A client who has a major depressive episode tells the nurse that, for the past two weeks, he has been hearing voices and at times thinks that someone is following him. History reveals that he had these alternating symptoms before. He also has experienced time with neither of these symptoms and has been able to function adequately. The nurse interprets these findings as suggesting which of the following?
Echolalia
Schizoaffective disorder
body complaints
fever
A client with schizoaffective disorder is prescribed clozapine to treat her symptoms. Which of the following instructions would the nurse provide?
"Keep a record of how often and how long you experience the side effect of dry mouth."
"Monitor your urinary output and notify your doctor if your urine changes color."
"Keep an eye on your weight, and if you gain weight rapidly, notify your doctor."
"If you experience any drowsiness, discontinue taking this medication."
A family member of a client diagnosed with schizoaffective disorder asks a nurse what causes the disorder. Which response by the nurse would be most appropriate
“Dysfunctional family dynamics has been identified as a strong link.”
“Research has suggested that the cause is predominately genetic."
“Dopamine, a substance in the brain, appears to be underactive.”
“Studies have indicated that birth order is strongly associated with this disorder.”
A family member of an adolescent who has expressed a desire to commit suicide asks the nurse, "What might predict the possibility of future suicide attempts?" Which of the following would the nurse include in the response?
Death of a spouse
Previous suicide attempt
Polydrug use
Unemployment
A group of nursing students is reviewing information about open and closed groups. The students demonstrate understanding of the information when they identify which of the following as an example of an open group?
Outpatient smoking cessation group
Community clinic psychoeducation group
Ambulatory psychotherapy group
Inpatient anger management group
A group of nursing students is reviewing information about grief and bereavement. The students demonstrate understanding of the information when they identify which of the following?
Bereavement is influenced by culture, but grief is not.
Grief involves confronting the stress, but bereavement helps avoid the stresses.
Grief and bereavement are used interchangeably as responses to loss.
bereavement is the process of mourning and grief is the emotional reaction.
A group of nursing students is reviewing information about suicide and associated concepts. The group demonstrates understanding of the information when members identify which as the probability that a person will successfully complete suicide?
parasuicide
suicidal ideation
suicidality
lethality
A group of nursing students is reviewing information about the different types of group. The students demonstrate understanding of the information when they identify which of the following as a characteristic of a self-help group that differentiates it from a supportive therapy group?
The group is led by a professional.
The group is led by a consumer.
There is no identified leader.
The group is focused on a specific problem.
A group of nursing students is reviewing risk and protective factors associated with mental disorders in the older adult population. The students demonstrate understanding of the information when they identify which of the following as a protective factor?
education
poverty
loss
chronic illness
A group of nursing students is reviewing system models used in caring for families. The students demonstrate understanding of the information when they identify which of the following as characteristic of the Calgary Family Model?
Differentiation of self
Sibling position
Family development
Subsystems
A group of nursing students is reviewing information about the differences that occur with grieving in children, adolescents, and adults. The students demonstrate understanding of this information when they identify which of the following as characteristic of adolescents?
View death as reversible
Mourn by talking about the loss
Need repeated explanations to understand the loss
Express a time limit for socially acceptable grieving
A group of nursing students is reviewing the physical changes that occur in older adults. The students demonstrate understanding of the information when they identify which of the following as contributing the patient's risk for drug toxicity?
Reduced liver function
Reduce brain gray matter volume
Lower metabolic rate at rest
Decreased body water
A group of students are reviewing the events associated with the fight-or-flight response. They demonstrate understanding of the information when they identify which of the following results from sympathetic nervous stimulation?
Hypoglycemia
Tachycardia
Hypotension
Hypercoagulability
A home-health nurse is working with a poverty-stricken family that has two small children, ages 2 and 3 years. The family lives in an isolated rural area. The family's home has a dirt floor, and there are chickens living in the house with the family. Because of a recent wind storm, there is a sizeable hole in the roof that lets rain and snow into the house. Which nursing intervention would be the highest priority in this situation?
Make immunization appointments for the children in a nearby town's public health clinic.
Help the family find funding and manpower to patch and repair the roof of their home.
Determine the educational readiness of the two children.
Report the family for child abuse because of neglect.
A nurse has just completed a suicide risk assessment of a 76-year-old widowed man. In addition to documenting the presence or absence of suicidal thoughts, plan, and means, the nurse would also document which of the following?
Use of substances 6 hours before the assessment
Speech patterns
Availability of support resources
Amount of sleep in past 24 hours
A nurse is completing an admission assessment of a young adult woman who has a history of depression and who was brought to the hospital by her boyfriend. In response to the nurse's question regarding suicidal ideation, the patient discloses that the she is thinking about killing herself. Which question would be most appropriate for the nurse to ask next?
“What does your boyfriend think about your desire to kill yourself?”
“What are your spiritual beliefs about suicide?”
“What will killing yourself accomplish?”
“What thoughts have you had about how you would kill yourself?”
A nurse is constructing a genogram of a family. Which of the following would the nurse do?
Use circles to represent the male members.
Use horizontal lines to connect the parents with children.
Use horizontal lines to show marriages.
Use asterisks to denote ages listed at the bottom.
A nurse is part of team working with hurricane victims. One of the hurricane victims is staying in a temporary shelter provided by the Red Cross. To determine the extent to which this victim can cognitively cope with his situation and how much support he needs, which question would be most appropriate for the nurse to ask?
“What kind of help do you need from us?”
“What are your thoughts about what you will do during the next few days?”
“How are you feeling about all that you have gone through?”
“Are you feeling guilty because you survived and some of your neighbors did not?”
A son brings his father to the clinic and tells the nurse that his father has begun to act strangely in the past few days and has unprovoked outbursts of anger. After the incidents, the father expresses remorse for his outburst. The son says, “I've never seen him act this way.” Which question would be most appropriate for the nurse to ask next?
“Does your father have a history of an anxiety disorder such as panic disorder?”
Has your father exhibited previous problems expressing anger appropriately?”
“Has your father suffered any traumatic injury to his brain recently?”
“Has your father injured the back of his head or next in the past week?”
After teaching a class about factors that enhance the risk of suicide, the instructor determines the need for additional teaching when the class identifies which of the following?
Family member committing suicide
Cautiousness
delusion
After teaching a group of students about protective factors for mental illness, the instructor determines that the teaching was successful when the students identify which of the following?
social support
cost
A client with a panic disorder has been prescribed a benzodiazepine medication. Which of the following would the nurse emphasize as a risk associated with using this medication?
agitation
fecal impaction
withdrawal symptoms
dietary restrictions
The nurse determines that a patient is at imminent risk for suicide. Which of the following would be least appropriate to include in the patient's plan of care?
Listening intently and nonjudgmentally
Validating the patient's feelings and experience
Instituting strict restriction on the patient's activity
Using cognitive interventions to foster hope
A patient who has attempted suicide has an underlying diagnosis of depression. Which of the following would the nurse anticipate being ordered for the patient?
Selective serotonin reuptake inhibitor
Mood stabilizer
Tricyclic antidepressant
Atypical antipsychotic
After teaching a group of students about the various concepts involving suicide, the instructor determines that the teaching was successful when the students describe parasuicide as which of the following?
Voluntary act of killing oneself
All suicide related behaviors and suicidal thoughts
Nonfatal act with the intent to die
Voluntary attempt without death as the aim
The nurse has explained some of the biologic theories of causation to a client diagnosed with borderline personality disorder and his family. The nurse determines that the client and family have understood the instructions when they state which of the following?
“The disorder may be caused by increased serotonin activity.”
“The disorder is caused by decreased dopamine activity in my brain.”
'A frontal lobe dysfunction may be causing this condition.”
“A decrease in hormonal substances increases the risk for this illness.”
A group of nursing students is reviewing information about antisocial personality disorder. The students demonstrate understanding of this disorder when they state which of the following?
The disorder occurs more frequently in women.
The individual must be at least 18 years of age.
The disorder is found primarily in Asian individuals.
Alcohol abuse disorder rarely accompanies this disorder.
A client hospitalized for treatment of schizophrenia has been receiving olanzapine (Zyprexa) for the past 2 months. The nurse would be especially alert for which of the following?
Weight loss
Hypertension
Diarrhea
Diabetes
A client has been diagnosed with schizophrenia. Assessment reveals that the client lives alone. His clothing is disheveled, his hair is uncombed and matted, and his body has a strange odor. During an interview, the client's family voices a desire for the client to live with them when he is discharged. Based on the assessment findings, which nursing diagnosis would be the priority?
Ineffective Role Performance related to symptoms of schizophrenia.
Social Isolation related to auditory hallucinations.
Dysfunctional Family Processes related to psychosis.
Bathing Self-Care Deficit related to symptoms of schizophrenia.
“Keep a record of how often and how long you experience the side effect of dry mouth.”
“Monitor your urinary output and notify your doctor if your urine changes color.”
“Keep an eye on your weight, and if you gain weight rapidly, notify your doctor.”
“If you experience any drowsiness, discontinue taking this medication.”
A group of nursing students is reviewing the various theories related to the etiology of schizophrenia. The students demonstrate understanding of the information when they identify which neurotransmitter as being responsible for hallucinations and delusions?
Dopamine
Serotonin
Norepinephrine
Gamma-amino butyric acid (GABA)
A hospitalized client with schizophrenia is receiving antipsychotic medications. While assessing the client, the nurse identifies signs and symptoms of a dystonic reaction. Which agent would the nurse expect to administer?
Diphenhydramine (Benadryl)
Propranolol (Inderal)
Risperidone (Risperdal)
Aripiprazole (Abilify)
A nurse is providing care to a client just recently diagnosed with schizophrenia during an inpatient hospital stay. Throughout the day, the nurse observes the client drinking from the water fountain quite frequently as well as carrying cans of soda and bottles of water with him wherever he goes. Upon entering the client's room, the nurse sees numerous empty cups that had been filled with fluids on his table and in the trash can. The room has an odor of urine. The nurse suspects which of the following?
Diabetes mellitus
Disordered water balance
Tardive dyskinesia
Orthostatic hypotension
The nurse is caring for a client with major depression. The client tells the nurse that she “just isn't sure that life is worth living.” The nurse documents which nursing diagnosis as the priority?
Self-esteem, Low, related to depressive episode
Hopelessness related to symptoms of depression
Anxiety related to lack of energy for self-care activities
Thought Processes, Disturbed, related to memory loss and depression
A family has recently lost all their belongings when their house burned down. They have been living in temporary housing. Although the parents were previously very supportive and able to help their young children with their homework in the evenings, they have been unable to do so under their present circumstances. Based on this information, which nursing diagnosis would be most appropriate for this family?
Interrupted Family Processes
Compromised Family Coping
Ineffective Family Therapeutic Regimen Management
Caregiver Role Strain
A female patient is an adolescent who recently tried to overdose because her boyfriend broke up with her. Her father is a single parent, and he has been drinking excessively to cope with his stress. The patient tells the nurse that whenever she needs to talk to her father, he is always drunk or away drinking with his drinking buddies. Based on this information, which nursing diagnosis would be most appropriate for this patient's family?
Ineffective Denial
A female patient, who is in her late 30s, is describing her home life to the nurse. The nurse determines that the patient is a member of the sandwich generation based on which of the following?
She has a young adult child at home and an elderly parent to care for at the same time.
She has a young adult child who is married and currently living away from home.
She has a young adult child away at college and without any living parents.
She has no responsibilities associated with her young adult children or her parents.
A group of nursing students is reviewing information about the types of crisis. The students demonstrate understanding of the information when they identify which of the following as a developmental crisis?
Going away to college
Obtaining a job promotion
Loss of a pet
earthquake
