A patient says to the nurse, “I dreamed I was stoned. When I woke up, I felt emotionally
drained, as though I hadn’t rested well.” Which response should the nurse use to clarify the
patient’s comment? “It sounds as though you were uncomfortable with the content of your dream.” “I understand what you’re saying. Bad dreams leave me feeling tired, too.” “So you feel as though you did not get enough quality sleep last night?” “Can you give me an example of what you mean by ‘stoned’?”.
A patient diagnosed with schizophrenia tells the nurse, “The Central Intelligence Agency is
monitoring us through the fluorescent lights in this room. The CIA is everywhere, so be
careful what you say.” Which response by the nurse is most therapeutic? “Let’s talk about something other than the CIA.” “It sounds like you’re concerned about your privacy.” “The CIA is prohibited from operating in health care facilities.” “You have lost touch with reality, which is a symptom of your illness.”.
The patient says, “My marriage is just great. My spouse and I always agree.” The nurse
observes the patient’s foot moving continuously as the patient twirls a shirt button. The
conclusion the nurse can draw is that the patient’s communication is clear. distorted. incongruous. inadequate.
A nurse interacts with a newly hospitalized patient. Select the nurse’s comment that applies
the communication technique of “offering self.” “I’ve also had traumatic life experiences. Maybe it would help if I told you about
them.” “Why do you think you had so much difficulty adjusting to this change in your
life?” “I hope you will feel better after getting accustomed to how this unit operates.” “I’d like to sit with you for a while to help you get comfortable talking to me.”.
Which technique will best communicate to a patient that the nurse is interested in listening? Restating a feeling or thought the patient has expressed. Asking a direct question, such as “Did you feel angry?” Making a judgment about the patient’s problem. Saying, “I understand what you’re saying.”.
A patient discloses several concerns and associated feelings. If the nurse wants to seek
clarification, which comment would be appropriate? “What are the common elements here?” “Tell me again about your experiences.” “Am I correct in understanding that.” “Tell me everything from the beginning.”.
A patient tells the nurse, “I don’t think I’ll ever get out of here.” Select the nurse’s most
therapeutic response. “Don’t talk that way. Of course you will leave here!” “Keep up the good work, and you certainly will.” “You don’t think you’re making progress?” “Everyone feels that way sometimes.”.
Documentation in a patient’s chart shows, “Throughout a 5-minute interaction, patient
fidgeted and tapped left foot, periodically covered face with hands, and looked under chair
while stating, ‘I enjoy spending time with you.’” Which analysis is most accurate? The patient is giving positive feedback about the nurse’s communication
techniques. The nurse is viewing the patient’s behavior through a cultural filter. The patient’s verbal and nonverbal messages are incongruent. The patient is demonstrating psychotic behaviors.
While talking with a patient diagnosed with major depressive disorder, a nurse notices the
patient is unable to maintain eye contact. The patient’s chin lowers to the chest. The patient
looks at the floor. Which aspect of communication has the nurse assessed? Nonverbal communication A message filter A cultural barrier Social skills.
During the first interview with a parent whose child died in a car accident, the nurse feels
empathic and reaches out to take the patient’s hand. Select the correct analysis of the nurse’s
behavior. It shows empathy and compassion. It will encourage the patient to continue to
express feelings. The gesture is premature. The patient’s cultural and individual interpretation of
touch is unknown. The patient will perceive the gesture as intrusive and overstepping boundaries. The action is inappropriate. Psychiatric patients should not be touched.
During a one-on-one interaction with the nurse, a patient frequently looks nervously at the
door. Select the best comment by the nurse regarding this nonverbal communication. “I notice you keep looking toward the door.” “This is our time together. No one is going to interrupt us.” “It looks as if you are eager to end our discussion for today.” “If you are uncomfortable in this room, we can move someplace else.”.
A black patient says to a white nurse, “There’s no sense talking about how I feel. You
wouldn’t understand because you live in a white world.” The nurse’s best action would be to explain, “Yes, I do understand. Everyone goes through the same experiences.” say, “Please give an example of something you think I wouldn’t understand.” reassure the patient that nurses interact with people from all cultures. change the subject to one that is less emotionally disturbing.
A Filipino American patient had a nursing diagnosis of situational low self-esteem related to
poor social skills as evidenced by lack of eye contact. Interventions were applied to increase
the patient’s self-esteem but after 3 weeks, the patient’s eye contact did not improve. What
is the most accurate analysis of this scenario? The patient’s eye contact should have been directly addressed by role playing to
increase comfort with eye contact. The nurse should not have independently embarked on assessment, diagnosis, and
planning for this patient. The patient’s poor eye contact is indicative of anger and hostility that were
unaddressed. The nurse should have assessed the patient’s culture before making this diagnosis
and plan.
When a female Mexican American patient and a female nurse sit together, the patient often
holds the nurse’s hand. The patient also links arms with the nurse when they walk. The
nurse is uncomfortable with this behavior. Which analysis is most accurate? The patient is accustomed to touch during conversation, as are members of many
Hispanic subcultures. The patient understands that touch makes the nurse uncomfortable and controls the
relationship based on that factor. The patient is afraid of being alone. When touching the nurse, the patient is
reassured and comforted. The patient is trying to manipulate the nurse using nonverbal techniques.
A Puerto Rican American patient uses dramatic body language when describing emotional
discomfort. Which analysis most likely explains the patient’s behavior? The patient has a histrionic personality disorder. believes dramatic body language is sexually appealing. wishes to impress staff with the degree of emotional pain. belongs to a culture in which dramatic body language is the norm.
During an interview, a patient attempts to shift the focus from self to the nurse by asking
personal questions. The nurse should respond by saying: “Why do you keep asking about me?” “Nurses direct the interviews with patients.” “Do not ask questions about my personal life.” “The time we spend together is to discuss your concerns.”.
Which principle should guide the nurse in determining the extent of silence to use during
patient interview sessions? A nurse is responsible for breaking silences. Patients withdraw if silences are prolonged. Silence can provide meaningful moments for reflection. Silence helps patients know that what they said was understood.
A patient is having difficulty making a decision. The nurse has mixed feelings about
whether to provide advice. Which principle usually applies? Giving advice is rarely helpful. fosters independence. lifts the burden of personal decision making. helps the patient develop feelings of personal adequacy.
A school age child tells the school nurse, “Other kids call me mean names and will not sit
with me at lunch. Nobody likes me.” Select the nurse’s most therapeutic response. “Just ignore them and they will leave you alone.” “You should make friends with other children.” “Call them names if they do that to you.” “Tell me more about how you feel.”.
A patient with acute depression states, “God is punishing me for my past sins.” What is the
nurse’s most therapeutic response? “You sound very upset about this.” “God always forgives us for our sins.” “Why do you think you are being punished?” “If you feel this way, you should talk to your minister.”.
A patient cries as the nurse explores the patient’s feelings about the death of a close friend.
The patient sobs, “I shouldn’t be crying like this. It happened a long time ago.” Which
responses by the nurse facilitate communication? (Select all that apply.) “Why do you think you are so upset?” “I can see that you feel sad about this situation.” “The loss of a close friend is very painful for you.” “Crying is a way of expressing the hurt you are experiencing.” “Let’s talk about something else because this subject is upsetting you.”.
Which benefits are most associated with use of telehealth technologies? (Select all that
apply.) Cost savings for patients Maximize care management Access to services for patients in rural areas Prompt reimbursement by third-party payers Rapid development of trusting relationships with patients.
Which comments by a nurse demonstrate use of therapeutic communication techniques?
(Select all that apply.) “Why do you think these events have happened to you?” “There are people with problems much worse than yours.” “I’m glad you were able to tell me how you felt about your loss.” “I noticed your hands trembling when you told me about your accident.” “You look very nice today. I’m proud you took more time with your appearance.”.
A nurse interacts with patients diagnosed with various mental illnesses. Which statements
reflect use of therapeutic communication? (Select all that apply.) “Tell me more about that situation.” “Let’s talk about something else.” “I notice you are pacing a lot.” “I’ll stay with you a while.” “Why did you do that?”.
The adult child of a patient diagnosed with major depressive disorder asks, “Do you think
depression and physical illness are connected? Since my father’s death, my mother has had
shingles and the flu, but she’s usually not one who gets sick.” Which answer by the nurse
best reflects current knowledge? “It is probably a coincidence. Emotions and physical responses travel on different
tracts of the nervous system.” “You may be paying more attention to your mother since your father died and
noticing more things such as minor illnesses.” “So far, research on emotions or stress and becoming ill more easily is unclear. We
do not know for sure if there is a link.” “Negative emotions and prolonged stress interfere with the body’s ability to
protect itself and can increase the likelihood of illness.”.
A patient diagnosed with emphysema has severe shortness of breath and needs portable
oxygen when leaving home. Recently the patient has reduced activity because of fear that
breathing difficulty will occur. A nurse suggests using guided imagery. Which image should
the patient be encouraged to visualize? Engaging in activity without using any supplemental oxygen Sleeping comfortably and soundly, without respiratory distress Feeling relaxed and taking regular deep breaths when leaving home Having a younger, healthier body that knows no exercise limitations.
A nurse leads a psychoeducational group for patients experiencing depression. The nurse
plans to implement an exercise regime for each patient. The rationale to use when
presenting this plan to the treatment team is that exercise has an antidepressant effect comparable to selective serotonin reuptake inhibitors. prevents damage from overstimulation of the sympathetic nervous system. detoxifies the body by removing metabolic wastes and other toxins. improves mood stability for patients with bipolar disorders.
A recent immigrant from Honduras comes to the clinic with a family member who has been
a U.S. resident for 10 years. The family member says, “The immigration to America has
been very difficult.” Considering cultural background, which expression of stress by this
patient would the nurse expect? Motor restlessness Somatic complaints Memory deficiencies Sensory perceptual alterations.
A patient nervously says, “Financial problems are stressing my marriage. I’ve heard rumors
about cutbacks at work; I am afraid I might get laid off.” The patient’s pulse is 112/minute;
respirations are 26/minute; and blood pressure is 166/88. Which nursing intervention will
the nurse implement? Advise the patient, “Go to sleep 30 to 60 minutes earlier each night to increase
rest.” Direct the patient in slow and deep breathing using abdominal muscles. Suggest the patient consider that a new job might be better than the present one. Tell the patient, “Relax by spending more time playing with your pet.”.
According to the Recent Life Changes Questionnaire, which situation would most
necessitate a complete assessment of a person’s stress status and coping abilities? A person who has been assigned more responsibility at work A parent whose job required relocation to a different city A person returning to college after an employer ceased operations A man who recently separated from his wife because of marital problems.
A patient newly diagnosed as HIV-positive seeks the nurse’s advice on how to reduce the
risk of infections. The patient says, “I went to church years ago and I was in my best health
then. Maybe I should start going to church again.” Which response will the nurse offer? “Religion does not usually affect health, but you were younger and stronger then.” “Contact with supportive people at a church might help, but religion itself is not
especially helpful.” “Studies show that spiritual practices can enhance immune system function and
coping abilities.” “Going to church would expose you to many potential infections. Let’s think about
some other options.”.
When a nurse asks a newly admitted patient to describe social supports, the patient says,
“My parents died last year and I have no family. I am newly divorced, and my former inlaws
blame me. I don’t have many friends because most people my age just want to go out
drinking.” Which action will the nurse apply? Advise the patient that being so particular about potential friends reduces social
contact. Suggest using the Internet as a way to find supportive others with similar values. Encourage the patient to begin dating again, perhaps with members of the church. Discuss how divorce support groups could increase coping and social support.
A patient experiencing significant stress associated with a disturbing new medical diagnosis
asks the nurse, “Do you think saying a prayer would help?” Select the nurse’s best answer. “It could be that prayer is your only hope.” “You may find prayer gives comfort and lowers your stress.” “I can help you feel calmer by teaching you meditation exercises.” “We do not have evidence that prayer helps, but it wouldn’t hurt.”.
A patient is brought to the Emergency Department after a motorcycle accident. The patient
is alert, responsive, and diagnosed with a broken leg. The patient’s vital signs are pulse (P)
72 and respiration (R) 16. After being informed surgery is required for the broken leg,
which vital sign readings would be expected? P 64, R 14 P 68, R 12 P 72, R 16 P 80, R 20.
A patient tells the nurse, “I know that I should reduce the stress in my life, but I have no
idea where to start.” What would be the best initial nursing response? “Physical exercise works to elevate mood and reduce anxiety.” “Reading about stress and how to manage it might be a good place to start.” “Why not start by learning to meditate? That technique will cover everything.” “Let’s talk about what is going on in your life and then look at possible options.”.
A patient tells the nurse, “My doctor thinks my problems with stress relate to the negative
way I think about things and suggested I learn new ways of thinking.” Which response by
the nurse would support the recommendation? Encourage the patient to imagine being in calm circumstances. Provide the patient with a blank journal and guidance about journaling. Teach the patient to recognize, reconsider, and reframe irrational thoughts. Teach the patient to use instruments that give feedback about bodily functions.
A patient who had been experiencing significant stress learned to use progressive muscle
relaxation and deep breathing exercises. When the patient returns to the clinic 2 weeks later,
which finding most clearly shows the patient is coping more effectively with stress? The patient’s systolic blood pressure has changed from the 140s to the 120s mm
Hg. The patient reports, “I feel better, and that things are not bothering me as much.” The patient reports, “I spend more time napping or sitting quietly at home.” The patient’s weight decreased by 3 pounds.
A patient tells the nurse, “I will never be happy until I’m as successful as my older sister.”
The nurse asks the patient to reassess this statement and reframe it. Which reframed
statement by the patient is most likely to promote coping? “People should treat me as well as they treat my sister.” “I can find contentment in succeeding at my own job level.” “I won’t be happy until I make as much money as my sister.” “Being as smart or clever as my sister isn’t really important.”.
A patient says, “One result of my chronic stress is that I feel so tired. I usually sleep from
11:00 PM to 6:30 AM. I started setting my alarm to give me an extra 30 minutes of sleep
each morning, but I don’t feel any better and I’m rushed for work.” Which nursing response
would best address the patient’s concerns? “You may need to speak to your doctor about taking a sedative to help you sleep.” “Perhaps going to bed a half-hour earlier would work better than sleeping later.” “A glass of wine in the evening might take the edge off and help you to rest.” “Exercising just before retiring for the night may help you to sleep better.”.
A patient reports, “I am overwhelmed by stress.” Which question by the nurse would be
most important to use in the initial assessment of this patient? “Tell me about your family history. Do you have any relatives who have problems
with stress?” “Tell me about your exercise. How much activity do you typically get in a day?” “Tell me about the kinds of things you do to reduce or cope with your stress.” “Stress can interfere with sleep. How much did you sleep last night?”.
Which scenario best demonstrates an example of eustress? An individual loses a beloved family pet. prepares to take a vacation to a tropical island with a group of close friends. receives a bank notice that there were insufficient funds in his/her account for a
recent rent payment. receives notification that his/her current employer is experiencing financial
problems and some workers will be terminated.
A person with a fear of heights drives across a high bridge. Which structure will stimulate a
response from the autonomic nervous system? Thalamus Parietal lobe Hypothalamus Pituitary gland.
A person with a fear of heights drives across a high bridge. Which division of the autonomic
nervous system will be stimulated in response to this experience? Limbic system Peripheral nervous system Sympathetic nervous system Parasympathetic nervous system.
Which changes reflect short-term physiological responses to stress? (Select all that apply.) Muscular tension, blood pressure, and triglycerides increase. Epinephrine is released, increasing heart and respiratory rates. Corticosteroid release increases stamina and impedes digestion. Cortisol is released, increasing glucogenesis and reducing fluid loss. Immune system functioning decreases, and risk of cancer increases. Risk of depression, autoimmune disorders, and heart disease increases.
Which comments by a nurse are likely to help a patient cope by addressing the mediators of
the stress response? (Select all that apply.) “A divorce, while stressful, can be the beginning of a new, better phase of life.” “You mentioned your spirituality. Are there aspects of your faith that could be
helpful to you at this time?” “Journaling often promotes awareness of how experiences have affected people.” “It seems to me you are overreacting to this change in your life. “There is a support group for newly divorced persons in your neighborhood.”.
The nurse wishes to use guided imagery to help a patient relax. Which comments would be
appropriate to include in the guided imagery script? (Select all that apply.) “Imagine others treating you the way they should, the way you want to be treated
…” “With each breath, you feel calmer, more relaxed, almost as if you are floating …” “You are alone on a beach, the sun is warm, and you hear only the sound of the
surf … “You have taken control, nothing can hurt you now. Everything is going your way “You have grown calm, your mind is still, there is nothing to disturb your wellbeing
…” “You will feel better as work calms down, as your boss becomes more
understanding …”.
An individual says to the nurse, “I feel so stressed out lately. I think the stress is affecting
my body also.” Which somatic complaints are most likely to accompany this feeling?
(Select all that apply.) Headache Neck pain Insomnia Anorexia
Myopia.
Which nursing diagnosis is universally applicable for children diagnosed with autism
spectrum disorders? Impaired social interaction related to difficulty maintaining relationships Chronic low self-esteem related to excessive negative feedback Deficient fluid volume related to abnormal eating habits Anxiety related to nightmares and repetitive activities.
Which behavior indicates that the treatment plan for a child diagnosed with an autism
spectrum disorder was effective? The child plays with one toy for 30 minutes. repeats words spoken by a parent. holds the parent’s hand while walking. spins around and claps hands while walking.
A kindergartener is disruptive in class. This child is unable to sit for expected lengths of
time, inattentive to the teacher, screams while the teacher is talking, and is aggressive
toward other children. The nurse plans interventions designed to promote integration of self-concept. provide inpatient treatment for the child. reduce loneliness and increase self-esteem. improve language and communication skills.
A nurse will prepare teaching materials for the parents of a child newly diagnosed with
ADHD. Information will focus on which medication likely to be prescribed? Paroxetine Imipramine Methylphenidate Carbamazepine.
What is the nurse’s priority focused assessment for side effects in a child taking
methylphenidate for ADHD? Dystonia, akinesia, and extrapyramidal symptoms Bradycardia and hypotensive episodes Sleep disturbances and weight loss Neuroleptic malignant syndrome.
A desired outcome for a 12-year-old diagnosed with ADHD is to improve relationships with
other children. Which treatment modality should the nurse suggest for the plan of care? Reality therapy Simple restitution Social skills group Insight-oriented group therapy.
The parent of a 6-year-old says, “My child is in constant motion and talks all the time. My
child isn’t interested in toys but is out of bed every morning before me.” The child’s
behavior is most consistent with diagnostic criteria for communication disorder. stereotypic movement disorder. intellectual development disorder. ADHD.
A child diagnosed with ADHD had this nursing diagnosis: impaired social interaction
related to excessive neuronal activity as evidenced by aggression and demanding behavior
with others. Which finding indicates the plan of care was effective? The child has an improved ability to identify anxiety and use self-control strategies. has increased expressiveness in communication with others. shows increased responsiveness to authority figures. engages in cooperative play with other children.
When a 5-year-old diagnosed with ADHD bounces out of a chair and runs over and slaps
another child, what is the nurse’s best action? Instruct the parents to take the aggressive child home. Direct the aggressive child to stop immediately. Call for emergency assistance from other staff. Take the aggressive child to another room.
A child diagnosed with ADHD will begin medication therapy. The nurse should prepare a
plan to teach the family about which classification of medications? CNS stimulants Tricyclic antidepressants Antipsychotics Anxiolytics.
Soon after parents announced they were divorcing, a child stopped participating in sports,
sat alone at lunch, and avoided former friends. The child told the school nurse, “If my
parents loved me, they would work out their problems.” Which nursing diagnosis has the
highest priority? Social isolation Decisional conflict Chronic low self-esteem Disturbed personal identity.
A nurse works with a child who is sad and irritable because the child’s parents are
divorcing. Why is establishing a therapeutic alliance with this child a priority? Therapeutic relationships provide an outlet for tension. Focusing on the strengths increases a person’s self-esteem. Acceptance and trust convey feelings of security to the child. The child should express feelings rather than internalize them.
A nurse assesses a 3-year-old diagnosed with an autism spectrum disorder. Which finding is
most associated with the child’s disorder? The child has occasional toileting accidents. interrupts or intrudes on others. cries when separated from a parent. continuously rocks in place for 30 minutes.
A 4-year-old cries for 5 minutes when the parents leave the child at preschool. The parents
ask the nurse, “What should we do?” Select the nurse’s best response. “Ask the teacher to let the child call you at play time.” “Withdraw the child from preschool until maturity increases.” “Remain with your child for the first hour of preschool time.” “Give your child a kiss before you leave the preschool program.”.
Which assessment finding would cause the nurse to consider a child to be most at risk for
the development of mental illness? The child has been raised by a parent with recurring major depressive disorder. The child’s best friend was absent from the child’s birthday party. The child was not promoted to the next grade one year. The child moved to three new homes over a 2-year period.
The child prescribed an antipsychotic medication to manage violent behavior is one most
likely diagnosed with ADHD. posttraumatic stress disorder (PTSD). communication disorder. an anxiety disorder.
A child reports to the school nurse of being verbally bullied by an aggressive classmate.
What is the nurse’s best first action? Give notice to the chief administrator at the school regarding the events. Encourage the victimized child to share feelings about the experience. Encourage the victimized child to ignore the bullying behavior. Discuss the events with the aggressive classmate.
Assessment data for a 7-year-old reveals an inability to take turns, blurting out answers to
questions before a question is complete, and frequently interrupting others’ conversations.
How should the nurse document these behaviors? Disobedience Hyperactivity Impulsivity Anxiety.
A child diagnosed with ADHD shows hyperactivity, aggression, and impaired play. The
health care provider prescribed amphetamine salts (Adderall). The nurse should monitor for
which desired behavior? Increased expressiveness in communication with others Abilities to identify anxiety and implement self-control strategies Improved abilities to participate in cooperative play with other children Tolerates social interactions for short periods without disruption or frustration.
When group therapy is prescribed as a treatment modality, the nurse would suggest
placement of a 9-year-old in a group that uses guided imagery. talk focused on a specific issue. play and talk about a play activity. group discussion about selected topics.
Which child demonstrates behaviors indicative of a neurodevelopmental disorder? A 4-year-old who stuttered for 3 weeks after the birth of a sibling A 9-month-old who does not eat vegetables and likes to be rocked A 3-month-old who cries after feeding until burped and sucks a thumb A 3-year-old who is mute, passive toward adults, and twirls while walking.
The parent of a child diagnosed with Tourette’s disorder says to the nurse, “I think my child
is faking the tics because they come and go.” Which response by the nurse is accurate? “Perhaps your child was misdiagnosed.” “Your observation indicates the medication is effective.” “Tics often change frequency or severity. That doesn’t mean they aren’t real.” “This finding is unexpected. How have you been administering your child’s
medication?”.
When a 5-year-old is disruptive, the nurse says, “You must take a time-out.” The
expectation is that the child will go to a quiet room until called for the next activity. slowly count to 20 before returning to the group activity. sit on the edge of the activity until able to regain self-control sit quietly on the lap of a staff member until able to apologize for the behavior.
A parent diagnosed with schizophrenia and 13-year-old child live in a homeless shelter. The
child formed a trusting relationship with a shelter volunteer. The child says, “My three
friends and I got an A on our school science project.” The nurse can assess that the child displays resiliency. has a passive temperament. uses intellectualization to deal with problems. is at risk for PTSD.
A nurse prepares to lead a discussion at a community health center regarding children’s
health problems. The nurse wants to use current terminology when discussing these issues.
Which terms are appropriate for the nurse to use? (Select all that apply.) Autism Bullying Mental retardation Autism spectrum disorder Intellectual development disorder.
A nurse prepares the plan of care for a 15-year-old diagnosed with moderate intellectual
developmental disorder. What are the highest outcomes that are realistic for this patient?
Within 5 years, the patient will (Select all that apply) graduate from high school. live independently in an apartment. independently perform own personal hygiene. obtain employment in a local sheltered workshop. correctly use public buses to travel in the community.
At the time of a home visit, the nurse notices that each parent and child in a family has his
or her own personal online communication device. Each member of the family is in a
different area of the home. Which nursing actions are appropriate? (Select all that apply.) Report the finding to the official child protection social services agency. Educate all members of the family about potential safety risks in online Talk with the parents about parental controls on the children’s communication
devices. Encourage the family to schedule daily time together without communication
devices. Obtain the family’s network password and examine online sites family members
have visited.
Which assessment findings present familial risks for a child to develop a psychiatric
disorder? (Select all that apply.) Having a mother diagnosed with schizophrenia Being the oldest child in a family Living with an alcoholic parent Being an only child Living in an urban community.
A patient has had difficulty keeping a job because of arguing with co-workers and accusing
them of conspiracy. Today this patient shouts, “They’re all plotting to destroy me. Isn’t that
true?” Select the nurse’s most therapeutic response. “Everyone here is trying to help you. No one wants to harm you.” “Feeling that people want to destroy you must be very frightening.” “That is not true. People here are trying to help you if you will let them.” “Staff members are health care professionals who are qualified to help you.”.
A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly
scans the environment. The patient states, “I saw two doctors talking in the hall. They were
plotting to kill me.” The nurse may correctly assess this behavior as echolalia. an idea of reference. a delusion of infidelity. an auditory hallucination.
A patient diagnosed with schizophrenia says, “My co-workers are out to get me. I also saw
two doctors plotting to kill me.” How does this patient perceive the environment? Disorganized Dangerous Supportive Bizarre.
When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol was
prescribed. The patient now says, “I stopped taking those pills. They made me feel like a
robot.” What are common side effects the nurse should validate with the patient? Sedation and muscle stiffness Sweating, nausea, and diarrhea Mild fever, sore throat, and skin rash Headache, watery eyes, and runny nose.
Which hallucination necessitates the nurse to implement safety measures? The patient says, “I hear angels playing harps. “The voices say everyone is trying to kill me.” “My dead father tells me I am a good person.” “The voices talk only at night when I’m trying to sleep.”.
A patient’s care plan includes monitoring for auditory hallucinations. Which assessment
findings suggest the patient may be hallucinating? Detachment and overconfidence Darting eyes, tilted head, mumbling to self Euphoric mood, hyperactivity, distractibility Foot tapping and repeatedly writing the same phrase.
A health care provider considers which antipsychotic medication to prescribe for a patient
diagnosed with schizophrenia who has auditory hallucinations and poor social function. The
patient is also overweight and hypertensive. Which drug should the nurse advocate? Clozapine Ziprasidone Olanzapine Aripiprazole.
A patient diagnosed with schizophrenia tells the nurse, “I eat skiller. Tend to end. Easter. It
blows away. Get it?” Select the nurse’s most therapeutic response. “Nothing you are saying is clear.” “Your thoughts are very disconnected.” “Try to organize your thoughts and then tell me again.” “I am having difficulty understanding what you are saying.”.
A patient diagnosed with schizophrenia exhibits little spontaneous movement and
demonstrates waxy flexibility. Which patient needs are of priority importance? Self-esteem Psychosocial Physiological Self-actualization.
A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has
waxy flexibility. The patient’s activities of daily living are severely compromised. An
appropriate outcome would be that the patient will demonstrate increased interest in the environment by the end of week 1. perform self-care activities with coaching by the end of day 3. gradually take the initiative for self-care by the end of week 2. accept tube feeding without objection by day 2.
A nurse observes a catatonic patient standing immobile, facing the wall with one arm
extended in a salute. The patient remains immobile in this position for 15 minutes, moving
only when the nurse gently lowers the arm. What is the name of this phenomenon? Echolalia Waxy flexibility Depersonalization Thought withdrawal.
A nurse leads a psychoeducational group about first-generation antipsychotic medications
with six adult men diagnosed with schizophrenia. The nurse will monitor for concerns
regarding body image with respect to which potential side effect of these medications? Photosensitivity Gynecomastia Visual changes Photosensitivity.
A nurse leads a psychoeducational group about problem solving with six adults diagnosed
with schizophrenia. Which teaching strategy is likely to be most effective? Suggest analogies that might apply to a common daily problem. Assign each participant a problem to solve independently and present to the group. Ask each patient to read aloud a short segment from a book about problem solving. Invite participants to come up with solution to getting incorrect change for a
purchase.
A nurse educates a patient about the antipsychotic medication regime. Afterward, which
comment by the patient indicates the teaching was effective? “I will need higher and higher doses of my medication as time goes on.” “I need to store my medication in a cool dark place, such as the refrigerator.” “Taking this medication regularly will reduce the severity of my symptoms.” “If I run out or stop taking my medication, I will experience withdrawal
symptoms.”.
A newly admitted patient diagnosed with schizophrenia says, “The voices are bothering me.
They yell and tell me I am bad. I have got to get away from them.” Select the nurse’s most
helpful reply. “Do you hear the voices often?” “Do you have a plan for getting away from the voices?” “I’ll stay with you. Focus on what we are talking about, not the voices. ” “Forget the voices and ask some other patients to play cards with you.”.
A patient diagnosed with schizophrenia has taken fluphenazine 5 mg po bid for 3 weeks.
The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which
term applies to these symptoms? Neuroleptic malignant syndrome Hepatocellular effects Pseudoparkinsonism Akathisia.
A patient diagnosed with schizophrenia is very disturbed and violent. After several doses of
haloperidol, the patient is calm. Two hours later the nurse sees the patient’s head rotated to
one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is
most likely? An acute dystonic reaction Tardive dyskinesia Waxy flexibility Akathisia.
An acutely violent patient diagnosed with schizophrenia received several doses of
haloperidol. Two hours later the nurse notices the patient’s head rotated to one side in a
stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the
nurse is indicated? Administer diphenhydramine 50 mg IM from the prn medication administration
record. Reassure the patient that the symptoms will subside. Practice relaxation exercises
with the patient. Give trihexyphenidyl 5 mg orally at the next regularly scheduled medication
administration time. Administer atropine sulfate 2 mg subcut from the prn medication administration
record.
A patient diagnosed with schizophrenia has received fluphenazine decanoate twice a month
for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips.
The patient’s neck and shoulders twist in a slow, snakelike motion. Which problem would
the nurse suspect? Agranulocytosis Tardive dyskinesia Tourette’s syndrome Anticholinergic effects.
A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh
uncontrollably, although the nurse has not said anything funny. Select the nurse’s most
therapeutic response. “Why are you laughing?” “Please share the joke with me.” “I don’t think I said anything funny.” “You’re laughing. Tell me what’s happening.”.
The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would
the nurse regard as a negative symptom of schizophrenia? Auditory hallucinations Delusions of grandeur Poor personal hygiene Psychomotor agitation.
What assessment findings mark the prodromal stage of schizophrenia? Withdrawal, misinterpreting, poor concentration, and preoccupation with religion Auditory hallucinations, ideas of reference, thought insertion, and broadcasting Stereotyped behavior, echopraxia, echolalia, and waxy flexibility Loose associations, concrete thinking, and echolalia neologisms.
A patient diagnosed with schizophrenia says, “Contagious bacteria are everywhere. When
they get in your body, you will be locked up with other infected people.” Which problem is
evident? Poverty of content Concrete thinking Neologisms Paranoia.
A patient diagnosed with schizophrenia begins a new prescription for ziprasidone. The
patient is 5'6'' and currently weighs 204 lbs. The patient has dry flaky skin, headaches about
twice a month, and a family history of colon cancer. Which intervention has the highest
priority for the nurse to include in the patient’s plan of care? Skin care techniques Scheduling a colonoscopy Weight management strategies Teaching to limit caffeine intake.
A patient diagnosed with schizophrenia says, “It’s beat. Time to eat. No room for the cat.”
What type of verbalization is evident? Neologism Idea of reference Thought broadcasting Associative looseness.
A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication
for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty
of thought, and social isolation. The nurse would expect a change to which medication? Haloperidol Olanzapine Chlorpromazine Diphenhydramine.
The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and
family’s role in recovery. Which type of therapy should the nurse recommend? Psychoeducational Psychoanalytic Transactional Family.
A patient diagnosed with schizophrenia has been stable for a year; however, the family now
reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating.
The patient says, “My computer is sending out infected radiation beams.” The nurse can
correctly assess this information as an indication of the need for psychoeducation. medication nonadherence. chronic deterioration. relapse.
A patient diagnosed with schizophrenia begins to talks about “macnabs” hiding in the
warehouse at work. The term “macnabs” should be documented as a neologism. concrete thinking. thought insertion. an idea of reference.
A patient diagnosed with schizophrenia anxiously says, “I can see the left side of my body
merging with the wall, then my face appears and disappears in the mirror.” While listening,
the nurse should sit close to the patient. place an arm protectively around the patient’s shoulders. place a hand on the patient’s arm and exert light pressure. maintain a normal social interaction distance from the patient.
A patient diagnosed with schizophrenia anxiously tells the nurse, “The voice is telling me to
do things.” Select the nurse’s priority assessment question. “How long has the voice been directing your behavior?” “Does what the voice tell you to do frighten you?” “Do you recognize the voice speaking to you?’ “What is the voice telling you to do?”.
A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200,
the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F;
pulse 110; respirations 26; 150/90. The patient is diaphoretic. Select the nurse’s best
analysis and action. Agranulocytosis; institute reverse isolation. Tardive dyskinesia; withhold the next dose of medication. Cholestatic jaundice; begin a high-protein, high-cholesterol diet Neuroleptic malignant syndrome; notify health care provider stat.
A nurse asks a patient diagnosed with schizophrenia, “What is meant by the old saying ‘You
can’t judge a book by looking at the cover.’?” Which response by the patient indicates
concrete thinking? “The table of contents tells what a book is about.” “You can’t judge a book by looking at the cover.” “Things are not always as they first appear.” “Why are you asking me about books?”.
The nurse is developing a plan for psychoeducational sessions for a small group of adults
diagnosed with schizophrenia. Which goal is best for this group? Members will gain insight into unconscious factors that contribute to their illness. explore situations that trigger hostility and anger. learn to manage delusional thinking. demonstrate improved social skills.
A client says, “Facebook has a new tracking capacity. If I use the Internet, Homeland
Security will detain me as a terrorist.” Select the nurse’s best initial action. Tell the client, “Facebook is a safe website. You don’t need to worry about
Homeland Security.” Tell the client, “You are in a safe place where you will be helped.” Administer a prn dose of an antipsychotic medication. Tell the client, “You don’t need to worry about that.”.
Which finding constitutes a negative symptom associated with schizophrenia? Hostility Bizarre behavior Poverty of thought Auditory hallucinations.
A patient insistently states, “I can decipher codes of DNA just by looking at someone.”
Which problem is evident? Visual hallucinations Magical thinking Idea of reference Thought insertion.
A newly hospitalized patient experiencing psychosis says, “Red chair out town board.”
Which term should the nurse use to document this finding? Word salad Neologism Anhedonia Echolalia.
A nurse at the mental health clinic plans a series of psychoeducational groups for persons
newly diagnosed with schizophrenia. Which two topics take priority? (Select all that apply.) “The importance of taking your medication correctly” “How to complete an application for employment” “How to dress when attending community events” “How to give and receive compliments” “Ways to quit smoking”.
A patient diagnosed with schizophrenia was hospitalized after arguing with co-workers and
threatening to harm them. The patient is aloof, suspicious, and says, “Two staff members I
saw talking were plotting to kill me.” Based on data gathered at this point, which nursing
diagnoses relate? (Select all that apply.) Risk for other-directed violence Disturbed thought processes Risk for loneliness Spiritual distress Social isolation.
A person was online continuously for over 24 hours, posting rhymes on official government
websites and inviting politicians to join social networks. The person has not slept or eaten
for 3 days. What features of mania are evident? Increased muscle tension and anxiety Vegetative signs and poor grooming Poor judgment and hyperactivity Cognitive deficits and paranoia.
A patient diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The
patient twirls and shadow boxes. The patient says gaily, “Do you like my scarves? Here they
are my gift to you.” How should the nurse document the patient’s mood? Euphoric Irritable Suspicious Confident.
A person was directing traffic on a busy street, rapidly shouting, “To work, you jerk, for
perks” and making obscene gestures at cars. The person has not slept or eaten for 3 days.
Which assessment findings will have priority concern for this patient’s plan of care? Insulting, aggressive behavior Pressured speech and grandiosity Hyperactivity; not eating and sleeping Poor concentration and decision making.
A patient diagnosed with acute mania has distributed pamphlets about a new business
venture on a street corner for 2 days. Which nursing diagnosis has priority? Risk for injury Impaired social interaction Impaired social interaction Ineffective therapeutic regimen management.
A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium.
The patient threatens to hit another patient. Which comment by the nurse is appropriate? “Stop that! No one did anything to provoke an attack by you.” “If you do that one more time, you will be secluded immediately.” “Do not hit anyone. If you are unable to control yourself, we will help you.” “You know we will not let you hit anyone. Why do you continue this behavior?”.
This nursing diagnosis applies to a patient experiencing acute mania: Imbalanced nutrition:
less than body requirements related to insufficient caloric intake and hyperactivity as
evidenced by 5-pound weight loss in 4 days. Select an appropriate outcome. The patient will ask staff for assistance with feeding within 4 days. drink six servings of a high-calorie, high-protein drink each day. consistently sit with others for at least 30 minutes at meal time within 1 week. consistently wear appropriate attire for age and sex within 1 week while on the
psychiatric unit.
A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium.
New orders are written to resume lithium twice daily and begin olanzapine. What is the
rationale for the addition of olanzapine to the medication regimen? It will minimize the side effects of lithium. bring hyperactivity under rapid control. enhance the antimanic actions of lithium. be used for long-term control of hyperactivity.
A patient diagnosed with bipolar disorder has rapidly changing mood cycles. The health
care provider prescribes an anticonvulsant medication. To prepare teaching materials, which
drug should the nurse anticipate will be prescribed? phenytoin clonidine risperidone carbamazepine.
The exact cause of bipolar disorder has not been determined; however, for most patients several factors, including genetics, are implicated. brain structures were altered by stress early in life. excess sensitivity in dopamine receptors may trigger episodes. inadequate norepinephrine reuptake disturbs circadian rhythms.
The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the
possibility of genetic transmission of bipolar disorders. Which response should the nurse
provide? “A high proportion of patients with bipolar disorders are found among creative
writers.” “A higher rate of relatives with bipolar disorder is found among patients with
bipolar disorder.” “Patients with bipolar disorder have higher rates of relatives who respond in an
exaggerated way to daily stress.” “More individuals with bipolar disorder come from high socioeconomic and
educational backgrounds.”.
A patient diagnosed with bipolar disorder commands other patients, “Get me a book. Take
this stuff out of here,” and other similar demands. The nurse wants to interrupt this behavior
without entering into a power struggle. Which initial approach should the nurse select? Distraction: “Let’s go to the dining room for a snack.” Humor: “How much are you paying servants these days?” Limit setting: “You must stop ordering other patients around.” Honest feedback: “Your controlling behavior is annoying others.”.
The nurse receives a laboratory report indicating a patient’s serum level is 1 mEq/L. The
patient’s last dose of lithium was 8 hours ago. This result is within therapeutic limits. below therapeutic limits. above therapeutic limits. invalid because of the time lapse since the last dose.
Consider these three anticonvulsant medications: divalproex, carbamazepine, and
gabapentin. Which medication also belongs to this classification? clonazepam risperidone lamotrigine aripiprazole.
When a hyperactive patient diagnosed with acute mania is hospitalized, what is the initial
nursing intervention? Allow the patient to act out feelings. Set limits on patient behavior as necessary. Provide verbal instructions to the patient to remain calm. Restrain the patient to reduce hyperactivity and aggression.
At a unit meeting, the staff discusses decor for a special room for patients with acute mania.
Which suggestion is appropriate? An extra-large window with a view of the street Neutral walls with pale, simple accessories Brightly colored walls and print drapes Deep colors for walls and upholstery.
A patient demonstrating behaviors associated with acute mania has exhausted the staff by
noon. Staff members are feeling defensive and fatigued. Which action will the staff take
initially? Confer with the health care provider to consider use of seclusion for this patient. Hold a staff meeting to discuss consistency and limit-setting approaches. Conduct a meeting with all staff and patients to discuss the behavior. Explain to the patient that the behavior is unacceptable.
A patient experiencing acute mania undresses in the group room and dances. The nurse
intervenes initially by quietly asking the patient, “Why don’t you put your clothes on?” firmly telling the patient, “Stop dancing and put on your clothing.” putting a blanket around the patient and walking with the patient to a quiet room letting the patient stay in the group room and moving the other patients to a
different area.
A patient waves a newspaper and says, “I must have my credit card and use the computer
right now. A store is having a big sale, and I need to order 10 dresses and four pairs of
shoes.” Select the nurse’s appropriate intervention. The nurse a. suggests the patient have a friend do the shopping and bring purchases to the unit. invites the patient to sit together and look at new fashion magazines. tells the patient computer use is not allowed until self-control improves. asks whether the patient has enough money to pay for the purchases.
An outpatient diagnosed with bipolar disorder takes lithium carbonate 300 mg three times
daily. The patient reports nausea. To reduce the nausea most effectively, the nurse suggests
that the lithium be taken with meals. an antacid. an antiemetic. a large glass of juice.
A health teaching plan for a patient taking lithium should include instructions to maintain normal salt and fluids in the diet. drink twice the usual daily amount of fluid double the lithium dose if diarrhea or vomiting occurs. double the lithium dose if diarrhea or vomiting occurs.
Which nursing diagnosis would most likely apply to a patient diagnosed with major
depressive disorder as well as one experiencing acute mania? Deficient diversional activity Disturbed sleep pattern Fluid volume excess Defensive coping.
Which dinner menu is best suited for a patient with acute mania? Spaghetti and meatballs, salad, and a banana Beef and vegetable stew, a roll, and chocolate pudding Broiled chicken breast on a roll, an ear of corn, and an apple Chicken casserole, green beans, and flavored gelatin with whipped cream.
Outcome identification for the treatment plan of a patient experiencing grandiose thinking
associated with acute mania will focus on developing an optimistic outlook. distorted thought self-control. interest in the environment. sleep pattern stabilization.
Which documentation indicates that the treatment plan for a patient diagnosed with acute
mania has been effective? “Converses with few interruptions; clothing matches; participates in activities.” “Irritable, suggestible, distractible; napped for 10 minutes in afternoon.” “Attention span short; writing copious notes; intrudes in conversations.” “Heavy makeup; seductive toward staff; pressured speech.”.
A patient experiencing acute mania dances around the unit, seldom sits, monopolizes
conversations, interrupts, and intrudes. Which nursing intervention will best assist the
patient with energy conservation? Monitor physiological functioning. Provide a subdued environment. Supervise personal hygiene. Observe for mood changes.
A patient with diagnosed bipolar disorder was hospitalized 7 days ago and has been taking
lithium 600 mg tid. Staff observes increased agitation, pressured speech, poor personal
hygiene, and hyperactivity. Which action demonstrates that the nurse understands the most
likely cause of the patient’s behavior? Educate the patient about the proper ways to perform personal hygiene and
coordinate clothing. Continue to monitor and document the patient’s speech patterns and motor
activity. Ask the health care provider to prescribe an increased dose and frequency of
lithium. Consider the need to check the lithium level. The patient may not be swallowing
medications.
A patient with acute mania has disrobed in the hall three times in 2 hours. The nurse should direct the patient to wear clothes at all times. ask if the patient finds clothes bothersome. tell the patient that others feel embarrassed. arrange for one-on-one supervision.
A patient experiencing acute mania is dancing atop a pool table in the recreation room. The
patient waves a cue in one hand and says, “I’ll throw the pool balls if anyone comes near
me.” To best assure safety, the nurse’s first intervention is to tell the patient, “You need to be secluded.” clear the room of all other patients. help the patient down from the table. assemble a show of force.
A patient diagnosed with bipolar disorder will be discharged tomorrow. The patient is taking
a mood stabilizing medication. What is the priority nursing intervention for the patient as
well as the patient’s family during this phase of treatment? Attending psychoeducation sessions Decreasing physical activity Increasing food and fluids Meeting self-care needs.
A patient diagnosed with bipolar disorder will be discharged tomorrow. The patient is taking
a mood stabilizing medication. What is the priority nursing intervention for the patient as
well as the patient’s family during this phase of treatment? Attending psychoeducation sessions Decreasing physical activity Increasing food and fluids Meeting self-care needs.
A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of
complications? Pharyngitis, mydriasis, and dystonia Alopecia, purpura, and drowsiness Diaphoresis, weakness, and nausea Ascites, dyspnea, and edema.
A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The
patient asks, “Do I have to keep taking this lithium even though my mood is stable now?”
Select the nurse’s appropriate response. “You will be able to stop the medication in about 1 month.” “Taking the medication every day helps reduce the risk of a relapse.” “Most patients take medication for approximately 6 months after discharge.” “It’s unusual that the health care provider hasn’t already stopped your medication.”.
An outpatient diagnosed with bipolar disorder is prescribed lithium. The patient telephones
the nurse to say, “I’ve had severe diarrhea for 4 days. I feel very weak and unsteady when I
walk. My usual hand tremor has gotten worse. What should I do?” The nurse will advise the
patient to restrict food and fluids for 24 hours and stay in bed. have someone bring the patient to the clinic immediately. drink a large glass of water with 1 teaspoon of salt added. take one dose of an over-the-counter antidiarrheal medication now.
A newly diagnosed patient is prescribed lithium. Which information from the patient’s
history indicates that monitoring of serum concentrations of the drug will be challenging
and critical? Arthritis Epilepsy Psoriasis Heart failure.
Four new patients were admitted to the behavioral health unit in the past 12 hours. The
nurse directs a psychiatric technician to monitor these patients for safety. Which patient will
need the most watchful supervision? A patient diagnosed with bipolar I disorder. bipolar II disorder. dysthymic disorder. cyclothymic disorder.
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