1. The nurse has developed a relationship with a client who has an addiction problem. Which information would indicate that the therapeutic interaction is in the working stage? Select all that apply. 1. The client addresses how the addiction has contributed to family distress. 2. The client reluctantly shares the family history of addiction. 3. The client verbalizes difficulty identifying personal strengths. 4. The client discusses the financial problems related to the addiction. 5. The client expresses uncertainty about meeting with the nurse. 6. The client acknowledges the addiction's effects on the children. Answer: 1, 3 ,6 RATIONALES: Options 1, 3, and 6 are examples of the nurse-client working phase of an interaction. In the working phase, the client explores, evaluates, and determines solutions to identified problems. Options 2, 4 and 5 address what happens during the introductory phase of the nurse-client interaction 2. The physician orders a new medication for a client with generalized anxiety disorder. During medication teaching, which statement or question by the nurse would be most appropriate? 1. "Take this medication. It will reduce your anxiety." 2. "Do you have any concerns about taking the medication?" 3. "Trust us. This medication has helped many people. We wouldn't have you take it if it were dangerous." 4. "How can we help you if you won't cooperate?" Answer: 2 RATIONALES: Providing an opportunity for the client to express concerns about a new medication and to make a choice about taking it can help the client regain a sense of control over his life. The client has the right to refuse the medication. Instead of simply ordering the client to take it, as in option 1, the nurse should provide the information the client needs to make an informed decision. Attempting to make the client feel guilty, as in option 3, or threatening the client, as in option 4, would increase anxiety 3. The nurse is explaining the Bill of Rights for psychiatric patients to a client who has voluntarily sought admission to an inpatient psychiatric facility. Which of the following rights should the nurse include in the discussion? 1. Right to select health care team members 2. Right to refuse treatment 3. Right to a written treatment plan 4. Right to obtain disability 5. Right to confidentiality 6. Right to personal mail Answer: 2,3,5,6 RATIONALES: An inpatient client usually receives a copy of the Bill of Rights for psychiatric patients, where they would find options 2, 3, 5, and 6 in writing. However, a client in an inpatient setting can't select health team members. A client may apply for disability as a result of a chronic, incapacitating illness; however, disability isn't a patient right, and members of a psychiatric institution don't decide who should receive it. 4. An adolescent, age 17, rarely expresses feelings and usually remains passive. However, when angry, her face becomes flushed and her blood pressure rises to 170/100 mm Hg. Her parents are passive and easygoing. The adolescent may be using which defense mechanism to handle anger? 1. Displacement 2. Introjection 3. Projection 4. Sublimation Answer: 2 RATIONALES: The adolescent may be introjecting (assuming as her own) her parents' belief that anger shouldn't be outwardly expressed. She may also be holding in and somatizing her angry feelings, as evidenced by her increased blood pressure. (A blood pressure rise is a common physiological reaction to the fight-or-flight response that may be brought on by strong emotions. Habitual failure to express anger may contribute to hypertension.) Displacement is the discharge of negative feelings onto another person or an object. Projection is the attribution of one's own thoughts or impulses to another person. Sublimation is the channeling of unbearable or socially unacceptable behaviors into more socially acceptable outlets. 5. Lorazepam (Ativan) is often given along with a neuroleptic agent. What is the purpose of administering the drugs together? 1. To reduce anxiety and potentiate the sedative action of the neuroleptic 2. To counteract extrapyramidal effects of the neuroleptic 3. To manage depressed clients 4. To increase the client's level of awareness and concentration Answer 1: RATIONALES: Lorazepam, when given with a neuroleptic such as haloperidol (Haldol), potentiates the sedating effect and is used to treat severely agitated clients. Haloperidol places the client at risk for extrapyramidal effects and, therefore, wouldn't be used to treat extrapyramidal effects. Both drugs can cause depression, so they aren't used to treat depression. Concentration would be decreased because of the depressant effect. 6. Because antianxiety agents such as chlordiazepoxide (Librium) can potentiate the effects of other drugs, the nurse should incorporate which of the following instructions in her teaching plan? 1. Avoid mixing antianxiety agents with alcohol or other central nervous system (CNS) depressants. 2. Avoid taking antianxiety drugs at bedtime. 3. Avoid taking antianxiety drugs on an empty stomach. 4. Avoid consuming aged cheese when taking antianxiety agents. Answer 1 RATIONALES: Potentiating effect refers to a drug's ability to increase the potency of another drug if taken together. Therefore, the client should be instructed to avoid alcohol while taking Librium because it potentiates the drug's CNS depressant effect. Taken at bedtime, this drug will induce sleep. Librium comes in capsule form and usually can be taken with water. Aged cheese is restricted with monoamine oxidase inhibitors, not Librium. 7. During a shift report, the nurse learns that she will be providing care for a client who's vulnerable to panic attack. Treatment for panic attacks includes behavioral therapy, supportive psychotherapy, and medication such as: 1. barbiturates. 2. antianxiety drugs. 3. depressants. 4. amphetamines. Answer 2 RATIONALES: Antianxiety drugs provide symptomatic relief. Barbiturates and amphetamines can precipitate panic attacks. Depressants aren't appropriate for treating panic attacks. 8. A client with the nursing diagnosis of Fear, related to being embarrassed in the presence of others, exhibits symptoms of social phobia. What should the goals be for this client? Select all that apply 1. Manage her fear in group situations. 2. Develop a plan to avoid situations that may cause stress. 3. Verbalize feelings that occur in stressful situations. 4. Develop a plan for responding to stressful situations. 5. Deny feelings that may contribute to irrational fears. 6. Use suppression to deal with underlying fears. Answer: 1,3,4 RATIONALES: Improving stress management skills, verbalizing feelings, and anticipating and planning for stressful situations are adaptive responses to stress. Avoidance, denial, and suppression are maladaptive defense mechanisms. 9. The nurse in a psychiatric inpatient unit is caring for a client with obsessive-compulsive disorder. As part of the client's treatment, the psychiatrist orders lorazepam (Ativan), 1 mg by mouth three times per day. During lorazepam therapy, the nurse should remind the client to: 1. avoid caffeine. 2. avoid aged cheeses. 3. stay out of the sun. 4. maintain an adequate salt intake. Answer 1: RATIONALES: Ingesting 500 mg or more of caffeine can significantly alter the anxiolytic effects of lorazepam. Other dietary restrictions are unnecessary. Staying out of the sun or using sunscreens is required when taking phenothiazines. An adequate salt intake is necessary for clients receiving lithium. 10. Which drugs have been known to be effective in treating obsessive-compulsive disorder (OCD)? 1. benztropine (Cogentin) and diphenhydramine (Benadryl) 2. chlordiazepoxide (Librium) and diazepam (Valium) 3. fluvoxamine (Luvox) and clomipramine (Anafranil) 4. divalproex (Depakote) and lithium (Lithobid) Answer 3 RATIONALES: The antidepressants fluvoxamine and clomipramine have been effective in the treatment of OCD. Librium and Valium may be helpful in treating anxiety related to OCD but aren't drugs of choice to treat the illness. The other medications mentioned aren't effective in the treatment of OCD. 11. Which term refers to the primary unconscious defense mechanism that keeps intense, anxietyproducing situations out of a person's conscious awareness? 1. Introjection 2. Regression 3. Repression 4. Denial Answer 3 RATIONALES: Repression, the unconscious exclusion from awareness of painful or conflicting thoughts, impulses, or memories, is the primary ego defense. Other defense mechanisms tend to reinforce anxiety. Introjection is an intense identification in which one incorporates another person's or group's values or qualities into one's own ego structure. Regression is a retreat to an earlier level of developmental behavioral during a time of stress. Denial is the avoidance of unpleasant realities by ignoring them. 12. Nursing implications for a client taking central nervous system (CNS) stimulants include monitoring the client for which of the following conditions? 1. Hyperpyrexia, slow pulse, and weight gain 2. Tachycardia, weight loss, and mood swings 3. Hypotension, weight gain, and listlessness 4. Increased appetite, slowing of sensorium, and arrhythmias Answer 2: RATIONALES: Stimulants produce mood swings, anorexia and weight loss, and tachycardia. The other symptoms indicate CNS depression. 13. A client diagnosed with anxiety disorder is prescribed buspirone (BuSpar). Teaching instructions for newly prescribed buspirone should include which of the following? 1. A warning that immediate sedation can occur with a resultant drop in pulse 2. A reminder of the need to schedule blood work in 1 week to check blood levels of the drug 3. A warning about the incidence of neuroleptic malignant syndrome (NMS) 4. A warning about the drug's delayed therapeutic effect, which occurs in 14 to 30 days Answer 4: RATIONALES: The client should be informed that the drug's therapeutic effect might not be reached for 14 to 30 days. The client must be instructed to continue taking the drug as directed. Blood level checks aren't necessary. NMS hasn't been reported with this drug, but tachycardia is frequently reported. 14. In the emergency department, a client reveals to the nurse a lethal plan for committing suicide and agrees to a voluntary admission to the psychiatric unit. Which information will the nurse discuss with the client to answer the question, "How long do I have to stay here?" select all that apply 1. "You may leave the hospital at any time unless you are suicidal." 2. "Let's talk more after the health team has assessed you." 3. "Once you've signed the papers, you have no say." 4. "Because you could hurt yourself, you must be safe before being discharged." 5. "You need a lawyer to help you make that decision." 6. "There must be a court hearing before you leave the hospital." Answer: 1,2,4 RATIONALES: A person who is admitted to a psychiatric hospital on a voluntary basis may sign out of the hospital unless the health care team determines that the person is harmful to himself or others. The health care team evaluates the client's condition before discharge. If there is reason to believe that the client is harmful to himself or others, a hearing can be held to determine if the admission status should be changed from voluntary to involuntary. Option 3 is incorrect because it denies the client's rights; option 5 is incorrect because the client doesn't need a lawyer to leave the hospital; and option 6 is incorrect because a hearing isn't mandated before discharge. A hearing is held only if the client remains unsafe and requires further treatment. 15. A busy attorney with a successful law practice is admitted to an acute care facility with epigastric pain. Since admission, the client has called the nurse every 15 minutes with one request or another. This client is most likely exhibiting: 1. repression. 2. somatization. 3. regression. 4. conversion. Answer 3 RATIONALES: The client is exhibiting the defense mechanism regression, a return to behavior that is characteristic of an earlier developmental level. Dependent, attention-seeking behavior is an attempt to relieve anxiety. Repression manifests as a denial of the symptoms. Somatization is the channeling of anxiety into a preoccupation with physical complaints. Conversion involves the transfer of a mental conflict into a physical symptom to relieve anxiety. 16. During the client-teaching session, which instruction should the nurse give to a client receiving alprazolam (Xanax)? 1. "Discontinue the medication immediately if you experience nausea." 2. "Notify the physician if you experience urine retention." 3. "Apply sunscreen to prevent photosensitivity." 4. "Inform the physician if you become pregnant or intend to do so." Answer 4: RATIONALES: Because alprazolam is contraindicated during pregnancy, the client should be instructed to inform the physician if she becomes pregnant. Nausea, urine retention, and photosensitivity are adverse reactions that may occur, but aren't contraindicated. 17. A recent diagnosis of cancer has caused a client severe anxiety. The nursing care plan should include which interventions? Select all that apply 1. Maintain a calm, nonthreatening environment. 2. Teach relevant aspects of chemotherapy. 3. Encourage the client to verbalize her concerns regarding the diagnosis. 4. Encourage the client to use deep-breathing exercises and other relaxation techniques during periods of increased stress. 5. Provide distractions for the client during periods of stress. 6. Teach the stages of grieving. Answer: 1,3,4 RATIONALES: During acute stress, interventions that help the client regain control will help the client master this new threat. Providing a calm, accepting attitude and encouraging verbalization of concerns will help the client face the unknown. Relaxation techniques have a physiologic and psychological effect in calming the client, which in turn allows further exploration of thoughts and feelings, as well as problem solving. Learning is limited during extreme stress, so teaching wouldn't be effective at this stage. Providing distractions would be ineffective at this point in the grief process. Teaching about the stages of grieving isn't appropriate at this time.