Correct Answer: 2

Rationale 1: The most effective intervention would be to actively listen to each identity state and provide support. Discouraging the use of psychometric tests that might support the diagnosis, confronting with secondary gain issues, and flooding the client with stressful stimuli are not helpful interventions for this client.

Rationale 2: The most effective intervention would be to actively listen to each identity state and provide support. Discouraging the use of psychometric tests that might support the diagnosis, confronting with secondary gain issues, and flooding the client with stressful stimuli are not helpful interventions for this client.

Rationale 3: The most effective intervention would be to actively listen to each identity state and provide support. Discouraging the use of psychometric tests that might support the diagnosis, confronting with secondary gain issues, and flooding the client with stressful stimuli are not helpful interventions for this client.

Rationale 4: The most effective intervention would be to actively listen to each identity state and provide support. Discouraging the use of psychometric tests that might support the diagnosis, confronting with secondary gain issues, and flooding the client with stressful stimuli are not helpful interventions for this client.

Chapter

Multiple Choice

1. A nurse works with a patient diagnosed with posttraumatic stress disorder who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care?

a. Trigger flashbacks intentionally in order to help the patient learn to copewith them.

b. Explain that the physical symptoms are related to the psychological state.

c. Encourage repression of memories associated with the traumatic event.

d. Support numbing as a temporary way to manage intolerable feelings.

ANS: B

Persons with posttraumatic stress disorder often experience somatic symptoms or sympathetic nervous system arousal that can be confusing and distressing. Explaining that these are the bodys responses to psychological trauma helps the patient understand how such symptoms are part of the illness and something that will respond to treatment. This decreases powerlessness over the symptoms and helps instill a sense of hope. It also helps the patient to understand howrelaxation, breathing exercises, and imagery can be helpful in symptom reduction. The goal of treatment for posttraumatic stress disorder is to come to terms with the event so treatment efforts would not include repression of memories or numbing. Triggering flashbacks would increase patient distress.

2. Four teenagers died in an automobile accident. One week later, which behavior by the parents of these teenagers most clearly demonstrates resilience? The parents who: a. visit their teenagers grave daily. b. return immediately to employment. c. discuss the accident within the family only. d. create a scholarship fund at their childs high school.

ANS: D a. Each day will get a little better. b. Her death is a terrible loss for you. c. Its important to recognize that she is no longer suffering. d. Your friends will help you cope with this change in your life.

Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest-risk situations for maladaptive grieving. The parents who create a scholarship fund are openly expressing their feelings and memorializing their child. The other parents in this question are isolating themselves and/or denying their feelings. Visiting the grave daily shows active continued mourning but is not as strongly indicative of resilience as the correct response.

3. After the sudden death of his wife, a man says, I cant live without hershe was my whole life. Select the nurses most therapeutic reply.

ANS: B a. The comment suggests potential allegations of malpractice. b. In some cultures, grief is expressed solely through anger. c. Anger is an expected emotion in an adjustment disorder. d. The patient had ambivalent feelings about her husband.

Adjustment disorders may be associated with grief. A statement that validates a bereaved persons loss is more helpful than false reassurances and clichs. It signifies understanding.

4. A woman just received notification that her husband died. She approaches the nurse who cared for him during his last hours and says angrily, If you had given him your undivided attention, he would still be alive. How should the nurse analyze this behavior?

ANS: C a. Say to the wife, I understand you are feeling upset. I will stay with you until your family comes. b. Say to the wife, Your husbands heart was so severely damaged that it could no longer pump. c. Say to the wife, I will call the health care provider to discuss this matter with you. d. Hold the wifes hand in silence until the family arrives.

Symptoms of adjustment disorder run the gamut of all forms of distress including guilt, depression, and anger. Anger may protect the bereaved from facing the devastating reality of loss.

5. A wife received news that her husband died of heart failure and called her family to come to the hospital. She angrily tells the nurse who cared for him, He would still be alive if you had given him your undivided attention. Select the nurses best intervention.

ANS: A

The nurse builds trust and shows compassion in the face of adjustment disorders. Therapeutic responses provide comfort. The nurse should show patience and tact while offering sympathy and warmth. The distracters are defensive, evasive, or placating.

6. A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the childs parents have adapted to their loss? The parents: a. visit their childs grave daily. b. maintain their childs room as the child left it 2 years ago. c. keep a place set for the dead child at the family dinner table. d. throw flowers on the lake at each anniversary date of the accident.

ANS: D a. Are you taking your medications the way they are prescribed? b. This loss is harder to accept because of your mental illness. Do you think you should be hospitalized? c. Im worried about how much you are crying. Your grief over your husbands death has gone on too long. d. The unexpected death of your husband is very painful. Im glad you are able to talk about your feelings.

Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest-risk situations for an adjustment disorder and maladaptive grieving. The parents who throw flowers on the lake on each anniversary date of the accident are openly expressing their feelings. The other behaviors are maladaptive because of isolating themselves and/or denying their feelings. After 2 years, the frequency of visiting the grave should have decreased.

7. A store clerk was killed during a robbery 2 weeks ago. His widow, who has a long history of schizoaffective disorder, cries spontaneously when talking about his death. Select the nurses most therapeutic response.

ANS: D a. After being caught in an extramarital affair, a man disappeared but then reappeared months later with no memory of what occurred while he was missing. b. A man is extremely anxious about his problems and sometimes experiences dazed periods of several minutes passing without conscious awareness of them. c. A woman finds unfamiliar clothes in her closet, is recognized when she goes to new restaurants, and complains of blackouts despite not drinking. d. A woman reports that when she feels tired or stressed, it seems like her body is not real and is somehow growing smaller.

The patient is expressing feelings related to the loss, and this is an expected and healthy behavior. This patient is at risk for a maladaptive response because of the history of a serious mental illness, but the nurses priority intervention is to form a therapeutic alliance and support the patients expression of feelings. Crying at 2 weeks after his death is expected and normal.

8. Which scenario demonstrates a dissociative fugue?

ANS: A

The patient in a dissociative fugue state relocates and lacks recall of his life before the fugue began. Often fugue states follow traumatic experiences and sometimes involve assuming a new identity. Such persons at some point find themselves in their new surroundings, unable to recall who they are or how they got there. A feeling of detachment from ones body or from the external reality is an indication of depersonalization disorder. Losing track of several minutes when highly anxious is not an indication of a dissociative disorder and is common in states of elevated anxiety. Finding evidence of having bought clothes or gone to restaurants without any explanation for these is suggestive of dissociative identity disorder, particularly when periods are lost to the patient (blackouts). See relationship to audience response question.

9. The nurse who is counseling a patient with dissociative identity disorder should understand that the assessment of highest priority is: a. risk for self-harm. b. cognitive function.

ANS: A c. memory impairment. d. condition of self-esteem. a. Acute stress disorder b. Dissociative amnesia c. Depersonalization disorder d. Disinhibited social engagement disorder

Assessments that relate to patient safety take priority. Patients with dissociative disorders may be at risk for suicide or self-mutilation, so the nurse must be alert for indicators of risk for selfinjury. The other options are important assessments but rank below safety. Treatment motivation, while an important consideration, is not necessarily a part of the nursing assessment.

10. A patient states, I feel detached and weird all the time. It is as though I am looking at life through a cloudy window. Everything seems unreal. It really messes up things at work and school. This scenario is most suggestive of which health problem?

ANS: C a. Spend as much time with her as you can and ask questions about her life. b. Use short, simple sentences and keep the environment calm and protective. c. Provide more information about her past to reduce the mysteries that are causing anxiety. d. Structure her time with activities to keep her busy, stimulated, and regaining concentration.

Depersonalization disorder involves a persistent or recurrent experience of feeling detached from and outside oneself. Although reality testing is intact, the experience causes significant impairment in social or occupational functioning and distress to the individual. Dissociative amnesia involves memory loss. Children with disinhibited social engagement disorder demonstrate no normal fear of strangers and are unusually willing to go off with strangers. Individuals with ASD experience three or more dissociative symptoms associated with a traumatic event, such as a subjective sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of surroundings; derealization; depersonalization or dissociative amnesia. In the scenario, the patient experiences only one symptom.

11. The unlicensed assistive personnel (UAP) says to the nurse, That patient with amnesia looks fine, but when I talk to her, she seems vague. What should I be doing for her? Select the nurses best reply.

ANS: B a. Notify the health care provider of this change in the patients behavior. b. Engage the patient in a physical activity such as exercise. c. Isolate the patient until the sensation has diminished. d. Administer a PRN dose of anti-anxiety medication.

Disruptions in ability to perform activities of daily living, confusion, and anxiety are often apparent in patients with amnesia. Offering simple directions to promote activities of daily living and reduce confusion helps increase feelings of safety and security. A calm, secure, predictable, protective environment is also helpful when a person is dealing with a great deal of uncertainty. Recollection of memories should proceed at its own pace, and the patient should only gradually be given information about her past. Asking questions that require recall that the patient does not possess will only add frustration. Quiet, undemanding activities should be provided as the patient tolerates them and should be balanced with rest periods; the patients time should not be loaded with demanding or stimulating activities.

12. A patient diagnosed with depersonalization disorder tells the nurse, Its starting again. I feel as though Im going to float away. Which intervention would be most appropriate at this point?

ANS: B a. Limbic system b. Peripheral nervous system

Helping the patient apply a grounding technique, such as exercise, assists the patient to interrupt the dissociative process. Medication can help reduce anxiety but does not directly interrupt the dissociative process. Isolation would allow the sensation to overpower the patient. It is not necessary to notify the health care provider.

13. A person runs from a crowded nightclub after a pyrotechnics show causes the building to catch fire. Which division of the autonomic nervous system will be stimulated in response tothis experience?

ANS: C c. Sympathetic nervous system d. Parasympathetic nervous system a. Weight gain b. Flashbacks

The autonomic nervous system is comprised of the sympathetic (fight or flight response) and parasympathetic nervous system (relaxation response). In times of stress, the sympathetic nervous system is stimulated. A person would experience stress associated with the experience of being in danger. The peripheral nervous system responds to messages from the sympathetic nervous system. The limbic system processes emotional responses but is not specifically part of the autonomic nervous system.

14. The gas pedal on a persons car stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. Afterward, this persons cortisol regulation was compromised. Which assessment finding would the nurse expect associated with the dysregulation of cortisol?

ANS: B c. Headache d. Diuresis

Cortisol is a hormone released in response to stress. Severe dissociation or mindflight occurs for those who have suffered significant trauma. The episodic failure of dissociation causes intrusive symptoms such as flashbacks, thus dysregulating cortisol. The cortisol level may go up or down, so diuresis and/or weight gain may or may not occur. Answering this question correctly requires that the student apply prior learning regarding the effects of cortisol.

15. A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with posttraumatic stress disorder (PTSD). The nurses highest priority is to screen this soldier for: a. bipolar disorder. b. schizophrenia.

ANS: C c. depression. d. dementia. a. Its good to be home. I missed my home, family, and friends. b. I saw my best friend get killed by a roadside bomb. I dont understand why it wasnt me. c. Sometimes I think I hear bombs exploding, but its just the noise of traffic in my hometown. d. I want to continue my education, but Im not sure how I will fit in with other college students.

Comorbidities for adults with PTSD include depression, anxiety disorders, sleep disorders, and dissociative disorders. Incidence of the disorders identified in the distracters is similar to the general population.

16. Two weeks ago, a soldier returned to the U.S. from active duty in a combat zone in Afghanistan. The soldier was diagnosed with posttraumatic stress disorder (PTSD). Which comment by the soldier requires the nurses immediate attention?

ANS: B a. Illusion b. Flashback

The correct response indicates the soldier is thinking about death and feeling survivors guilt. These emotions may accompany suicidal ideation, which warrants the nurses follow-up assessment. Suicide is a high risk among military personnel diagnosed with posttraumatic stress disorder. One distracter indicates flashbacks, common with persons with PTSD, but not solely indicative that further problems exist. The other distracters are normal emotions associated with returning home and change.

17. A soldier returned home from active duty in a combat zone in Afghanistan and was diagnosed with posttraumatic stress disorder (PTSD). The soldier says, If theres a loud noise at night, I get under my bed because I think were getting bombed. What type of experience has the soldier described?

ANS: B c. Nightmare d. Auditory hallucination a. Halloween festival with neighborhood children b. Singing carols around a Christmas tree c. A family outing to the seashore d. Fireworks display on July 4th

Flashbacks are dissociative reactions in which an individual feels or acts as if the traumatic event were recurring. Illusions are misinterpretations of stimuli, and although the experience is similar, it is better termed a flashback because of the diagnosis of PTSD. Auditory hallucinations have no external stimuli. Nightmares commonly accompany PTSD, but this experience was stimulated by an actual environmental sound.

18. A soldier returned 3 months ago from Afghanistan and was diagnosed with posttraumatic stress disorder (PTSD). Which social event would be most disturbing for this soldier?

ANS: D a. Immediately upon return to the U.S. from Afghanistan b. Before departing Afghanistan to return to the U.S. c. One year after returning from Afghanistan d. Screening should be on-going

The exploding noises associated with fireworks are likely to provoke exaggerated responses for this soldier. The distracters are not associated with offensive sounds.

19. A soldier served in combat zones in Iraq during 2010 and was deployed to Afghanistan in 2013. When is it most important for the nurse to screen for signs and symptoms of posttraumatic stress disorder (PTSD)?

ANS: D a. Reexperiencing b. Hyperarousal

20. A soldier in a combat zone tells the nurse, I saw a child get blown up over a year ago, and I still keep seeing bits of flesh everywhere. I see something red, and the visions race back to my mind. Which phenomenon associated with posttraumatic stress disorder (PTSD) is the soldier describing?

ANS: A c. Avoidance d. Psychosis a. Reexperiencing b. Hyperarousal

Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic events are often associated with PTSD. The soldier has described intrusive thoughts and visions associated with reexperiencing the traumatic event. This description does not indicate psychosis, hypervigilance, or avoidance.

21. A soldier who served in a combat zone returned to the U.S. The soldiers spouse complains to the nurse, We had planned to start a family, but now he wont talk about it. He wont even look at children. The spouse is describing which symptom associated with posttraumatic stress disorder (PTSD)?

ANS: C c. Avoidance d. Psychosis a. Posttraumatic stress disorder often changes a persons sexual functioning. b. I encourage you to continue to participate in social activities where children are present. c. Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior. d. Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support.

Physiological reactions to reminders of the event that include persistent avoidance of stimuli associated with the trauma results in the individuals avoiding talking about the event or avoiding activities, people, or places that arouse memories of the trauma. Avoidance is exemplified by a sense of foreshortened future and estrangement. There is no evidence this soldier is having hyperarousal or reexperiencing war-related traumas. Psychosis is not evident.

22. A soldier returned home last year after deployment to a war zone. The soldiers spouse complains, We were going to start a family, but now he wont talk about it. He will not look at children. I wonder if were going to make it as a couple. Select the nurses best response.

ANS: D

Posttraumatic stress disorder precipitates changes that often lead to divorce. Its important to provide support to both the veteran and spouse. Confrontation will not be effective. While its important to provide information, on-going support will be more effective.

23. Which assessment finding best supports dissociative fugue? The patient states: a. I cannot recall why Im living in this town. b. I feel as if Im living in a fuzzy dream state. c. I feel like different parts of my body are at war. d. I feel very anxious and worried about my problems.

ANS: A

The patient in a fugue state frequently relocates and assumes a new identity while not recalling previous identity or places previously inhabited. The distracters are more consistent with depersonalization disorder, generalized anxiety disorder, or dissociative identity disorder. See relationship to audience response question.

24. After major reconstructive surgery, a patients wounds dehisced. Extensive wound care was required for 6 months, causing the patient to miss work and social activities. Which pathophysiology would be expected for this patient? Dysfunction of the: a. pons. b. occipital lobe. c. hippocampus. d. hypothalamus.

ANS: C

The scenario presents chronic and potentially debilitating stress. If arousal continues unabated, neuronal changes occur that alter the neural circuitry of the prefrontal cortex, reducing the size the hippocampus so that memory is impaired.

25. Relaxation techniques help patients who have experienced major traumas because they: a. engage the parasympathetic nervous system. b. increase sympathetic stimulation. c. increase the metabolic rate. d. release hormones.

ANS: A

In response to trauma, the sympathetic arousal symptoms of rapid heart rate and rapidrespiration prepare the person for flight or fight responses. Afterward, the dorsal vagal response damps down the sympathetic nervous system. This is a parasympathetic response with the heart rate and respiration slowing down and decreasing the blood pressure. Relaxation techniques promote activity of the parasympathetic nervous system.

26. Select the correct etiology to complete this nursing diagnosis for a patient with dissociative identity disorder. Disturbed personal identity related to: a. obsessive fears of harming self or others. b. poor impulse control and lack of self-confidence. c. depressed mood secondary to nightmares and intrusive thoughts. d. cognitive distortions associated with unresolved childhood abuse issues.

ANS: D

Nearly all patients with dissociative identity disorder have a history of childhood abuse or trauma. None of the other etiology statements is relevant. See relationship to audience response question.

Multiple Response

1. A young adult says, I was sexually abused by my older brother. During those assaults, I went somewhere else in my mind. I dont remember the details. Now, I often feel numb or unreal in romantic relationships, so I just avoid them. Which disorders should the nurse suspect based on this history? Select all that apply.

a. Acute stress disorder b. Depersonalization disorder c. Generalized anxiety disorder d. Posttraumatic stress disorder e. Reactive attachment disorder f. Disinhibited social engagement disorder

ANS: A, B, D

Acute stress disorder, depersonalization disorder, and posttraumatic stress disorder can involve dissociative elements, such as numbing, feeling unreal, and being amnesic for traumatic events. All three disorders are also responses to acute stress or trauma, which has occurred here. The distracters are disorders not evident in this patients presentation. Generalized anxiety disorder involves extensive worrying that is disproportionate to the stressors or foci of the worrying. Reactive attachment disorder and disinhibited social engagement disorder are problems of childhood.

2. A 10-year-old child was placed in a foster home after being removed from parental contact because of abuse. The child has apprehension, tremulousness, and impaired concentration. The foster parent also reports the child has an upset stomach, urinates frequently, and does not understand what has happened. What helpful measures should the nurse suggest to the foster parents? The nurse should recommend: (select all that apply) a. conveying empathy and acknowledging the childs distress. b. explaining and reinforcing reality to avoid distortions. c. using a calm manner and low, comforting voice. d. avoiding repetition in what is said to the child. e. staying with the child until the anxiety decreases. f. minimizing opportunities for exercise and play.

ANS: A, B, C, E

The childs symptoms and behavior suggest that he is exhibiting posttraumatic stress disorder. Interventions appropriate for this level of anxiety include using a calm, reassuring tone, acknowledging the childs distress, repeating content as needed when there is impaired cognitive processing and memory, providing opportunities for comforting and normalizing play and physical activities, correcting any distortion of reality, and staying with the child to increase his sense of security.

3. The nurse interviewing a patient with suspected posttraumatic stress disorder should be alertto findings indicating the patient: (select all that apply) a. avoids people and places that arouse painful memories. b. experiences flashbacks or reexperiences the trauma. c. experiences symptoms suggestive of a heart attack. d. feels driven to repeat selected ritualistic behaviors. e. demonstrates hypervigilance or distrusts others. f. feels detached, estranged, or empty inside.

ANS: A, B, C, E, F a. A young adult bungee jumped from a bridge with a best friend. b. An 8-year-old child watched an R-rated movie with both parents. c. An adolescent was kidnapped and held for 2 years in the home of a sexual predator. d. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. e. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.

These assessment findings are consistent with the symptoms of posttraumatic stress disorder. Ritualistic behaviors are expected in obsessive-compulsive disorder.

4. Which experiences are most likely to precipitate posttraumatic stress disorder (PTSD)? Select all that apply.

ANS: C, D, E

PTSD usually occurs after a traumatic event that is outside the range of usual experience. Examples are childhood physical abuse, torture/kidnap, military combat, sexual assault, and natural disasters, such as floods, tornados, earthquakes, tsunamis; human disasters, such as a bus or elevator accident; or crime-related events, such being taken hostage. The common element in these experiences is the individuals extraordinary helplessness or powerlessness in the face of such stressors. Bungee jumps by adolescents are part of the developmental task and might be frightening, but in an exhilarating way rather than a harmful way. A child may be disturbed by an R-rated movie, but the presence of the parents would modify the experience in a positiveway.

Chapter 15. Psychopharmacotherapy and Psychotherapy

Question 1

Type: MCMA

Which of the following is part of the ongoing nursing assessments of the client on psychiatric medications?

Standard Text: Select all that apply.

1. How well the medication is managing the clients symptoms

2. The clients cultural belief system related to illness and medication

3. Whether the medication is causing side effects

4. The clients favorite activities

5. The clients readiness to learn

Correct Answer: 1,2,3,5

Rationale 1: How well the medication is managing the clients symptoms. The nurse must assess how effective the medication is in terms of managing the symptoms of the clients illness.

Rationale 2: The clients cultural belief system related to illness and medication. A clients cultural belief system related to taking medications for behavioral symptoms may impact the clients willingness to take medications.

Rationale 3: Whether the medication is causing side effects. If a client is having a distressing side effect, the client may not adhere to the medication treatment regimen.

Rationale 4: The clients favorite activities. The clients favorite activities are not directly related to taking medications.

Rationale 5: The clients readiness to learn. Ongoing education is vital for adhering to medications and clients readiness to learn fluctuates throughout the course of the illness.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Assess the effectiveness of medications in psychiatricmental health settings.

Question 2

Type: MCSA

Which of the following questions would the nurse ask a woman to assess for hyperprolactinemia as a side effect of an antipsychotic medication?

1. Are you having trouble sitting still?

2. Are you constipated?

3. Are you having any discharge from your breasts?

4. Do you have a dry mouth?

Correct Answer: 3

Rationale 1: Galactorrhea is a symptom of hyperprolactinemia. The inability to sit still could be a sign of akathisia. A dry mouth and constipation are often due to anticholinergic side effects.

Rationale 2: Galactorrhea is a symptom of hyperprolactinemia. The inability to sit still could be a sign of akathisia. A dry mouth and constipation are often due to anticholinergic side effects.

Rationale 3: Galactorrhea is a symptom of hyperprolactinemia. The inability to sit still could be a sign of akathisia. A dry mouth and constipation are often due to anticholinergic side effects.

Rationale 4: Galactorrhea is a symptom of hyperprolactinemia. The inability to sit still could be a sign of akathisia. A dry mouth and constipation are often due to anticholinergic side effects.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Assess the effectiveness of medications in psychiatricmental health settings.

Question 3

Type: MCSA

Which of the following is a priority assessment for a child in the initial stages of antidepressant treatment?

1. School successes

2. Food preferences

3. Suicide assessment

4. Family functioning

Correct Answer: 3

Rationale 1: Children, adolescents, and young adults are at risk for suicidal behaviors early in the treatment with antidepressants. Family functioning, school successes, and eating are important assessments, but not as important as assessing for lethality/suicidality.

Rationale 2: Children, adolescents, and young adults are at risk for suicidal behaviors earlyin the treatment with antidepressants. Family functioning, school successes, and eating are important assessments, but not as important as assessing for lethality/suicidality.

Rationale 3: Children, adolescents, and young adults are at risk for suicidal behaviors earlyin the treatment with antidepressants. Family functioning, school successes, and eating are important assessments, but not as important as assessing for lethality/suicidality.

Rationale 4: Children, adolescents, and young adults are at risk for suicidal behaviors earlyin the treatment with antidepressants. Family functioning, school successes, and eating are important assessments, but not as important as assessing for lethality/suicidality.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Assess the effectiveness of medications in psychiatricmental health settings.

Question 4

Type: MCSA

The nurse would be alert to assess for signs of lithium toxicity in a patient with which of the following lithium levels?

1. 1.5 mEq/l

2. 0.1 mEq/l

3. 0.5 mEq/l

4. 1.0 mEq/l

Correct Answer: 1

Rationale 1: Significant side effects are often present in clients with a lithium level above 1.2 mEq/l.

Rationale 2: Significant side effects are often present in clients with a lithium level above 1.2 mEq/l.

Rationale 3: Significant side effects are often present in clients with a lithium level above 1.2 mEq/l.

Rationale 4: Significant side effects are often present in clients with a lithium level above 1.2 mEq/l.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Assess the effectiveness of medications in psychiatricmental health settings.

Question 5

Type: MCSA

The nurse would assess which of the following as early signs of lithium poisoning?

1. Elevated blood pressure, paralysis, and impulsivity

2. Cardiac arrest, seizures, and change in level of consciousness

3. Vomiting, diarrhea, lethargy, and muscle twitching

4. Hallucinations, agitation, and anger

Correct Answer: 3

Rationale 1: Vomiting, diarrhea, lethargy, and muscle twitching are early signs of lithium poisoning. Cardiac arrest, seizures, and change in level of consciousness are late and life threatening signs that could be avoided if the early signs are recognized. The combination of hallucinations, agitation, anger, elevated blood pressure, paralysis, and impulsivity are not early signs of lithium toxicity.

Rationale 2: Vomiting, diarrhea, lethargy, and muscle twitching are early signs of lithium poisoning. Cardiac arrest, seizures, and change in level of consciousness are late and life threatening signs that could be avoided if the early signs are recognized. The combination of hallucinations, agitation, anger, elevated blood pressure, paralysis, and impulsivity are not early signs of lithium toxicity.

Rationale 3: Vomiting, diarrhea, lethargy, and muscle twitching are early signs of lithium poisoning. Cardiac arrest, seizures, and change in level of consciousness are late and life threatening signs that could be avoided if the early signs are recognized. The combination of hallucinations, agitation, anger, elevated blood pressure, paralysis, and impulsivity are not early signs of lithium toxicity.

Rationale 4: Vomiting, diarrhea, lethargy, and muscle twitching are early signs of lithium poisoning. Cardiac arrest, seizures, and change in level of consciousness are late and life threatening signs that could be avoided if the early signs are recognized. The combination of hallucinations, agitation, anger, elevated blood pressure, paralysis, and impulsivity are not early signs of lithium toxicity.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Assess the effectiveness of medications in psychiatricmental health settings.

Question 6

Type: MCSA

Which of the following medications carries the highest risk of QTc prolongation and, therefore, the need to monitor cardiac side effects most carefully?

1. Thioridazine (Mellaril)

2. Risperidone (Risperdal)

3. Quetiapine (Seroquel)

4. Olanzapine (Zyprexa)

Correct Answer: 1

Rationale 1: Thioridazine has an FDA black box warning to call attention to the risk of QTc prolongation. The other antipsychotics listed do not carry this warning.

Rationale 2: Thioridazine has an FDA black box warning to call attention to the risk of QTc prolongation. The other antipsychotics listed do not carry this warning.

Rationale 3: Thioridazine has an FDA black box warning to call attention to the risk of QTc prolongation. The other antipsychotics listed do not carry this warning.

Rationale 4: Thioridazine has an FDA black box warning to call attention to the risk of QTc prolongation. The other antipsychotics listed do not carry this warning.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Integrate an understanding of the positive and negative effects of psychiatric medications into pharmacological treatment.

Question 7

Type: MCSA

Which of the following client behaviors would indicate a need for further intervention in the anxious patient on a benzodiazepine?

1. The client asking to be taken off the medication gradually

2. The client relying more on coping skills and taking less medication

3. The client inquiring about behavior methods for anxiety control

4. The client requesting a higher dose of drug to achieve the intended effect

Correct Answer: 4

Rationale 1: Requesting higher doses of a benzodiazepine can be a sign of tolerance and addiction. The other responses are actually signs of relying less on the medication and more on coping strategies and are positive signs.

Rationale 2: Requesting higher doses of a benzodiazepine can be a sign of tolerance and addiction. The other responses are actually signs of relying less on the medication and more on coping strategies and are positive signs.

Rationale 3: Requesting higher doses of a benzodiazepine can be a sign of tolerance and addiction. The other responses are actually signs of relying less on the medication and more on coping strategies and are positive signs.

Rationale 4: Requesting higher doses of a benzodiazepine can be a sign of tolerance and addiction. The other responses are actually signs of relying less on the medication and more on coping strategies and are positive signs.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Integrate an understanding of the positive and negative effects of psychiatric medications into pharmacological treatment.

Question 8

Type: MCSA

The client received aripiprazole (Abilify) on admission to the inpatient unit with a diagnosis of schizophrenia, paranoid type. Which of the following would the nurse note as a sign that the aripiprazole is becoming effective?

1. The client paces in the hall and engages in solitary activities most of the day.

2. The client sleeps for shorter periods of time during the day.

3. The client establishes eye contact and remains in conversation with the nurse for longer periods.

4. The client eats only the food that is in its original container such as individual packages of crackers.

Correct Answer: 3

Rationale 1: Because suspiciousness is a central feature of paranoid delusions, efficacy is shown by the client demonstrating behaviors that suggest increasing trust in the nurse. Sleeping less during the day is not a sign that aripiprazole is alleviating psychotic symptoms. Engaging in solitary activities and eating prepackaged food are signs of paranoia.

Rationale 2: Because suspiciousness is a central feature of paranoid delusions, efficacy is shown by the client demonstrating behaviors that suggest increasing trust in the nurse. Sleeping less during the day is not a sign that aripiprazole is alleviating psychotic symptoms. Engagingin solitary activities and eating prepackaged food are signs of paranoia.

Rationale 3: Because suspiciousness is a central feature of paranoid delusions, efficacy is shown by the client demonstrating behaviors that suggest increasing trust in the nurse. Sleeping less during the day is not a sign that aripiprazole is alleviating psychotic symptoms. Engaging in solitary activities and eating prepackaged food are signs of paranoia.

Rationale 4: Because suspiciousness is a central feature of paranoid delusions, efficacy is shown by the client demonstrating behaviors that suggest increasing trust in the nurse. Sleeping less during the day is not a sign that aripiprazole is alleviating psychotic symptoms. Engaging in solitary activities and eating prepackaged food are signs of paranoia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Integrate an understanding of the positive and negative effects of psychiatric medications into pharmacological treatment.

Question 9

Type: MCSA

Which of the following is an indication that the client understands the teaching related to buspirone (BuSpar)?

1. I will not drink grapefruit juice while taking this medication.

2. I should sleep though the night on this medication.

3. I should feel a relief of anxiety within a half hour.

4. I will not hear voices after being on this medication for two weeks.

Correct Answer: 1

Rationale 1: When taken with grapefruit juice, buspirone levels can be raised to nine times the normal level. Buspirone takes up to two weeks to show efficacy for anxiety control and is not a sedative. Buspirone is an antianxiety agent and does not impact auditory hallucinations.

Rationale 2: When taken with grapefruit juice, buspirone levels can be raised to nine times the normal level. Buspirone takes up to two weeks to show efficacy for anxiety control and is not a sedative. Buspirone is an antianxiety agent and does not impact auditory hallucinations.

Rationale 3: When taken with grapefruit juice, buspirone levels can be raised to nine times the normal level. Buspirone takes up to two weeks to show efficacy for anxiety control and is not a sedative. Buspirone is an antianxiety agent and does not impact auditory hallucinations.

Rationale 4: When taken with grapefruit juice, buspirone levels can be raised to nine times the normal level. Buspirone takes up to two weeks to show efficacy for anxiety control and is not a sedative. Buspirone is an antianxiety agent and does not impact auditory hallucinations.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Integrate an understanding of the positive and negative effects of psychiatric medications into pharmacological treatment.

Question 10

Type: MCSA

Which of the following would indicate to the nurse that fluoxetine (Prozac) is effective for the client with major depressive disorder?

1. The client remained up all night discussing negative life situations with the nursing staff.

2. The client ate 100% of breakfast and lunch and ate 25% of the evening meal the past two days.

3. The client remained in the room reading and watching listening to music 90% of the day.

4. The client slept 60% of the night while remaining in bed from 11 p.m. to 5 a.m.

Correct Answer: 2

Rationale 1: An improvement in appetite is a sign of an improvement in a symptom of major depressive disorder. Ruminating on negative life events, not sleeping, and isolating are symptoms of depression and do not show an improvement from the medication.

Rationale 2: An improvement in appetite is a sign of an improvement in a symptom of major depressive disorder. Ruminating on negative life events, not sleeping, and isolating are symptoms of depression and do not show an improvement from the medication.

Rationale 3: An improvement in appetite is a sign of an improvement in a symptom of major depressive disorder. Ruminating on negative life events, not sleeping, and isolating are symptoms of depression and do not show an improvement from the medication.

Rationale 4: An improvement in appetite is a sign of an improvement in a symptom of major depressive disorder. Ruminating on negative life events, not sleeping, and isolating are symptoms of depression and do not show an improvement from the medication.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity