A patient is diagnosed with agoraphobia.

Which of the following would the

healthcare identify as a characteristic of
this disorder?
Fears the use of public transportation

Refuses to use a public restroom

Avoids interacting with strangers

Avoids being in the presence of clowns

Agoraphobia is a type of anxiety disorder where the patient

fears situations that make the patient feel trapped, helpless,
or embarrassed. The patient fears an actual or even an
anticipated situation. Examples of agoraphobic situations
include being outside of the home alone or being in a crowd.
Other agoraphobic situations include being in a train or a
bus, or other forms of public transportation. Refusing to use
a public restroom is a sign of a social phobia. Xenophobia is
a fear of strangers, and coulrophobia is a fear of clowns.
A client with chronic kidney disease
(CKD) learns that her condition has
progressed and she now requires
hemodialysis. She becomes angry and
tells the nurse, "My life is ruined.
Nothing will ever be the same." The
understands that the client's statement
is related to
Confusion due to toxins building up in the client's
bloodstream.

Grief because of the physical and lifestyle changes.

Anxiety about getting an AV fistula and the dialysis

process.

Likely noncompliance because of time demands for

dialysis.

Clients with chronic disease or conditions that require

change in appearance, physical health, or lifestyle changes
undergo a grief process for the loss of their former lives,
similar to the death of a loved one. The client may also have
an altered body image due to the impact of hemodialysis.
A patient is receiving care after being
diagnosed with generalized anxiety
disorder (GAD). Which of these
statements made by the patient indicate
to the healthcare provider that the
patient is beginning to show signs of
improvement?
"Situations that cause anxiety can always be
avoided."
"Now I know that my anxiety is caused by a lack of
sleep."

"As long as I take my medication, I can deal with

anxiety."

"I can tell when I'm beginning to experience

anxiety."

GAD is characterized by excessive worrying that may result

in problems such as a hyperarousal, muscle tension,
difficulty relaxing, and impaired sleep patterns. Patients
diagnosed with GAD often engage in avoidance behaviors.
Recognizing when symptoms of anxiety occur is an initial
goal for the patient. Once anxiety is recognized, the patient
can employ coping skills to manage the anxiety.
Medications can be helpful in managing GAD, but should be
used in conjunction with cognitive-behavioral therapies.
The children of a patient diagnosed with
Alzheimer's disease (AD) tell the
healthcare provider, "Our mother seems
better during the day, but she gets very
confused and agitated in the late
afternoon and evenings." How should
the healthcare provider document the
patient's behavior?
Sundowning

Depression

Psychosis

Delirium

This patient is experiencing sundowning or sundowner

syndrome, also called "late-day confusion," a phenomenon
prevalent in patients diagnosed with dementia. Sundowning
may be associated with impaired circadian rhythms,
environmental or social factors, and impaired cognition. The
patient may also begin pacing or wandering, or the patient
may become aggressive.
A patient is admitted to the mental
health unit with a diagnosis of vascular
dementia. Which of the following
describes the brain alteration involved
in this disorder?
Hypoxic damage to brain tissue

Decreased choline acetyltransferase

Formation of beta-amyloid plaques

Enlargement of the ventricles

Vascular dementia is characterized by a progressive

worsening of cognitive function due to vascular disease
within the brain. Decreased blood flow and tissue hypoxia is
often secondary to cerebrovascular disease. Patients
diagnosed with vascular dementia will have additional
physical health problems that are associated with the
dementia. Vascular dementia does not involve the
accumulation of abnormal proteins within the brain.
During the administration of a Mini-
Mental Status Exam (MMSE), the
healthcare provider asks the patient to
copy a simple geometric shape. This part
of the exam tests which of the following
mental functions?
Hearing and language skills

Orientation and short-term memory

Visual comprehension and praxis

Attention and calculation abilities

The MMSE screens for cognitive loss by testing the patient's

orientation, attention, calculation, comprehension, recall,
language, and motor skills. The healthcare provider will
observe how well the patient copies the shape. Copying the
shape successfully demonstrates visual comprehension and
the ability to plan and execute coordinated movement
(praxis). THE MMSE is used to screen for dementia.
A patient diagnosed with depression is
prescribed a monoamine oxidase
inhibitor (MAOI). When teaching the
patient about the medication, which
statement made by the patient indicates
the need for additional teaching?
"I don't have to limit the pepperoni on my pizza."

"I can still eat out at restaurants as long as I'm

careful."

"I'm glad I can still eat hamburgers and french fries."

"I will miss putting soy sauce on my noodles."

The patient will need to avoid consuming foods which are

high in tyramine. Processed meats such a pepperoni are
high in tyramine. Combining tyramine-rich foods with a
monoamine oxidase inhibitor (MAOI) can result in a
hypertensive crisis. Other foods to avoid are cheese, yogurt,
alcohol, fermented foods (sauerkraut, kimchi, soy sauce),
and some fruits and vegetables.
A patient diagnosed with delirium sees
the intravenous (IV) tubing and believes
it to be a snake. How should the
healthcare provider document this
behavior?
Illusion
Hallucination

Delusion

Confusion

The patient is experiencing an illusion, which is the

misinterpretation of a real stimulus. A hallucination is a
false sensory perception not associated with a real
stimulus. A delusion is a false personal belief that is
maintained in spite of evidence to the contrary. A patient
who is confused would not believe the IV tubing is a snake.
Which of the following assessment
findings in a patient's health history
supports a diagnosis of substance
dependence?
Continued tardiness and absenteeism from work

Numerous legal problems and interpersonal conflicts

Withdrawal symptoms when not using the substance

Impaired judgment and risk-taking behaviors

Substance dependence is characterized by the need to

continually use the substance in order to avoid unpleasant
physical symptoms of withdrawal (physical dependence),
often accompanied by an intense craving for the substance
(psychological dependence). Problems related to substance
use tend to become more serious with repeated use.
Answers 1, 3, and 4 are behavior-related. Answer 2
demonstrates a physical finding.
After being robbed and beaten by an
unknown assailant, a patient is
diagnosed with post-traumatic stress
disorder (PTSD). When developing a
plan of care for the patient, which of
these interventions will the healthcare
provider plan to implement first?
Assist the patient in recalling the details of the event

Ensure the patient is taking medications as

prescribed

Promote the establishment of a trusting relationship

Teach the patient coping skills to deal with anxiety

PTSD can develop after experiencing or witnessing a life-

threatening event. PTSD is characterized by intrusive
thoughts, nightmares, and flashbacks of past traumatic
events, causing severe anxiety. Medication therapy and
teaching effective coping skills will be part of the patient's
plan of care, but these will have limited effectiveness until
the patient feels safe and has a trusting relationship with
the healthcare provider. Typically, the patient will avoid
reminders of the trauma, so the patient should be
encouraged to talk about the trauma at his or her own pace.
During a group therapy session, a client
with heroine addiction states, "I have
caused my wife and kids so much pain.
I'm such a loser." What is the nurse's
best response?
"Addiction is a treatable disease."

"They will eventually forgive you."

"You're going to have to earn their trust again."

"Drug dependence affects the whole family."

Addiction, or drug/alcohol dependence, is considered an

illness that can be treated, so the nurse should offer hope.
The other responses are not therapeutic, because they
increase the client's guilt and doubt.
A nurse is caring for an elderly
Vietnamese patient in the terminal
stages of lung cancer. Many family
members are in the room around the
clock performing unusual rituals and
bringing ethnic foods. Which of the
following actions should the nurse take?
If possible, keep the other bed in the room
unassigned to provide privacy and comfort to the
family

Restrict visiting hours and ask the family to limit

visitors to two at a time

Contact the physician to report the unusual rituals

and activities

Notify visitors with a sign on the door that the

patient is limited to clear fluids only with no solid
food allowed

When a family member is dying, it is most helpful for nursing

staff to provide a culturally sensitive environment to the
degree possible within the hospital routine. In the
Vietnamese culture, it is important that the dying be
surrounded by loved ones and not left alone. Traditional
rituals and foods are thought to ease the transition to the
next life. When possible, allowing the family privacy for this
traditional behavior is best for them and the patient.
Answers A, B, and D are incorrect because they create
unnecessary conflict with the patient and family.
A patient diagnosed with major
depressive disorder is admitted for
inpatient care. Which of the following is
the primary goal during the admission
assessment?
Establishing desired outcomes for the patient
Reviewing the policies for patient conduct

Administering antidepressant medications

Collecting and organizing patient data

The primary goal during the admission assessment is to

collect and organize objective and subjective data so
patient problems and needs can be identified. Goals and
outcomes are based on patient problems that have been
identified. Medication may be part of the treatment plan, but
is not a primary goal.
During a discussion group on the
psychiatric unit, a female client
suddenly becomes upset and leaves the
group, yelling, "Everyone here hates
me!" What should the nurse do?
After group, approach the client to talk about her
feelings.

Describe the client's situation to the other group

members.

Require the client to return to group and discuss her

concerns.

Ask the group members to apologize for upsetting

the client.
It is most therapeutic to talk with this client privately about
her feelings, after discussion group. A suspicious client is
not likely to share her feelings in a group setting. Discussing
any client's situation with another client is a strict violation
of a client's privacy. The other clients have no reason to
apologize.
A patient diagnosed with bipolar
disorder is prescribed lithium carbonate
(Lithobid). When teaching the patient
about the medication, which of these
statements is a priority for the
healthcare provider include?
"Drink lots of fluids, especially if you are active
during hot weather."

"You should avoid consuming dairy products when

you are taking this medication."

"Call our office immediately if you experience any

unusual bruising or bleeding."

"You should follow this low calorie, low sodium diet

to prevent weight gain."

Lithium increases urine output and antagonizes the effects

of antidiuretic hormone. In order to avoid dehydration,
patients should be instructed to drink 10 - 12 glasses of
water each day. Additional fluids will be needed during
strenuous activity, in hot weather, or if the patient
experiences fluid loss through vomiting or diarrhea. If
sodium levels are low, the kidneys will retain lithium, which
could result in toxicity.
A parent brings a 3 year-old to the
Emergency Department for a dislocated
shoulder, The parent reports that the
child fell down the stairs. Which
behavior should cause suspicion that the
child was abused?
The child sobs constantly throughout the
examination.

The child does not cry when the shoulder is touched.

The child doesn’t make eye contact with the

healthcare provider.

The child pulls away from contact with the

healthcare providers.

A characteristic behavior of abused children is the lack of

crying when they undergo a painful procedure or are
examined by a health care professional. Child abuse is the
third leading cause of death in children between ages 1 and
4. The first three answers are typical behaviors for a 3 year-
old child.
When assessing a patient with severe
depression, which of the following
would the healthcare provider identify
as a cognitive alteration?
Powerlessness

Anxiety

Somatic Delusions

Low self-esteem

Patients diagnosed with depression may experience

cognitive, affective, behavioral, or physiological alterations.
A somatic delusion, the false belief that the patient has
some physical defect or disease (e.g. the patient might think
he/she has an internal parasite), is a cognitive alteration
associated with depression. The other choices are affective
alterations.
A 19-year old female presents to the
Emergency Department stating she was
raped at a college party. After providing
treatment and preserving evidence, what
is the nurse's first intervention?
Instructing the client on the need for medical follow-
up.

Notify the social services department to begin

counseling.
Obtain consent to contact others who can provide
safe shelter.

Begin anticipatory guidance for upcoming legal

investigations.

Following medical treatment and preservation of evidence,

the nurse should provide support and assist in finding a safe
shelter for the client. The other options are valid, and part of
the client's future actions, but not the immediate priority.
A newly-admitted patient's medication
orders include donepezil hydrochloride
(Aricept). The nurse knows this
medication is prescribed for
Alzheimer's disease

Major depression

Bipolar disorder

Schizophrenia

Donepezil hydrochloride is prescribed for mild to moderate

Alzheimer's disease. Cholinergic drugs, also called
parasympathomimetic drugs, work by increasing the
concentration of acetylcholine. Acetylcholine relays
messages between brain nerve cells. In Alzheimer's. there is
also destruction of nerve cells that use acetylcholine.
Decreased acetylcholine levels and progressive loss of
nerve cells are linked to worsening symptoms. The drug can
slow the progression of the disease, but not reverse it.
A patient diagnosed with obsessive-
compulsive disorder (OCD) continually
carries a toothbrush, and will brush and
floss up to fifty times each day. The
healthcare provider understands that
the patient's behavior is an attempt to
accomplish which of the following?
Promote oral health

Avoid social interaction

Experience pleasure

Relieve anxiety

OCD is an anxiety disorder identified by unwanted thoughts

that the patient attempts to control by repeating actions
that are excessive and interfere with the patient's normal
routine. The continual brushing and flossing are a result of
persistent thoughts that compel the patient to perform the
ritual in order to get temporary relief. The ritualistic
behavior (brushing and flossing the teeth) are compulsions
which are performed in an attempt to provide relief from
anxiety-provoking obsessions.
During a counseling session with a
patient diagnosed with depression, the
patient states, "I know my husband
doesn't love me anymore." Which
response by the healthcare provider
demonstrates therapeutic
communication?
"What happened to make you think your husband
doesn't love you anymore?"

"You really should try not to dwell on something that

probably isn't true."

"Let's talk about what you did to cause him to stop

loving you."

"Try not to think about it too much because it will

make your depression worse."

Initially, the healthcare provider will want to communicate

understanding of the situation. Therapeutic communication
in this situation would consist of asking a question to
explore the patient's perceptions and valuing the patient's
feelings.
A patient diagnosed with an anxiety
disorder is prescribed a benzodiazepine.
When teaching the patient about the
medication, which of the following
information would the healthcare
provider include?
"Call our office right away if you experience
increased restlessness or agitation."

"Decreasing your daily caffeine intake is not

necessary when taking this medication."

"It's important that you discontinue this medication

if you begin to feel drowsy."

"You should avoid taking aspirin while you are taking

this medication."

Benzodiazepines increase the effects of GABA. GABA

(gamma-aminobutyric acid) is the major inhibitory
neurotransmitter in the central nervous system. Decreased
anxiety and a feeling of drowsiness are expected effects of
benzodiazepines. Patients should be advised of a possible
paradoxical reaction of restlessness or agitation.
You are taking the history of a 14-year-
old girl who has a (BMI) of 18. The girl
reports inability to eat, induced
vomiting and severe constipation.
Which of the following would you most
likely suspect?
Bulimia nervosa
Multiple sclerosis

Systemic sclerosis

Anorexia nervosa

All of the clinical signs and symptoms point to a condition of

anorexia nervosa. The key feature of anorexia nervosa is
self-imposed starvation, resulting from a distorted body
image and an intense, irrational fear of gaining weight, even
when the patient is emaciated. Anorexia nervosa may
include refusal to eat accompanied by compulsive
exercising, self-induced vomiting, or laxative or diuretic
abuse. On the other hand, bulimia nervosa features binge
eating followed by a feeling of guilt, humiliation, and self-
deprecation. These feelings cause the patient to engage in
self-induced vomiting, use of laxatives or diuretics. Multiple
sclerosis (MS) is a demyelinating disease in which the
insulating covers of the nerve cells in the brain and spinal
cord are damaged. Systemic sclerosis or systemic
scleroderma is an autoimmune disease of the connective
tissue.
The pediatric nurse is caring for a 9-year
old girl with a known history of having
been abused. Which therapeutic action
should the nurse include in the child's
care plan?
Encourage the child to identify potential abusive
settings.
Instruct the child on typical characteristics of
abusers.

Ensure that the care setting allows the child to

redevelop trust.

Ask the child to call the nurse if the abuser visits the
unit.

An abused child will require long-term support and therapy,

starting with an environment of safety, security, and
empathy. The nurse can model appropriate behavior while
giving care.
Which of the following goals would the
healthcare provider identify as realistic
for a patient with a substance abuse
problem?
Explore genetic anomalies associated with
substance abuse

Use the substance only in moderation and in certain

situations

Focus on how cravings can be eliminated by

enhancing willpower

Identify situations that trigger a desire to use the

substance

Most patients with a substance abuse problem will not be

able to use the substance in moderation. The most realistic
goal for a patient with a substance abuse problem is to
avoid people, places, and events that can trigger substance
use. Continued substance abuse is associated with a lack of
effective coping skills rather than a lack of willpower.
When a client diagnosed with bipolar
disorder returns from a church service
and tells the nurse, "God has chosen me
for a special mission," the nurse
understands that the client is displaying
symptoms of
Impending suicide

Thought insertion

Ideas of reference

Hallucinations

An idea of reference is the client's belief that everything

that happens is somehow related to the client's destiny. In
this example, the client interprets that the church sermon,
along with all the songs and bulletins, are messages from
God, intended only for the client. Ideas of reference are
related to schizophrenia, delusional disorder, and the manic
state of bipolar disorder.
When administering medication to an
inpatient with paranoid schizophrenia,
which is the best method?
Leave the patient's door open

Wait until the patient seems calm

Show trust by closing the door

Two nurses should be present

When working in mental health settings, patient and staff

safety come first. The patient's door should remain open,
except for an invasive procedure, which requires a second
staff member as witness and chaperone. Medications are
given by schedule, not patient behavior. A nurse should
never look elsewhere or turn away from a patient, especially
if the patient has a diagnosis that includes possible angry or
violent behavior.
A 9-year old girl with a diagnosis of
attention deficit hyperactivity disorder
(ADHD) is starting on methylphenidate
(Ritalin). What will the pediatric nurse
assess during follow-up appointments?
Deep tendon reflexes

Vital sign trends

Acetone in urine
Height and weight

A possible adverse effect of stimulants such as Ritalin,

Adderall, and Concerta is slowing of growth. A 2013 study
found that by adulthood, most ADHD children who received
medication had achieved normal height. However, growth is
still monitored during medication therapy.
The healthcare provider is caring for a
patient who has undergone
electroconvulsive therapy (ECT). The
patient should be carefully assessed for
which of the following common adverse
effects of this treatment?
Aggression and violent behavior

Headache and memory loss

Dizziness and blurred vision

Palpitations and cardiac arrest

ECT is a procedure performed under general anesthesia in

which small electric currents are passed through the brain.
ECT induces a seizure, which can cause transient increases
in blood pressure, pulse, and intracranial pressure. The most
common adverse effects a patient may experience after ECT
include headache, confusion, and memory loss. It seems to
cause chemical changes in the brain that can reverse
symptoms in certain conditions, such as severe depression
or suicidal patients are unable to wait for medications to
take effect.
What behaviors can be expected with a
new patient who has been diagnosed
with disorganized schizophrenia?
Social withdrawal and nonsensical speech

Suspiciousness toward others and auditory

disturbances

Stupor or presence of waxy flexibility

No prominent symptoms or emotional expression

Disorganized schizophrenia is characterized by regressive

behavior with social withdrawal, odd mannerisms, and
nonsensical speech, including making up words. Absence of
prominent symptoms and little or no emotional expression
are characteristic of residual-type schizophrenia. Stupor (no
psychomotor activity) and presence of waxy flexibility
(maintaining a position until moved by another person) are
indicative of catatonic schizophrenia. Suspiciousness
toward others, auditory disturbances, and increased
hostility are characteristic of paranoid schizophrenia.
A patient presents to the clinic with a
report of fatigue and difficulty
concentrating. Which additional
statement made by the patient would
alert the healthcare provider to possible
marijuana use?
"I've noticed that my eyes are red lately."

"I keep having really vivid and scary nightmares."

"I feel anxious and have trouble sleeping."

"I'm nauseous and don't feel like eating."

Marijuana use can cause corneal vasodilation and

conjunctivitis. THC (tetrahydrocannabinol), the active
ingredient in marijuana, affects thinking, memory, appetite,
and coordination. It's more likely that marijuana would
increase appetite, decrease anxiety, and promote sleep.
Hallucinogens such as LSD (lysergic acid diethylamide) can
cause nightmares and flashbacks.
When caring for a patient during an
acute panic attack, which of the
following actions by the healthcare
provider is most appropriate?
Ask open-ended questions to encourage
communication

Offer the patient reassurance of safety and security

Use distraction techniques to change the patient's

focus
Explore common phobias associated with panic
attacks

During a panic attack, the patient is experiencing intense

apprehension and fear. There are often physical symptoms
such as chest pain, palpitations, and trembling. During the
panic attack, the patient's focus is on the distressing
physical symptoms caused by the anxiety. Distraction
techniques, open-ended questioning, or exploration of
phobias will not be helpful during an acute attack. Because
the patient may experience a feeling of impending doom and
fears for his or her life, reassurance of safety and security is
the best initial intervention for this patient.
On the fifth day postpartum, a woman
calls her healthcare provider and reports
pronounced fatigue, sadness and
tearfulness. She states, "I feel so
overwhelmed, I don't know what to do!"
Which of the following questions is most
appropriate for the healthcare provider
to ask?
"Is there a friend or relative that come and help you
care for your baby?"

"Do you blame yourself for not being able to cope

with motherhood?"
"Do you ever think about harming yourself or your
baby?"

"How much sleep do you get in a twenty-four hour

period?"

Feelings of fatigue, sadness, and tearfulness can be

common symptoms experienced in the postpartum period.
Both postpartum blues and postpartum depression share
similar symptoms, including sadness, crying spells, mood
swings, irritability, and insomnia. However, patients who are
diagnosed with postpartum depression may experience
more severe symptoms, including thoughts of harming
themselves or the infant.
A patient who overdosed on oxycodone
is given naloxone. When assessing the
patient, the healthcare provider would
anticipate which of these clinical
manifestations of opioid withdrawal?
Hyperthermia and euphoria

Irritability and nausea

Bradycardia and hypothermia

Depressed respirations and somnolence

Naloxone, an opioid antagonist, will displace opioids at the

opioid receptor site. The healthcare provider would expect
to observe irritability and nausea. Heart rate and blood
pressure will be baseline or elevated, and temperature will
be unchanged. Depressed respirations and somnolence are
signs of opioid intoxication.
Which of the following alterations in
sensory function is normal for an elderly
client?
Increased ability to taste spice

Decreased sensitivity to bright light

Increased sound discrimination

Decreased chronic pain perception

As people age, perception and reporting of chronic pain

decreases after the seventh decade. Studies show that
many elderly people feel pain is a natural part of aging, and
that they perceive pain less serious than other life events,
such as loss of a spouse or independence. Acute pain
remains consistent across all age groups.
A young man with newly-diagnosed
human immunodeficiency virus (HIV)
asks the nurse if he is ready for hospice
care. How should the nurse respond?
"Hospice care is only available for cancer patients
and their families."
"Every person with HIV can request hospice services
at any time. Are you ready?"

"You have about three years before you need to

worry about hospice care."

"Hospice care is intended for people who will die in a

few weeks or months."

Hospice care is a special service for clients and families

when life expectancy is just a few weeks or months.
According to HIV.gov, HIV+ people who do not receive
antiretroviral therapy (ART) can progress to AIDS in about
three years. With ART, clients with HIV can live for decades
without progressing to AIDS.
A patient diagnosed with Alzheimer
disease (AD) is demonstrating signs of
impaired reasoning. The healthcare
provider suspects an alteration in which
area of the brain?
Amygdala

Hippocampus

Frontal lobe

Occipital lobe

The frontal lobe controls responses from the rest of the

central nervous system. It is responsible for emotion,
behavior, intellect, and memory. Frontal lobe function will be
involved if the patient is demonstrating signs of impaired
reasoning. The occipital lobe regulates the comprehension
of visual images and written words. The hippocampus is the
center for learning and processing information into long-
term memory. There are two amygdalae in the brain, part of
the limbic system that controls emotions and the ability to
perceive emotions in others.
The healthcare provider is caring for a
patient diagnosed with a mild cognitive
impairment. Which of these would be
the most effective intervention for this
patient?
Frequent reorientation

Behavior modification

Relaxation therapy

Application of soft restraints

Frequent reorientation is the most effective intervention for

a patient diagnosed with mild cognitive impairment.
Behavior modification is an intervention aimed at changing
undesirable behaviors. Restraints can increase agitation and
should not be used unless absolutely necessary and only
when certain criteria are met.
When planning care for a patient
diagnosed with Alzheimer disease (AD),
which of these interventions is most
therapeutic?
Giving the patient several directions at a time to
improve memory

Encouraging both verbal and nonverbal

communication

Providing immediate feedback by correcting errors in

the patient's speech

Speaking in a loud, clear voice when talking to the

patient

As the ability to communicate verbally declines, nonverbal

communication may become more prominent. Encouraging
both can facilitate communication and decrease frustration.
Speaking clearly and calmly is effective, but increasing the
volume of the voice is not effective and can increase the
patient's anxiety. Giving several directions at a time is
useless and frustrating for the patient.
A patient is brought to the emergency
department by a family member. The
patient has been agitated for the past
several hours and has alternated
between grandiosity and expressing a
desire to commit suicide. Upon
examination, the patient is diaphoretic,
hypertensive, and tachycardic.
Intoxication with which of the following
substances would contribute to these
symptoms?
Marijuana

Methamphetamine

Benzodiazepine

Alcohol

Methamphetamine intoxication causes a surge of adrenergic

stimulation secondary to increased epinephrine and
norepinephrine. Methamphetamine use and overdose can be
life-threatening. Physical signs are hypertension,
tachycardia and arrhythmia, which can lead to circulatory
collapse. Hyperthermia and seizures may occur. Behavior
changes can include insomnia, anxiety, aggression,
hallucinations, mood disturbances, and paranoia. The
patient's presentation is related to decreased monoamine
degradation and an increased amount of monoamines in the
nervous system synapses.
A male patient informs his nurse that
the CIA is monitoring and recording
every movement, and that microphones
have been plated in walls of the unit.
Which response by the nurse is the most
therapeutic?
"Why don't you wait and bring this up at your next
therapy session?"

"I am going to put you in your room for awhile, so you

don't scare the others."

"There is no way this is true. Let's walk around the

unit and I will prove it to you."

"This must seem frightening to you, but I believe you

are safe here."

Delusions are common for patients with schizophrenia. The

patient absolutely believes the delusion is true, in spite of
any evidence otherwise. Acknowledge the patient's feelings
and offer support, but do not contradict; this could lead to
lack of trust by the patient. Waiting to talk about the beliefs
only reinforces the delusion. Isolation increases fear and
anxiety.
A 28-year old male is admitted with a
diagnosis of paranoid schizophrenia. His
care provider prescribes fluphenazine 10
mg TID. After 9 days, the client remains
unkempt and refuses to get out of bed.
The nurse knows that fluphenazine
needs to be constantly adjusted for maximum
benefit.

is most effective with the positive symptoms of

schizophrenia.

requires 2-3 weeks to attain a therapeutic drug level.

leads to agitation when given in large doses.

Fluphenazine is a phenothiazine used to treat schizophrenia.

It is most effective with positive symptoms, such as
hallucinations, delusions, and racing thoughts. This client is
displaying some negative symptoms. Other negative
symptoms include apathy, lack of emotion, and nonexistent
social functioning. The drug takes effect in 3-7 days when
administered for positive symptoms. Increasing the dosage
or continuing the drug for negative symptoms is not
effective. Depression is a common side effect.
A 22-year old mother from Mexico
arrives at the Emergency Department
with her 3-month old daughter, who has
a temperature of 100.6 degrees F (38.1
degrees C) and signs of sepsis. The ED
physician orders a lumbar puncture, but
the mother is hesitant to consent until
her husband arrives. What should the
ED nurse do?
Contact Dept. of Children's Services to report abuse.

Tell the ED physician that the mother refuses.

Continue to try and contact the father.

Ask the ED social worker to intervene.

In Mexican and other Hispanic cultures, the male is head of

the household and makes major decisions. The nurse should
continue to try to reach the baby's father. Symptoms of
sepsis in newborns and young babies include: poor feeding,
vomiting. fever (above 100.4°F [38°C] or higher rectally) or
sometimes low temperatures, pale skin, cool extremities,
and irritability.
A patient is admitted to the medical unit
after experiencing chest pain. Which of
these additional findings would support
a diagnosis of cocaine abuse?
Perforated nasal septum

Profuse diarrhea

Hypotension

Jaundice
Cocaine is a central nervous system stimulant, increasing
heart rate and blood pressure. Because of vasoconstriction,
long-term intranasal use of cocaine is associated with a
perforated nasal septum, as well as loss of smell. Reduced
blood flow can also lead to gangrenous bowels and chronic
diarrhea. Jaundice is related to impaired liver function; if
present, it is usually due to viral hepatitis or concurrent
alcohol use.
Which occupation is at least risk for
developing sensory alterations?
Waitress

Carpenter

Disc Jockey

Welder

A waitress is the least likely to develop a sensory alteration,

although there is a risk for musculoskeletal injury. Welders
risk visual alterations. A disc jokey can develop hearing
deficits. A carpenter can develop repetitive strain injuries
and peripheral neuropathy.
A patient diagnosed with general anxiety
disorder (GAD) reports ongoing nausea
and abdominal bloating. A physical
examination fails to confirm a medical
illness to explain these symptoms. The
healthcare provider suspects these
findings are a result of which of the
following?
Derealization

Dysthymia

Somatization

Dissociation

Somatization, or somatic symptom disorder (SSD) is a form

of mental illness that causes physical symptoms, including
pain. Somatization is a means of coping with psychosocial
distress by developing physical symptoms (soma =
body).The physical symptoms the patient is experiencing are
caused by anxiety. The symptoms may or may not be
explained by a known medical condition, but cause unusual
levels of distress for the patient. Dysthymia is a persistent
depressive disorder that may occur together with anxiety
and somatization. Derealization is a sense of detachment
from reality. Dissociation is impaired awareness of one's
body, self, or environment, and may include derealization.
After receiving shift report, the nurse
enters the room of a 92-year old male
diagnosed with a cognitive impairment
disorder. The reason the nurse asks him
what day it is and where he is now, is to
assess for
Level of consciousness

Orientation

Sensory impairment

Hallucinations

Orientation of time, place, and person is the most

appropriate way to do an initial assessment of a client with
a cognitive impairment disorder.
When interviewing the parents of an
injured 6 month-old baby, which of the
following is the strongest indicator that
child abuse may have occurred?
The family lives in one of the poorest neighborhoods.

The parents are argumentative and demanding with

the ED staff.

The mother and father tell different stories about

what happened.

The injury isn't consistent with the baby's age.

A child's injuries should be consistent with the

developmental age. If not, child abuse is a possibility. The
parents may tell different stories, because of their
perspectives. Child abuse occurs in every socioeconomic
group. Stress and anxiety can lead to demanding or angry
behavior.
The hospice nurse is caring for a client
with cancer. He has acute bone pain
related to metastases. The best way to
assess the client's level of pain is to
Ask the client to rate his pain on a scale from 1-10.

Evaluate verbal and non-verbal actions.

Check vital signs after giving pain medication.

Note observations about the client's behavior.

Only the client can report on his level of pain; it is a

subjective perception that should not be judged or
dismissed. Asking him to rate his pain on a scale of 1-10
should be the guide for managing his care and pain relief.
A patient is admitted to an inpatient
psychiatric unit because of a plan to
commit suicide by taking an overdose of
medication. When administering
medications to this patient, which of
these interventions is the priority?
Monitor the patient's vital signs before
administration of mediations

Teach the patient how to recognize adverse effects

of the medications

Monitor the patient for signs of anorexia, nausea,

and xerostomia

Ensure that the patient is not "cheeking" the

medications

A patient who has suicidal ideation, especially by

overdosing on medications, should be monitored for
"cheeking." Cheeking occurs when a patient hides the
medication in the mouth, and hoards it so it can be used for
another suicide attempt.
Emergency medical personnel bring an
unconscious patient to the emergency
department. The patient's pupils are
pinpoint and respirations are depressed.
Intoxication of which of the following
substances could contribute to these
clinical signs?
Methadone

Cocaine

Methamphetamine
Ecstasy

Actions of opioids include constriction of pupils (secondary

to parasympathetic stimulation) and depression of
respirations (secondary to decreased respiratory center
responsiveness to carbon dioxide). The other drugs are
stimulants, which cause pupil dilation, excitability,
increased heart rate and blood pressure.
The healthcare provider is counseling a
patient who is diagnosed with
depression. Which of the following
statements made by a patient should the
healthcare provider recognize as a sign
of transference?
"It's amazing how much you remind me of my
favorite teacher."

"I drink so I can deal with the difficult situation at

work."

"I may not be good looking, but I get really good

grades."

"I'm glad I lost my job because now I don't have to

commute."

Transference occurs when a patient directs feelings and

attributes from a person or situation in the past on to a
person or situation in the present. Transference is an
unconscious response that may create a therapeutic
impasse in the patient-healthcare provider relationship if not
handled by the counselor. The other responses are examples
of rationalization, which occurs when the patient attempts
to create an acceptable explanation for unacceptable
behavior.
A patient diagnosed with depression is
prescribed fluoxetine (Prozac). Which of
the following would the healthcare
provider most likely observe if the
patient experiences an adverse effect of
this medication?
Urinary Retention

Weight loss

Decreased libido

Bradycardia

Fluoxetine increases the synaptic concentration of

serotonin the central nervous system, but may have effects
on other nervous system functions. Although the mechanism
has not been completely elucidated, sexual dysfunction is
one of the most common adverse effects of SSRIs in both
men and women. Other side effects include insomnia, cold
symptoms (stuffy nose, sneezing, sore throat), and GI
symptoms (dry mouth, nausea, upset stomach,
constipation).
A patient with Alzheimer's disease picks
up her toothbrush and tries to brush her
hair. This behavior is known as
Agnosia

Apraxia

Anomia

Aphasia

Ideational apraxia is the inability to use objects

appropriately. Agnosia is loss of sensory comprehension,
anomia is the inability to find words, and aphasia is the
inability to speak or understand.
A female patient who is at high risk for
suicide requires close supervision. To
best ensure the patient’s safety, the
priority is to
Ignore any decreased communication or silence.

Remind the patient of her previous unsuccessful

suicide attempts.

Offer to let the patient speak in complete confidence

about her feelings.
Check the patient frequently, but at different
intervals.

By checking the patient frequently, but at different time

intervals, the patient is unable to change her behavior.
Reminding her about past suicide attempts may actually
motivate her to try again. Promising complete confidence is
never appropriate. Decreased communication or silence can
be a warning signal that the patient has decided to attempt
suicide.
A male patient with a diagnosis of panic
disorder suddenly begins to cry and
hyperventilate, while yelling, "This is
terrible! Nothing is right!" The first
therapeutic action is to
Invite the patient to share his feelings

Quickly give the patient diazepam (Valium)

Lead the patient through a breathing exercise

Firmly direct the patient to a new activity

A patient with a panic disorder can have sudden attacks of

fear and anxiety, which include physical symptoms:
tachycardia, sweating, and rapid breathing, Hyperventilation
can lead to respiratory alkalosis, which can increase
anxiety. Assist the patient to do deep breathing, which is
calming and restores normal respirations. Medication such
as diazepam or lorazepam are useful, but not the priority.
After the patient has improved, other interventions can be
appropriate.
When reviewing the medical record of a
patient diagnosed with Alzheimer
disease (AD), the healthcare provider
notes the patient is aphasic. Which
behavior supports this finding?
Unable to speak

Unable to recognize objects

Difficulty swallowing

Difficultly with motor function

Aphasia is the inability to understand and/or express

speech; it can also impact reading and writing. It's caused
by damage to the language center of the brain, usually on
the left side. Aphasia in AD is just one component of the
brain's deterioration.
A patient is abusive to others, insensitive
to their feelings, and shows no remorse.
The most likely personality disorder is
Narcissistic

Paranoid
Antisocial

Histrionic

When a patient has an antisocial personality disorder, there

is a lack of regard for rules, safety, and others. The patient
will lie and act impulsively. A narcissistic personality
disorder is demonstrated by airs of grandiosity and a
constant need for admiration from others. A patient with a
paranoid disorder show distrust and interprets others'
actions as threatening. A histrionic disorder includes
excessive displays of emotions and attention-seeking
behavior.
When a patient presents to the
Emergency Department with a toxic
acetaminophen (Tylenol) level, drug
should the nurse expect to administer?
Deferxamine mesylate (Desferal)

Succimer (Chemet)

Acetylcysteine (Mucomyst)

Flumazenil (Romazicon)

Acetylcysteine (Mucomyst) is given to convert toxic

metabolites to nontoxic. Deferoxamine mesylate is the
antidote for iron intoxication. Flumazenil (Romazicon) is the
antidote for the sedative effect of benzodiazepines.
Succimer (Chemet) is the antidote for lead poisoning.
A child who is newly diagnosed with
attention deficit disorder (ADHD) will
likely display which of the following?
Constant movement and squirming

Complaints of fatigue and somatic conditions

Ability to focus on subjects of interest

Attempting to run away

Constant movement and squirming are indications of ADHD.

Other signs include inability to pay attention to directions or
details; talking all the time, even when inappropriate; and
being easily distracted. Somatic complaints and running
away are indicative of emotional distress.