Behavioral Clues and Symptoms of Substance Abuse and Personality Disorders, Exams of Nursing

Download Behavioral Clues and Symptoms of Substance Abuse and Personality Disorders and more Exams Nursing in PDF only on Docsity! pg. 1 1 ATI RN Mental Health and Psychiatric Nursing Test bank with answers & Rationale (Comprehensive Mental Health and Psychiatric Nursing) (Set 10) 1. Tristan is on Lithium and has suffered from diarrhea and vomiting. What should the nurse in- charge do first: A. Recognize this as a drug interaction. B. Give the client Cogentin. C. Reassure the client that these are common side effects of lithium therapy. D. Hold the next dose and obtain an order for a stat serum lithium level. Correct Answer: D. Hold the next dose and obtain an order for a stat serum lithium level Diarrhea and vomiting are manifestations of Lithium toxicity. The next dose of lithium should be withheld and a test is done to validate the observation. Monitoring of therapeutic levels includes trough plasma levels drawn 8 to 12 hours after the last dose. The therapeutic range is 1.0 to 1.5 mEq/L for acute treatment and 0.6 to 1.2 mEq/L for chronic therapy. Monitoring should be done every 1 to 2 weeks until reaching the desired therapeutic levels. Then, check lithium levels every 2 to 3 months for six months. It is also important to monitor patients for dehydration and lower the dose when there are signs of infection, excessive sweating, or diarrhea. Toxic levels are when the drug level is more than 2 mEq/L. Option A: The manifestations are not due to drug interaction. Lithium has a very narrow therapeutic index, and toxic levels are when the drug is above 2 mEq/L, which is very close to its therapeutic range. Lithium toxicity can cause interstitial nephritis, arrhythmia, sick sinus syndrome, hypotension, T wave abnormalities, and bradycardia. Rarely, toxicity can cause pseudotumor cerebri and seizures. Lithium toxicity has no antidote. Option B: Cogentin is used to manage the extrapyramidal symptom side effects of antipsychotics. Benztropine is used to treat symptoms of Parkinson’s disease or involuntary movements due to the side effects of certain psychiatric drugs (antipsychotics such as chlorpromazine/haloperidol). Benztropine belongs to a class of medication called anticholinergics that work by blocking a certain natural substance (acetylcholine). This helps decrease muscle stiffness, sweating, and the production of saliva, and helps improve walking ability in people with Parkinson’s disease. Option C: The common side effects of Lithium are fine hand tremors, nausea, polyuria, and polydipsia. Lithium can cause several adverse effects. Typically the side effects are dose-related. Treatment for lithium toxicity is primarily hydration and to stop the drug. Give hydration with normal saline, which will also enhance lithium excretion. Avoid all diuretics. If the patient has severe renal dysfunction or failure, or severely altered mental status, then start with hemodialysis. 20 to 30 mg of propranolol given 2 to 3 times per day may help reduce tremors. pg. 2 2 2. What herbal medication for depression, widely used in Europe, is now being prescribed in the United States? A. Ginkgo biloba B. Echinacea C. St. John's wort D. Ephedra Correct Answer: C. St. John’s wort St. John’s wort has been found to have serotonin-elevating properties, similar to prescription antidepressants. St. John’s Wort (Hypericum perforatum) is commonly used to treat mild-to-moderate depression. Several bioactive compounds have been identified in St. John’s Wort that work synergistically to provide its antidepressant and anti-inflammatory attributes. St. John’s Wort was more efficacious than standard antidepressant therapy in patients with mild-to-moderate depression. Option A: Ginkgo biloba is prescribed to enhance mental acuity. Ginkgo biloba is commonly used to improve memory and cognition in the elderly suffering from impaired cerebral circulation. Mitochondrial dysfunction is one theory proposed as the leading cause of cognitive decline. The two main components in Gingko biloba leaves are flavonoids and terpenes tri lactones. Together, these compounds enhance and protect mitochondrial function and scavenge reactive molecules like hydroxyl and peroxyl radicals, nitric oxide, and superoxide ions. Option B: Echinacea has immune-stimulating properties. Echinacea is known as an immunostimulant, boosting both innate and specific immunity. It has also demonstrated anti-viral, anti-inflammatory, and antimicrobial effects. Intracellular bactericidal activity and enhanced phagocytosis were also observed. A randomized, double-blind study of 473 patients virologically confirmed with influenza infection, showed Echinacea was as effective as oseltamivir with fewer adverse events and reduced risk. Option D: Ephedra is a naturally occurring stimulant that is similar to ephedrine. Ephedra is a medicinal preparation from the plant Ephedra sinica. Several additional species belonging to the genus Ephedra have traditionally been used for a variety of medicinal purposes, and are a possible candidate for the Soma plant of Indo-Iranian religion. 3. A male client recently admitted to the hospital with sharp, substernal chest pain suddenly complains of palpitations. Nurse Ryan notes a rise in the client’s arterial blood pressure and a heart rate of 144 beats/minute. On further questioning, the client admits to having used cocaine recently after previously denying use of the drug. The nurse concludes that the client is at high risk for which complication of cocaine use? A. Coronary artery spasm B. Bradyarrhythmias pg. 5 5 “psychodynamic approach” has made its understanding more difficult, particularly with the rise of other counseling styles that may not emphasize self-awareness and exploration. Option D: This is a transference reaction where a client has an emotional reaction towards the nurse based on her past. Signs of countertransference in therapy can include a variety of behaviors, including excessive self-disclosure on the part of the therapist or an inappropriate interest in irrelevant details from the life of the person in treatment. A therapist who acts on their feelings toward the person being treated or that person’s situation or engages in behavior not appropriate to the treatment process may not be effectively managing countertransference. 6. After taking an overdose of phenobarbital (Barbita), Mario is admitted to the emergency department. Dr. Trinidad prescribes activated charcoal (Charcocaps) to be administered by mouth immediately. Before administering the dose, the nurse verifies the dosage ordered. What is the usual minimum dose of activated charcoal? A. 5 g mixed in 250 ml of water B. 15 g mixed in 500 ml of water C. 30 g mixed in 250 ml of water D. 60 g mixed in 500 ml of water Correct Answer: C. 30 g mixed in 250 ml of water The usual adult dosage of activated charcoal is 5 to 10 times the estimated weight of the drug or chemical ingested, or a minimum dose of 30 g, mixed in 250 ml of water. Doses less than this will be ineffective; doses greater than this can increase the risk of adverse reactions, although toxicity doesn’t occur with activated charcoal, even at the maximum dose. Activated charcoal is widely used in Emergency Departments to treat many types of toxic ingestions. Its use significantly prevents the absorption of many toxic drugs and other poisons if given early post-ingestion. Option A: An oral suspension of activated charcoal (AC) should merit consideration in poisonings when there is an indication for gastrointestinal decontamination of an ingested toxin, and the clinician can administer activated charcoal within 1 hour of ingestion. When the dose of the ingested toxin is known, experts recommend activated charcoal at a 10 to 1 ratio of activated charcoal to the ingested toxin. This ratio may be impractical to achieve when the patient has ingested large doses of a toxin. Option B: When the amount of toxin ingested is unknown, or it is impractical to achieve a 10 to 1 ratio in large dose toxic ingestions, SDAC should be administered at a dose of 1g/kg of body weight or using a simplified age-based dosing scheme. Formulations have been attempted to increase the palatability of activated charcoal, which is black and has a gritty texture. Ready-to-use aqueous suspensions of activated charcoal are available in 15 g, 25 g, and 50 g doses as well as formulations premixed with sorbitol. Option D: Pulmonary aspiration and a resulting aspiration pneumonitis are the most concerning risks of administration of activated charcoal. Aspiration from emesis and misplaced nasogastric tubes for activated charcoal administration can lead to severe respiratory compromise and even pg. 6 6 death. Therefore, an adequate airway assessment must take place before the administration of activated charcoal. 7. A female client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client’s wrists are scratched from a recent suicide attempt. Based on this finding, the nurse Lenny should formulate a nursing diagnosis of: A. Ineffective individual coping related to feelings of guilt. B. Situational low self-esteem related to feelings of loss of control. C. Risk for violence: Self-directed related to impulsive mutilating acts. D. Risk for violence: Directed toward others related to verbal threats. Correct Answer: C. Risk for violence: Self-directed related to impulsive mutilating acts. The predominant behavioral characteristic of the client with borderline personality disorder is impulsiveness, especially of a physically self-destructive sort. The observation that the client has scratched wrists doesn’t substantiate the other options. Borderline personality disorder (BPD) is 1 of 4 Cluster-B disorders that include borderline, antisocial, narcissistic, and histrionic. Borderline personality disorder (BPD) is characterized by hypersensitivity to rejection and resulting instability of interpersonal relationships, self-image, affect, and behavior Option A: Inappropriate, intense anger, or difficulty controlling anger, for example, frequent displays of temper, constant anger, recurrent physical fights. A careful history and physical exam should be performed before performing a comprehensive psychiatric assessment. There are structured diagnostic screening tools used to assess personality disorders and specifically borderline personality disorder, for example, the Zanarini Rating Scale for Borderline Personality Disorder. Option B: There is identity disturbance which is a markedly and persistently unstable self-image or sense of self. Borderline personality disorder is multifactorial in etiology. There is a genetic predisposition. Twin studies show over 50% heritability (greater than that for major depression). Twin studies performed in 2000 and 2008 both demonstrated higher concordance of the rate of borderline personality disorder for monozygotic versus dizygotic twins. Option D: Self-injurious behavior, boundary issues, and frequent suicidal threats present therapeutic challenges specific to the treatment of patients with borderline personality disorder. High rates of comorbid substance abuse may also confound the treatment of borderline personality disorder patients. 8. Nurse Taylor is aware that the victims of domestic violence should be assessed for what important information? A. Reasons they stay in the abusive relationship (for example, lack of financial autonomy and isolation). B. Readiness to leave the perpetrator and knowledge of resources. C. Use of drugs or alcohol. pg. 7 7 D. History of previous victimization. Correct Answer: B. Readiness to leave the perpetrator and knowledge of resources. Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of the resources available to them. Nurses can then provide the victims with information and options to enable them to leave when they are ready. Training and support programs for clinicians and administrative staff have been shown to improve identification of women experiencing domestic violence and referral to advocacy services. Use of a domestic violence advocate in the ED resulted in a higher incidence of detection of incidents of acute violence than the data reported in the literature. Option A: The reasons they stay in the relationship are complex and can be explored at a later time. Reportedly, at least 40% of domestic violence victims never contact the police. Of female victims of domestic violence homicide, 44% had visited an ED within 2 years of their murder. Option C: The use of drugs or alcohol is irrelevant. Since substance abuse may develop or worsen as a result of domestic violence, it is appropriate to consider domestic violence when evaluating a patient for alcohol intoxication, drug toxicity, or drug overdose. A family history of alcohol and drug abuse or similar history in the patient’s partner is also an important risk factor. Option D: There is no evidence to suggest that previous victimization results in a person’s seeking or causing abusive relationships. The frequency and severity of previous attacks indicate the degree of present danger. Threats are as important as any actual injury. The presence of weapons in the home is a risk factor. In addition to threats and physical abuse, relationships with high risk for injury or death commonly feature exaggerated forms of coercion and manipulation to maintain the partner’s dependence. This may result in the Stockholm syndrome. 9. A 35-year-old female has intense fear of riding an elevator. She claims “ As if I will die inside.” The client is suffering from: A. Agoraphobia B. Social phobia C. Claustrophobia D. Xenophobia Correct Answer: C. Claustrophobia Claustrophobia is fear of closed space. Claustrophobia is a type of specific phobia, where one has a fear of closed spaces. Examples of closed spaces are engine rooms, MRI machines, elevators, etc. Those with specific phobias generally will report avoidance behaviors regarding the particular object or situation that triggers their fear. The fear can be expressed as a danger of harm, disgust, or experience of the physical symptoms in a phobic scenario. physical symptoms include, but are not limited to, difficulty breathing, trembling, sweating, tachycardia, dry mouth, and chest pain. Emotional symptoms include, but are not limited to, feeling overwhelming anxiety or fear, fear of losing control, feeling an intense need to leave the situation, the understanding of the fear as irrational, but an inability to overcome it. pg. 10 10 Option A: A shortened version of the term used in the ICD-10 – Mental and behavioral disorders due to psychoactive substance use. The term encompasses acute intoxication, harmful use, dependence syndrome, withdrawal state, withdrawal state with delirium, psychotic disorder, and amnesic syndrome. For a particular substance, these conditions may be grouped together as, for example, alcohol disorders, cannabis use disorders, stimulant use disorders. Psychoactive substance use disorders are defined as being of clinical relevance; the term ‘psychoactive substance use problems’ is a broader one, which includes conditions and events not necessarily of clinical relevance. Option B: Production, distribution, sale, or non-medical use of many psychoactive drugs is either controlled or prohibited outside legally sanctioned channels by law. Psychoactive drugs have different degrees of restriction of availability, depending on their risks to health and therapeutic usefulness, and classified according to a hierarchy of schedules at both national and international levels. At the international level, there are international drug conventions concerned with the control of production and distribution of psychoactive drugs: the 1961 Single Convention on Narcotic Drugs, amended by a 1972 Protocol; the 1971 Convention on Psychotropic Substances; the 1988 Convention Against Illicit Traffic in Narcotic Drugs and Psychotropic Substances. Option C: It is an essential characteristic of the dependence syndrome that either substance taking or a desire to take a particular substance should be present; the subjective awareness of compulsion to use drugs is most commonly seen during attempts to stop or control substance use. This diagnostic requirement would exclude, for instance, surgical patients given opiate drugs for the relief of pain and who may show signs of an opiate withdrawal state when drugs are not given, but who have no desire to continue taking drugs. 12. Nurse Harry is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan? A. Restrict visits with the family until the client begins to eat. B. Provide privacy during meals. C. Set up a strict eating plan for the client. D. Encourage the client to exercise, which will reduce her anxiety. Correct Answer: C. Set up a strict eating plan for the client. Establishing a consistent eating plan and monitoring the client’s weight is important for this disorder. Establish a minimum weight goal and daily nutritional requirements. Malnutrition is a mood-altering condition, leading to depression and agitation and affecting cognitive function and decision making. Improved nutritional status enhances thinking ability, allowing initiation of psychological work. Make a selective menu available, and allow the patient to control choices as much as possible. Patient who gains confidence in himself and feels in control of the environment is more likely to eat preferred foods. Option A: The family should be included in the client’s care. Involve patients in setting up or carrying out a program of behavior modification. Provide a reward for weight gain as individually determined; ignore the loss. It provides a structured eating situation while allowing the patient some control in choices. Behavior modification may be effective in mild cases or for short-term weight gain. pg. 11 11 Option B: The client should be monitored during meals — not given privacy. Provide one-to-one supervision and have a patient with bulimia remain in the day room area with no bathroom privileges for a specified period (2 hr) following eating, if contracting is unsuccessful. Prevents vomiting during and after eating. Patients may desire food and use a binge-purge syndrome to maintain weight. Note: Patients may purge for the first time in response to the establishment of a weight gain program. Option D: Exercise must be limited and supervised. Monitor exercise programs and set limits on physical activities. Chart activity and level of work (pacing and so on). Moderate exercise helps in maintaining muscle tone, weight and combating depression; however, patients may exercise excessively to burn calories. 13. Nurse Pauline is aware that Dementia unlike delirium is characterized by: A. Slurred speech B. Insidious onset C. Clouding of consciousness D. Sensory perceptual change Correct Answer: B. insidious onset Dementia has a gradual onset and progressive deterioration. It causes pronounced memory and cognitive disturbances. The pathophysiology of dementia is not understood completely. Most types of dementia, except vascular dementia, are caused by the accumulation of native proteins in the brain. History must be obtained from the patient and their family members. Patients may present with symptoms of change in behavior, getting lost in familiar neighborhoods, memory loss, mood changes, aggression, social withdrawal, self-neglect, cognitive difficulty, personality changes, difficulty performing tasks, forgetfulness, difficulty in communication, vulnerability to infections, loss of independence, etc., A detailed history should include past medical, family, drug, and alcohol history. Option A: Physical examination should evaluate head-to-toe and vital signs to determine any possible cause. Neurologic examination should focus on evaluating new focal findings that suggest an intracranial cause, for example, a stroke. The dopamine excess contributes to hyperactive delirium and is related to decreased acetylcholine. The dopaminergic and cholinergic pathways overlap in the brain. This explains why dopamine receptors impact acetylcholine levels and explain the clinical manifestations of delirium, including hyperactive and hypoactive forms. The imbalance between neurotransmitters and the cholinergic pathway may result in delirium. Option C: Acetylcholine is a very important neurotransmitter in attention and consciousness. It is known, acetylcholine acts as a modulator in sensory and cognitive input, so an impairment in the route leads to developing symptoms of hypoactive or hyperactive delirium, including inattention, disorganized thinking, and perceptual disturbances. Cholinergic pathways project from basal forebrain and pontomesencephalon to interneurons in the striatum and finally targets throughout the cortex. pg. 12 12 Option D: This is also a characteristic of delirium. The DSM-5 defines delirium as the presence of all the following criteria: disturbance in attention and awareness that develops acutely and tends to fluctuate in severity; at least one additional disturbance in cognition; disturbances not better explained by preexisting dementia; disturbances that do not occur in the context of a severely reduced level of arousal or coma; or evidence of an underlying organic cause or causes. 14. Which nursing intervention would be most appropriate if a male client develops orthostatic hypotension while taking amitriptyline (Elavil)? A. Consulting with the physician about substituting a different type of antidepressant. B. Advising the client to sit up for 1 minute before getting out of bed. C. Instructing the client to double the dosage until the problem resolves. D. Informing the client that this adverse reaction should disappear within 1 week. Correct Answer: B. Advising the client to sit up for 1 minute before getting out of bed. To minimize the effects of amitriptyline-induced orthostatic hypotension, the nurse should advise the client to sit up for 1 minute before getting out of bed. Amitriptyline is FDA approved medication to treat depression in adults. Secondary to its alpha-adrenergic receptor blockade, it can cause orthostatic hypotension, dizziness, and sedation. It can also cause heart rate variability, slow intracardiac conduction, induce various arrhythmias, and cause QTc (corrected QT) prolongation. Option A: Orthostatic hypotension commonly occurs with tricyclic antidepressant therapy. Cardiac symptoms include tachycardia, hypotension, conduction abnormalities include QTc prolongation. Amitriptyline is in the tricyclic antidepressant (TCA) drug classification and acts by blocking the reuptake of both serotonin and norepinephrine neurotransmitters. The three-ring central structure, along with a side chain, is the basic structure of tricyclic antidepressants. Amitriptyline is a tertiary amine and has strong binding affinities for alpha-adrenergic, histamine (H1), and muscarinic (M1) receptors. It is more sedating and has increased anticholinergic properties compared to other TCAs. Option C: In these cases, the dosage may be reduced or the physician may prescribe nortriptyline, another tricyclic antidepressant. Once the patient is stable, amitriptyline should be continued for three months or longer to prevent relapse of depression. In cases of therapy cessation, the clinician should gradually taper to avoid withdrawal. Amitriptyline administration comes in various forms, the most common being oral form. The initial dose recommended for depression is 25 mg/day at bedtime, as it can be sedating. Option D: Orthostatic hypotension disappears only when the drug is discontinued. The most commonly encountered side effects of amitriptyline include weight gain, gastrointestinal symptoms like constipation, xerostomia, dizziness, headache, and somnolence. Patients on amitriptyline can have anticholinergic, antihistaminic, and alpha-adrenergic blocking effects. It may not be appropriate for patients with cardiac problems. pg. 15 15 The manifestations indicate intoxication with cocaine, a CNS stimulant. CNS reactions may be excitatory then depressant. In its mild form, the patient may display anxiety, restlessness, and excitement. Full- body tonic-clonic seizures may result from moderate to severe CNS stimulation. These seizures are often followed by CNS depression, with death resulting from respiratory failure and/or asphyxiation if concomitant emesis is present. Option A: Intoxication with heroine is manifested by euphoria then impairment in judgment, attention and the presence of pupillary constriction. The intended effects of heroin misuse are those classically associated with any opioid effects. These are analgesia, euphoria, and often alleviation of opioid withdrawal symptoms. All other effects of heroin could be considered adverse. Respiratory depression is likely the most concerning adverse effect, leading to death in an increasing number of misusers. The extreme physiologic dependence also represents a major concern in those who misuse heroin. Option C: Intoxication with hallucinogen like LSD is manifested by grandiosity, hallucinations, synesthesia, and increase in vital signs. Adverse effects are extremely subjective, with significant variability and unpredictability. One patient may experience a positive effect filled with bright hallucinations, sights and sensations, increased awareness owing to mind expansion, and marked euphoria. The positive spectrum of effects is colloquially called a “good trip.” Option D: Intoxication with Marijuana, a cannabinoid is manifested by sensation of slowed time, conjunctival redness, social withdrawal, impaired judgment, and hallucinations. The most common emergency caused by marijuana ingestion is a panic attack. Other common adverse effects include dizziness, dry mouth, nausea, disorientation, euphoria, confusion, sedation, increased heart rate, and breathing problems. Marijuana is classified as a Schedule I substance by the FDA, and therefore is not accepted for medical use and has a high abuse potential from a federal point of view. As a result, doctors cannot prescribe marijuana, but in states that allow its use to treat medical conditions, doctors may be able to certify its use. 18. A male client has approached the nurse asking for advice on how to deal with his alcohol addiction. Nurse Sally should tell the client that the only effective treatment for alcoholism is: A. Psychotherapy B. Total abstinence C. Alcoholics Anonymous (AA) D. Aversion therapy Correct Answer B. Total abstinence Total abstinence is the only effective treatment for alcoholism. For people who have severe alcohol use disorder, this is a key step. The goal is to stop drinking and give the body time to get the alcohol out of the system. That usually takes a few days to a week. Psychotherapy, attendance at AA meetings, and aversion therapy are all adjunctive therapies that can support the client in his efforts to abstain. Option A: With alcohol use disorder, controlling your drinking is only part of the answer. You also need to learn new skills and strategies to use in everyday life. Psychologists, social workers, or pg. 16 16 alcohol counselors can teach you how to change the behaviors that make you want to drink; deal with stress and other triggers; build a strong support system; and set goals and reach them. Option C: Group therapy or a support group can help during rehab and help the client stay on track as life gets back to normal. Group therapy, led by a therapist, can give the client the benefits of therapy along with the support of other members. Support groups aren’t led by therapists. Instead, these are groups of people who have alcohol use disorder. Examples include Alcoholics Anonymous, SMART Recovery, and other programs. The peers can offer understanding and advice and help keep the client accountable. Many people stay in groups for years. Option D: Aversion therapy is a type of behavioral therapy that involves repeatedly pairing an unwanted behavior with discomfort. For example, a person undergoing aversion therapy to stop smoking might receive an electrical shock every time they view an image of a cigarette. The goal of the conditioning process is to make the individual associate the stimulus with unpleasant or uncomfortable sensations. 19. A 25 –year old client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority? A. The client will commit to a drug-free lifestyle. B. The client will work with the nurse to remain safe. C. The client will drink plenty of fluids daily. D. The client will make a personal inventory of strength. Correct Answer: B. The client will work with the nurse to remain safe. The priority goal in alcohol withdrawal is maintaining the client’s safety. Alcohol withdrawal can range from very mild symptoms to the severe form, which is named delirium tremens. The hallmark is autonomic dysfunction resulting from the excitation of the central nervous system. Mild signs/symptoms can arise within six hours of alcohol cessation. If symptoms do not progress to more severe symptoms within 24 to 48 hours, the patient will likely recover. Option A: Delirium tremens is the most severe form of alcohol withdrawal, and its hallmark is that of an altered sensorium with significant autonomic dysfunction and vital sign abnormalities. It includes visual hallucinations, tachycardia, hypertension, hyperthermia, agitation, and diaphoresis. Symptoms of delirium tremens can last up to seven days after alcohol cessation and may last even longer. Option C: The diagnosis of alcohol withdrawal can be made by taking an excellent history and performing a thorough physical examination. It is a clinical diagnosis based on mild, moderate, or severe symptoms. Patients with suspicion for alcohol withdrawal should be evaluated for other underlying disease processes such as dehydration, infection, cardiac issues, electrolyte abnormalities, gastrointestinal bleeding, and traumatic injury. Laboratory studies (electrolytes, blood counts) may be drawn, but will likely be nondiagnostic. Option D: Patients with prolonged altered sensorium or significant renal abnormalities should have an evaluation for the potential ingestion of another toxic alcohol. Patients who become financially pg. 17 17 strapped due to alcoholism could ingest other alcohols to become intoxicated. These can include isopropyl alcohol, commonly known as rubbing alcohol, which can lead to acidemia without ketosis as well as hemorrhagic gastritis. 20. A 24-year old client with anorexia nervosa tells the nurse, “When I look in the mirror, I hate what I see. I look so fat and ugly.” Which strategy should the nurse use to deal with the client’s distorted perceptions and feelings? A. Avoid discussing the client’s perceptions and feelings. B. Focus discussions on food and weight. C. Avoid discussing unrealistic cultural standards regarding weight. D. Provide objective data and feedback regarding the client’s weight and attractiveness. Correct Answer: D. Provide objective data and feedback regarding the client’s weight and attractiveness By focusing on reality, this strategy may help the client develop a more realistic body image and gain self-esteem. Anorexia nervosa is an eating disorder defined by restriction of energy intake relative to requirements, leading to a significantly low body weight. Patients will have an intense fear of gaining weight and distorted body image with the inability to recognize the seriousness of their significantly low body weight. The mental health nurse should educate the patient on changes in behavior, easing stress, and overcoming any emotional issues. Option A: This is inappropriate because discussing the client’s perceptions and feelings wouldn’t help her to identify, accept, and work through them. Since recovery involves patients having to face their deepest, most painful, and traumatic thoughts and emotions, supporting them as they go through treatment can be emotionally challenging for nurses. This emotional challenge can be exacerbated when the patient has also been diagnosed with Obsessive-Compulsive Disorder (OCD), depression, or substance abuse, as these may require more intensive one-to-one support. Option B: Focusing discussions on food and weight would give the client attention for not eating. During the early stages of treatment when patients are still new to recovery, they look to nurses to provide them with a highly structured environment, which sometimes involves nurses making food and behavioral decisions on their behalf. While this might not be an ongoing issue for primary care nurses, they may still be required to offer decisive advice on these areas. Here, it is imperative that nurses offer such advice with a clear message that patients have the power to make these decisions themselves. Option C: This is inappropriate because recognizing unrealistic cultural standards wouldn’t help the client establish more realistic weight goals. Furthermore, learning motivational interviewing techniques can help facilitate communication with those who might be resistant to discussing topics related to food, weight, and recovery. Such techniques can help develop the skills of empathic understanding, rolling with resistance, and gently assisting patients to make their own, autonomous decision to work towards recovery. Often, the aim is to help patients learn new and healthier ways pg. 20 20 Option A: Norepinephrine’s predominant use is as a peripheral vasoconstrictor. Specifically, the FDA has approved its use for blood pressure control in specific acute hypotensive states, as well as being a potential adjunct in the treatment of cardiac arrest with profound hypotension. Option B: Lidocaine, an antiarrhythmic, isn’t indicated because the client doesn’t have an arrhythmia. The drug is commonly used for local anesthesia, often in combination with epinephrine (which acts as a vasopressor and extends its duration of action at a site by opposing the local vasodilatory effects of lidocaine). Option C: Although nitroglycerin may be used to treat coronary vasospasm, it isn’t the drug of choice in hypertension. Nitroglycerin is a vasodilatory drug used primarily to provide relief from anginal chest pain. Nitroglycerin has been FDA approved since 2000 and was first sold by Pfizer under the brand name Nitrostat. It is currently FDA approved for the acute relief of an attack or acute prophylaxis of angina pectoris secondary to coronary artery disease. 24. Nurse Mary is assigned to care for a suicidal client. Initially, which is the nurse’s highest care priority? A. Assessing the client’s home environment and relationships outside the hospital. B. Exploring the nurse’s own feelings about suicide. C. Discussing the future with the client. D. Referring the client to a clergyperson to discuss the moral implications of suicide. Correct Answer: B. Exploring the nurse’s own feelings about suicide. The nurse’s values, beliefs, and attitudes toward self-destructive behavior influence responses to a suicidal client; such responses set the overall mood for the nurse-client relationship. Therefore, the nurse initially must explore personal feelings about suicide to avoid conveying negative feelings to the client. Option A: Assessment of the client’s home environment and relationships may reveal the need for family therapy; however, conducting such an assessment isn’t a nursing priority. A clear and complete evaluation and clinical interview provide the information upon which to base a suicide intervention. Although risk factors offer major indications of the suicide danger, nothing can substitute for a focused patient inquiry. However, although all the answers a patient gives may be inclusive, a therapist often develops a visceral sense that his or her patient is going to commit suicide. The clinician’s reaction counts and should be considered in the intervention. Option C: Discussing the future and providing anticipatory guidance can help the client prepare for future stress, but this isn’t a priority. If suicidal ideation is present, the next question must be about any plans for suicidal acts. The general formula is that more specific plans indicate greater danger. Although vague threats, such as a threat to commit suicide sometime in the future, are the reason for concern, responses indicating that the person has purchased a gun, has ammunition, has made out a will, and plans to use the gun are more dangerous. The plan demands further questions. If the person envisions a gun-related death, determine whether he or she has the weapon or access to it. pg. 21 21 Option D: Referring the client to a clergyperson may increase the client’s trust or alleviate guilt; however, it isn’t the highest priority. The only way to prevent suicides is to work in an interprofessional team that includes a mental health nurse, psychiatrist, the primary care provider, social worker, and nurse practitioner. Practitioners must work with the patient’s family and friends, as well as with the other patients who knew the client 25. Kitty, a 9-year-old child has a very limited vocabulary and interaction skills. She has an I.Q. of 45. She is diagnosed to have Mental retardation of this classification: A. Profound B. Mild C. Moderate D. Severe Correct Answer: C. Moderate The child with moderate mental retardation has an I.Q. of 35- 50. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the diagnosis of intellectual disability requires deficits in intellectual function, deficits in adaptive function, and onset before the age of 18. The IQ test is widely used to assess the intellectual function of individuals. IQ test derives from Stanford- Binet Intelligence Scales, used for school placement in France. Option A: Profound Mental retardation has an I.Q. of below 20. Lewis Terman adapted the test to measure general intelligence. Scores were reported as “mental age” divided by chronological age, multiplied by 100. The current version of the IQ test is standardized, and two standard deviations below the test taker’s group are calculated as IQ of 70. An IQ of 70 or below suggests an intellectual disability diagnosis. Option B: Mild mental retardation has an I.Q. of 50-70. However, it is no longer a standard to classify intellectual disability by IQ score alone. For instance, if an individual has IQ below 70, but has a good adaptive function, the subject does not have an intellectual disability. On the other side, individuals with a normal, or even higher than normal IQ, may manifest severe deficits in adaptive functions and are, therefore, classified as having an intellectual disability. Option D: Severe mental retardation has an I.Q. of 20-35. In turn, the current diagnosis of intellectual disability also considers a person’s adaptive function. The Adaptive Behaviour Assessment System can measure adaptive function. It encompasses the social and practical domain. Adaptive function measures ability in communication, social participation, and independent living. 26. Macoy and Helen seek emergency crisis intervention because he slapped her repeatedly the night before. The husband indicates that his childhood was marred by an abusive relationship with his father. When intervening with this couple, nurse Gerry knows they are at risk for repeated violence because the husband: A. Has only moderate impulse control. B. Denies feelings of jealousy or possessiveness. pg. 22 22 C. Has learned violence as an acceptable behavior. D. Feels secure in his relationship with his wife. Correct Answer: C. Has learned violence as an acceptable behavior Family violence usually is a learned behavior, and violence typically leads to further violence, putting this couple at risk. Unfortunately, each form of family violence begets interrelated forms of violence, and the “cycle of abuse” is often continued from exposed children into their adult relationships, and finally to the care of the elderly. Domestic violence is thought to be underreported. Domestic violence affects the victim, families, co-workers, and community. It causes diminished psychological and physical health, decreases the quality of life, and results in decreased productivity. Option A: Repeated slapping may indicate poor, not moderate, impulse control. According to the CDC, 1 in 4 women and 1 in 7 men will experience physical violence by their intimate partner at some point during their lifetimes. About 1 in 3 women and nearly 1 in 6 men experience some form of sexual violence during their lifetimes. Intimate partner violence, sexual violence, and stalking are high, with intimate partner violence occurring in over 10 million people each year. Option B: At least 5 million acts of domestic violence occur annually to women aged 18 years and older, with over 3 million involving men. While most events are minor, for example grabbing, shoving, pushing, slapping, and hitting, serious and sometimes fatal injuries do occur. Approximately 1.5 million intimate partner female rapes and physical assaults are perpetrated annually, and approximately 800,000 male assaults occur. About 1 in 5 women have experienced completed or attempted rape at some point in their lives. About 1% to 2% of men have experienced completed or attempted rape. Option D: Violent people commonly are jealous and possessive and feel insecure in their relationships. While the research is not definitive, a number of characteristics are thought to be present in perpetrators of domestic violence. Abusers tend to be possessive, jealous, suspicious, and paranoid. Approximately one-third of women and one-fifth of men will be victims of abuse. The most common sites of injuries are the head, neck, and face. Clothes may cover injuries to the body, breasts, genitals, rectum, and buttocks. One should be suspicious if the history is not consistent with the injury. 27. A male adult client voluntarily admits himself to the substance abuse unit. He confesses that he drinks one (1) qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition? A. Vomiting, diarrhea, and bradycardia B. Dehydration, temperature above 101° F (38.3° C), and pruritus C. Hypertension, diaphoresis, and seizures D. Diaphoresis, tremors, and nervousness Correct Answer: D. Diaphoresis, tremors, and nervousness pg. 25 25 restlessness/akathisia), gastrointestinal (nausea/vomiting, dry mouth, decreased appetite, weight loss, abdominal pain), and cardiovascular systems (tachycardia, and palpitations). Option D: Side effects of Ritalin include anorexia, insomnia, diarrhea, and irritability. It is important to note that there have been reported cases of sudden death in both children and adults with a pre- existing structural cardiac abnormality. Stroke and myocardial infarction also have been observed in adults. Due to the risk of such fatal side effects, it is advisable to avoid methylphenidate in patients with a structural cardiac abnormality, cardiomyopathy, or arrhythmias. 30. Kevin is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since then. His history suggests maladaptive coping, which is associated with: A. Antisocial personality disorder B. Borderline personality disorder C. Obsessive-compulsive personality disorder D. Narcissistic personality disorder Correct Answer: A. Antisocial personality disorder The client’s history of delinquency, running away from home, vandalism, and dropping out of school are characteristic of antisocial personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others. Antisocial personality disorder (ASPD) is a deeply ingrained and rigid dysfunctional thought process that focuses on social irresponsibility with exploitive, delinquent, and criminal behavior with no remorse. Disregard for and the violation of others’ rights are common manifestations of this personality disorder, which displays symptoms that include failure to conform to the law, inability to sustain consistent employment, deception, manipulation for personal gain, and incapacity to form stable relationships. Option B: In borderline personality disorder, the client exhibits mood instability, poor self-image, identity disturbance, and labile affect. Borderline personality disorder (BPD) is 1 of 4 Cluster-B disorders that include borderline, antisocial, narcissistic, and histrionic. Borderline personality disorder (BPD) is characterized by hypersensitivity to rejection and resulting instability of interpersonal relationships, self-image, affect, and behavior. Option C: Obsessive-compulsive personality disorder is characterized by a preoccupation with impulses and thoughts that the client realizes are senseless but can’t control. Obsessive-compulsive disorder (OCD) is often a disabling condition consisting of bothersome intrusive thoughts that elicit a feeling of discomfort. To reduce the anxiety and distress associated with these thoughts, the patient may employ compulsions or rituals. These rituals may be personal and private, or they may involve others to participate; the rituals are to compensate for the ego-dystonic feelings of the obsessional thoughts and can cause a significant decline in function. Option D: Narcissistic personality disorder is marked by a pattern of self-involvement, grandiosity, and demand for constant attention. Narcissistic personality disorder (NPD) is a pattern of pg. 26 26 grandiosity, need for admiration, and lack of empathy per the Diagnostic and Statistical Manual of Mental Disorders (DSM–5). The disorder is classified in the dimensional model of “Personality Disorders.”NPD is highly comorbid with other disorders in mental health. 31. A male client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from nurse Julia? A. “Why didn’t you get someone else to drive you?” B. “Tell me how you feel about the accident.” C. “You should know better than to drink and drive.” D. “I recommend that you attend an Alcoholics Anonymous meeting.” Correct Answer: B. “Tell me how you feel about the accident.” An open-ended statement or question is the most therapeutic response. It encourages the widest range of client responses, makes the client an active participant in the conversation, and shows the client that the nurse is interested in his feelings. mix open-ended questions with focus questions. Open-ended questions may allow the patient to express their thoughts and feelings, and focused questions allow the interviewer to obtain important details with yes or no answers in a more time-efficient manner. Option A: Asking the client why he drove while intoxicated can make him feel defensive and intimidated. The first question posed in the interview is often open-ended. For example, “What is the main reason you seek medical assistance today?” This provides an opportunity for the interviewer to allow the patient to share their concerns, and the interviewer can show he or she is actively listening. This includes listening without judgment and displaying concern for the patient during communication. Option C: A judgmental approach isn’t therapeutic. During the interview, meaningful questions inquired positively will reduce defensiveness from the patient. Often this can be accomplished by suggesting or sharing a common behavior associated with the actions of the patient. For example, the interviewer may convey the commonality for people to consume alcohol when under stress. It then becomes acceptable to inquire if this is also occurring with the patient. The patient may feel a sense of trust and therefore share pertinent information. Option D: By giving advice, the nurse suggests that the client isn’t capable of making decisions, thus fostering dependency. At the conclusion of the patient interview, an appropriate transition statement to begin the physical exam may be, “Is there anything else that you would like to share with me before I start the physical examination?” This statement serves 2 purposes. First, it elicits any additional information the patient deems necessary, and second, it signals a transition to the physical exam. Lastly, before concluding the interview, it is important to discuss the probable follow- up plan and further treatment. In the outpatient setting, this may include admission to the hospital or going home and returning for a follow-up appointment at a designated time. 32. In the emergency department, a client with facial lacerations states that her husband beat her with a shoe. After the health care team repairs her lacerations, she waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the client’s husband pg. 27 27 arrives, shouting that he wants to “finish the job.” What is the first priority of the health care worker who witnesses this scene? A. Remaining with the client and staying calm. B. Calling a security guard and another staff member for assistance. C. Telling the client’s husband that he must leave at once. D. Determining why the husband feels so angry. Correct Answer: B. Calling a security guard and another staff member for assistance. The health care worker who witnesses this scene must take precautions to ensure personal as well as client safety but shouldn’t attempt to manage a physically aggressive person alone. Therefore, the first priority is to call a security guard and another staff member. Domestic violence is defined as a pattern of abusive behaviors by one partner against another in an intimate relationship such as marriage, dating, family, or cohabitation. In this definition, domestic violence takes many forms, including physical aggression or assault, sexual abuse, emotional abuse, controlling or domineering behavior, intimidation, stalking, passive/covert abuse, and economic deprivation. Option A: After doing this, the health care worker should inform the husband what is expected, speaking in concise statements, and maintaining a firm but calm demeanor. This approach makes it clear that the health care worker is in control and may diffuse the situation until the security guard arrives. Nurses can play an important role in working toward the creation of a violence-free community but they must first become informed. They must then insist the organizations in which they work to accept this responsibility and work together to create environments that support people experiencing domestic violence. Option C: Telling the husband to leave would probably be ineffective because of his agitated and irrational state. Although the exact rates are widely disputed, especially within the United States, there is a large body of cross-cultural evidence that women are subjected to domestic violence significantly more often than men. In addition, there is broad consensus that women are more often subjected to severe forms of abuse and are more likely to be injured by an abusive partner. According to a report by the United States Department of Justice, a survey of 16,000 Americans showed 22.1 percent of women and 7.4 percent of men reported being physically assaulted by a current or former spouse, cohabiting partner, boyfriend, girlfriend, or date in their lifetime. Option D: Exploring his anger doesn’t take precedence over safeguarding the client and staff. Gender roles and expectations play a role in abusive situations, and exploring these roles and expectations can be helpful in addressing abusive situations. Likewise, it can be helpful to explore factors such as race, class, religion, sexuality, and philosophy. However, studies investigating whether sexist attitudes are correlated with domestic violence have shown conflicting results. 33. Nurse Jannah is monitoring a male client who has been placed in restraints because of violent behavior. Nurse determines that it will be safe to remove the restraints when: A. The client verbalizes the reasons for the violent behavior. B. The client apologizes and tells the nurse that it will never happen again. pg. 30 30 selective serotonin reuptake inhibitor (SSRI). This medication works by helping to restore the balance of a certain natural substance (serotonin) in the brain. Option D: Paroxetine is a selective serotonin reuptake inhibitor (SSRI), and, as such, is identified as an antidepressant. It is FDA approved for major depressive disorder (MDD), obsessive-compulsive disorder (OCD), social anxiety disorder (SAD), panic disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), and premenstrual dysphoric disorder (PMDD), vasomotor symptoms associated with menopause. 36. For a female client with anorexia nervosa, nurse Rose plans to include the parents in therapy sessions along with the client. What fact should the nurse remember to be typical of parents of clients with anorexia nervosa? A. They tend to overprotect their children. B. They usually have a history of substance abuse. C. They maintain emotional distance from their children. D. They alternate between loving and rejecting their children. Correct Answer: A. They tend to overprotect their children. Clients with anorexia nervosa typically come from a family with parents who are controlling and overprotective. These clients use eating to gain control of an aspect of their lives. Similarly, issues like anxiety, depression, and addiction can also run in families, and have also been found to increase the chances that a person will develop an eating disorder. Many people with anorexia report that, as children, they always followed the rules and felt there was one “right way” to do things. Option B: Substance abuse and eating disorders frequently co-occur, with up to 50% of individuals with eating disorders who abuse alcohol or illicit drugs, a rate five times higher than the general population. Substance abuse problems may begin before or during an eating disorder, or even after recovery. Those struggling with co-occurring substance use and disordered eating should speak with a trained professional who can understand, diagnose, and treat both substance use disorders and eating disorders. Option C: Loneliness and isolation are some of the hallmarks of anorexia; many with the disorder report having fewer friends and social activities, and less social support. Whether this is an independent risk factor or linked to other potential causes (such as social anxiety) isn’t clear. Option D: Eating disorders are complex and affect all kinds of people. Risk factors for all eating disorders involve a range of biological, psychological, and sociocultural issues. These factors may interact differently in different people, so two people with the same eating disorder can have very diverse perspectives, experiences, and symptoms. Still, researchers have found broad similarities in understanding some of the major risks for developing eating disorders. 37. Dennis has a lithium level of 2.4 mEq/L. The nurse immediately would assess the client for which of the following signs or symptoms? A. Weakness pg. 31 31 B. Diarrhea C. Blurred vision D. Fecal incontinence Correct Answer: C. Blurred vision At lithium levels of 2 to 2.5 mEq/L the client will experience blurred vision, muscle twitching, severe hypotension, and persistent nausea and vomiting. Intoxication degree is of utmost importance for understanding lithium toxicity diagnosis and management. The severity of lithium toxicity is often divided into the following three grades: mild, moderate, and severe. In mild, there is nausea, vomiting, lethargy, tremor, and fatigue (Serum lithium concentration between 1.5-2.5 mEq/L). Option A: Symptoms of intoxication include coarse tremor, hyperreflexia, nystagmus, and ataxia. Patients often show varying consciousness levels, ranging from mild confusion to delirium. Although the neurological symptoms are mostly reversible, some reports indicate that symptoms might persist for 12 months and never resolve. Option B: With levels between 1.5 and 2 mEq/L the client experiencing vomiting, diarrhea, muscle weakness, ataxia, dizziness, slurred speech, and confusion. Symptoms typically occur within 1 hour of ingestion and are more common in the acute overdose setting. To determine the extent of lithium toxicity, one must determine the ingested amount, time of ingestion, whether there are coingestants, and if the ingestion was intentional or unintentional. It is worth noting that lithium toxicity signs do not often conform to the measured lithium level. Option D: At lithium levels of 2.5 to 3 mEq/L or higher, urinary and fecal incontinence occurs, as well as seizures, cardiac dysrhythmias, peripheral vascular collapse, and death. Renal toxicity is more common in patients on chronic lithium treatment. Toxicity includes impaired urinary concentrating ability, nephrogenic diabetes insipidus (the most common cause of drug-induced NDI), sodium- losing nephritis, nephrotic syndrome along other manifestations. 38. A male client is being treated for alcoholism. After a family meeting, the client’s spouse asks the nurse about ways to help the family deal with the effects of alcoholism. Nurse Lily should suggest that the family join which organization? A. Al-Anon B. Make Today Count C. Emotions Anonymous D. Alcoholics Anonymous Correct Answer: A. Al-Anon Al-Anon is an organization that assists family members to share common experiences and increase their understanding of alcoholism. Al?Anon members come to understand problem drinking as a family illness that affects everyone in the family. By listening to Al?Anon members speak at Al?Anon meetings, they can hear how they came to understand their own role in this family illness. This insight put them in a better position to play a positive role in the family’s future. pg. 32 32 Option B: Make Today Count is a support group for people with life-threatening or chronic illnesses. MTC is a mutual support group for persons with terminal illnesses. Organized in 1974, it is part of what some have called the “happy death movement.” This movement seeks to make death more humane and less technological. Option C: Emotions Anonymous is a support group for people experiencing depression, anxiety, or similar conditions. Emotions Anonymous International (EAI) is a nonprofit organization that facilitates the ongoing efforts of an international fellowship of men and women who desire to improve their emotional well-being. EA members come together in weekly meetings for the purpose of working toward recovery from any sort of emotional difficulties. EA members are of diverse ages, races, economic status, social and educational backgrounds. The only requirement for membership is a desire to become well emotionally. Option D: Alcoholics Anonymous is an organization that helps alcoholics recover by using a twelve- step program. Alcoholics Anonymous is an international fellowship of men and women who have had a drinking problem. It is nonprofessional, self-supporting, multiracial, apolitical, and available almost everywhere. There are no age or education requirements. Membership is open to anyone who wants to do something about their drinking problem. 39. A 14-year-old client was brought to the clinic by her mother. Her mother expresses concern about her daughter’s weight loss and constant dieting. Nurse Kris conducts a health history interview. Which of the following comments indicates that the client may be suffering from anorexia nervosa? A. “I like the way I look. I just need to keep my weight down because I’m a cheerleader.” B. “I don’t like the food my mother cooks. I eat plenty of fast food when I’m out with my friends.” C. “I just can’t seem to get down to the weight I want to be. I’m so fat compared to other girls.” D. “I do diet around my periods; otherwise, I just get so bloated.” Correct Answer: C. “I just can’t seem to get down to the weight I want to be. I’m so fat compared to other girls.” Low self-esteem is the highest risk factor for anorexia nervosa. Constant dieting to get down to a “desirable weight” is characteristic of the disorder. Feeling inadequate when compared to peers indicates poor self-esteem. Anorexia is also more common among teenagers. Still, people of any age can develop this eating disorder, though it’s rare in those over 40. Teens may be more at risk because of all the changes their bodies go through during puberty. They may also face increased peer pressure and be more sensitive to criticism or even casual comments about weight or body shape. Option A: Most clients with anorexia nervosa don’t like the way they look, and their self-perception may be distorted. A girl with cachexia may perceive herself to be overweight when she looks in the mirror. Some people with anorexia may have obsessive-compulsive personality traits that make it easier to stick to strict diets and forgo food despite being hungry. They may have an extreme drive pg. 35 35 42. A male client who reportedly consumes one (1) qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, Dr. Smith is most likely to prescribe which drug? A. Clozapine (Clozaril) B. Thiothixene (Navane) C. Lorazepam (Ativan) D. Lithium carbonate (Eskalith) Correct Answer: C. Lorazepam (Ativan) The best choice for preventing or treating alcohol withdrawal symptoms is lorazepam, a benzodiazepine. Lorazepam is a benzodiazepine medication developed by DJ Richards. It went on the market in the United States in 1977. Lorazepam has common use as the sedative and anxiolytic of choice in the inpatient setting owing to its fast (1 to 3 minute) onset of action when administered intravenously. Lorazepam is also one of the few sedative-hypnotics with a relatively clean side effect profile. ff-label (non-FDA-approved) uses for Lorazepam include rapid tranquilization of the agitated patient, alcohol withdrawal delirium, alcohol withdrawal syndrome, insomnia, panic disorder, delirium, chemotherapy- associated anticipatory nausea and vomiting (adjunct or breakthrough), as well as psychogenic catatonia. Option A: Clozapine is an FDA-approved atypical antipsychotic drug for treatment-resistant schizophrenia.[1] The definition of treatment-resistant schizophrenia is persistent or moderate delusions or hallucinations after failing two trials of antipsychotic medicines. Clozapine is part of a group of drugs known as second-generation antipsychotics or atypical antipsychotics.[1] Antipsychotic drugs are vital in treating the core symptoms of schizophrenia: hallucinations and delusions. Option B: Thiothixene is used to treat the symptoms of schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). Thiothixene is in a group of medications called conventional antipsychotics. It works by decreasing abnormal excitement in the brain. Option D: Lithium was the first mood stabilizer and is still the first-line treatment option, but is underutilized because it is an older drug. Lithium is a commonly prescribed drug for a manic episode in bipolar disorder as well as maintenance therapy of bipolar disorder in a patient with a history of a manic episode. The primary target symptoms of lithium are mania and unstable mood. Lithium is also prescribed for major depressive disorder as an adjunct therapy, bipolar disorder without a history of mania, treatment of vascular headaches, and neutropenia. These are off-label uses, meaning they are not FDA-approved. Patients with rapid cycling and mixed state types of bipolar disorder generally do less well on lithium. 43. A male client with a history of cocaine addiction is admitted to the coronary care unit for evaluation of substernal chest pain. The electrocardiogram (ECG) shows a 1-mm ST-segment elevation of the anteroseptal leads and T-wave inversion in leads V3 to V5. Considering the client’s history of drug abuse, nurse Greg expects the physician to prescribe: pg. 36 36 A. Lidocaine (Xylocaine). B. Procainamide (Pronestyl). C. Nitroglycerin (Nitro-Bid IV). D. Epinephrine. Correct Answer: C. Nitroglycerin (Nitro-Bid IV). The elevated ST segments in this client’s ECG indicate myocardial ischemia. To reverse this problem, the physician is most likely to prescribe an infusion of nitroglycerin to dilate the coronary arteries. Nitroglycerin is a vasodilatory drug used primarily to provide relief from anginal chest pain. Although nitroglycerin has a vasodilatory effect in both arteries and veins, the profound desired effects caused by nitroglycerin are primarily due to venodilation. Venodilation causes pooling of blood within the venous system, reducing preload to the heart, which causes a decrease in cardiac work, reducing anginal symptoms secondary to demand ischemia. Option A: Lidocaine, formerly also referred to as lignocaine, is an amide local anesthetic agent. The drug is commonly used for local anesthesia, often in combination with epinephrine (which acts as a vasopressor and extends its duration of action at a site by opposing the local vasodilatory effects of lidocaine). Option B: Procainamide is a cardiac drug that may be indicated for this client at some point but isn’t used for coronary artery dilation. Procainamide is a medication used in the management and treatment of ventricular arrhythmias, supraventricular arrhythmias, atrial flutter, atrial fibrillation, AV nodal reentrant tachycardia, and Wolf-Parkinson-White syndrome. It is a Class 1A antiarrhythmic agent. Option D: If a cocaine user experiences ventricular fibrillation or asystole, the physician may prescribe epinephrine. However, this drug must be used with caution because cocaine may potentiate its adrenergic effects. Epinephrine is one of the most commonly used agents in a variety of settings as it functions as medication and hormone. It is currently FDA-approved for various situations, including emergency treatment of type 1 hypersensitivity reactions including anaphylaxis, induction, and maintenance of mydriasis during intraocular surgeries, and hypotension due to septic shock. 44. For a female client with anorexia nervosa, Nurse Jimmy is aware that which goal takes the highest priority? A. The client will establish adequate daily nutritional intake. B. The client will make a contract with the nurse that sets a target weight. C. The client will identify self-perceptions about body size as unrealistic. D. The client will verbalize the possible physiological consequences of self-starvation. Correct Answer: A. The client will establish adequate daily nutritional intake. pg. 37 37 According to Maslow’s hierarchy of needs, all humans need to meet basic physiological needs first. Because a client with anorexia nervosa eats little or nothing, the nurse must first plan to help the client meet this basic, immediate physiological need. Treatment for anorexia nervosa is centered on nutrition rehabilitation and psychotherapy. Refeeding syndrome can occur following prolonged starvation. As the body utilizes glucose to produce molecules of adenosine triphosphate (ATP), it depletes the remaining stores of phosphorus. Also, glucose entry into cells is mediated by insulin and occurs rapidly following long periods without food. Both cause electrolyte abnormalities such as hypophosphatemia and hypokalemia, triggering cardiac and respiratory compromise. Patients should be followed carefully for signs of refeeding syndrome and electrolytes closely monitored. Option B: Recovery from an eating disorder can be a long process that requires not only a qualified team of professionals but also the love and support of family and friends. It is not uncommon for someone who suffers from an eating disorder to feel uncertain about their progress or for their loved ones to feel disengaged from the treatment process. These potential roadblocks may lead to feelings of ambivalence, limited progress, and treatment dropout. Option C: Anorexia nervosa is a psychiatric disease in which patients restrict their food intake relative to their energy requirements through eating less, exercising more, and/or purging food through laxatives and vomiting. Despite being severely underweight, they do not recognize it and have distorted body images. They can develop complications from being underweight and purging food. Diagnose by history, physical, and lab work that rules out other conditions that can make people lose weight. Treatment includes gaining weight (sometimes in a hospital if severe), therapy to address body image, and management of complications from malnourishment. Option D: The nurse may give lesser priority to goals that address long-term plans, self-perception, and potential complications. Eating disorders can affect every organ system in the body, and people struggling with an eating disorder need to seek professional help. The earlier a person with an eating disorder seeks treatment, the greater the likelihood of physical and emotional recovery. 45. Mr. Garcia, an attorney who throws books and furniture around the office after losing a case, is referred to the psychiatric nurse in the law firm’s employee assistance program. Nurse Beatriz knows that the client’s behavior most likely represents the use of which defense mechanism? A. Regression B. Projection C. Reaction-formation D. Intellectualization Correct Answer: A. Regression An adult who throws temper tantrums, such as this one, is displaying regressive behavior, or behavior that is appropriate at a younger age. Adapting one’s behavior to earlier levels of psychosocial development. For example, a stressful event may cause an individual to regress to bed-wetting after they have already outgrown this behavior. pg. 40 40 48. A male client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, “It felt so wonderful to get high.” Which of the following is the most appropriate response? A. “If you continue to talk like that, I’m going to stop speaking to you.” B. “You told me you got fired from your last job for missing too many days after taking drugs all night.” C. “Tell me more about how it felt to get high.” D. “Don’t you know it’s illegal to use drugs?” Correct Answer: B. “You told me you got fired from your last job for missing too many days after taking drugs all night.” Confronting the client with the consequences of substance abuse helps to break through denial. Present reality by spending time with the client to facilitate reality orientation because your physical presence is the reality. Be simple, direct, and concise when speaking to the client. Talk with the client about concrete or familiar things; avoid ideological or theoretical discussions. The client’’s ability to process abstractions or complexities is impaired. Option A: Making threats isn’t an effective way to promote self-disclosure or establish a rapport with the client. Motivational counseling works according to the idea that motivation for change is dynamic rather than static. Professional uses may influence change by developing a therapeutic relationship to increase therapeutic alliance, developing insight, and coping skills to resolve ambivalence, and change health-related behavior. Option C: Although the nurse should encourage the client to discuss feelings, the discussion should focus on how the client felt before, not during, an episode of substance abuse. Encouraging elaboration about his experience while getting high may reinforce the abusive behavior. Persons may withdraw from their environment with regressive behavior, fail to engage with others, or even notice physical illness and pain. Social exclusion and homelessness may ensue. In the longer term, psychosis and its potential disruption of the capacity to fulfill social roles can result in further burdens. Option D: The client undoubtedly is aware that drug use is illegal; a reminder to this effect is unlikely to alter behavior. Drug addiction exacerbates social alienation and increases potential for violent lashing out and low self-esteem, along with poor coping skills. Under these circumstances, emotional, social, or symptom-related cues can provoke recourse to available substances and suicidal ideation. They may also contribute to psychosocial instability, self-image issues, and achievement motivation. In some cases, social hostility and rejection may result. 49. Celia with a history of polysubstance abuse is admitted to the facility. She complains of nausea and vomiting 24 hours after admission. The nurse assesses the client and notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through which of the following withdrawals? A. Alcohol withdrawal B. Cannabis withdrawal pg. 41 41 C. Cocaine withdrawal D. Opioid withdrawal Correct Answer: D. Opioid withdrawal The symptoms listed are specific to opioid withdrawal. According to Diagnostic and Statistical Manual of Mental Disorders (DSM–5) criteria, signs and symptoms of opioid withdrawal include lacrimation or rhinorrhea, piloerection “goose flesh,” myalgia, diarrhea, nausea/vomiting, pupillary dilation and photophobia, insomnia, autonomic hyperactivity (tachypnea, hyperreflexia, tachycardia, sweating, hypertension, hyperthermia), and yawning. Opioid withdrawal syndrome is a life-threatening condition resulting from opioid dependence. Opioids are a group of drugs used for the management of severe pain. They are also commonly used as psychoactive substances around the world. Option A: Alcohol withdrawal would show elevated vital signs. Alcohol withdrawal symptoms occur when patients stop drinking or significantly decrease their alcohol intake after long-term dependence. Withdrawal has a broad range of symptoms from mild tremors to a condition called delirium tremens, which results in seizures and could progress to death if not recognized and treated promptly. Alcohol withdrawal can range from very mild symptoms to the severe form, which is named delirium tremens. The hallmark is autonomic dysfunction resulting from the excitation of the central nervous system. Mild signs/symptoms can arise within six hours of alcohol cessation. Option B: There is no real withdrawal from cannabis. Cannabis is considered by the Food and Drug Administration, along with heroin and peyote, as a schedule I drug. It has no accepted medical purpose and has a high potential for abuse. The mental status of the individual is a critical part of the exam and can point at the phase of cannabis use. Intoxication can include euphoria, anxiety, uncontrollable laughter, increased appetite, inattentiveness, forgetfulness, restlessness, tachycardia, conjunctival injection, and dry mouth. And less commonly may include delusions, hallucinations, and derealization. Option C: Symptoms of cocaine withdrawal include depression, anxiety, and agitation. Central nervous system (CNS) stimulants like cocaine and amphetamine can also produce withdrawal symptoms. Like opioids, the withdrawal symptoms are mild and not life-threatening. Often the individual will develop marked depression, excessive sleep, hunger, dysphoria, and severe psychomotor retardation but all vital functions are well preserved. Recovery is usually slow, and depression can last for several weeks. 50. Nurse Penny is aware that the following medical conditions are commonly found in clients with bulimia nervosa? A. Allergies B. Cancer C. Diabetes mellitus D. Hepatitis A Correct Answer: C. Diabetes mellitus pg. 42 42 Bulimia nervosa can lead to many complications, including diabetes, heart disease, and hypertension. Girls and young women with type 1 diabetes have about twice the risk of developing eating disorders as their peers without diabetes. This may be because of the weight changes that can occur with insulin therapy and good metabolic control and the extra attention people with diabetes must pay to what they eat. Option A: The most common features of eating disorders in girls and young women with type 1 diabetes are dissatisfaction with their body weight and shape and desire to be thinner; dieting or manipulation of insulin doses to control weight; and, binge eating. Researchers estimate that 10–20 percent of girls in their mid-teen years and 30–40 percent of late teenaged girls and young adult women with diabetes skip or alter insulin doses to control their weight. Option B: In people with diabetes, eating disorders can lead to poor metabolic control and repeated hospitalizations for dangerously high or low blood sugar. Chronic poor blood sugar control leads to long-term complications, such as eye, kidney, and nerve damage. Diabulimia is a media-coined term that refers to an eating disorder in a person with diabetes, typically type I diabetes, wherein the person purposefully restricts insulin in order to lose weight. Some medical professionals use the term ED-DMT1, Eating Disorder-Diabetes Mellitus Type 1, which is used to refer to any type of eating disorder comorbid with type 1 diabetes. Option D: The human body is surprisingly resilient and people with diabulimia often manage to function with much higher blood sugars than should be possible. Thus, the major consequences of diabulimia or ED-DMT1 are usually related to prolonged elevated blood sugar. These complications can be severe and irreversible, so proper treatment and early detection are critical. High blood sugar causes the body to produce certain enzymes and hormones that negatively affect the immune system and reduce the body’s defense against infection. This risk of infection plus slowed healing heightens a person’s chance of developing gangrene, sepsis, or a bone infection. 51. Eighteen hours after undergoing an emergency appendectomy, a client with a reported history of social drinking displays these vital signs: temperature, 101.6° F (38.7° C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm Hg. The client exhibits gross hand tremors and is screaming for someone to kill the bugs in the bed. Nurse Melinda should suspect: A. A postoperative infection B. Alcohol withdrawal C. Acute sepsis. D. Pneumonia. Correct Answer: B. Alcohol withdrawal The client’s vital signs and hallucinations suggest delirium tremens or alcohol withdrawal syndrome. Alcohol withdrawal symptoms occur when patients stop drinking or significantly decrease their alcohol intake after long-term dependence. Withdrawal has a broad range of symptoms from mild tremors to a condition called delirium tremens, which results in seizures and could progress to death if not recognized and treated promptly. pg. 45 45 hospital if severe), therapy to address body image, and management of complications from malnourishment. Option D: This would reward the client with attention for not eating and reinforce the control issues that are central to the underlying psychological problem; also, the client may record food and fluid intake inaccurately. Patient and family education is key to preventing high morbidity. The dietitian should educate the family on the importance of nutrition and limiting exercise. The mental health nurse should educate the patient on changes in behavior, easing stress, and overcoming any emotional issues. 54. Nurse Amy is aware that the client is at highest risk for suicide? A. One who appears depressed frequently thinks of dying and gives away all personal possessions. B. One who plans a violent death and has the means readily available. C. One who tells others that he or she might do something if life doesn’t get better soon. D. One who talks about wanting to die. Correct Answer: B. One who plans a violent death and has the means readily available. The client at highest risk for suicide is one who plans a violent death (for example, by gunshot, jumping off a bridge, or hanging), has a specific plan (for example, after the spouse leaves for work), and has the means readily available (for example, a rifle hidden in the garage). Several suicide-related demographic factors often occur in the same person. For example, if a male police officer with major depression and a significant problem with alcohol commits suicide using his service revolver (which, unfortunately, happens not infrequently), 5 risk factors are involved: sex, occupation, depression, alcohol, and gun availability. Option A: A host of thoughts and behaviors are associated with self-destructive acts. Although many assume that people who talk about suicide will not follow through with it, the opposite is true; a threat of suicide can lead to the completed act, and suicidal ideation is highly correlated with suicidal behaviors. Option C: They are without hope and therefore cannot foresee things ever improving; they also view themselves as helpless in 2 ways: (1) they cannot help themselves, and all their efforts to liberate themselves from the sea of depression in which they are drowning are to no avail; and (2) no one else can help them. Option D: A client who talks about wanting to die or attempting suicide is considered at a lower risk for suicide because this behavior typically serves to alert others that the client is contemplating suicide and wishes to be helped. Determine whether the person has any thoughts of hurting him or herself. Suicidal ideation is highly linked to completed suicide. Some inexperienced clinicians have difficulty asking this question. They fear the inquiry may be too intrusive or that they may provide the person with an idea of suicide. In reality, patients appreciate the question as evidence of the clinician’s concern. A positive response requires further inquiry. pg. 46 46 55. A female client with anorexia nervosa describes herself as “a whale.” However, the nurse’s assessment reveals that the client is 5′ 8″ (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client’s unrealistic body image, which intervention should nurse Angel be included in the plan of care? A. Asking the client to compare her figure with magazine photographs of women her age. B. Assigning the client to group therapy in which participants provide realistic feedback about her weight. C. Confronting the client about her actual appearance during one-on-one sessions, scheduled during each shift. D. Telling the client of the nurse’s concern for her health and desire to help her make decisions to keep her healthy. Correct Answer: D. Telling the client of the nurse’s concern for her health and desire to help her make decisions to keep her healthy A client with anorexia nervosa has an unrealistic body image that causes consumption of little or no food. Therefore, the client needs assistance with making decisions about health. Respond (confront) with reality when a patient makes unrealistic statements. The patient may be denying the psychological aspects of their own situation and is often expressing a sense of inadequacy and depression. Option A: Instead of protecting the client’s health, option A may serve to make the client defensive and more entrenched in her unrealistic body image. Allow the patient to draw a picture of self. It provides an opportunity to discuss the patient’s perception of self and body image and realities of an individual situation. Option B: Encourage personal development program, preferably in a group setting. Provide information about the proper application of makeup and grooming. Learning about methods to enhance personal appearance may be helpful to a long-range sense of self-esteem and image. Feedback from others can promote feelings of self-worth. Option C: Establish a therapeutic nurse-patient relationship. Within a helping relationship, the patient can begin to trust and try out new thinking and behaviors. Assist the patient to assume control in areas other than dieting and weight loss such as management of their own daily activities, work, and leisure choices. Feelings of personal ineffectiveness, low self-esteem, and perfectionism are often part of the problem. The patient feels helpless to change and requires assistance to problem-solve methods of control in life situations. 56. A male client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is Nurse Alice most likely to administer to reduce the symptoms of alcohol withdrawal? A. Naloxone (Narcan) B. Haloperidol (Haldol) pg. 47 47 C. Magnesium sulfate D. Chlordiazepoxide (Librium) Correct Answer: D. Chlordiazepoxide (Librium) Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of alcohol withdrawal. Chlordiazepoxide is a long-acting benzodiazepine and is an FDA approved medication for adults with mild-moderate to severe anxiety disorder, preoperative apprehension and anxiety, and withdrawal symptoms of acute alcohol use disorder. Chlordiazepoxide has anti-anxiety, sedative, appetite- stimulating, and weak analgesic actions. It binds to benzodiazepine receptors at the GABA-A ligand- gated chloride channel complex and enhances GABA’s inhibitory effects. Option A: Naloxone (Narcan) is administered for narcotic overdose. Naloxone is indicated for the treatment of opioid toxicity, specifically to reverse respiratory depression from opioid use. It is useful in accidental or intentional overdose and acute or chronic toxicity. Naloxone is a pure, competitive opioid antagonist with a high affinity for the mu-opioid receptor, allowing for reversal of the effects of opioids. The onset of action varies depending on the route of administration but can be as fast as one minute when delivered intravenously (IV) or intraosseous (IO). Option B: Haloperidol (Haldol) may be given to treat clients with psychosis, severe agitation, or delirium. Haloperidol is a first-generation (typical antipsychotic) which exerts its antipsychotic action by blocking dopamine D2 receptors in the brain. When 72% of dopamine receptors are blocked, this drug achieves its maximal effect. Haloperidol is not selective for the D2 receptor. It also has noradrenergic, cholinergic, and histaminergic blocking action. The blocking of these receptors is associated with various side effects. Option C: Magnesium sulfate and other anticonvulsant medications are only administered to treat seizures if they occur during withdrawal. Magnesium sulfate administration can be oral (PO), intramuscular (IM), intraosseous (IO), or intravenous (IV). For every 1 gram of magnesium sulfate, it contains 98.6 mg or 8.12Eq of elemental magnesium. Magnesium sulfate can be combined with dextrose 5% or water to make intravenous solutions. 57. Isabel with a diagnosis of depression is started on imipramine (Tofranil), 75 mg by mouth at bedtime. The nurse should tell the client that: A. This medication may be habit-forming and will be discontinued as soon as the client feels better. B. This medication has no serious adverse effects. C. The client should avoid eating such foods as aged cheeses, yogurt, and chicken livers while taking the medication. D. This medication may initially cause tiredness, which should become less bothersome over time. Correct Answer: D. This medication may initially cause tiredness, which should become less bothersome over time. pg. 50 50 Option B: If the client shows signs of agitation or confusion or poses a threat, the nurse should retreat and request assistance. For the care to surpass the technical focus, the psychological care and the continuous observation of patients and family members are also necessary, aiming to prioritize the communication in accordance with the qualified listening, as these patients are often insecure. It is important to highlight that all people who attempted suicide should receive professional care due to the emotional fragility in which they find themselves. The competence of the emergency team is saving lives, considering not only the physical aspects but also the psychological aspects involved in the process of caring Option C: The nurse shouldn’t attempt to sit next to the client or examine injuries without first announcing the nurse’s presence and assessing the dangers of the situation. There are some essential behaviors that nursing can use to meet a person who attempted suicide or has suicidal ideation, namely: listen carefully, be empathetic, convey non-verbal messages of acceptance, express respect for the opinion of another, talk honestly, show concern, and focus on the feelings of the person. The mere interaction with the patient has a great potential to calm down, prevent, or minimize the severity and intensity of the symptoms. Still, the team should try to establish a bond of trust from the start, whereas, on the other hand, the idea that the patient attempted suicide to manipulate others should be abandoned. 60. Which of the following drugs should Nurse Mary prepare to administer to a client with a toxic acetaminophen (Tylenol) level? A. Deferoxamine mesylate (Desferal) B. Succimer (Chemet) C. Flumazenil (Romazicon) D. Acetylcysteine (Mucomyst) Correct Answer: D. Acetylcysteine (Mucomyst) The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion of toxic metabolites to nontoxic metabolites. Acetaminophen (N-acetyl-para-aminophenol, paracetamol, APAP) toxicity is common primarily because the medication is so readily available, and there is a perception that it is very safe. More than 60 million Americans consume acetaminophen on a weekly basis. All patients with high levels of acetaminophen need admission and treatment with N-acetyl-cysteine (NAC). This agent is fully protective against liver toxicity if given within 8 hours after ingestion. Option A: Deferoxamine mesylate is the antidote for iron intoxication. Desferal is indicated for the treatment of acute iron intoxication and chronic iron overload due to transfusion-dependent anemias. Desferal is an adjunct to, and not a substitute for, standard measures used in treating acute iron intoxication, which may include the following: induction of emesis with syrup of ipecac; gastric lavage; suction and maintenance of a clear airway; control of shock with intravenous fluids, blood, oxygen, and vasopressors; and correction of acidosis. Option B: Succimer is an antidote for lead poisoning. Succimer is an oral heavy metal chelating agent used to treat lead and heavy metal poisoning. Succimer has been linked to a low rate of transient serum aminotransferase elevations during therapy, but its use has not been linked to cases pg. 51 51 of clinically apparent liver injury with jaundice. Succimer does not significantly chelate essential metals such as zinc, copper, or iron, and its specificity, safety and oral availability make it preferable to other chelating agents for treating lead poisoning such as Ca-EDTA which must be given intravenously and dimercaprol (British anti-Lewisite [BAL) which requires intramuscular administration. Option C: Flumazenil reverses the sedative effects of benzodiazepines. Flumazenil is a benzodiazepine antagonist. Flumazenil is also indicated for the management and treatment of benzodiazepine overdose in adults. It is useful in reversing coma due to benzodiazepine overdose. Flumazenil is more effective in reversing sedation or coma in patients with benzodiazepine intoxication rather than in patients with multiple drug overdoses. 61. Marielle, 17 years old was sexually attacked while on her way home from school. She is brought to the hospital by her mother. Rape is an example of which type of crisis: A. Situational B. Adventitious C. Developmental D. Internal Correct Answer: B. Adventitious Adventitious crisis is a crisis involving a traumatic event. It is not part of everyday life. An adventitious crisis can be triggered by a major natural disaster, a man-made disaster, or a crime of violence. Therefore, a tsunami or earthquake can result in an adventitious crisis. Childbirth, the death of a pet, or a leg amputation can cause a situational crisis. Option A: Situational crisis is from an external source that upsets one’s psychological equilibrium. These sudden and unexpected crises include accidents and natural disasters. Getting in a car accident, experiencing a flood or earthquake, or being the victim of a crime are just a few types of situational crises. Option C: These occur as part of the process of growing and developing through various periods of life. Sometimes a crisis is a predictable part of the life cycle, such as the crisis described in Erikson’s stages of psychosocial development. Option D: Developmental and internal crises are the same. They are transitional or developmental periods in life. A crisis can sometimes be quite obvious, such as a person losing his or her job, getting divorced, or being involved in some type of accident. In other cases, a personal crisis might be less apparent but can still lead to dramatic changes in behavior and mood. 62. Edward, a 66-year-old client with slight memory impairment and poor concentration, is diagnosed with primary degenerative dementia of the Alzheimer’s type. Early signs of this dementia include subtle personality changes and withdrawal from social interactions. To assess for progression to the middle stage of Alzheimer’s disease, the nurse should observe the client for: pg. 52 52 A. Occasional irritable outbursts. B. Impaired communication. C. Lack of spontaneity. D. Inability to perform self-care activities. Correct Answer: B. Impaired communication. Signs of advancement to the middle stage of Alzheimer’s disease include exacerbated cognitive impairment with obvious personality changes and impaired communication, such as inappropriate conversation, actions, and responses. Symptoms of Alzheimer’s disease depend on the stage of the disease. Alzheimer’s disease is classified into preclinical or presymptomatic, mild, and dementia-stage depending on the degree of cognitive impairment. These stages are different from the DSM-5 classification of Alzheimer’s disease. Option A: Neuropsychiatric symptoms like apathy, social withdrawal, disinhibition, agitation, psychosis, and wandering are also common in the mid to late stages. However, other than occasional irritable outbursts and lack of spontaneity, the client is usually cooperative and exhibits socially appropriate behavior. Option C: Initially, memory impairment may be the only cognitive deficit in a client with Alzheimer’s disease. During the early stage of this disease, subtle personality changes may also be present. In the early stages, impairment in executive functioning ranges from subtle to significant. This is followed by language disorder and impairment of visuospatial skills. The initial and most common presenting symptom is episodic short-term memory loss with relative sparing of long-term memory and can be elicited in most patients even when not the presenting symptom. Option D: During the late stage, the client can’t perform self-care activities and may become mute. Difficulty performing learned motor tasks (dyspraxia), olfactory dysfunction, sleep disturbances, extrapyramidal motor signs like dystonia, akathisia, and parkinsonian symptoms occur late in the disease. This is followed by primitive reflexes, incontinence, and total dependence on caregivers. 63. A female client begins to experience alcoholic hallucinosis. Nurse Joy is aware that the best nursing intervention at this time? A. Keeping the client restrained in bed. B. Checking the client’s blood pressure every 15 minutes and offering juices. C. Providing a quiet environment and administering medication as needed and prescribed. D. Restraining the client and measuring blood pressure every 30 minutes. Correct Answer: C. Providing a quiet environment and administering medication as needed and prescribed. Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment for reducing stimulation and administering prescribed central nervous system depressants in dosages that control pg. 55 55 established. The next step is to refer all patients deemed to be at higher risk for suicide to a mental health counselor as soon as possible. Every state has laws and procedures regarding this process which must be incorporated into the clinical practice when addressing individuals at high suicide risk. Option D: Decreased communication is a sign of withdrawal that may indicate the client has decided to commit suicide; the nurse shouldn’t disregard it. In some cases, assessment of the mental status may provide a clue to the individual’s potential for self-harm. Depressed patients will often tend to appear unclean and unkempt. The clothing may not be ironed or dirty. The risk of suicide is often high in people who appear very anxious or depressed. The patient may exhibit a flat affect or no emotions at all. Some depressed patients may develop hallucinations that may be telling him or her to kill themselves. The majority of these hallucinations are auditory. 66. Anthony is very hostile toward one of the staff for no apparent reason. He is manifesting: A. Splitting B. Transference C. Countertransference D. Resistance Correct Answer: B. Transference Transference is a positive or negative feeling associated with a significant person in the client’s past that are unconsciously assigned to another. Transference occurs when a person redirects some of their feelings or desires for another person to an entirely different person. Transference can also happen in a healthcare setting. For example, transference in therapy happens when a patient attaches anger, hostility, love, adoration, or a host of other possible feelings onto their therapist or doctor. Therapists know this can happen. They actively try to monitor it. Option A: Splitting is a defense mechanism commonly seen in a client with personality disorder in which the world is perceived as all good or all bad Failing to reconcile both positive and negative attributes into a whole understanding of a person or situation, resulting in all-or-none thinking. Splitting is commonly associated with borderline personality disorder. Option C: Countertransference is a phenomenon where the nurse shifts feelings assigned to someone in her past to the patient. Countertransference, which occurs when a therapist transfers emotions to a person in therapy, is often a reaction to transference, a phenomenon in which the person in treatment redirects feelings for others onto the therapist. Option D: Resistance is the client’s refusal to submit himself to the care of the nurse. Clients are sometimes resistant because the counselor is asking them to deal with an undesired agenda. Resistance means we’re working on the wrong problem, a problem that the client doesn’t care to work on. Counselors need to connect with the client in order to find the right problem. pg. 56 56 67. Nurse Josefina is caring for a client who has been diagnosed with delirium. Which statement about delirium is true? A. It's characterized by an acute onset and lasts about 1 month. B. It's characterized by a slowly evolving onset and lasts about 1 week. C. It's characterized by a slowly evolving onset and lasts about 1 month. D. It's characterized by an acute onset and lasts hours to a number of days. Correct Answer: D. It’s characterized by an acute onset and lasts hours to a number of days Delirium has an acute onset and typically can last from several hours to several days. Delirium, also known as the acute confusional state, is a clinical syndrome that usually develops in the elderly. It is characterized by an alteration of consciousness and cognition with reduced ability to focus, sustain, or shift attention. Option A: It develops over a short period and fluctuates during the day. The clinical presentation can vary, but usually, it flourishes with psychomotor behavioral disturbances such as hyperactivity or hypoactivity with increased sympathetic activity and impairment in sleep duration and architecture. It is caused by a medical condition, substance intoxication, or withdrawal in addition to the medication side effects, as well as; it is no better explained by another preexisting, involving, or established neurocognitive disorder. Option B: Delirium can be a life-threatening emergency. Affected patients require an appropriate evaluation with history taking, physical, and neurologic examination and laboratory tests. Physical examination should evaluate head-to-toe and vital signs to determine any possible cause. Neurologic examination should focus on evaluating new focal findings that suggest an intracranial cause, for example, a stroke. Option C: Only 12% to 35% of delirium cases are recognized. The first thing one has to do is determine the patient’s baseline mental status and the acuity of the symptom presentation, delirium presents over hours to days. This step requires a knowledgeable informant to obtain the history. Although, it is necessary for the diagnosis to know if the disturbance in mental status started alone or with other symptoms as dyspnea or dysuria or with medication changes. 68. Nurse Helen is assigned to care for a client with anorexia nervosa. Initially, which nursing intervention is most appropriate for this client? A. Providing one-on-one supervision during meals and for one (1) hour afterward. B. Letting the client eat with other clients to create a normal mealtime atmosphere. C. Trying to persuade the client to eat and thus restore nutritional balance. D. Giving the client as much time to eat as desired. Correct Answer: A. Providing one-on-one supervision during meals and for one (1) hour afterward. pg. 57 57 Because the client with anorexia nervosa may discard food or induce vomiting in the bathroom, the nurse should provide one-on-one supervision during meals and for 1 hour afterward. Provide one-to- one supervision and have a patient with bulimia remain in the day room area with no bathroom privileges for a specified period (1 hr) following eating, if contracting is unsuccessful. Prevents vomiting during and after eating. The patient may desire food and use a binge-purge syndrome to maintain weight. Note: The patient may purge for the first time in response to the establishment of a weight gain program. Option B: This wouldn’t be therapeutic because other clients may urge the client to eat and give attention for not eating. Supervise the patient during mealtimes and for a specified period after meals (usually one hour). It prevents vomiting during or after eating. Option C: This would reinforce control issues, which are central to this client’s underlying psychological problem. Establish a minimum weight goal and daily nutritional requirements. Malnutrition is a mood-altering condition, leading to depression and agitation and affecting cognitive function and decision making. Improved nutritional status enhances thinking ability, allowing initiation of psychological work. Option D: Instead of giving the client unlimited time to eat, the nurse should set limits and let the client know what is expected. Make a selective menu available, and allow the patient to control choices as much as possible. Patient who gains confidence in himself and feels in control of the environment is more likely to eat preferred foods. Be alert to choices of low-calorie foods and beverages; hoarding food; disposing of food in various places, such as pockets or wastebaskets. Patients will try to avoid taking in what is viewed as excessive calories and may go to great lengths to avoid eating. 69. When planning care for a client who has ingested phencyclidine (PCP), nurse Wayne is aware that the following is the highest priority? A. Client’s physical needs B. Client’s safety needs C. Client’s psychosocial needs D. Client’s medical needs Correct Answer: B. Client’s safety needs The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as the staff. Drug effects are unpredictable and prolonged, and the client may lose control easily. Phencyclidine (PCP) is a dissociative anesthetic that is a commonly used recreational drug. PCP is a crystalline powder that can be ingested orally, injected intravenously, inhaled, or smoked. PCP is available as a powder, crystal, liquid, and tablet. It produces both stimulation and depression of the CNS. PCP is a non- competitive antagonist to the NMDA receptor, which causes analgesia, anesthesia, cognitive defects, and psychosis. Option A: Depending on the dose and route of administration, PCP can have a wide range of central nervous system (CNS) manifestations. Emergency department providers should become familiar pg. 60 60 72. Cely with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication? A. Calcium B. Sodium C. Chloride D. Potassium Correct Answer: B. Sodium Lithium is chemically similar to sodium. If sodium levels are reduced, such as from sweating or diuresis, lithium will be reabsorbed by the kidneys, increasing the risk of toxicity. Clients taking lithium shouldn’t restrict their intake of sodium and should drink adequate amounts of fluid each day. It is also important to monitor patients for dehydration and lower the dose when there are signs of infection, excessive sweating, or diarrhea. Toxic levels are when the drug level is more than 2 mEq/L. Option A: Lithium modifies sodium transport in nerve and muscle cells. It alters the metabolism of neurotransmitters, specifically catecholamines, and serotonin. It may alter intracellular signaling via second messenger systems by inhibition of inositol monophosphate. This inhibition, in turn, affects neurotransmission through the phosphatidylinositol secondary messenger system. Option C: Before starting treatment with lithium, it is essential to get kidney function tests and thyroid function tests. In patients above 50 years of age, an electrocardiogram is also necessary. Repeat these tests once or twice a year in patients on lithium therapy. Because lithium is associated with weight gain, it is important to weigh a patient before starting treatment. It is also beneficial to determine if the patient has prediabetes, diabetes, or dyslipidemia. Option D: The other electrolytes are important for normal body functions but sodium is most important to the absorption of lithium. Monitoring of therapeutic levels includes trough plasma levels drawn 8 to 12 hours after the last dose. The therapeutic range is 1.0 to 1.5 mEq/L for acute treatment and 0.6 to 1.2 mEq/L for chronic therapy. Monitoring should be done every 1 to 2 weeks until reaching the desired therapeutic levels. Then, check lithium levels every 2 to 3 months for six months. 73. A male client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink six (6) hours before admission. Based on this response, nurse Lorena should expect early withdrawal symptoms to: A. Begin after seven (7) days. B. Not occur at all because the time period for their occurrence has passed. C. Begin anytime within the next one (1) to two (2) days. D. Begin within two (2) to seven (7) days. Correct Answer: C. Begin anytime within the next one (1) to two (2) days pg. 61 61 Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1 to 2 days later. Delirium tremens may occur 2 to 4 days — even up to 7 days — after the last drink. Moderate symptoms include alcohol withdrawal seizures (rum fits) that can occur 12 to 24 hours after cessation of alcohol and are typically generalized in nature. There is a 3% incidence of status epilepticus in these patients. About 50% of patients who have had a withdrawal seizure will progress to delirium tremens. Option A: Mild signs/symptoms can arise within six hours of alcohol cessation. If symptoms do not progress to more severe symptoms within 24 to 48 hours, the patient will likely recover. However, the time to presentation and range of symptoms can vary greatly depending on the patient, their duration of alcohol dependence, and volume typically ingested. Option B: Most cases should be described by their severity of symptoms, not the time since their last drink. Noting the time of their last drink is essential in any patient with an alcohol dependence history who may be presenting with other complaints. Mild symptoms can be insomnia, tremulousness, hyperreflexia, anxiety, gastrointestinal upset, headache, palpitations. Option D: Delirium tremens is the most severe form of alcohol withdrawal, and its hallmark is that of an altered sensorium with significant autonomic dysfunction and vital sign abnormalities. It includes visual hallucinations, tachycardia, hypertension, hyperthermia, agitation, and diaphoresis. Symptoms of delirium tremens can last up to seven days after alcohol cessation and may last even longer. 74. A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect that the child was abused? A. The child cries uncontrollably throughout the examination. B. The child pulls away from contact with the physician. C. The child doesn’t cry when the shoulder is examined. D. The child doesn’t make eye contact with the nurse. Correct Answer: C. The child doesn’t cry when the shoulder is examined. A characteristic behavior of abused children is the lack of crying when they undergo a painful procedure or are examined by a healthcare professional. Therefore, the nurse should suspect child abuse. Physical abuse may include beating, shaking, burning, and biting. The threshold for defining corporal punishment as abuse is unclear. Rib fractures are found to be the most common finding associated with physical abuse. Any child younger than two years old for whom there is a concern of physical abuse should have a skeletal survey. Additionally, any sibling younger than two years of age of an abused child should also have a skeletal survey. A skeletal survey consists of 21 dedicated views, as recommended by the American College of Radiology. Option A: The World Health Organization (WHO) defines child maltreatment as “all forms of physical and emotional ill-treatment, sexual abuse, neglect, and exploitation that results in actual or potential harm to the child’s health, development or dignity.” There are four main types of abuse: pg. 62 62 neglect, physical abuse, psychological abuse, and sexual abuse. Abuse is defined as an act of commission and neglect is defined as an act of omission in the care leading to potential or actual harm. Option B: Physical abuse should be considered in the evaluation of all injuries of children. A thorough history of present illness is important to make a correct diagnosis. Important aspects of the history-taking involve gathering information about the child’s behavior before, during, and after the injury occurred. History-taking should include the interview of each caretaker separately and the verbal child, as well. The parent or caretaker should be able to provide their history without interruptions in order not to be influenced by the physician’s questions or interpretations. Option D: The second most common type of child abuse after neglect is physical abuse. Eighty percent of abusive fractures occur in non-ambulatory children, particularly in children younger than 18 months of age. The most important risk factor for abusive skeletal injury is age. There is no fracture pathognomonic for abuse, but there are some fractures that are more suggestive of abuse. These include posterior or lateral rib fractures and “corner” or “bucket handle” fractures, which occur at the ends of long bones and which result from a twisting mechanism. Other highly suspicious fractures are sternal, spinal and scapular fractures. 75. Flumazenil (Romazicon) has been ordered for a male client who has overdosed on oxazepam (Serax). Before administering the medication, nurse Gina should be prepared for which common adverse effect? A. Seizures B. Shivering C. Anxiety D. Chest pain Correct Answer: A. Seizures Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. Benzodiazepine reversal has correlations with seizures. Seizures may happen more frequently in patients who have been on benzodiazepines for long-term sedation or in patients who are showing signs of severe tricyclic antidepressant overdose. The required dosage of Flumazenil should be measured and prepared by the practitioners to manage seizures. Flumazenil use requires caution in patients relying on a benzodiazepine for seizure control. Option B: Shivering is not an adverse effect of flumazenil. Monitor the patient for the possible return of sedation, mostly in those who are tolerant of benzodiazepines. Patients should have monitoring for respiratory depression, benzodiazepine withdrawal, and other residual effects of benzodiazepines for at least 2 hours. Option C: Anxiety is a rare adverse effect for people using flumazenil. Flumazenil has some associations with precipitation of seizures in patients with benzodiazepine dependence with a