NCLEX Psychiatric Nursing questions & answers part 2

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NCLEX Psychiatric Nursing questions & answers part 2

101. A nurse says to a client, “Things will look better tomorrow after a good night’s sleep.” This is an example of which communication technique?

1. The therapeutic technique of giving advice

2. The therapeutic technique of defending

3. The nontherapeutic technique of presenting reality

4. The nontherapeutic technique of giving reassurance

ANS: 4

Rationale: The nurse’s statement, “Things will look better tomorrow after a good night’s sleep,” is an example of the nontherapeutic communication technique of giving reassurance. Giving reassurance indicates to the client that there is no cause for anxiety, thereby devaluing the client’s feelings.

102. A client diagnosed with post-traumatic stress disorder related to a rape is admitted to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic communication technique might a nurse use that is an example of “broad openings”?

1. “What occurred prior to the rape, and when did you go to the emergency department?”

2. “What would you like to talk about?”

3. “I notice you seem uncomfortable discussing this.”

4. “How can we help you feel safe during your stay here?”

ANS: 2

Rationale: The nurse’s statement, “What would you like to talk about?” is an example of the therapeutic communication technique of a broad opening. Using broad openings allows the client to take the initiative in introducing the topic and emphasizes the importance of the client’s role in the interaction.

103. A nurse maintains an uncrossed arm and leg posture when communicating with a client. This nonverbal behavior is reflective of which letter of the SOLER acronym for active listening?

1. S

2. O

3. L

4. E

5. R

ANS: 2

Rationale: The nurse should identify that maintaining an uncrossed arm and leg posture is nonverbal behavior that reflects the O in the active-listening acronym SOLER. The acronym SOLER includes sitting squarely facing the client (S), observing and open posture (O), leaning forward toward the client (L), establishing eye contact (E), and relaxing (R).

104. An instructor is correcting a nursing student’s clinical worksheet. Which instructor statement is the best example of effective feedback?

1. “Why did you use the client’s name on your clinical worksheet?”

2. “You were very careless to refer to your client by name on your clinical worksheet.”

3. “Surely you didn’t do this deliberately, but you breeched confidentiality by using names.”

4. “It is disappointing that after being told you’re still using client names on your worksheet.”

ANS: 3

Rationale: The instructor’s statement, “Surely you didn’t do this deliberately, but you breeched confidentiality by using names,” is an example of effective feedback. Feedback is method of communication for helping others consider a modification of behavior. Feedback should be descriptive, specific, and directed toward a behavior that the person has the capacity to modify and should impart information rather than offer advice.

105. What is a nurse’s purpose for providing appropriate feedback?

1. To give the client good advice

2. To advise the client on appropriate behaviors

3. To evaluate the client’s behavior

4. To give the client critical information

ANS: 4

Rationale: The purpose of providing appropriate feedback is to give the client critical information. Feedback should not be used to give advice or evaluate behaviors.

106. A client exhibiting dependent behaviors says, “Do you think I should move from my parent’s house and get a job?” Which nursing response is most appropriate?

1. “It would be best to do that in order to increase independence.”

2. “Why would you want to leave a secure home?”

3. “Let’s discuss and explore all of your options.”

4. “I’m afraid you would feel very guilty leaving your parents.”

ANS: 3

Rationale: The most appropriate response by the nurse is, “Let’s discuss and explore all of your options.” In this example, the nurse is encouraging the client to formulate ideas and decide independently the appropriate course of action.

107. A mother rescues two of her four children from a house fire. In an emergency department, she cries, “I should have gone back in to get them. I should have died, not them.” What is the nurse’s best response?

1. “The smoke was too thick. You couldn’t have gone back in.”

2. “You’re experiencing feelings of guilt, because you weren’t able to save your children.”

3. “Focus on the fact that you could have lost all four of your children.”

4. “It’s best if you try not to think about what happened. Try to move on.”

ANS: 2

Rationale: The best response by the nurse is, “You’re experiencing feelings of guilt, because you weren’t able to save your children.” This response uses the therapeutic communication technique of restating what the client has said. This lets the client know whether an expressed statement has been understood or if clarification is necessary.

108. A newly admitted client, diagnosed with obsessive-compulsive disorder (OCD), washes his hands continually. This behavior prevents unit activity attendance. Which nursing statement best addresses this situation?

1. “Everyone diagnosed with OCD needs to control their ritualistic behaviors.”

2. “It is important for you to discontinue these ritualistic behaviors.”

3. “Why are you asking for help, if you won’t participate in unit therapy?”

4. “Let’s figure out a way for you to attend unit activities and still wash your hands.”

ANS: 4

Rationale: The most appropriate statement by the nurse is, “Let’s figure out a way for you to attend unit activities and still wash your hands.” This statement reflects the therapeutic communication technique of formulating a plan of action. The nurse attempts to work with the client to develop a plan without damaging the therapeutic relationship.

109. Which of the following characteristics should be included in a therapeutic nurse-client relationship? (Select all that apply.)

1. Meeting the psychological needs of the nurse and the client

2. Ensuring therapeutic termination

3. Promoting client insight into problematic behavior

4. Collaborating to set appropriate goals

5. Meeting both the physical and psychological needs of the client

ANS: 2, 3, 4, 5

Rationale: The nurse-client therapeutic relationship should include promoting client insight into problematic behavior, collaboration to set appropriate goals, meeting the physical and psychological needs of the client, and ensuring therapeutic termination. Meeting the nurse’s psychological needs should never be addressed within the nurse-client relationship.

110. Which of the following individuals are communicating a message? (Select all that apply.)

1. A mother spanking her son for playing with matches

2. A teenage boy isolating himself and playing loud music

3. A biker sporting an eagle tattoo on his biceps

4. A teenage girl writing, “No one understands me”

5. A father checking for new e-mail on a regular basis

ANS: 1, 2, 3, 4

Rationale: The nurse should determine that spanking, isolating, getting tattoos, and writing are all ways in which people communicate messages to others. It is estimated that about 70% to80% of communication is nonverbal.

111. Which statement is most accurate regarding the assessment of clients diagnosed with psychiatric problems?

1. Medical history is of little significance and can be eliminated from the nursing assessment.

2. Assessment provides a holistic view of the client, including biopsychosocial aspects.

3. Comprehensive assessments can be performed only by advanced practice nurses.

4. Psychosocial evaluations are gained by subjective reports rather than objective observations.

ANS: 2

Rationale: The assessment of clients diagnosed with psychiatric problems should provide a holistic view of the client. A thorough assessment involves collecting and analyzing data from the client, significant others, and health-care providers, which may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, functional abilities, developmental, economic, and lifestyle.

112. Which statement regarding nursing interventions should a nurse identify as accurate?

1. Nursing interventions are independent from the treatment team’s goals.

2. Nursing interventions are solely directed by written physician orders.

3. Nursing interventions occur independently but in concert with overall treatment team goals.

4. Nursing interventions are standardized by policies and procedures.

ANS: 3

Rationale: The nurse should understand that nursing interventions occur independently but in concert with overall treatment goals. Nursing interventions should be developed and implemented in collaboration with other health-care professionals involved in the client’s care.

113. Within the nurse’s scope of practice, which function is exclusive to the advanced practice psychiatric nurse?

1. Teaching about the side effects of neuroleptic medications

2. Using psychotherapy to improve mental health status

3. Using milieu therapy to structure a therapeutic environment

4. Providing case management to coordinate continuity of health services

ANS: 2

Rationale: The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health. This includes individual, couples, group, and family psychotherapy. Education, case management, and milieu therapy can be provided by registered psychiatric mental health nurses.

Cognitive Level: Application

114. The nurse should recognize which acronym as representing problem-oriented charting?

1. SOAPIE

2. APIE

3. DAR

4. PQRST

ANS: 1

Rationale: The acronym SOAPIE represents problem-oriented charting, which reflects the subjective, objective, assessment, plan, implementation, and evaluation format. Used in nursing, nursing diagnoses (problems) are identified on a written plan of care, with appropriate nursing interventions described for each.

115. Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and immediately following electroconvulsive therapy (ECT)?

1. CIWA scale

2. GGT

3. MMSE

4. CAPS scale

ANS: 3

Rationale: The MMSE, or mini mental status exam, would be the appropriate tool to use to assess the mental acuity of a client prior to and immediately following ECT. The CIWA scale, or clinical institute withdrawal assessment scale, would be used to assess withdraw from substances such as alcohol. The CAPS refers to the clinician-administered PTSD scale and would be used to assess signs and symptoms of PTSD. The GGT test is a blood test used to assess gamma-glutamyl transferase levels, which may be an indication of alcoholism.

116. What is being assessed when a nurse asks a client to identify name, date, residential address, and situation?

1. Mood

2. Perception

3. Orientation

4. Affect

ANS: 3

Rationale: The nurse should ask the client to identify name, date, residential address, and situation to assess the client’s orientation. Assessment of the client’s orientation to reality is part of a mental status evaluation.

117. What is the purpose of a nurse gathering client information?

1. It enables the nurse to modify behaviors related to personality disorders.

2. It enables the nurse to make sound clinical judgments and plan appropriate care.

3. It enables the nurse to prescribe the appropriate medications.

4. It enables the nurse to assign the appropriate Axis I diagnosis.

ANS: 2

Rationale: The purpose of gathering client information is to enable the nurse to make sound clinical judgments and plan appropriate care. The nurse should complete a thorough assessment of the client, including information collected from the client, significant others, and health-care providers.

118. A nurse on an inpatient psychiatric unit implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. These actions reflect which role of the nurse?

1. Health teacher

2. Case manager

3. Milieu manager

4. Psychotherapist

ANS: 3

Rationale: The milieu manager implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. Health teaching involves promoting health in a safe environment. Case management is used to organize client care so that outcomes are achieved. Psychotherapy involves conducting individual, couples, group, and family counseling.

119. The following outcome was developed for a client: “Client will list five personal strengths by the end of day one.” Which correctly written nursing diagnostic statement most likely generated the development of this outcome?

1. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements

2. Self-care deficit R/T altered thought process

3. Disturbed body image R/T major depressive disorder AEB mood rating of 2/10

4. Risk for disturbed self-concept R/T hopelessness AEB suicide attempt

ANS: 1

Rationale: The nurse should determine that altered self-esteem and self-deprecating statements would generate the outcome to list personal strengths by the end of day one. Self-care deficit, disturbed body image, and risk for disturbed self-concept would generate specific outcomes in accordance with specific needs and goals. The self-care deficit and risk for disturbed self-concept nursing diagnoses are incorrectly written.

120. How should a nurse prioritize nursing diagnoses?

1. By the established goal of care

2. By the life-threatening potential

3. By the physician’s priority of care

4. By the client’s preference

ANS: 2

Rationale: The nurse should prioritize nursing diagnoses related to their life-threatening potential. Safety is always the nurse’s first priority.

121. A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB MNA, DFA, and daytime napping. Which is a correctly written and appropriate outcome for this client?

1. The client will avoid daytime napping and attend all groups.

2. The client will exercise, as needed, before bedtime.

3. The client will sleep seven uninterrupted hours by day four of hospitalization.

4. The client’s sleep habits will improve during hospitalization.

ANS: 3

Rationale: The outcome “The client will sleep seven uninterrupted hours by day four of hospitalization” is accurately written and an appropriate outcome for a client diagnosed with insomnia. Nursing outcomes should be derived from the diagnosis, measurable, and include a time estimate for attainment. The outcome must also be realistic for the client’s capabilities.

122. The following NANDA-I nursing diagnostic stem was developed for a client on an inpatient unit: Risk for injury. What assessment data most likely led to the development of this problem statement?

1. The client is receiving ECT and is diagnosed with Parkinsonism.

2. The client has a history of four suicide attempts in adolescence.

3. The client expresses hopelessness and helplessness and isolates self.

4. The client has disorganized thought processes and delusional thinking.

ANS: 1

Rationale: The nurse should identify that a client receiving ECT and who is diagnosed with Parkinsonism is at risk for injury. History of suicide, hopelessness, and disorganized thoughts would not lead the nurse to formulate a nursing diagnostic stem of Risk for injury.

123. A student nurse asks an instructor how best to develop nursing outcomes for clients. Which response by the instructor most accurately answers the student’s question?

1. “You can use NIC, a standardized reference for nursing outcomes.”

2. “Look at your client’s problems and set a realistic, achievable goal.”

3. “With client collaboration, outcomes should be based on client problems.”

4. “Copy your standard outcomes from a nursing care plan textbook.”

ANS: 3

Rationale: Client outcomes are most realistic and achievable when there is collaboration among the interdisciplinary team members, the client, and significant others.

124. A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client is hearing things that others do not. Which nursing diagnosis, which was recently removed from the NANDA-I list, still accurately reflects this client’s problem?

1. Disturbed thought processes

2. Disturbed sensory perception

3. Anxiety

4. Chronic confusion

ANS: 2

Rationale: The nursing diagnosis disturbed sensory perception accurately reflects the client’s symptoms of hearing things that others do not. The nursing diagnosis describes the client’s condition and facilitates the prescription of interventions.

125. Which of the following nursing interventions fall within the standards of psychiatric–mental health clinical nursing practice for a nurse generalist? (Select all that apply.)

1. Assist the client to perform activities of daily living.

2. Consult with other clinicians to provide services for clients and effect system change.

3. Encourage the client to discuss triggers for relapse.

4. Use prescriptive authority in accordance with state and federal laws.

5. Educate the family about signs and symptoms of alcohol dependence and withdrawal.

ANS: 1, 3, 5

Rationale: Assisting the client to perform daily living activities, encouraging the client to discuss triggers, and educating the family are nursing interventions that fall within the standards of psychiatric clinical nursing practice for a nurse generalist. Psychiatric–mental health advanced practice registered nurses can consult with other clinicians and use prescriptive authority.

126. Which of the following characteristics of accurately developed client outcomes should a nurse identify? (Select all that apply.)

1. Client outcomes are specifically formulated by nurses.

2. Client outcomes are not restricted by time frames.

3. Client outcomes are specific and measurable.

4. Client outcomes are realistically based on client capability.

5. Client outcomes are formally approved by the psychiatrist.

ANS: 3, 4

Rationale: The nurse should identify that client outcomes should be specific, measurable, and realistically based on client capability. Outcomes should be derived from the diagnosis and should include a time estimate for attainment. Outcomes are most effective when formulated cooperatively by the interdisciplinary team members, the client, and significant others.

127. An angry client on an inpatient unit approaches a nurse stating, “Someone took my lunch! People need to respect others, and you need to do something about this now!” The nurse’s response should be guided by which basic assumption of milieu therapy?

1. Conflict should be avoided at all costs on inpatient psychiatric units.

2. Conflict should be resolved by the nursing staff.

3. On inpatient units, every interaction is an opportunity for therapeutic intervention.

4. Conflict resolution should only be addressed during group therapy.

ANS: 3

Rationale: The nurse’s response should be guided by the basic assumption that every interaction is an opportunity for therapeutic intervention. The nurse can use milieu therapy to effect behavioral change and improve psychological health and functioning.

128. A client on an inpatient unit angrily says to a nurse, “Peter is not cleaning up after himself in the community bathroom. You need to address this problem.” Which is the appropriate nursing response?

1. “I’ll talk to Peter and present your concerns.”

2. “Why are you overreacting to this issue?”

3. “You should bring this to the attention of your treatment team.”

4. “I can see that you are angry. Let’s discuss ways to approach Peter with your concerns.”

ANS: 4

Rationale: The most appropriate nursing response involves restating the client’s feeling and developing a plan with the client to solve the problem. According to Skinner, every interaction is an opportunity for therapeutic intervention to improve communication and relationship-development skills.

129. A newly admitted client asks, “Why do we need a unit schedule? I’m not going to these groups. I’m here to get some rest.” Which is the most appropriate nursing response?

1. “The purpose of group therapy is to learn and practice new coping skills.”

2. “Group therapy is mandatory. All clients must attend.”

3. “Group therapy is optional. You can go if you find the topic helpful and interesting.”

4. “Group therapy is an economical way of providing therapy to many clients concurrently.”

ANS: 1

Rationale: The nurse should explain to the client that the purpose of group therapy is to learn and practice new coping skills. The client owns his or her environment and can make decisions to attend group or not.

130. A client diagnosed with schizophrenia functions well and is bright, spontaneous, and interactive during hospitalization but then decompensates after discharge. What does the milieu provide that may be missing in the home environment?

1. Peer pressure

2. Structured programming

3. Visitor restrictions

4. Mandated activities

ANS: 2

Rationale: The milieu, or therapeutic community, provides the client with structured programming that may be missing in the home environment. The therapeutic community provides a structured schedule of activities in which interpersonal interaction and communication with others are emphasized. Time is also devoted to personal problems and focus groups.

131. To promote self-reliance, how should a psychiatric nurse best conduct medication administration?

1. Encourage clients to request their medications at the appropriate times.

2. Refuse to administer medications unless clients request them at the appropriate times.

3. Allow the clients to determine appropriate medication times.

4. Take medications to the clients’ bedside at the appropriate times.

ANS: 1

Rationale: The psychiatric nurse promoting self-reliance would encourage clients to request their medications at the appropriate times. Nurses are responsible for the management of medication administration on inpatient psychiatric units, but nurses must work with clients to encourage self-reliance and responsibility, which may result in independent decision-making, leading to medication adherence.

132. A nurse working on an inpatient psychiatric unit is assigned to conduct a 45-minute education group. What should the nurse identify as an appropriate group topic?

1. Dream analysis

2. Creative cooking

3. Paint by number

4. Stress management

ANS: 4

Rationale: The nurse should identify that teaching clients about stress management is an appropriate education group topic. Nurses should be able to perform the role of client teacher in the psychiatric area. Nurses need to be able to assess a client’s learning readiness. Other topics for education groups include medical diagnoses, side effects of medications, and the importance of medication adherence.

133. What is the best rationale for including family in the client’s therapy within the inpatient milieu?

1. To structure a program of social and work-related activities

2. To facilitate discharge from hospitalization

3. To provide a concrete demonstration of caring

4. To encourage the family to model positive behaviors

ANS: 2

Rationale: The nurse should include the client’s family in therapy within the inpatient milieu to facilitate discharge from the hospital. Family members are invited to participate in some therapy groups and to share meals with the client in the communal dining room. Family involvement may also serve to prevent the client from becoming too dependent on the therapeutic environment.

134. How does a democratic form of self-government in the milieu contribute to client therapy?

1. By setting punishments for clients who violate the community rules

2. By dealing with inappropriate behaviors as they occur

3. By setting expectations wherein all clients are treated on an equal basis

4. By interacting with professional staff members to learn about therapeutic interventions

ANS: 3

Rationale: A democratic form of self-government in the milieu contributes to client therapy by setting the expectation that all clients should be treated on an equal basis. Clients participate in the decision-making and problem-solving aspects that affect treatment setting. The norms, rules, and behavioral limits are established by the staff and clients. All individuals have input.

135. A client is to undergo psychological testing. Which member of the interdisciplinary team should a nurse consult for this purpose?

1. The psychiatrist

2. The psychiatric social worker

3. The clinical psychologist

4. The clinical nurse specialist

ANS: 3

Rationale: The nurse should consult with the clinical psychologist to obtain psychological testing for the client. Clinical psychologists can administer, interpret, and evaluate psychological tests to assist in the diagnostic process.

136. In the role of milieu manager, which activity should the nurse prioritize?

1. Setting the schedule for the daily unit activities

2. Evaluating clients for medication effectiveness

3. Conducting therapeutic group sessions

4. Searching newly admitted clients for hazardous objects

ANS: 4

Rationale: The milieu manager should search newly admitted clients for hazardous objects. Safety of the client and others always takes priority. Nurses are responsible for ensuring that the client’s safety and physiological needs are met.

137. A nurse attends an interdisciplinary team meeting regarding a newly admitted client. Which of the following individuals are typically included as members of the interdisciplinary treatment team in psychiatry? (Select all that apply.)

1. Respiratory therapist and psychiatrist

2. Occupational therapist and psychologist

3. Recreational therapist and art therapist.

4. Social worker and hospital volunteer

5. Mental health technician and chaplain

ANS: 2, 3, 5

Rationale: The interdisciplinary treatment team in psychiatry consists of a psychologist, occupational therapist, recreational therapist, art therapist, mental health technician, and chaplain. In addition, a psychiatrist, psychiatric nurse, psychiatric social worker, music therapist, psychodramatist, and dietitian also participate in the interdisciplinary treatment team. Respiratory therapists and hospital volunteers are not included in the interdisciplinary treatment team in psychiatry.

138. Which of the following conditions promote a therapeutic community? (Select all that apply.)

1. The unit schedule includes unlimited free time for personal reflection.

2. Unit responsibilities are assigned according to client capabilities.

3. A flexible schedule is determined by client needs.

4. The individual is the sole focus of therapy.

5. A democratic form of government exists.

ANS: 2, 5

Rationale: A therapeutic community is promoted when unit responsibilities are assigned according to client capability and a democratic form of government exists. Therapeutic communities are structured and provide therapeutic interventions that focus on communication and relationship-development skills.

139. During a therapeutic group, which nursing action demonstrates a laissez-faire leadership style?

1. The nurse mandates that all group members reveal an embarrassing personal situation.

2. The nurse asks for a show of hands to determine group topic preference.

3. The nurse sits silently as the group members stray from the assigned topic.

4. The nurse shuffles through papers to determine the facility policy on length of group.

ANS: 3

Rationale: The nurse leader who sits silently and allows group members to stray from the assigned topic is demonstrating a laissez-faire leadership style. This style allows group members to do as they please with no direction from the leader. Group members often become frustrated and confused in reaction to a laissez-faire leadership style.

140. During a community meeting, a nurse encourages clients to present unit problems and discuss possible solutions. Which type of leadership style is the nurse demonstrating?

1. Democratic

2. Autocratic

3. Laissez-faire

4. Bureaucratic

ANS: 1

Rationale: The nurse who encourages clients to present problems and discuss solutions is demonstrating a democratic leadership style. Democratic leaders share information with group members and promote decision-making by the members of the group. The leader provides guidance and expertise as needed.

141. Which situation should a nurse identify as an example of an autocratic leadership style?

1. The president of Sigma Theta Tau assigns members to committees to research problems.

2. Without faculty input, the dean mandates that all course content be delivered via the Internet.

3. During a community meeting, a nurse listens as clients generate solutions.

4. The student nurses’ association advertises for candidates for president.

ANS: 2

Rationale: The nurse should identify that mandating decisions without consulting the group is considered an autocratic leadership style. Autocratic leadership increases productivity but often reduces morale and motivation owing to lack of member input and creativity.

142. A single, pregnant teenager in a parenting class discloses her ambivalence toward the pregnancy and the subsequent guilt that these thoughts generate. A mother of three admits to having felt that way herself. Which of Yalom’s curative group factors does this illustrate?

1. Imparting of information

2. Instillation of hope

3. Altruism

4. Universality

ANS: 4

Rationale: The scenario is an example of the curative group factor of universality. Universality occurs when individuals realize that they are not alone in the problems, thoughts, and feelings they are experiencing. This realization reduces anxiety by the support and understanding of others.

143. A client diagnosed with alcohol use disorder experiences a first relapse. During an AA meeting, another group member states, “I relapsed three times, but now have been sober for 15 years.” Which of Yalom’s curative group factors does this illustrate?

1. Imparting of information

2. Instillation of hope

3. Catharsis

4. Universality

ANS: 2

Rationale: This scenario is an example of the curative group factor instillation of hope. This occurs when members observe the progress of others in the group with similar problems and begin to believe that personal problems can also be resolved.

144. During a group discussion, members freely interact with each other. Which member statement is an example of Yalom’s curative group factor of imparting information?

1. “I found a Web site explaining the different types of brain tumors and their treatment.”

2. “My brother also had a brain tumor and now is completely cured.”

3. “I understand your fear and will be by your side during this time.”

4. “My mother was also diagnosed with cancer of the brain.”

ANS: 1

Rationale: Yalom’s curative group factor of imparting information involves group members sharing knowledge gained through formal instruction as well as advice and suggestions.

145. Prayer group members at a local Baptist church are meeting with a poor, homeless family whom they are supporting. Which member statement is an example of Yalom’s curative group factor of altruism?

1. “I’ll give you the name of a friend that rents inexpensive rooms.”

2. “The last time we helped a family, they got back on their feet and prospered.”

3. “I can give you all of my baby clothes for your little one.”

4. “I can appreciate your situation. I had to declare bankruptcy last year.”

ANS: 3

Rationale: Yalom’s curative group factor of altruism occurs when group members provide assistance and support to each other that creates a positive self-image and promotes self-growth. Individuals gain self-esteem through mutual caring and concern.

146. During an inpatient educational group, a client shouts out, “This information is worthless. Nothing you have said can help me.” These statements indicate to a nurse leader that the client is assuming which group role?

1. The group role of aggressor

2. The group role of initiator

3. The group role of gatekeeper

4. The group role of blocker

ANS: 1

Rationale: The nurse should identify that the client is assuming the group role of the aggressor. The aggressor expresses negativism and hostility toward others in the group or to the group leader and may use sarcasm in an effort to degrade the status of others.

147. During a group session, which client statement demonstrates that the group has progressed to the middle, or working, phase of group development?

1. “It’s hard for me to tell my story when I’m not sure about the reactions of others.”

2. “I think Joe’s Antabuse suggestion is a good one and might work for me.”

3. “My situation is very complex, and I need professional, not peer, advice.”

4. “I am really upset that you expect me to solve my own problems.”

ANS: 2

Rationale: The nurse should recognize that group members have progressed to the working phase of group development when members begin to look to each other instead of to the leader for guidance. Group members in the working phase begin to accept criticism from each other and use it constructively to create change.

148. Which group leader activity should a nurse identify as being most effective in the final, or termination, phase of group development?

1. The group leader establishes the rules that will govern the group after discharge.

2. The group leader encourages members to rely on each other for problem solving.

3. The group leader presents and discusses the concept of group termination.

4. The group leader helps the members to process feelings of loss.

ANS: 4

Rationale: The most effective intervention in the final, or termination, phase of group development would be for the group leader to help the members to process feelings of loss. The leader should encourage the members to review the goals and discuss outcomes, reminisce about what has occurred, and encourage members to provide feedback to each other about progress.

149. A nursing instructor is teaching students about self-help groups like Alcoholics Anonymous (AA). Which student statement indicates that learning has occurred?

1. “There is little research to support AA’s effectiveness.”

2. “Self-help groups used to be the treatment of choice, but their popularity is waning.”

3. “These groups have no external regulation, so clients need to be cautious.”

4. “Members themselves run the group, with leadership usually rotating among the members.”

ANS: 4

Rationale: The student indicates an understanding of self-help groups when stating, “Members themselves run the group, with leadership usually rotating among the members.” Nurses may or may not be involved in self-help groups. These groups allow members to talk about feelings and reduce feelings of isolation, while receiving support from others undergoing similar experiences.

150. When planning group therapy, a nurse should identify which configuration as most optimal for a therapeutic group?

1. Open-ended membership; circle of chairs; group size of 5 to 10 members

2. Open-ended membership; chairs around a table; group size of 10 to 15 members

3. Closed membership; circle of chairs; group size of 5 to 10 members

4. Closed membership; chairs around a table; group size of 10 to 15 members

ANS: 3

Rationale: The nurse should identify that the most optimal conditions for a therapeutic group is one in which the membership is closed and in which the group size is between 5 and 10 members, who are arranged in a circle of chairs. The focus of therapeutic groups is directed to relations within the group and the interactions among group members.

151. During the sixth week of a 10-week parenting skills group, a nurse observes as several members get into a heated dispute about spanking. As a group, they decide to create a pros-and-cons poster on the use of physical discipline. At this time, what is the role of the group leader?

1. The leader should referee the debate.

2. The leader should adamantly oppose physical disciplining measures.

3. The leader should redirect the group to a less-controversial topic.

4. The leader should encourage the group to solve the problem collectively.

ANS: 4

Rationale: The role of the group leader is to encourage the group to solve the problem collectively. A democratic leadership style supports members in their participation and problem-solving. Members are encouraged to solve issues that relate to the group cooperatively.

152. A 10-week, prenuptial counseling group composed of five couples is terminating. At the last group meeting, a nurse notices that the two most faithful and participative couples are absent. When considering concepts of group development, what might explain this behavior?

1. They are experiencing problems with termination, leading to feelings of abandonment.

2. They did not think any new material would be covered at the last session.

3. They were angry with the leader for not extending the length of the group.

4. They were bored with the material covered in the group.

ANS: 1

Rationale: The nurse should determine that the clients’ absence from the final group meeting may indicate that they are experiencing problems with termination. The termination phase of group development may elicit feelings of abandonment and anger. Successful termination may help members develop skills to cope with future unrelated losses.

153. An experienced psychiatric registered nurse has taken a new position leading groups in a day treatment program. Which group is this nurse most qualified to lead?

1. A psychodrama group

2. A psychotherapy group

3. A parenting group

4. A family therapy group

ANS: 3

Rationale: A psychiatric registered nurse is qualified to lead a parenting group. A parenting group can be classified as either a teaching group or therapeutic group. Psychodrama, psychotherapy, and family therapy are forms of group therapy and must be lead by qualified leaders who generally have advanced degrees in psychology, social work, nursing, or medicine.

154. A nursing instructor is teaching about psychodrama, a specialized type of therapeutic group. Which student statement indicates that further teaching is necessary?

1. “Psychodrama provides a safe setting in which to discuss painful issues.”

2. “In psychodrama, the client is the protagonist.”

3. “In psychodrama, the client observes actor interactions from the audience.”

4. “Psychodrama facilitates resolution of interpersonal conflicts.”

ANS: 2

Rationale: The nurse should educate the student that in psychodrama the client plays the role of him or herself in a life-situation scenario and is called the protagonist. During psychodrama, the client does not observe interactions from the audience. Other group members perform the role of the audience and discuss the situation they have observed, offer feedback, and express their feelings. Leaders of psychodrama must have specialized training to become a psychodramatist.

155. Which of the following behavioral skills should a nurse implement when leading a group that is functioning in the orientation phase of group development? (Select all that apply.)

1. Encourage members to provide feedback to each other about individual progress.

2. Ensure that group rules do not interfere with goal fulfillment.

3. Work with group members to establish rules that will govern the group.

4. Emphasize the need for and importance of confidentiality within the group.

5. Help the leader to resolve conflicts and foster cohesiveness within the group.

ANS: 2, 3, 4

Rationale: During the orientation phase of group development, the nurse leader should work together with members to establish rules that will govern the group. The leader should ensure that group rules do not interfere with goal fulfilment and establish the need for and importance of confidentiality within the group. Members need to establish trust and cohesion in order to move into the working phase.

156. A nursing instructor is teaching about recovery as it applies to mental illness. Which student statement indicates that further teaching is needed?

1. “The goal of recovery is improved health and wellness.”

2. “The goal of recovery is expedient, comprehensive behavioural change.”

3. “The goal of recovery is the ability to live a self-directed life.”

4. “The goal of recovery is the ability to reach full potential.”

ANS: 2

Rationale: The Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery from mental health disorders and substance use disorders as a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. Change in recovery is not an expedient process. It occurs incrementally over time.

157. Which situation presents an example of the basic concept of a recovery model?

1. The client’s family is encouraged to make decisions in order to facilitate discharge.

2. A social worker, discovering the client’s income, changes the client’s discharge placement.

3. A psychiatrist prescribes an antipsychotic drug based on observed symptoms.

4. A client diagnosed with schizophrenia schedules follow-up appointments and group therapy.

ANS: 4

Rationale: The basic concept of a recovery model is empowerment of the consumer. The recovery model is designed to allow consumers primary control over decisions about their own care.

158. A nursing instructor is teaching about the guiding principles of the recovery model, as described by the SAMHSA. Which student statement indicates that further teaching is needed?

1. “Recovery occurs via many pathways.”

2. “Recovery emerges from strong religious affiliations.”

3. “Recovery is supported by peers and allies.”

4. “Recovery is culturally based and influenced.”

ANS: 2

Rationale: SAMHSA lists the following as guiding principles for the recovery model: recovery emerges from hope, recovery is person-driven, recovery occurs via many pathways, recovery is holistic, recovery is supported by peers and allies, recovery is supported through relationship and social networks, recovery is culturally based and influenced, recovery is supported by addressing trauma, recovery involves individual, family, and community strengths and responsibility, recovery is based on respect. Recovery emerges from hope but affiliation with any particular religion would have little bearing on the recovery process.

159. A client diagnosed with alcohol abuse disorder is referred to a residential care facility after discharge. According to the SAMHSA, which dimension of recovery is supporting this client?

1. Health

2. Home

3. Purpose

4. Community

ANS: 2

Rationale: SAMHSA describes the dimension of Home as a stable and safe place to live.

160. A client diagnosed with obsessive-compulsive disorder states, “I really think my future will improve because of my successful treatment choices. I’m going to make my life better.” Which guiding principle of recovery has assisted this client?

1. Recovery emerges from hope.

2. Recovery is person-driven.

3. Recovery occurs via many pathways.

4. Recovery is holistic.

ANS: 1

Rationale: The SAMHSA lists the following as guiding principles for the recovery model: recovery emerges from hope, recovery is person-driven, recovery occurs via many pathways, recovery is holistic, recovery is supported by peers and allies, recovery is supported through relationship and social networks, recovery is culturally based and influenced, recovery is supported by addressing trauma, recovery involves individual, family, and community strengths and responsibility, recovery is based on respect. This client has internalized hope. This hope is the catalyst of the recovery process.

161. A nurse maintains a client’s confidentiality, addressed the client appropriately, and does not discriminate based on gender, age, race, or religion. Which guiding principle of recovery has this nurse employed?

1. Recovery is culturally based and influenced.

2. Recovery is based on respect.

3. Recovery involves individual, family, and community strengths and responsibility.

4. Recovery is person-driven.

ANS: 2

Rationale: The SAMHSA lists the following as guiding principles for the recovery model: recovery emerges from hope, recovery is person-driven, recovery occurs via many pathways, recovery is holistic, recovery is supported by peers and allies, recovery is supported through relationship and social networks, recovery is culturally based and influenced, recovery is supported by addressing trauma, recovery involves individual, family, and community strengths and responsibility, recovery is based on respect. This nurse accepts and appreciates clients who are affected by mental health and substance use problems. This nurse protects the rights of clients and does not discriminate against them.

162. A nurse on an inpatient unit helps a client understand the significance of treatments, and provides the client with copies of all documents related to the plan of care. This nurse is employing which commitment in the “Tidal Model of Recovery?”

1. Know that Change Is Constant

2. Reveal Personal Wisdom

3. Be Transparent

4. Give the Gift of Time

ANS: 3

Rationale: Barker & Buchanan-Barker developed a set of essential values termed the The 10 Tidal Commitments upon which the Tidal Model is based. They include: Value the Voice, Respect the Language, Develop Genuine Curiosity, Become the Apprentice, Use the Available Toolkit, Craft the Step Beyond, Give the Gift of Time, Reveal Personal Wisdom, Know that Change Is Constant, and Be Transparent. This nurse is employing the Be Transparent commitment.

163. Which is the priority focus of recovery models?

1. Empowerment of the health-care team to bring their expertise to decision-making

2. Empowerment of the client to make decisions related to individual health care

3. Empowerment of the family system to provide supportive care

4. Empowerment of the physician to provide appropriate treatments

ANS: 2

Rationale: The basic concept of a recovery model is empowerment of the client. The recovery model is designed to allow clients primary control over decisions about their own care.

164. A client experiences an exacerbation of psychiatric symptoms to the point of threatening self-harm. Which action step of the Wellness Recovery Action Plan (WRAP) model should be employed, and what action reflects this step?

1. Step 3: Triggers that cause distress or discomfort are listed.

2. Step 4: Signs indicating relapse are identified and plans for responding are developed.

3. Step 5: A specific plan to help with symptoms is formulated.

4. Step 6: Following client-designed plan, caregivers now become decision-makers.

ANS: 4

Rationale: The WRAP recovery model is a step-wise process through which an individual is able to monitor and manage distressing symptoms that occur in daily life. The six steps include: Step 1. Develop a Wellness Toolbox; Step 2. Daily Maintenance List; Step 3. Triggers; Step 4. Early Warning Signs; Step 5. Things Are Breaking Down or Getting Worse; Step 6. Crisis Planning. In step 6 (Crisis Planning) clients can no longer care for themselves, make independent decisions, or keep themselves safe. Caregivers take an active role in this step on behalf of the client and implement the plan that the client has previously developed. All other actions presented require the client to be functionally capable.

165. A nursing instructor is teaching about components present in the recovery process as described by Andresen and associates that led to the development of the Psychological Recovery Model. Which student statement indicates that further teaching is needed?

1. “A client has a better chance of recovery if he or she truly believes that recovery can occur.”

2. “If a client is willing to give the responsibility of treatment to the health-care team, they are likely to recover.”

3. “A client who has a positive sense of self and a positive identity is likely to recover.”

4. “A client has a better chance of recovery if he or she has purpose and meaning in life.”

ANS: 2

Rationale: In examining a number of studies, Andresen and associates identified four components that were consistently evident in the recovery process. These components are hope, responsibility, self and identity, and meaning and purpose. Under responsibility, this model tasks the client, not the health-care team, with taking responsibility for his or her life and well-being.

166. A client states, “My illness is so devastating, I feel like my life is on hold.” The nurse recognizes that this client is in which stage of the Psychological Recovery Model as described by Andersen and associates?

1. Moratorium

2. Awareness

3. Preparation

4. Rebuilding

ANS: 1

Rationale: Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include: Stage 1: Moratorium, Stage 2: Awareness, Stage 3: Preparation, Stage 4: Rebuilding, and Stage 5: Growth. The moratorium stage is identified by dark despair and confusion. It is called moratorium, because it seems that “life is on hold.”

167. A client states, “I have come to the conclusion that this disease has not paralyzed me.” The nurse recognizes that this client is in which stage of the Psychological Recovery Model as described by Andersen and associates?

1. Moratorium

2. Awareness

3. Preparation

4. Rebuilding

ANS: 2

Rationale: Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include: Stage 1: Moratorium, Stage 2: Awareness, Stage 3: Preparation, Stage 4: Rebuilding, and Stage 5: Growth. In the awareness stage, the individual comes to a realization that a possibility for recovery exists. Andresen and associates state, “It involves an awareness of a possible self other than that of ‘sick person’: a self that is capable of recovery.”

168. A psychiatrist who embraces the Psychological Recovery Model tells the nurse that a client is in the Growth stage. What should the nurse expect to fine when assessing this client?

1. A client feeling confident about achieving goals in life.

2. A client who is aware of the need to set goals in life.

3. A client who has mobilized personal and external resources.

4. A client who begins to actively take control of his or her life

ANS: 1

Rationale: Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include: Stage 1: Moratorium, Stage 2: Awareness, Stage 3: Preparation, Stage 4: Rebuilding, and Stage 5: Growth. In the growth stage, the individual feels a sense of optimism and hope of a rewarding future. Skills that have been nurtured in the previous stages are applied with confidence, and the individual strives for higher levels of well-being.

169. Which of the following has the SAMHSA described, as major dimensions of support for a life of recovery? (Select all that apply)

1. Health

2. Community

3. Home

4. Religious affiliation

5. Purpose

ANS: 1, 2, 3, 5

Rationale: SAMHSA suggests that a life in recovery is supported by four major dimensions, which include health, home, purpose, and community. Religious affiliation is not included in the listed dimensions.

Cognitive Level: Application

170. A nurse uses the commitments of the Tidal Model of Recovery in psychiatric nursing practice. Which of the following nursing actions reflect the use of the Develop Genuine Curiosity commitment? (Select all that apply.)

1. The nurse expresses interest in the client’s story.

2. The nurse asks for clarification of certain points.

3. The nurse encourages the client to speak his own words in his own unique way.

4. The nurse assists the client to unfold the story at his or her own rate.

5. The nurse provides the clients with copies of all documents relevant to care.

ANS: 1, 2, 4

Rationale: Barker & Buchanan-Barker developed a set of essential values termed the The 10 Tidal Commitments, upon which the Tidal Model is based. They include: Value the Voice, Respect the Language, Develop Genuine Curiosity, Become the Apprentice, Use the Available Toolkit, Craft the Step Beyond, Give the Gift of Time, Reveal Personal Wisdom, Know that Change Is Constant, and Be Transparent. This nurse is employing the Develop Genuine Curiosity commitment, by expressing interest, asking for clarification, and assisting the client to unfold the story at his or her own rate.

171. A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client’s safety?

1. Assess for medication nonadherance.

2. Note escalating behaviors and intervene immediately.

3. Interpret attempts at communication.

4. Assess triggers for bizarre, inappropriate behaviors.

ANS: 2

Rationale: The nurse should note escalating behaviors and intervene immediately, to maintain this client’s safety. Early intervention may prevent an aggressive response and keep the client and others safe.

172. A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be included in the nurse’s teaching?

1. The side effects of medications

2. Deep breathing techniques to decrease stress

3. How to make eye contact when communicating

4. How to be a leader

ANS: 3

Rationale: The nurse should plan to teach the client how to make eye contact when communicating. Social skills, such as making eye contact, can assist clients to communicate needs and to establish relationships.

173. A 16-year-old client diagnosed with schizophrenia spectrum disorder experiences command hallucinations to harm others. The client’s parents ask a nurse, “Where do the voices come from?” Which is the appropriate nursing response?

1. “Your child has a chemical imbalance of the brain, which leads to altered perceptions.”

2. “Your child’s hallucinations are caused by medication interactions.”

3. “Your child has too little serotonin in the brain, causing delusions and hallucinations.”

4. “Your child’s abnormal hormonal changes have precipitated auditory hallucinations.”

ANS: 1

Rationale: The nurse should explain that a chemical imbalance of the brain leads to altered perceptions. Hallucinations, or false sensory perceptions, may occur in all five senses. The client hearing voices is experiencing an auditory hallucination.

174. Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia spectrum disorder, tells them that voices command him to harm others. Which is the appropriate nursing response?

1. “Tell him to stop discussing the voices.”

2. “Ignore what he is saying, while attempting to discover the underlying cause.”

3. “Focus on the feelings generated by the hallucinations and present reality.”

4. “Present objective evidence that the voices are not real.”

ANS: 3

Rationale: The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should accept that their child is experiencing the hallucination but should not reinforce this unreal sensory perception.

175. A nurse is assessing a client diagnosed with schizophrenia spectrum disorder. The nurse asks the client, “Do you receive special messages from certain sources, such as the television or radio?” The nurse is assessing which potential symptom of this disorder?

1. Thought insertion

2. Paranoid delusions

3. Magical thinking

4. Delusions of reference

ANS: 4

Rationale: The nurse is assessing for the potential symptom of delusions of reference. A client that believes he or she receives messages through the radio is experiencing delusions of reference. These delusions involve the client interpreting events within the environment as being directed toward him- or herself.

176. A client diagnosed with schizophrenia spectrum disorder states, “Can’t you hear him? It’s the devil. He’s telling me I’m going to hell.” Which is the most appropriate nursing response?

1. “Did you take your medicine this morning?”

2. “You are not going to hell. You are a good person.”

3. “The voices must sound scary, but the devil is not talking to you. This is part of your illness.”

4. “The devil only talks to people who are receptive to his influence.”

ANS: 3

Rationale: The most appropriate nursing response is to reassure the client while not reinforcing the hallucination. Reminding the client that “the voices” are a part of the illness is a way to help the client accept that the hallucinations are not real. It is also important for the nurse to connect with the client’s fears and inner feelings.

177. A client diagnosed with schizophrenia spectrum disorder tells a nurse about voices commanding him to kill the president. Which is the priority nursing diagnosis for this client?

1. Disturbed sensory perception

2. Altered thought processes

3. Risk for violence: directed toward others

4. Risk for injury

ANS: 3

Rationale: The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices commanding him to kill someone is at risk for other-directed violence. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions.

178. Which nursing intervention would be most appropriate when caring for an acutely agitated paranoid client diagnosed with schizophrenia spectrum disorder?

1. Provide neon lights and soft music.

2. Maintain continual eye contact throughout the interview.

3. Use therapeutic touch to increase trust and rapport.

4. Provide personal space to respect the client’s boundaries.

ANS: 4

Rationale: The most appropriate nursing intervention is to provide personal space to respect the client’s boundaries. Providing personal space may serve to reduce anxiety and thus reduce the client’s risk for violence.

179. Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia spectrum disorder?

1. Establishing personal contact with family members

2. Being reliable, honest, and consistent during interactions

3. Sharing limited personal information

4. Sitting close to the client to establish rapport

ANS: 2

Rationale: The nurse can enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia spectrum disorder by being reliable, honest, and consistent during interactions. The nurse should also convey acceptance of the client’s needs and maintain a calm attitude when dealing with agitated behavior.

180. A paranoid client diagnosed with schizophrenia spectrum disorder states, “My psychiatrist is out to get me. I’m sad that the voice is telling me to stop him.” What symptom is the client exhibiting, and what is the nurse’s legal responsibility related to this symptom?

1. Magical thinking; administer an antipsychotic medication.

2. Persecutory delusions; orient the client to reality.

3. Command hallucinations; warn the psychiatrist.

4. Altered thought processes; call an emergency treatment team meeting.

ANS: 3

Rationale: The nurse should determine that the client is exhibiting command hallucinations. The nurse’s legal responsibility is to warn the psychiatrist of the potential for harm. Clients demonstrating a risk for violence could potentially be physically, emotionally, and/or sexually harmful to others or to self.

181. A client is diagnosed with schizophrenia spectrum disorder. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?

1. Tactile hallucinations

2. Tardive dyskinesia

3. Restlessness and muscle rigidity

4. Reports of hearing disturbing voices

ANS: 3

Rationale: The symptom of tactile hallucinations and reports of hearing disturbing voices would be addressed by an antipsychotic medication such as haloperidol. Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of an antipsychotic medication such as haloperidol. An anticholinergic medication such as benztropine would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity.

182. A nurse is caring for a client who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client’s positive and negative symptoms of schizophrenia?

1. Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia.

2. Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia.

3. Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia.

4. Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia.

ANS: 2

Rationale: The nurse should recognize that positive symptoms of schizophrenia include, but are not limited to, paranoid delusions, neologisms, and echolalia. The negative symptoms of schizophrenia include, but are not limited to, flat affect, anhedonia, and anergia. Positive symptoms reflect an excess or distortion of normal functions. Negative symptoms reflect a diminution or loss of normal functions.

183. A 60-year-old client diagnosed with schizophrenia spectrum disorder presents in an ED with uncontrollable tongue movements, stiff neck, and difficulty swallowing. Which medical diagnosis and treatment should a nurse anticipate when planning care for this client?

1. Neuroleptic malignant syndrome treated by discontinuing antipsychotic medications

2. Agranulocytosis treated by administration of clozapine (Clozaril)

3. Extrapyramidal symptoms treated by administration of benztropine (Cogentin)

4. Tardive dyskinesia treated by discontinuing antipsychotic medications

ANS: 4

Rationale: The nurse should expect that an ED physician would diagnose the client with tardive dyskinesia and discontinue antipsychotic medication. Tardive dyskinesia is a condition of abnormal involuntary movements of the mouth, tongue, trunk, and extremities that can be a side effect of typical antipsychotic medications.

184. After taking chlorpromazine (Thorazine) for 1 month, a client presents to an ED with severe muscle rigidity, tachycardia, and a temperature of 105oF (40.5°C). Which medical diagnosis and treatment should a nurse anticipate when planning care for this client?

1. Neuroleptic malignant syndrome treated by discontinuing Thorazine and administering dantrolene (Dantrium)

2. Neuroleptic malignant syndrome treated by increasing Thorazine dosage and administering an antianxiety medication

3. Dystonia treated by administering trihexyphenidyl (Artane)

4. Dystonia treated by administering bromocriptine (Parlodel)

ANS: 1

Rationale: The nurse should expect that an ED physician would diagnose the client with neuroleptic malignant syndrome and treat the client by discontinuing chlorpromazine and administering dantrolene. Neuroleptic malignant syndrome is a potentially fatal condition characterized by rigidity, fever, altered consciousness, and autonomic instability. The use of typical antipsychotics is largely being replaced by atypical antipsychotics because they have fewer side effects and present a lower risk.

185. A client diagnosed with schizophrenia spectrum disorder takes an antipsychotic agent daily. Which assessment finding should a nurse prioritize?

1. Respirations of 22 beats/minute

2. Weight gain of 8 pounds in 2 months

3. Temperature of 104°F (40°C)

4. Excessive salivation

ANS: 3

Rationale: When assessing a client diagnosed with schizophrenia spectrum disorder who takes an antipsychotic agent daily, the nurse should immediately address a temperature of 104°F (40°C). A temperature this high may indicate neuroleptic malignant syndrome, a life-threatening side effect of antipsychotic medications.

186. An aging client diagnosed with schizophrenia spectrum disorder takes an antipsychotic and a beta-adrenergic blocking agent for hypertension. Understanding the combined side effects of these drugs, which statement by a nurse is most appropriate?

1. “Make sure you concentrate on taking slow, deep, cleansing breaths.”

2. “Watch your diet and try to engage in some regular physical activity.”

3. “Rise slowly when you change position from lying to sitting or sitting to standing.”

4. “Wear sunscreen and try to avoid midday sun exposure.”

ANS: 3

Rationale: The most appropriate statement by the nurse is to instruct the client to rise slowly when changing positions. Antipsychotic medications and beta blockers cause a decrease in blood pressure. When given in combination, the additive effect of these drugs places the client at risk for developing orthostatic hypotension.

187. A client diagnosed with schizophrenia spectrum disorder is prescribed clozapine (Clozaril). Which client symptoms, related to the side effects of this medication, should prompt a nurse to intervene immediately?

1. Sore throat, fever, and malaise

2. Akathisia and hypersalivation

3. Akinesia and insomnia

4. Dry mouth and urinary retention

ANS: 1

Rationale: The nurse should intervene immediately if the client experiences signs of an infectious process, such as a sore throat, fever, and malaise, when taking the atypical antipsychotic drug clozapine. Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur, leading to infection.

188. During an admission assessment, a nurse assesses that a client diagnosed with schizophrenia spectrum disorder has allergies to penicillin, prochlorperazine (Compazine), and bee stings. Based on this assessment data, which antipsychotic medication would be contraindicated?

1. Haloperidol (Haldol), because it is used only in older patients

2. Clozapine (Clozaril), because it is incompatible with desipramine

3. Risperidone (Risperdal), because it exacerbates symptoms of depression

4. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines

ANS: 4

Rationale: The nurse should know that thioridazine would be contraindicated because of cross-sensitivity among phenothiazines. Prochlorperazine and thioridazine are both classified as phenothiazines.

189. A client has been assigned an admission diagnosis of brief psychotic disorder. Which assessment information would alert the nurse to question this diagnosis?

1. The client has experienced impaired reality testing for a 24-hour period.

2. The client has experienced auditory hallucinations for the past 3 hours.

3. The client has experienced bizarre behavior for 1 day.

4. The client has experienced confusion for 3 weeks.

ANS: 2

Rationale: This disorder is identified by the sudden onset of psychotic symptoms that may or may not be preceded by a severe psychosocial stressor. These symptoms last at least 1 day but less than 1 month.

190. A nurse is assessing a client diagnosed with substance induced psychotic disorder (SIPD). What would differentiate this client’s symptoms from the symptoms of a client diagnosed with brief psychotic disorder (BPD)?

1. Clients diagnosed with SIPD experience delusions, whereas clients diagnosed with BPD do not.

2. Clients diagnosed with BPD experience hallucinations, whereas clients diagnosed with SIPD do not.

3. Catatonic features may be associated with SIPD, whereas BPD has no catatonic features.

4. Catatonic features may be associated with BPD, whereas SIPD has no catatonic features.

ANS: 3

Rationale: The diagnosis of SIPD is made when symptoms are directly attributable to substance intoxication or withdrawal. The symptoms are more excessive and more severe than those usually associated with the intoxication or withdrawal syndrome. Hallucinations and delusions are associated with both SIPD and BPD. Catatonic features may be associated with SIPD, whereas BPD has no catatonic features.

191. A nurse prepares to assess a client using the Abnormal Involuntary Movement Scale (AIMS). Which side effect of antipsychotic medications led to the use of this assessment tool?

1. Dystonia

2. Tardive dyskinesia

3. Akinesia

4. Akathisia

ANS: 2

Rationale: The AIMS is a rating scale that was developed in the 1970s by the National Institute of Mental Health to measure involuntary movements associated with tardive dyskinesia.

192. Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with schizophrenia spectrum disorder? (Select all that apply.)

1. Group therapy

2. Medication management

3. Deterrent therapy

4. Supportive family therapy

5. Social skills training

ANS: 1, 2, 4, 5

Rationale: The nurse should recognize that group therapy, medication management, supportive family therapy, and social skills training all play an integral part of rehabilitative programs for clients diagnosed with schizophrenia spectrum disorder. Schizophrenia results from various combinations of genetic predispositions, biochemical dysfunctions, physiological factors, and psychological stress. Effective treatment requires a comprehensive, multidisciplinary effort.

193. A nurse is administering risperidone (Risperdal) to a client diagnosed with schizophrenia spectrum disorder. Which of the following client symptoms would most likely decrease because of the therapeutic effect of this medication? (Select all that apply.)

1. Somatic delusions

2. Social isolation

3. Gustatory hallucinations

4. Flat affect

5. Clang associations

ANS: 1, 3, 5

Rationale: The nurse should expect that risperidone would be effective treatment for the positive symptoms of somatic delusions, gustatory hallucinations, and clang associations. Risperidone is an atypical antipsychotic that has been effective in the treatment of the positive symptoms of schizophrenia and in maintenance therapy to prevent exacerbation of schizophrenic symptoms.

194. Laboratory results reveal decreased levels of prolactin in a client diagnosed with schizophrenia spectrum disorder. Which of the following client symptoms would a nurse expect to observe during assessment? (Select all that apply.)

1. Apathy

2. Social withdrawal

3. Anhedonia

4. Auditory hallucinations

5. Delusions

ANS: 1, 2, 3

Rationale: The nurse should expect that a client with decreased levels of prolactin may experience apathy, social withdrawal, and anhedonia. Decreased levels of prolactin can cause depression, which could result in these symptoms.

195. The diagnosis of catatonic disorder associated with another medical condition is made when the client’s medical history, physical examination, or laboratory findings provide evidence that symptoms are directly attributed to which of the following? (Select all that apply.)

1. Hyperthyroidism

2. Hypothyroidism

3. Hyperadrenalism

4. Hypoadrenalism

5. Hyperaphia

ANS: 1, 2, 3, 4

Rationale: The diagnosis of catatonic disorder associated with another medical condition is made when the symptomatology is evidenced from medical history, physical examination, or laboratory findings to be directly attributable to the physiological consequences of a general medical condition. Types of medical conditions that have been associated with catatonic disorder include metabolic disorders (e.g., hepatic encephalopathy, hypo- and hyperthyroidism, hypo- and hyperadrenalism, and vitamin B12 deficiency) and neurological conditions (e.g., epilepsy, tumors, cerebrovascular disease, head trauma, and encephalitis). Hyperaphia is an excessive sensitivity to touch.

196. A nursing instructor is teaching about specific phobias. Which student statement indicates to the instructor that learning has occurred?

1. “These clients recognize their fear as excessive and frequently seek treatment.”

2. “These clients have a panic level of fear that is overwhelming and unreasonable.”

3. “These clients experience symptoms that mirror a cerebrovascular accident (CVA).”

4. “These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis.”

ANS: 2

Rationale: The nursing instructor should evaluate that learning has occurred when the student knows that clients with phobias have a panic level of fear that is overwhelming and unreasonable. Phobia is fear cued by a specific object or situation in which exposure to the stimuli produces an immediate anxiety response. Even though the disorder is relatively common among the general population, people seldom seek treatment unless the phobia interferes with ability to function.

197. Which nursing statement to a client about social anxiety disorder versus schizoid personality disorder (SPD) is most accurate?

1. “Clients diagnosed with social anxiety disorder can manage anxiety without medications, whereas clients diagnosed with SPD can only manage anxiety with medications.”

2. “Clients diagnosed with SPD are distressed by the symptoms experienced in social settings, whereas clients diagnosed with social anxiety disorder are not.”

3. “Clients diagnosed with social anxiety disorder avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life.”

4. “Clients diagnosed with SPD avoid interactions only in social settings, whereas clients diagnosed with social anxiety disorder tend to avoid interactions in all areas of life.”

ANS: 3

Rationale: Clients diagnosed with social anxiety disorder avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. Social anxiety disorder is an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others.

198. What symptoms should a nurse recognize that differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)?

1. GAD is acute in nature, and panic disorder is chronic.

2. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders.

3. Hyperventilation is a common symptom in GAD and rare in panic disorder.

4. Depersonalization is commonly seen in panic disorder and absent in GAD.

ANS: 4

Rationale: The nurse should recognize that a client diagnosed with panic disorder experiences depersonalization, whereas a client diagnosed with GAD would not. Depersonalization refers to being detached from oneself when experiencing extreme anxiety.

199. Which treatment should a nurse identify as most appropriate for clients diagnosed with generalized anxiety disorder (GAD)?

1. Long-term treatment with diazepam (Valium)

2. Acute symptom control with citalopram (Celexa)

3. Long-term treatment with buspirone (BuSpar)

4. Acute symptom control with ziprasidone (Geodon)

ANS: 3

Rationale: The nurse should identify that an appropriate treatment for clients diagnosed with GAD is long-term treatment with buspirone. Buspirone is an anxiolytic medication that is effective in 60% to 80% of clients diagnosed with GAD. Buspirone takes 10 to 14 days for alleviation of symptoms but does not have the dependency concerns of other anxiolytics.

200. Which symptoms should a nurse recognize that differentiate a client diagnosed with obsessive-compulsive disorder (OCD) from a client diagnosed with obsessive-compulsive personality disorder?

1. Clients diagnosed with OCD experience both obsessions and compulsions, and clients diagnosed with obsessive-compulsive personality disorder do not.

2. Clients diagnosed with obsessive-compulsive personality disorder experience both obsessions and compulsions, and clients diagnosed with OCD do not.

3. Clients diagnosed with obsessive-compulsive personality disorder experience only obsessions, and clients diagnosed with OCD experience only compulsions.

4. Clients diagnosed with OCD experience only obsessions, and clients diagnosed with obsessive-compulsive personality disorder experience only compulsions.

ANS: 1

Rationale: A client diagnosed with OCD experiences both obsessions and compulsions. Clients with obsessive-compulsive personality disorder exhibit a pervasive pattern of preoccupation with orderliness, perfectionism, mental and interpersonal control, but do not experience obsessions and compulsions.

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