control postoperatively

b.

Reduced bronchial secretions

c.

Decreased patient anxiety

d.

Increased patient alertness

ANS: C Preoperatively, sedatives will help decrease patient anxiety and facilitate sleep.

Sedatives are not long acting enough to affect postoperative pain control. Sedatives do not affect bronchial secretions. Sedatives diminish patient alertness.

6.

Which two phases make up normal sleep?

a.

Hypnagogic and hypnopompic

b.

Rapid eye movement (REM) and non REM

c.

Alpha and beta

d.

Delta and theta

ANS: B Normal sleep can be divided into two phases, REM and non REM. Hypnagogic is the state between waking and sleeping; hypnopompic is the transition between sleeping and waking states. Beta waves are those associated with day to day wakefulness.

During periods of relaxation while still awake, our brain waves become slower, increase in amplitude, and become more synchronous. These types of waves are called alpha waves. The first stage of sleep is characterized by theta waves. During a normal

nights sleep, a sleeper passes from the theta waves of stages 1 and 2 to the delta waves of stages 3 and 4. Delta waves are the slowest and highest amplitude brain waves.

7.

Which sleep pattern stage diminishes as an effect of aging?

a.

Stage I

b.

Stage II

c.

Stage III

d.

Stage IV

ANS: D As we age, stage IV sleep diminishes. Many people older than 75 years do not demonstrate any stage IV sleep patterns. Between 2% and 5% of sleep is stage I. Stage II

comprises about 50% of normal sleep time. Stage III is a transition between lighter sleep and deeper sleep.

8.

A patient has been prescribed lorazepam (Ativan), a benzodiazepine used to treat insomnia. Which action will the nurse take? a.

Advise the patient to take the medication with food.

b.

Assess the patients blood pressure in sitting and lying positions.

c.

Inform the patient to discontinue the medication once sleep improves.

d.

Instruct the patient to lie down before taking the medication.

ANS: B Measuring blood pressure in sitting and lying positions is important to assess for transient hypotension. Ativan does not have to be taken with food. Rapid discontinuance of the medication after long term use may result in symptoms similar to those of alcohol withdrawal. Gradual withdrawal of benzodiazepines is over 2 to 4 weeks. Medications should be taken sitting up.

9.

Which disease is associated with insufficient sleep?

a.

Cancer

b.

Glaucoma

c.

Myocardial infarction

d.

Renal failure

ANS: C Individuals who sleep less than 5 hours a night have a threefold increased risk of heart attacks. Cancer, glaucoma, and renal failure are not associated with lack of sleep.

10.

The nurse is caring for an older patient recently admitted to an assisted living center who is experiencing insomnia associated with the recent relocation. At bedtime, which nursing action will assist the patient to sleep? a.

Offering the patient hot tea

b.

Encouraging the patient to ambulate in the hallway

c.

Performing back massage

d.

Administering an analgesic

ANS: C Providing a back rub will promote relaxation and reduce anxiety associated with a new environment. This would also provide an opportunity for the nurse to encourage the patient to express feelings. The patient should avoid products containing caffeine, such as coffee, tea, soft drinks, and chocolate. A quiet unwinding activity before bedtime is helpful for sleep promotion. Administering an analgesic is not an appropriate action.

11.

The nurse is explaining the use of medications to a patient with insomnia.

Which statement about sedatives is true? a.

A sedative will produce sleep.

b.

Sedatives increase the total time in REM sleep.

c.

Increased relaxation occurs with sedatives.

d.

Sedatives are more potent than hypnotics.

ANS: C A hypnotic is a drug that produces sleep; a sedative quiets the patient and gives a feeling of relaxation and rest, not necessarily accompanied by sleep. Sedatives do not increase the total time in REM sleep. A small dose of a drug may act as a sedative, whereas a larger dose of the same drug may act as a hypnotic and produce sleep.

12.

The nurse is assessing a patient who is being evaluated in an outpatient clinic for complaints of back pain. The patient reports taking diphenhydramine for insomnia related to job stress. Which statement by the nurse is accurate regarding this medication? a.

This medication should only be taken for 1 week.

b.

This medication can cause nausea.

c.

The medication should not be taken after eating a high fat meal.

d.

This is an herbal medication that has been used for hundreds of years.

ANS: A Antihistamines (particularly diphenhydramine and doxylamine) have sedative properties that may be used for short term treatment of mild insomnia. They are common ingredients in over the counter (OTC) sleep aids. Tolerance develops after only a few nights of use; increasing the dose actually causes a more restless and irregular sleep pattern. Diphenhydramine does not cause nausea. There is no

restriction on taking diphenhydramine after a high fat meal. Diphenhydramine is not an herbal medication.

13.

When reviewing a patients history and physical information, the nurse notes that the patient has physicians orders for chloral hydrate and warfarin. During assessment of this patient, the nurse observes areas of petechiae and ecchymosis on the upper and lower extremities. The most appropriate lab work for the nurse to assess next is: a.

liver function studies.

b.

C-reactive protein.

c.

sedimentation rate.

d.

prothrombin time.

ANS: D Chloral hydrate may enhance the anticoagulant effects of warfarin. The patient should be observed for petechiae, ecchymoses, nosebleeds, bleeding gums, dark tarry stools, and bright red or coffee ground emesis. Prothrombin time should be monitored, and the physician should reduce the dosage of warfarin, if necessary.

14.

The nurse is administering Somnote to a patient. When providing medication education to the patient, the nurse will include that Somnote should be: a.

thoroughly chewed.

b.

taken with a full glass of water.

c.

taken on an empty stomach.

d.

taken only before bedtime.

ANS: B Somnote is available in capsule form and should not be chewed, should be taken with a full glass of water, should be taken after meals, and is usually ordered to be taken three times a day after meals.

MULTIPLE RESPONSE 15.

Why are benzodiazepines often preferred over barbiturates? (Select all that apply.) a.

They have selective action at specific receptor sites.

b.

There is a wide range of safety between therapeutic and lethal levels.

c.

REM sleep is decreased to a lesser extent.

d.

Accidental overdoses are well tolerated.

e.

There are no hypotensive episodes when rising to a sitting position.

ANS: A, B, C, D The selectivity of specific drugs at receptor sites accounts for the wide variety of uses.

There is a wide safety margin between the therapeutic and lethal dosages for these drugs.

Benzodiazepines decrease REM sleep to a lesser extent. Intentional and unintentional overdoses of benzodiazepines are often well tolerated and not fatal. There are transient hypotensive episodes with benzodiazepine therapy.

16.

Barbiturates have which common adverse effect(s)? (Select all that apply.)

a.

Residual daytime sedation

b.

Headache

c.

Hyperactivity

d.

Blurred vision

e.

Impaired coordination

ANS: A, B, D, E The long half life of a barbiturate medication often causes residual daytime sedation. Headache is a general adverse effect of barbiturates. Blurred vision is an adverse effect associated with the hypnotic dosages of long acting barbiturates.

Impaired coordination is an adverse effect of barbiturates. Hyperactivity is not generally an adverse effect of barbiturates unless the patient is experiencing a paradoxical response.

17.

What can occur as a result of rapid withdrawal from long term use of barbiturate therapy? (Select all that apply.) a.

Anxiety

b.

Delirium

c.

Weakness

d.

Grand mal seizures

e.

Severe pain

ANS: A, B, C, D Anxiety, delirium, weakness, and grand mal seizures can be symptoms of rapid withdrawal from long term use of barbiturate therapy. Severe pain is not a symptom of rapid withdrawal from long term use of barbiturate therapy.

18.

The nurse is assessing a patient prior to discharge from same day surgery following an incisional breast biopsy. When assessing the patients central nervous system (CNS) function following sedative hypnotic therapy, what will the nurse include? (Select all that apply.) a.

Level of alertness

b.

Orientation

c.

Ability to perform motor functions

d.

Blood pressure

e.

Usual pattern of sleep

ANS: A, B, C Because sedative hypnotics depress overall CNS function, the nurse should identify the patients level of alertness and orientation and ability to perform motor functions. Blood pressure is a vital sign and falls under cardiovascular assessment. Usual sleep pattern should be obtained for information on sleep pattern disruption, but not for CNS function.

Chapter 12 Attention deficit hyperactivity disorder and its treatment MULTIPLE CHOICE 1.

Which complaint is representative of anxiety in a 6-year-old child?

a.

I worry that my dad will get hurt at work.

b.

I get a stomach ache when its my weekend at my dads house.

c.

I cant sleep when I stay at Grandmas because I worry about my mom.

d.

Im not going to sports camp because I dont like being away from my friends.

ANS: A Developmental differences exist with regard to the symptoms of anxiety. Children between the ages of 5 and 8 years old most commonly report unrealistic worry about

harm to their parents. Between the ages of 9 and 12 years, children report excessive distress during times of separation. Adolescents typically report somatic complaints.

2.

Which of the following meets the DSM-IV-TR criteria for moderate mental retardation? a.

Requires constant one-on-one supervision and total physical care

b.

Advanced as far as the sixth grade and works at a warehouse every day and supports himself

c.

Advanced as far as the second grade and provides her own personal care with supervision

d.

Attends the local community college for developmental English and math courses ANS: C Individuals diagnosed as having moderate mental retardation acquire some communication skills, but rarely advance academically beyond the second grade. With supervision they can provide for their own personal care. Persons requiring constant supervision and total physical care would be considered profoundly retarded. Persons achieving elementary or above learning skills would be considered mildly retarded.

3.

The nurse is assessing a child with autism. Which of the following behaviors would the nurse expect to observe? a.

Referring to their imaginary friend, Skipper

b.

Asking to telephone my friends on the weekends

c.

Repeating, milk, milk, milk, milk until given a drink

d.

Is insistent that a dim light be left on in the bedroom at night

ANS: C

Stereotyped and repetitive use of language or idiosyncratic language is one of the characteristic behaviors seen in autism. The remaining options are normal characteristics of a child in various developmental stages.

4.

Which behavior best supports the diagnosis of attention-deficit/hyperactivity disorder in an 8-year-old child? a.

Cries when separated from his mother or father

b.

Refuses to pick up toys as instructed by his parents

c.

Is fascinated with spinning and moving toys and objects

d.

Can concentrate on school work for only very short periods of time

ANS: D Experiencing difficulty concentrating on tasks is a hallmark for ADHD. Crying is a characteristic of separation anxiety. Disobedience as described may represent oppositional behavior. Focusing on repetitious motion is characteristic of autism.

5.

Which behavior is most characteristic of a conduct disorder?

a.

Frequently getting up and interrupting while being read to

b.

Only apologizes for hitting a friend to avoid being punished

c.

Finds it difficult to spend the night away from family members

d.

Becomes extremely agitated when the television is turned off

ANS: B Children or adolescents with conduct disorder generally do not empathize with other peoples feelings and are unconcerned with others situations or needs. They exhibit uncaring behavior, but they will often express words of guilt or remorse because they have learned that it reduces or prevents punishment. ADHD is often characterized by hyperactivity. Separation anxiety is often responsible for a childs resistance to spending time away from home. Autism can be the cause of exaggerated responses.

6.

Which assessment finding should be considered a high risk factor for adolescent suicide? a.

Being sexually abused

b.

Having experienced panic attacks

c.

Being mildly cognitively impaired

d.

Having a diagnosis of type 1 diabetes

ANS: A

Suicide risk factors include a history of sexual abuse. There is no current research to support a strong relationship between suicide attempts and any of the other options.

7.

Planning for a patient with Aspergers disorder will be facilitated if the nurse understands that this disorder is different from autism. The nurse will base care on knowledge that Aspergers disorder is characterized by:

a.

Repetitive patterns of behavior

b.

Age-appropriate language development

c.

Stereotypic movements and speech patterns

d.

Obsession with objects that move in a spinning motion

ANS: B Communication will be facilitated knowing that a patient with Aspergers disorder has no clinically significant delays in language or cognitive function. The remaining options are characteristics of both disorders.

8.

Which behaviors would support a diagnosis of oppositional-defiant disorder?

a.

Exhibits involuntary facial twitching and blinking and makes barking sounds

b.

Negative, hostile, and spiteful toward parents and blames others for misbehavior

c.

Displays high anxiety when away from parents, has nightmares, and fears being kidnapped

d.

Violates others rights, is cruel to people or animals, lies and steals, and is truant from school ANS: B Children with oppositional defiant disorder argue with adults, actively defy adults requests, deliberately annoy adults, and refuse to take responsibility for their behaviors. Lying, stealing, and animal cruelty describes a child with conduct disorder.

Being afraid of being kidnapped describes a child with separation anxiety. Facial twitching is associated with Tourettes disorder.

9.

Which childs history is a risk for developing a reactive attachment disorder?

a.

Father is a chronic alcoholic

b.

Was born with a congenital cardiac disorder

c.

Experienced head trauma at age 7 months of age

d.

Spent first 12 months of life in an Asian orphanage

ANS: D Reactive attachment disorder is a disorder that occurs in some children who are institutionalized.

10.

Which intervention will best help a teenager manage aggressive behavior?

a.

Administering prescribed medication as ordered

b.

Supporting the patients interest in writing poetry

c.

Reenacting situations that may trigger aggression

d.

Providing information on anger management techniques

ANS: C

Role-play situations that trigger aggressiveness explore and reinforce alternative methods of coping. The other options although appropriate lack the opportunity to reflect on the triggers and practice the coping skills.

11.

Which intervention will best help a child manage hyperactive behavior?

a.

Arranging for the child to play basketball 4 times a week

b.

Allowing the child to play a favorite video game as a reward

c.

Using a favorite food and beverage to distract the child

d.

Placing the child in a low stimulation environment for 30-60 minutes

ANS: A Redirect disruptive behavior with recreational activities to channel excess energy. The remaining options will have little positive effect on the childs energy level.

12.

The nursing diagnosis that would be universally applicable for children with autistic disorder would be: a.

Risk for constipation related to odd eating habits

b.

Chronic low self-esteem related to negative social feedback

c.

Impaired social interaction related to inability to relate to others

d.

Disturbed thought processes related a neurological dysfunction

ANS: C Children with autistic disorder display profoundly disturbed social relationships.

Essentially, they lack social reciprocity. They seem aloof and indifferent to others and prefer inanimate objects to people. The remaining options are not necessarily true of this mental illness.

13.

A childs diagnosis of conduct disorder is supported by the fact that:

a.

The childs mother is a chronic alcoholic.

b.

The child engages in ritualistic behaviors.

c.

A brain scan shows structural abnormalities.

d.

There is a family history of respiratory disorders.

ANS: B Conduct disorder occurs more frequently when a biologic parent has alcohol dependency. There is no research to support a connection between a conduct disorder and any of the remaining options.

14.

Which intervention will best help minimize parental guilt in the family of a child diagnosed with a psychiatric disorder? a.

Helping them to develop realistic expectations for their child

b.

Educating them on the need to provide the child with boundaries

c.

Providing them with information regarding locally available services

d.

Encouraging them to use respite care periodically to allow for downtime

ANS: A

Teach the parents about the patients disorder to minimize their guilt related to causing or caring for the child. The remaining options although appropriate do not focus on the potential for self guilt.

15.

Which behavior demonstrates that a child is achieving appropriate management of separation anxiety? a.

Earned two As, three Bs, and one C this report card period

b.

Falls asleep with a parent sitting outside the bedroom door

c.

Sleeps on a chair in the parents bedroom rather than in their bed

d.

Reports having only a little stomach ache during breakfast on school days

ANS: A Children with separation anxiety disorder demonstrate academic difficulties resulting from a refusal to attend school or frequent absences resulting from somatic illnesses.

The other options show continued behaviors seen with this disorder.

16.

A 15-year-old has been diagnosed with major depression and admitted to the adolescent unit. Which behavior would the nurse expect to observe in this patient? a.

Discussing repeated run-ins with the law

b.

Being manipulative and callous towards others

c.

Blaming adults for his admission to the adolescent unit

d.

Reporting decreased enjoyment of school-related activities

ANS: D Anhedonia, the absence of pleasure, is a common manifestation of depression. Legal behavior and manipulative and uncaring behavior are characteristic of conduct disorder. Seeing adults as the root of their problems is common in conduct disorder and oppositional-defiant disorder.

17.

When discussing depression and suicide with parents of teenagers, the nurse is accurate in reporting that the most common method used in late adolescent suicide is: a.

Hanging

b.

Firearms

c.

Oral poisoning

d.

Drug overdose

ANS: B

Statistics show the use of firearms is the most commonly used method of committing suicide among adolescents. With this in mind, the nurse could counsel parents about the importance of keeping firearms locked away from teens. The other options are less-often used methods for attempting suicide.

18.

Planning safety interventions for a teenager with a history of self-injurious behavior is based on what research-based information? a.

Teenagers rarely entertain the idea of suicide.

b.

Suicides can occur accidentally as a result of self-injurious behaviors.

c.

Self-injury is always viewed as a risk factor for future suicidal attempts.

d.

Assessment for suicidal ideations is a vital component of this childs care.

ANS: B Self-injurious behavior is not suicidal behavior and is not viewed as a risk factor for suicidal ideations or attempts, but some teenagers accidentally commit suicide in the process. Teenagers are acting on suicidal thoughts at an alarming rate.

19.

Which statement made by a teenage male hospitalized after a failed suicide attempt is most concerning to the nurse? a.

My uncle shot himself but he didnt die.

b.

I dont know why I get so depressed and want to die.

c.

The gun I got for my birthday is my most prized possession.

d.

I hope I dont ever get depressed enough to try and hurt myself again.

ANS: C Factors associated with suicidal behaviors include access to firearms providing the teenage patient with the opportunity and means to harm himself if he again becomes depressed. Although the remaining options represent possible risk factors, none provide insight into opportunity and means.

20.

The mother of a child describes her childs annoying behavior as not being able to sit still or to stop jerking his arms when told to. Which disorder does the nurse suspect?

a.

Tourettes disorder

b.

Oppositional-defiant disorder

c.

Pervasive developmental disorder

d.

Attention-deficit/hyperactivity disorder

ANS: A The parent describes simple motor tics that are involuntary behaviors and characteristic of Tourettes disorder. The child is not being defiant because he has no control of the tics. Although the child displays repeated motor behaviors, they are unrelated to hyperactivity because they are not generalized and occur only

sporadically. These involuntary tics are not seen in pervasive developmental disorders such as autism.

21.

Which response is most therapeutic when a parent whose child is diagnosed with Tourettes disorder voices concerns that their childs facial contortions are merely acts of defiance? a.

Your child isnt defiant but rather mentally ill.

b.

What makes you think he is doing that out of defiance?

c.

I think with the use of some behavior modification techniques, he can learn to control the facial tics.

d.

Your sons behavior is likely due to a neurological dysfunction that causes those involuntary facial tics.

ANS: D Tourettes disorder is most often thought to be a genetic neurologic disorder whose characteristic behaviors are involuntary in nature. Referring to the child as mentally ill is not a true description of the situation. Asking the parent to further discuss the idea that the tics are an act of defiance is inappropriate since that is not true. Behavioral modification is not effective on involuntary behaviors.

22.

Which description is characteristic of an impulsive child?

a.

Pacing and speaking in a very loud, disruptive voice

b.

Frequently talking about hearing voices telling him what to do

c. first

Running out into the street regardless of frequent instruction to look both ways

d.

Having a difficult time concentrating on reading since his attention is easily diverted ANS: C Running into the street is an example of impulsive behavior because it is clearly taking action before considering consequences. Hyperactivity refers to such things as increased pace and volume of activity. Thought disorders include such perceptual dysfunction as auditory hallucinations. Distractibility is characterized by poor concentration.

23.

Which intervention would qualify as primary prevention of violent behaviors in children and adolescents? a.

Forbidding the child to continue friendships with violent peers

b.

Limiting exposure to violence on TV, video, and computer games

c.

Seeking counseling for a child who has been experimenting with drugs

d.

Showing a unified approach to parenting when dealing with a violent child

ANS: B

Studies suggest that an obsession with violence in video games, movies, music, and writings increases aggressiveness in children and adolescents. The other options are relevant only after the risk for violence has been established.

24.

A friend says to a nurse, I am not going to get vaccines for my baby. I hear that vaccines cause autism. The nurses best reply is: a.

The exact cause of autism is not really known

b.

Its believed that autism is really a result of birth trauma.

c.

There is no conclusive evidence to connect autism to vaccinations.

d.

Please tell me more about where you got that information about autism?

ANS: C There is no research to connect autism to a reaction to vaccinations or to birth trauma.

The exact cause of autism remains undetermined but that response doesnt address the patients statement nor does asking the patient to give additional information regarding their original statement.

25.

A 5-year-old girl on a behavior modification program is admitted to the unit.

The nurse would expect to participate in which activity based on this approach? a.

Firmly challenging the childs irrational thoughts

b.

Including the child in the creation of a behavioral contract

c.

Family therapy with every member present for each session

d.

Play therapy with dolls representing every member of the family

ANS: B Behavior modification includes constructing a contract that outlines behavioral changes that is a result of the input of therapists, family and the child. Family therapy, play therapy, and thought challenging are not generally used with a behavior modification program.

26.

A mother asks why the whole family needs to meet with the therapist because it is her teenage stepdaughter who has the substance abuse problem. The nurse replies with the knowledge that: a.

Mothers usually have insight into their childrens problem.

b.

The parents are responsible for changing the teens behavior.

c.

The family will probably use behavior modification with the teen.

d.

Sometimes the teenaged patient is actually acting out family dynamics.

ANS: D It is important to remember that children will often act out the underlying family dynamics or family psychopathology. Mothers may not have an understanding of the problems their children are experiencing. Behavior modification is not typically a

treatment for teen substance abuse. The teen is responsible for changing personal behavior.

MULTIPLE RESPONSE 1. The parents of a child diagnosed with ADHD ask the nurse what current medications are available for their child. The nurse should list which of the following medications?

(Select all that apply.) a.

Methylphenidate (Concerta)

b.

Zolpidem (Ambien)

c.

Dextroamphetamine (Adderall)

d.

Atomoxetine (Strattera)

e.

Haloperidol (Haldol)

ANS: A, C, D Ambien is a sleeping medication and not typically used to treat ADHD. Haldol is an antipsychotic that is not specified for use for ADHD. The other medications are sometimes used for ADHD.

Chapter 13 Dementia and its treatment MULTIPLE CHOICE 1.

A patient diagnosed with moderate dementia consistently appears to be distorting the truth resulting in his wife asking, What should I do when he lies to me about unimportant things? Upon what rationale should the nurses response be based? a.

Changing the topic provides diversion.

b.

Delusions should be confronted to clarify thinking.

c.

Ignoring memory deficit avoids catastrophic reactions.

d.

This isnt lying but rather a way to fill in the memory gaps.

ANS: D Confabulation is not lying but rather a method for filling in the memory gaps.

Ignoring, using confrontation, and changing the topic would not be as useful as gently reorienting.

2.

The nurse is to perform a complete assessment of a patient in her home, using the Mini-Mental State Examination (MMSE) as one component. When the nurse arrives,

the patient is seated at the table with her husband, the TV is on, and several grandchildren are visiting. The patient is quiet, but her hands are gripped tightly, and she is staring at the ceiling. The best action for the nurse to take would be which of the following?

a.

Ask the husband to make an appointment to bring his wife to the clinic for testing.

b.

Explain to the husband that accurate data will be sought, and ask him to stay with the grandchildren in another room.

c.

Do not perform the test during the assessment (because it will not be valid) and rely on observations and reports from the family.

d.

Explain the importance of the testing process and make an appointment for another day when the environment can be better controlled.

ANS: D Testing the patient in her home under quieter, less distracting circumstances is the best solution. Asking the husband to leave is likely to increase the patients anxiety and alter test results. Use of the MMSE is an integral component of the assessment and must not be deleted. Testing in the more familiar, comfortable surroundings of the home will yield more reliable results.

3.

A patient has been admitted with a diagnosis of hypoactive delirium. Which nursing intervention is supported by this diagnosis? a.

Encouraging fluids to minimize constipation

b.

Frequently assessing both visual and auditory hallucinations

c.

Scheduling frequent changing of position to prevent skin breakdown

d.

Dimming the lights to help control eye discomfort resulting from cataracts

ANS: C

Because of inactivity, hypoactive delirium patients are more likely to develop further complications, including decubiti that could be minimized by frequent repositioning.

The remaining options identify interventions that are not generally a result of this diagnosis.

4.

Which of the following should the nurse use as a basis for explaining the etiology of Alzheimers disease to the family of a patient with this disease?

a.

It is a secondary dementia indicated by loss of recent memory and disorientation to time and place.

b.

It is a primary dementia that is incurable, irreversible, and fatal. It is caused by the presence of a beta-amyloid protein in the neurons resulting in senile plaques.

c.

It is a secondary dementia that is treatable with analysis of the diet and removal of toxic substances from the diet and environment.

d.

It is a primary dementia characterized by stepwise decreases in cognitive abilities. It is irreversible but treatable with antihypertensive medications.

ANS: B This option provides accurate information about Alzheimers disease. Alzheimers disease is not a secondary dementia nor is it treated with antihypertensive medications.

5.

Which outcome is realistic for a patient with stage 1 Alzheimers disease?

a.

Caregiver will assume role of decision maker for patient to reduce stress.

b.

The patient will maintain the highest possible functional level to preserve autonomy.

c.

Arrangements will be made for appropriate long-term placement to minimize risk of injury.

d.

The patient will retain full physical functioning through cognitive and occupational therapies.

ANS: B This outcome addresses health maintenance (i.e., maintaining an optimal functional level as determined by present capacity). Although long-term placement may be an option, it is not necessarily appropriate during this stage. Patients in stage 1 are often able to make simple decisions. Continuing to make decisions gives the patient a sense of control. Although a patient in stage 1 does not appear markedly deteriorated, some diminution of function may be present.

6.

The home care nurse is visiting a patient who was discharged to home after a procedure at an ambulatory surgical center. The patient lives alone in a senior retirement community. The nurses assessment documents mild dysphasia. The patient repeatedly asks, Why is there a bandage on my arm? and is not able to state the appropriate day and year. Appropriate planning for the patient should include:

a.

Assessing diet and meal preparation, assessing environment for safety problems, referral to a dementia program

b.

Attending English class to improve speech, transferring finances to a conservator, employing an aide to help with medications

c.

Arranging Meals on Wheels, attending speech therapy, relocation to a skilled nursing facility if no improvement in 1 month

d.

Arranging an appointment at a geriatric assessment program, OT referral for swallowing therapy, teaching to manage public transportation ANS: A Further assessment is appropriate before making changes in the living environment.

Enrolling in a dementia program will provide stimulation and help the patient maintain intellectual skills. English classes will not improve speech. The other plans might have

relevance, however. The remaining sets of options are either irrelevant or beyond the patients abilities.

7.

A patient diagnosed with Alzheimers disease has a catastrophic reaction during an activity involving simultaneous playing of music and working on a craft project. The patient starts shouting no, no, no and rushes out of the room. The nurse should: a.

Discontinue the activity program since it upsets the patients.

b.

Follow the patient, reassure her, and redirect her to a quieter activity.

c.

Isolate the patient until she is calm, and then direct her back to the activity.

d.

Give the patient prn antianxiety medication and restrict her activity participation.

ANS: B These actions will restore safety and self-esteem. Isolation will decrease self-esteem and may increase confusion. It is only one patient that is distressed, not the entire group. Behavioral interventions should be attempted prior to administering medication.

8.

Which behaviors would indicate that a therapeutic activity program for a patient with Alzheimers disease had been successful?

a.

Accurate recent memory, positive emotional response, and increased verbal expression

b.

Increased attention span, verbal expression of remote memory, and positive emotional response

c.

Positive use of perseveration, reduction in use of habitual skills, and improved abstract reasoning

d.

Positive emotional response, ability to remember multiple steps, and accurate recent memory ANS: B These are all observations that would indicate that a therapeutic activity program has kept the patient functioning at the highest level of which he is capable. The behaviors described in the other options are not realistic expectations for this patient.

9.

A patient has been diagnosed with dementia secondary to cerebral disease. The family members note the patient has not been as sharp as he once was and that he has developed urinary incontinence and a gait disturbance. Which pathophysiology can cause such symptoms? a.

Normal pressure hydrocephalus

b.

Vitamin B12 deficiency

c.

Hepatic disease

d.

Tuberculosis

ANS: A Normal pressure hydrocephalus is a disorder characterized by dementia, gait disorder, and urinary incontinence. Dilation of ventricles in the absence of increased CSF is a prominent manifestation. Early urinary incontinence is not seen in the disorders listed in the other options.

10.

When asked about the prognosis for a patient diagnosed with a dementia secondary to normal pressure hydrocephalus the nurse replies: a.

Unfortunately the prognosis is for a downhill course ending in death.

b.

There will be good days and bad days for the rest of the patients life.

c.

The symptoms generally remit after a shunt is inserted to drain fluid.

d.

Well try our very best, but only time will tell how successful we are.

ANS: C By relieving the cause, the symptoms of secondary dementias are largely reversible.

The statements reflected in the other options do not reflect this fact.

11.

Which statement by an adult child concerning the behaviors of their parent supports the diagnosis of Alzheimers disease? a.

Mom forgot to pay her utility bills last month.

b.

Mom isnt as interested in keeping a neat house as she was.

c.

Mom doesnt seem interested in going out with friends anymore.

d.

Mom refuses to stop driving even though her reaction time is very slow.

ANS: A Increased forgetfulness, particularly that involving former routine activities (such as bill paying), is symptomatic of Alzheimers disease. The other options do not indicate cognitive deficit.

12.

The daughter of an older patient with dementia tearfully tells the nurse that she doesnt know whats wrong with her mother, who has begun accusing the family of holding her prisoner. Which nursing diagnosis would be appropriate for this patient? a.

Powerlessness

b.

Defensive coping

c.

Ineffective coping

d.

Disturbed thought processes

ANS: D Paranoid thinking is common in patients with dementia. Inability to correctly interpret environmental clues and to think logically leads to delusional thinking as the patient tries to make sense of a confusing world. The remaining options are not supported by the data in the scenario.

13.

The daughter of an elderly patient with dementia tearfully tells the nurse that she doesnt know whats wrong with her mother, who has begun accusing the family of stealing her money. The nurse assesses the patients stage of Alzheimers disease as stage: a.

1

b.

2

c.

3

d.

4

ANS: B

In stage 2, memory and cognitive deficits are worsening. The patient is less able to make sense of a confusing world and makes faulty interpretations resulting in paranoid delusional thinking. The patient in stage 1 does not usually have delusions.

The patient in stage 3 often is unable to communicate meaningfully. There is no stage 4 of Alzheimers disease.

14.

An elderly patient was well until 12 hours ago, when she reported to her family that in the middle of the night she awakened to see a man standing at the foot of her bed. There is no evidence that this situation ever happened. This series of events supports which possible diagnosis?

a.

Delirium

b.

Anxiety

c.

Paranoia

d.

Dementia

ANS: A Delirium is a disturbance of consciousness and cognition that develops over a short period. It is secondary to a medical condition. The scenario does not fit the disorders mentioned in the remaining options.

15.

A patient diagnosed with delirium has become agitated and fearful. Which nursing intervention should the nurse implement to help prevent a catastrophic response? a.

Interact with the patient on an adult-to-child level.

b.

Place the patient in a safe, nonstimulating environment.

c.

Ask the patient to explain what is causing the agitation and fear.

d.

Be prepared to apply physical restraints to minimize the patients risk for injury.

ANS: B The safety of a patient with delirium is of primary importance. Symptoms of delirium fluctuate and may worsen, especially at night. The greater the patients confusion and disorientation, the greater the possibility for self-harm. The patient should be treated as an adult; to do otherwise is demeaning. Asking for an explanation is inappropriate,

because delirious patients cannot formulate rational answers. Patients are never restrained unless all other less restrictive measures have failed.

16.

A patient has been diagnosed with Alzheimers disease, stage 1. The nurse would expect to help the family plan measures to assist the patient with: a.

Perseveration

b.

Recent memory loss

c.

Catastrophic reactions

d.

Progressive gait disturbances

ANS: B Recent memory loss is the only symptom listed in the options that would be expected in stage 1 Alzheimers disease.

17.

An elderly patient with dementia has a nursing diagnosis of self-care deficit: bathing, hygiene. She lives alone and the nursing assessment proves reason to believe she has forgotten how to perform hygiene and bathing activities. Which intervention is most appropriate for this patient? a.

Bathe daily with reminders.

b.

Bathe twice weekly with assistance.

c.

Patient will be provided with in-home nursing care.

d.

Patient will be transferred to an assisted living facility.

ANS: B Bathing twice weekly would be a realistic goal. Assistance should be provided, both to prevent falls and to regulate shower temperature. The elderly are advised not to bathe daily because it is too drying to their skin. The remaining options are not supported by the information given in the scenario.

18.

Which situation would be most likely to serve as a trigger to a catastrophic reaction in a patient with stage 2 Alzheimers disease? a.

Participating in singing Happy Birthday to another patient at dinner

b.

Being scolded by an aide for spilling a glass of milk

c.

Listening to Big Band music from the 1940s

d.

Eating cupcakes in the activities room

ANS: B Catastrophic reactions are overexaggerated negative emotional responses initiated as a result of a perceived failure at a task or change in the environment. Being scolded by the aide presents a situation that would clearly be frustrating to the patient.

19.

Which theory of etiology of Alzheimers disease, suggested by current research, might the nurse use to help a family understand that this disorder is not of psychosocial origin? Alzheimers disease is associated with: a.

Abnormal serotonin reuptake

b.

Prion infection of gray matter

c.

-Amyloid protein deposits in the brain

d.

Excessive acetylcholine in the frontal cortex

ANS: C The prevailing theories of etiology of Alzheimers disease include the following: angiopathy and blood-brain barrier incompetence; neurotransmitter and receptor deficiencies of acetylcholine; abnormal proteins, specifically -amyloid and their products; and genetic defects. Neither serotonin nor prions are implicated as problems in Alzheimers disease.

20.

The nurse is administering donepezil (Aricept) to a patient with stage 1 Alzheimers disease. Based on this drugs mechanism of action, the nurse will seek evidence of improvement in the patients: a.

Social behaviors

b.

Existing delusions

c.

Ability to tolerate stress

d.

Ability to remember recent events

ANS: D Donepezil is a cholinesterase inhibitor that increases the concentration of acetylcholine. Acetylcholine is needed for intact memory and for learning. This medication is not prescribed for the conditions identified in the remaining options.

21.

A patient with dementia is unable to name ordinary objects. Instead, he describes the function of each item (e.g., the thing you cut meat with). The nurse assesses this as: a.

Apraxia

b.

Agnosia

c.

Aphasia

d.

Amnesia

ANS: B Agnosia is the failure to identify objects despite intact sensory function. Apraxia is the inability to carry out purposeful, complex movements and use objects properly.

Aphasia refers to inability to speak (expressive) or inability to comprehend what is said or written (receptive). Amnesia is inability to remember a significant block of information.

22.

Which intervention has highest priority for a patient with stage 3 Alzheimers disease? a.

Cutting the patients food into bite size pieces

b.

Providing fluids to the patient every hour while awake

c.

Demonstrating to the patient how to put toothpaste on the brush

d.

Assisting the patient in signing a birthday care for a granddaughter

ANS: B The severe dementia characteristics of stage 3 renders the patient incapable of independently meeting hydration and nutrition needs. These needs are basic to life, so they are of highest priority. The remaining options are not applicable for such an impaired patient.

23.

A patient was admitted to a dementia unit after persistently wandering away from home. Which intervention will best address this patients risk for injury? a.

Place the patient in a geriatric chair with a tray across the lap.

b.

Provide one-to-one supervision when the patient is ambulatory.

c.

Reinforce verbal explanation to the patient concerning the dangers of wandering.

d.

Activate alarm system that will alert staff to the patients attempt to open the door.

ANS: D Electronic alarms allow patients freedom of movement although still preventing them from wandering off the unit. One-to-one supervision is not necessary in an environment designed as a dementia unit. The geriatric chair would be an unacceptable form of restraint for this patient. The patient would not be capable of processing the verbal explanation.

24.

A patient with moderate dementia does not remember her sons name. The son repeatedly questions the mother asking, Do you know my name? The mother invariably becomes agitated. The nurse can most effectively intervene by explaining to the son:

a.

Your mother is angry with you and is punishing you by forgetting who you are.

Be patient and shell get over it.

b.

Your mothers dementia is preventing her from retaining information even for short periods of time. She senses your distress and becomes agitated.

c.

You will need to reorient your mother often during your visits with her. With reinforcement, she may be able to begin to recall who you are.

d.

Because you both become so distressed, it might be better if you come to see your mother less frequently and stay for only shorter periods of time.

ANS: B When a patient with dementia is presented with a demand that exceeds their capacity to function, the demand creates a high level of stress. Showing anxiety and disapproval adds even greater stress. The son should be counseled to make every attempt to

demonstrate positive responses to his mother. The other options are not effective interventions.

25.

The wife of a patient with moderate to severe dementia tells the nurse, Im exhausted. He wanders at night instead of sleeping, so I get no rest. Im afraid to leave him during the day, so I have to take him with me wherever I go. The nurse recognizes the need to provide teaching for this caregiver. An appropriate outcome for this teaching would include: a.

Experiences less stress indicated by improved sleep patterns

b.

Feels comfortable leaving the patient in the care of others occasionally

c.

No longer experiences resentment concerning the need to care for the patient

d.

Feels at peace with the decision to admit the patient to an appropriate care facility ANS: A

Stress reduction allowing for better rest is an appropriate outcome. The other options are not necessarily appropriate nor will they result in improvement for the caregiver.

26.

A teenager is admitted to the ED after being alternately hyperalert and difficult to arouse. The symptoms started within the last few hours, during which time he became disoriented, confused, and delusional. These symptoms support the diagnosis of: a.

Amnesia

b.

Delirium

c.

Dementia

d.

Depression

ANS: B The symptoms are indicative of delirium. The other options are not supported by the scenario.

MULTIPLE RESPONSE 1.

Which interventions provided by the caregiver will help ensure effective care for the patient diagnosed with dementia? (Select all that apply)

a.

Taking the patients blood pressure regularly

b.

Being alert to ways the patient might be hurt

c.

Keeping the patient on a predictable schedule

d.

Assuming responsibility for meeting the patients needs

e.

Providing the patient with nonstimulating, private time

ANS: B, C, E These interventions take responsibility for areas in which the patient is incapable of providing self-care and addressing the special needs this patient has. Taking the blood pressure is not necessary unless there is a medical condition that requires doing so.

Although the patients ability to provide self-care will deteriorate, independence should be encouraged as appropriate.

2.

For which medication will the nurse prepare material for the family of a patient diagnosed with mild to moderate Alzheimers disease? (Select all that apply.) a.

Tacrine (Cognex)

b.

Donepezil (Aricept)

c.

Haloperidol (Haldol)

d.

Rivastigmine (Exelon)

e.

Galantamine (Razadyne)

ANS: A, B, D, E The only drug that is not generally prescribed for Alzheimers disease is Haldol.

Chapter 14 Impulsivity, compulsivity, and addiction MULTIPLE CHOICE 1.

When asked, What causes alcoholism? the nurses response will be based on the fact that: a.

The response to alcohol is a result of a brain-based disorder.

b.

Alcoholism is believed to be an allergic response to the alcohol.

c.

Every individual has the same susceptibility for developing alcoholism.

d.

It is a physical response to alcohol but its etiology is not fully understood.

ANS: A It has been determined that alcoholism is not an allergy but rather it is recognized as a partial brain-based disorder that some brains are more susceptible to than others.

2.

Which patient response would support the conclusion that the patient has moved into the dark side of a narcotic addition? a.

Ive been abusing drugs for at least 10 years.

b.

Drugs makes me feel good; that why I use them.

c.

I dont like the way I feel when I dont use drugs.

d.

Drugs are something that I can either take or leave

ANS: C During beginning use (the light side), the feel good effects are dominant. As the individual becomes habituated to the drug, tolerance and withdrawal symptoms develop; this constitutes the dark side. The remaining options do not describe effects of drug use.

3.

A substance use disorder (SUD) is a likely comorbid mental illness in which patient? a.

The soldier diagnosed with posttraumatic stress disorder

b.

The teenager demonstrating symptoms of poor impulse control

c.

The older adult diagnosed with early stage Alzheimers disease

d.

The new mother exhibiting symptoms of postpartum depression

ANS: A Posttraumatic stress disorder creates a risk for substance use or relapse. A total of 30% to 60% of persons with SUDs meet the criteria for comorbid posttraumatic stress disorder. The remaining options have not shown such a prevalence of comorbid relationship with SUDs. 4.

Which group would be the target population for educational material on the dangers of binge drinking?

a.

Full-time college students

b.

Blue-collared young adults

c.

Older widows and widowers

d.

High school juniors and seniors

ANS: A The highest prevalence of binge and heavy drinking is among young adults between the ages of 18 and 25 years, with the majority being full-time college students.

5.

Which social factor has the greatest impact on the changing nature of alcohol abuse treatment? a.

Development of new pharmaceutical treatment options

b.

Dramatic increase of alcoholism among young adult males

c.

Raising cost of both inpatient and outpatient treatment programs

d.

Womens substance abuse only recently acknowledge by society

ANS: D The existence of an alcohol abuse problem among women has only been recently recognized and this has dramatically affected treatments and services being provided.

Although the other options are true, they do not have the impact on treatment modalities as much as the correct option.

6.

Which assessment data poses the greatest risk for injury in a patient who abuses alcohol? a.

Takes a baby aspirin each morning

b.

Uses over-the-counter antihistamines for seasonal allergies

c.

Has been taking a tricyclic antidepressant for more than 2 years

d.

Took a narcotic for 1 week to manage postdental surgery pain

ANS: C Tricyclic antidepressants are strictly contraindicated with alcohol consumption because of their potential effect on cardiac function. Although aspirin increases

bleeding times and antihistamines and narcotics increase sedation, the outcome of combining alcohol and these drugs is not as dangerous as that of the correct option.

7.

If an individual is admitted with a diagnosis of Wernicke-Korsakoffs syndrome, the nurse would expect to assess: a.

Peptic ulcer

b.

Vivid illusions

c.

Cognitive deficits

d.

Auditory hallucinations

ANS: C Wernicke-Korsakoffs syndrome includes a severe form of amnesia and an inability to learn new skills which reflects a cognitive impairment. The other options are not associated with the syndrome.

8.

Which sociological aspect, vital to relapse prevention, is greatly affected when a patient is found to have a dual diagnosis of psychosis and alcoholism? a.

Ability to afford the cost of outpatient services

b.

A supportive, reliable, accessible support system

c.

Protection from both physical and emotional abuse

d.

Access to reasonable housing and employment opportunities

ANS: B Often individuals with this type of diagnosis have lost their support systems as a result of chronic mistreatment of their family and friends and an inability to maintain and recognize the importance of this aspect to their treatment plan. Although the remaining options impact relapse prevention, they are generally available when the patient is being supported appropriately.

9.

Which nursing intervention best demonstrates an understanding of the relationship between confirmed intravenous drug abuse and specific infections? a.

Screening the patient for hepatitis B virus (HBV)

b.

Assessing the patient for potentially infected injection sites

c.

Determining if the patient has ever been tested for human immunodeficiency virus (HIV)

d.

Evaluating the patients understanding of the increased risk for developing sexually transmitted diseases ANS: A Injecting drug users have one of the highest HBV rates among all risk groups and account for at least half of all new HCV cases, so screening for such infections demonstrates that the nurse understands the severity of the problem. Although the other options reflect potential infection risks, they are not as commonly seen in patients with this diagnosis.

10.

Which assessment data would bring into question a patients statement that, I have only a few drinks on special occasions.? a.

History of treatment for glaucoma

b.

Fasting serum blood glucose level of 182 mg/dL

c.

Patient reports numbness in hands and feet bilaterally

d.

Red rash observed over neck, shoulders, and upper chest

ANS: C Peripheral nerve deterioration in both hands and feet result from chronic alcohol intake. Peripheral neuropathy occurs in about 10% of alcoholics after years of heavy drinking causing the nurse to question the patients statement. The remaining options do not reflect symptomology generally associated with alcoholism.

11.

Which intervention has priority when a nurse suspects a staff member of providing patient care while being impaired by alcohol or drugs? a.

Asking the staff member to explain their suspicious behavior

b.

Adjust the staff members assignment to minimize patient contact

c.

Providing the staff member with material regarding alcohol abuse and treatment

d. duty

Reporting the staff members suspicious behavior to the nursing supervisor on

ANS: D It is a professional obligation to report suspected impaired practice. The remaining options do not have prior in this situation since the concern is patient safety.

12.

Which nursing intervention demonstrates an understanding regarding the primary form of substance use disorder among older adults?

a.

Assessing the patients hands and feet for the presence of both numbness and tingling

b.

Having the patient, describe your relationship with you adult children, coworkers, and friends.

c.

Asking, Please identify for me all the medications both prescribed and over the counter you regularly take.

d.

Evaluate the patients understanding of the possible health risks that alcohol and medication abuse has on ones health ANS: C Misuse of prescription medications is the most common form of drug abuse among older adults. This population is especially vulnerable because of the multiple drugs that are often prescribed for medical conditions. The remaining options do not help identify the presence of multiple medications.

13.

Which assessment demonstrates the nurses understanding of the relationship between substance abuse and the development of symptoms characteristic of delirium? a.

Determining the patients age and gender

b.

Evaluating the patients food and fluid intake over the last 48 hours

c.

Observing the patient for fine tremors of the hands, especially the fingers

d.

Determining the amount of caffeine the patient ingested in the last 24 hours

ANS: D Some people who ingest large amounts of caffeine develop delirium. The remaining options are not relevant to caffeine ingestion or the abuse of any other substance.

14.

Which protocol should guide the nurse responsible for administering pharmacologic interventions for a patient who is experiencing alcohol intoxication? a.

Medication interventions are based on the presence of withdrawal symptoms.

b.

Medications are prescribed at appropriate intervals for at least one full week.

c.

Symptoms are managed with medications for only the initial 24 hours of hospitalization.

d.

Medications are introduced to treat grand mal seizures that may accompany withdrawal symptoms.

ANS: A The course of intoxication is usually self-limiting to approximately 24 hours, after which withdrawal symptoms can occur for a time period unique to each patient.

Treatment is directed by the symptoms the patient is experiencing, which generally emerge during the withdrawal stage. Seizures are among several serious symptoms that can occur during the withdrawal stage.

15.

A patient recently discharged from an alcohol rehabilitation program is brought to the hospital in a state of prostration with severe throbbing headache, tachycardia, a beet-red face, dyspnea, and continuous vomiting. The patients significant other states the patient got sick about 15 minutes after drinking a glass of wine. The nurse should be guided in assessment by the suspicion that the patient: a.

Is having a stroke

b.

Has alcohol intoxication

c.

Is reacting to disulfiram (Antabuse)

d.

Is exhibiting symptoms of cross-dependence

ANS: C The alcohol deterrent drug, Antabuse, commonly prescribed in recovering alcoholic treatment, causes this reaction when taken in combination with alcohol. Alcohol intoxication, stroke, and cross-dependence do not present with the listed prostration symptoms.

16.

Which question is most appropriate when assessing a patient who is exhibiting symptoms of a systemic infection including a fever of unknown origin? a.

Are you an intravenous drug user?

b.

Have you been told that you drink too much alcohol?

c.

Have you been diagnosed with an acute bacterial infection before?

d.

Are you familiar with an infection of the heart called endocarditis?

ANS: A Intravenous drug users are at risk for subacute bacterial endocarditis and other circulatory compromise created by foreign substances introduced during the process of intravenous use. Regardless of the setting, nurses need to ask about intravenous drug use whenever a patient presents with fever of unexplained origin. Assessing the patients knowledge related to bacterial infections and endocarditis will not address the possible cause of the fever. Alcohol consumption is not relevant in this situation.

17.

Which observation seen in a teenage patient supports the suspicion of anabolic steroid abuse? a.

Lack of facial hair

b.

Ritualized hand washing

c.

Stealing and hiding a magazine belonging to another patient

d.

Throwing a chair when told it was time to turn off the television

ANS: D For all individuals abusing anabolic steroids, extreme mood swings occur, and these may be accompanied by violent behaviors. Obsessive-compulsive behaviors and stealing are not generally associated with this disorder. The increased hormone presence would result not in a lack, but rather an increase, in facial hair.

18.

A patients wife has chronic alcoholism, and the husband is concerned about the possibility that their children may develop the disease. He asks the nurse what the risk is. The nurses best response is:

a.

The risk for developing alcoholism is increased if there is a family history of alcoholism.

b.

Studies have confirmed that individuals with dependent personality traits are at high risk for this disease.

c.

Cultures that include alcohol as part of the ritualized behavior have a higher rate of alcoholism.

d.

Twin studies have indicated that the environment of a person is more important than the biologic influences of parents.

ANS: A Problems with alcohol increase with the number of relatives with alcoholism. No unique personality profile is prone to addiction. Ritualized use of alcohol does not predispose to alcoholism and twin studies indicate a significant genetic contribution to susceptibility to alcoholism.

19.

Which observation best supports the patients success with achieving long-term sobriety? a.

Asking a family member to, get rid of all the alcohol before I come home

b.

Identifying all the problems alcoholism has caused the family over the years

c.

Being able to discuss the importance of attending a support group for alcoholics

d.

Promising to, stop the drinking so I can be a good parent and raise a good child

ANS: B

One of the most prominent factors that leads an individual to recovery is the patients recognition that substance use has caused or influenced his or her lifes problems and interrupted his or her functioning. The remaining options lack that element of selfreflection.

20.

Which principle of recovery is the basis of the nurses response when a patient relapses and is hospitalized for alcohol detox treatment? a.

Alcoholism requires a lifelong commitment to control.

b.

Most people who are serious about treatment achieve sobriety.

c.

Relapsing is an expected occurrence for the patient diagnosed with alcohol abuse.

d.

Rehabilitation generally involves several relapses before true sobriety is achieved.

ANS: D Sobriety is the goal of complete abstention from drugs, alcohol, and addictive behaviors. Sobriety often involves several attempts, and many patients relapse 9 or 10 times before achieving and sustaining sobriety. This information is the basis for the physical and emotional support provided by the nurse. Although citing that a relapse is not a failure but an expected part of the recovery process, this option does not include the needed information of the frequency of the possible relapses. The remaining options are not focused on relapsing.

21.

Which assessment observation is the best support for a patients diagnosis of alcoholism? a.

Reporting, I messed up three marriages.

b.

Testing positive for hepatitis B virus (HBV)

c.

Admission that, I drink more than I should.

d.

A positive response to three items on the CAGE test

ANS: D The CAGE questionnaire is a well-validated screening instrument. A positive response to two of the four items of the CAGE questionnaire indicates a potential problem with

alcoholism. Although the remaining options are recognized red flags for possible alcoholism, they lack the selectivity of the screening tool.

22.

Which factor has the greatest negative impact on the use of laboratory serum alcohol results in determining legal intoxication? a.

The variable time it takes to metabolize alcohol in the body

b.

States differs greatly in their definitions of legal intoxication

c.

Legal issues with securing consent for the test from an impaired patient

d.

The relatively short period of time alcohol can be detected in the blood

ANS: D The major disadvantage of blood alcohol testing is the narrow window of time for the detection of drugs in the blood stream. Although the variability of individual metabolism rates may be considered a factor, they are stable enough to allow for testing timetables. The legal issues related to consent and the definition of legal intoxication limits does not impact the reliability of the test itself to determine intoxication.

23.

Which intervention will the nurse caring for a patient suspected of phencyclidine (PCP) abuse implement based on an understanding of the medications unique properties? a.

Assessing for chronic renal failure

b.

Focusing attention on providing patient safety

c.

Implementing suicide precautions immediately

d.

Monitoring for delayed development of psychotic symptoms

ANS: D Phencyclidine (PCP) is a hallucinogen, but it has its own set of CNS reactions. PCP has a long duration of action that can result in delayed psychotic symptoms. Chronic renal failure would not be immediately observable. Patient safety is a nursing responsibility regardless of the diagnosis. Self-harm is not generally a characteristic of this type of substance abuse.

24.

Which outcome would be appropriate for the detoxification phase of treatment for alcoholism? a.

Adequate dietary protein intake

b.

Re-connection with family and support system

c.

Identification of triggers that cause alcohol abuse

d.

Control over emotions resulting in aggressive behavior

ANS: A When implementing any plan, patient safety and health are always the first priorities, so the nurse focuses on nutritional support, including providing a protein-rich diet.

The remaining options are outcomes reserved for the later stages of the recovery process.

25.

Which intervention will the nurse plan for when managing the detoxification of a patient diagnosed with chronic alcoholism? a.

Low-protein diet to minimize risk of kidney failure

b.

Seclusion to help manage aggression towards others

c.

Transporting patient to scheduled 12-step support group meetings

d.

Administering Ativan (lorazepam) to manage alcohol withdrawal symptoms

ANS: D During the process of detoxification, the nurse gives enough of a drug (or one to which the person has cross-tolerance) to relieve the withdrawal symptoms.

Benzodiazepines like lorazepam (Ativan) have a cross-tolerance with alcohol, so they are used to manage withdrawal symptoms. The detoxification diet would be high in protein. Seclusion would not be initiated before less severe attempts to manage the behavior failed. Attending a support group would not be appropriate for the detoxification stage of rehabilitation.

MULTIPLE RESPONSE 1.

Which behaviors would demonstrate a strong possibility for successful rehabilitation for a patient with a substance abuserelated diagnosis? Select all that apply. a.

States that, I promise Ill never use drugs again.

b.

Has shown ability to use effective coping mechanisms

c.

Expresses an understanding of the severity of their addiction

d.

Plans to associate with old friends only when they arent drinking

e.

Demonstrates an interest in staying involved in an appropriate support group

ANS: B, C, E The correct options show an understanding of the disease process and examples of needed skills as well as the commitment to maintain control over their addiction. The remaining options reflect promises but not true insight into the severity of their problem and the effects needed to manage it successfully.

2.

A nurse engaged in primary prevention for substance abuse among adolescents could advise parents to (select all that apply): a.

Watch for signs of depression.

b.

Help the teen anticipate pressures.

c.

Be a role model for effective coping skills.

d.

Support the teens interest in hobbies and sports.

e.

Require academic tutoring when grades begin to drop.

ANS: B, C, D

The correct options are proactive and focus on preventing the problem although the remaining options intervene once there are indications that the problem may exist.

3.

When suspicious of possible fetal alcohol syndrome, which assessment findings would support this diagnosis? Select all that apply. a.

Webbed toes

b.

An enlarged head

c.

Super sensitive hearing

d.

A flattened bridge of the nose

e.

Symptoms of a septal heart defect

ANS: A, D, E The correct options are characteristics of FAS but one would not include hearing loss or a small head in children with this disorder.

4.

A teen says to the school nurse, Huffing is harmless. There are no reasons not to sniff inhalants. The nurse can reply knowing that (select all that apply): a.

Such behavior can result in irreversible hearing impairment.

b.

There has been minimal research done on the effects in teens.

c.

Long-term use can result in poor short- and long-term memory.

d.

Irreversible kidney damage is often observed with even casual use.

e.

Research indicates both central nervous system and bone marrow damage.

ANS: A, C, E Research as shown that even teens who engage in sniffing high concentrations on inhalants often experience hearing loss, CNS and bone marrow damage, and impaired cognitive function. Kidney impairment is often seen as reversible.