Chapter 31 My Nursing Test Banks

 

Kneisl, Contemporary Psychiatric-Mental Health Nursing, 3/e Test Bank
Chapter 31

Question 1

Type: MCMA

Which of the following is part of the ongoing nursing assessments of the client on psychiatric medications?

Standard Text: Select all that apply.

1. How well the medication is managing the clients symptoms

2. The clients cultural belief system related to illness and medication

3. Whether the medication is causing side effects

4. The clients favorite activities

5. The clients readiness to learn

Correct Answer: 1,2,3,5

Rationale 1: How well the medication is managing the clients symptoms. The nurse must assess how effective the medication is in terms of managing the symptoms of the clients illness.

Rationale 2: The clients cultural belief system related to illness and medication. A clients cultural belief system related to taking medications for behavioral symptoms may impact the clients willingness to take medications.

Rationale 3: Whether the medication is causing side effects. If a client is having a distressing side effect, the client may not adhere to the medication treatment regimen.

Rationale 4: The clients favorite activities. The clients favorite activities are not directly related to taking medications.

Rationale 5: The clients readiness to learn. Ongoing education is vital for adhering to medications and clients readiness to learn fluctuates throughout the course of the illness.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Assess the effectiveness of medications in psychiatricmental health settings.

Question 2

Type: MCSA

Which of the following questions would the nurse ask a woman to assess for hyperprolactinemia as a side effect of an antipsychotic medication?

1. Are you having trouble sitting still?

2. Are you constipated?

3. Are you having any discharge from your breasts?

4. Do you have a dry mouth?

Correct Answer: 3

Rationale 1: Galactorrhea is a symptom of hyperprolactinemia. The inability to sit still could be a sign of akathisia. A dry mouth and constipation are often due to anticholinergic side effects.

Rationale 2: Galactorrhea is a symptom of hyperprolactinemia. The inability to sit still could be a sign of akathisia. A dry mouth and constipation are often due to anticholinergic side effects.

Rationale 3: Galactorrhea is a symptom of hyperprolactinemia. The inability to sit still could be a sign of akathisia. A dry mouth and constipation are often due to anticholinergic side effects.

Rationale 4: Galactorrhea is a symptom of hyperprolactinemia. The inability to sit still could be a sign of akathisia. A dry mouth and constipation are often due to anticholinergic side effects.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Assess the effectiveness of medications in psychiatricmental health settings.

Question 3

Type: MCSA

Which of the following is a priority assessment for a child in the initial stages of antidepressant treatment?

1. School successes

2. Food preferences

3. Suicide assessment

4. Family functioning

Correct Answer: 3

Rationale 1: Children, adolescents, and young adults are at risk for suicidal behaviors early in the treatment with antidepressants. Family functioning, school successes, and eating are important assessments, but not as important as assessing for lethality/suicidality.

Rationale 2: Children, adolescents, and young adults are at risk for suicidal behaviors early in the treatment with antidepressants. Family functioning, school successes, and eating are important assessments, but not as important as assessing for lethality/suicidality.

Rationale 3: Children, adolescents, and young adults are at risk for suicidal behaviors early in the treatment with antidepressants. Family functioning, school successes, and eating are important assessments, but not as important as assessing for lethality/suicidality.

Rationale 4: Children, adolescents, and young adults are at risk for suicidal behaviors early in the treatment with antidepressants. Family functioning, school successes, and eating are important assessments, but not as important as assessing for lethality/suicidality.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Assess the effectiveness of medications in psychiatricmental health settings.

Question 4

Type: MCSA

The nurse would be alert to assess for signs of lithium toxicity in a patient with which of the following lithium levels?

1. 1.5 mEq/l

2. 0.1 mEq/l

3. 0.5 mEq/l

4. 1.0 mEq/l

Correct Answer: 1

Rationale 1: Significant side effects are often present in clients with a lithium level above 1.2 mEq/l.

Rationale 2: Significant side effects are often present in clients with a lithium level above 1.2 mEq/l.

Rationale 3: Significant side effects are often present in clients with a lithium level above 1.2 mEq/l.

Rationale 4: Significant side effects are often present in clients with a lithium level above 1.2 mEq/l.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Assess the effectiveness of medications in psychiatricmental health settings.

Question 5

Type: MCSA

The nurse would assess which of the following as early signs of lithium poisoning?

1. Elevated blood pressure, paralysis, and impulsivity

2. Cardiac arrest, seizures, and change in level of consciousness

3. Vomiting, diarrhea, lethargy, and muscle twitching

4. Hallucinations, agitation, and anger

Correct Answer: 3

Rationale 1: Vomiting, diarrhea, lethargy, and muscle twitching are early signs of lithium poisoning. Cardiac arrest, seizures, and change in level of consciousness are late and life threatening signs that could be avoided if the early signs are recognized. The combination of hallucinations, agitation, anger, elevated blood pressure, paralysis, and impulsivity are not early signs of lithium toxicity.

Rationale 2: Vomiting, diarrhea, lethargy, and muscle twitching are early signs of lithium poisoning. Cardiac arrest, seizures, and change in level of consciousness are late and life threatening signs that could be avoided if the early signs are recognized. The combination of hallucinations, agitation, anger, elevated blood pressure, paralysis, and impulsivity are not early signs of lithium toxicity.

Rationale 3: Vomiting, diarrhea, lethargy, and muscle twitching are early signs of lithium poisoning. Cardiac arrest, seizures, and change in level of consciousness are late and life threatening signs that could be avoided if the early signs are recognized. The combination of hallucinations, agitation, anger, elevated blood pressure, paralysis, and impulsivity are not early signs of lithium toxicity.

Rationale 4: Vomiting, diarrhea, lethargy, and muscle twitching are early signs of lithium poisoning. Cardiac arrest, seizures, and change in level of consciousness are late and life threatening signs that could be avoided if the early signs are recognized. The combination of hallucinations, agitation, anger, elevated blood pressure, paralysis, and impulsivity are not early signs of lithium toxicity.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Assess the effectiveness of medications in psychiatricmental health settings.

Question 6

Type: MCSA

Which of the following medications carries the highest risk of QTc prolongation and, therefore, the need to monitor cardiac side effects most carefully?

1. Thioridazine (Mellaril)

2. Risperidone (Risperdal)

3. Quetiapine (Seroquel)

4. Olanzapine (Zyprexa)

Correct Answer: 1

Rationale 1: Thioridazine has an FDA black box warning to call attention to the risk of QTc prolongation. The other antipsychotics listed do not carry this warning.

Rationale 2: Thioridazine has an FDA black box warning to call attention to the risk of QTc prolongation. The other antipsychotics listed do not carry this warning.

Rationale 3: Thioridazine has an FDA black box warning to call attention to the risk of QTc prolongation. The other antipsychotics listed do not carry this warning.

Rationale 4: Thioridazine has an FDA black box warning to call attention to the risk of QTc prolongation. The other antipsychotics listed do not carry this warning.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Integrate an understanding of the positive and negative effects of psychiatric medications into pharmacological treatment.

Question 7

Type: MCSA

Which of the following client behaviors would indicate a need for further intervention in the anxious patient on a benzodiazepine?

1. The client asking to be taken off the medication gradually

2. The client relying more on coping skills and taking less medication

3. The client inquiring about behavior methods for anxiety control

4. The client requesting a higher dose of drug to achieve the intended effect

Correct Answer: 4

Rationale 1: Requesting higher doses of a benzodiazepine can be a sign of tolerance and addiction. The other responses are actually signs of relying less on the medication and more on coping strategies and are positive signs.

Rationale 2: Requesting higher doses of a benzodiazepine can be a sign of tolerance and addiction. The other responses are actually signs of relying less on the medication and more on coping strategies and are positive signs.

Rationale 3: Requesting higher doses of a benzodiazepine can be a sign of tolerance and addiction. The other responses are actually signs of relying less on the medication and more on coping strategies and are positive signs.

Rationale 4: Requesting higher doses of a benzodiazepine can be a sign of tolerance and addiction. The other responses are actually signs of relying less on the medication and more on coping strategies and are positive signs.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Integrate an understanding of the positive and negative effects of psychiatric medications into pharmacological treatment.

Question 8

Type: MCSA

The client received aripiprazole (Abilify) on admission to the inpatient unit with a diagnosis of schizophrenia, paranoid type. Which of the following would the nurse note as a sign that the aripiprazole is becoming effective?

1. The client paces in the hall and engages in solitary activities most of the day.

2. The client sleeps for shorter periods of time during the day.

3. The client establishes eye contact and remains in conversation with the nurse for longer periods.

4. The client eats only the food that is in its original container such as individual packages of crackers.

Correct Answer: 3

Rationale 1: Because suspiciousness is a central feature of paranoid delusions, efficacy is shown by the client demonstrating behaviors that suggest increasing trust in the nurse. Sleeping less during the day is not a sign that aripiprazole is alleviating psychotic symptoms. Engaging in solitary activities and eating prepackaged food are signs of paranoia.

Rationale 2: Because suspiciousness is a central feature of paranoid delusions, efficacy is shown by the client demonstrating behaviors that suggest increasing trust in the nurse. Sleeping less during the day is not a sign that aripiprazole is alleviating psychotic symptoms. Engaging in solitary activities and eating prepackaged food are signs of paranoia.

Rationale 3: Because suspiciousness is a central feature of paranoid delusions, efficacy is shown by the client demonstrating behaviors that suggest increasing trust in the nurse. Sleeping less during the day is not a sign that aripiprazole is alleviating psychotic symptoms. Engaging in solitary activities and eating prepackaged food are signs of paranoia.

Rationale 4: Because suspiciousness is a central feature of paranoid delusions, efficacy is shown by the client demonstrating behaviors that suggest increasing trust in the nurse. Sleeping less during the day is not a sign that aripiprazole is alleviating psychotic symptoms. Engaging in solitary activities and eating prepackaged food are signs of paranoia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Integrate an understanding of the positive and negative effects of psychiatric medications into pharmacological treatment.

Question 9

Type: MCSA

Which of the following is an indication that the client understands the teaching related to buspirone (BuSpar)?

1. I will not drink grapefruit juice while taking this medication.

2. I should sleep though the night on this medication.

3. I should feel a relief of anxiety within a half hour.

4. I will not hear voices after being on this medication for two weeks.

Correct Answer: 1

Rationale 1: When taken with grapefruit juice, buspirone levels can be raised to nine times the normal level. Buspirone takes up to two weeks to show efficacy for anxiety control and is not a sedative. Buspirone is an antianxiety agent and does not impact auditory hallucinations.

Rationale 2: When taken with grapefruit juice, buspirone levels can be raised to nine times the normal level. Buspirone takes up to two weeks to show efficacy for anxiety control and is not a sedative. Buspirone is an antianxiety agent and does not impact auditory hallucinations.

Rationale 3: When taken with grapefruit juice, buspirone levels can be raised to nine times the normal level. Buspirone takes up to two weeks to show efficacy for anxiety control and is not a sedative. Buspirone is an antianxiety agent and does not impact auditory hallucinations.

Rationale 4: When taken with grapefruit juice, buspirone levels can be raised to nine times the normal level. Buspirone takes up to two weeks to show efficacy for anxiety control and is not a sedative. Buspirone is an antianxiety agent and does not impact auditory hallucinations.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Integrate an understanding of the positive and negative effects of psychiatric medications into pharmacological treatment.

Question 10

Type: MCSA

Which of the following would indicate to the nurse that fluoxetine (Prozac) is effective for the client with major depressive disorder?

1. The client remained up all night discussing negative life situations with the nursing staff.

2. The client ate 100% of breakfast and lunch and ate 25% of the evening meal the past two days.

3. The client remained in the room reading and watching listening to music 90% of the day.

4. The client slept 60% of the night while remaining in bed from 11 p.m. to 5 a.m.

Correct Answer: 2

Rationale 1: An improvement in appetite is a sign of an improvement in a symptom of major depressive disorder. Ruminating on negative life events, not sleeping, and isolating are symptoms of depression and do not show an improvement from the medication.

Rationale 2: An improvement in appetite is a sign of an improvement in a symptom of major depressive disorder. Ruminating on negative life events, not sleeping, and isolating are symptoms of depression and do not show an improvement from the medication.

Rationale 3: An improvement in appetite is a sign of an improvement in a symptom of major depressive disorder. Ruminating on negative life events, not sleeping, and isolating are symptoms of depression and do not show an improvement from the medication.

Rationale 4: An improvement in appetite is a sign of an improvement in a symptom of major depressive disorder. Ruminating on negative life events, not sleeping, and isolating are symptoms of depression and do not show an improvement from the medication.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Integrate an understanding of the positive and negative effects of psychiatric medications into pharmacological treatment.

Question 11

Type: MCSA

The nurse instructs the clients to take the medications that are prescribed because the psychiatrist knows what is best for the client. How would the nurses supervisor evaluate the effectiveness of the nurses teaching?

1. The nurse is demonstrating a paternalistic attitude that may contribute to client nonadherence.

2. Teaching the client to take all medications should help keep the client out of the hospital.

3. The nurse is helping the client develop trust in the psychiatrist.

4. The nurse is giving simple instructions that will be readily accepted by the client.

Correct Answer: 1

Rationale 1: In order to promote adherence, the nurse should partner with the client and the clients family. Telling the client that someone else knows what is best for the client is paternalistic and interferes with partnering with clients. Although the nurses statement is simple, it is not one that is readily accepted by clients. One develops trust through actions, not by telling someone to trust.

Rationale 2: In order to promote adherence, the nurse should partner with the client and the clients family. Telling the client that someone else knows what is best for the client is paternalistic and interferes with partnering with clients. Although the nurses statement is simple, it is not one that is readily accepted by clients. One develops trust through actions, not by telling someone to trust.

Rationale 3: In order to promote adherence, the nurse should partner with the client and the clients family. Telling the client that someone else knows what is best for the client is paternalistic and interferes with partnering with clients. Although the nurses statement is simple, it is not one that is readily accepted by clients. One develops trust through actions, not by telling someone to trust.

Rationale 4: In order to promote adherence, the nurse should partner with the client and the clients family. Telling the client that someone else knows what is best for the client is paternalistic and interferes with partnering with clients. Although the nurses statement is simple, it is not one that is readily accepted by clients. One develops trust through actions, not by telling someone to trust.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Incorporate the different perspectives clients have about pharmacology into treatment regimens.

Question 12

Type: MCSA

The client tells the nurse that their spouse does not believe that medications are needed to improve depression. What nursing response would be most helpful in improving the clients medication adherence?

1. Suggest that the spouses views are not important

2. Ask the client to consider marriage counseling

3. Tell the client to ignore the spouse

4. Include the spouse in medication teaching

Correct Answer: 4

Rationale 1: Lack of support from significant others can contribute to medication nonadherence. Partnering with the family may help the family to be supportive. It is difficult to ignore ones spouse, and there is no evidence that marriage counseling is needed at this point. Usually the views of ones significant others are important.

Rationale 2: Lack of support from significant others can contribute to medication nonadherence. Partnering with the family may help the family to be supportive. It is difficult to ignore ones spouse, and there is no evidence that marriage counseling is needed at this point. Usually the views of ones significant others are important.

Rationale 3: Lack of support from significant others can contribute to medication nonadherence. Partnering with the family may help the family to be supportive. It is difficult to ignore ones spouse, and there is no evidence that marriage counseling is needed at this point. Usually the views of ones significant others are important.

Rationale 4: Lack of support from significant others can contribute to medication nonadherence. Partnering with the family may help the family to be supportive. It is difficult to ignore ones spouse, and there is no evidence that marriage counseling is needed at this point. Usually the views of ones significant others are important.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Incorporate the different perspectives clients have about pharmacology into treatment regimens.

Question 13

Type: MCSA

What is the primary rationale for the nurse asking a client on antidepressant medication about changes in sexual functioning?

1. Antidepressants used frequently contributes to sexual promiscuity and tragic regrets.

2. A side effect of antidepressants may be sexual dysfunction that contributes to nonadherence.

3. Cultural attitudes about sexual functioning may impact the effectiveness of the antidepressant medication.

4. A lack of libido is a symptom of depression that may interfere with the clients relationships.

Correct Answer: 2

Rationale 1: Sexual dysfunctions are frequent side effects of antidepressants and the client may be too embarrassed to initiate this discussion and quit taking the medication. Even though loss of libido may be a symptom of depression, it does not address the issue of the medication side effect. Cultural attitudes about sexual functioning are not directly related to the question. Antidepressants do not frequently contribute to sexual promiscuity when given to a person with a depressive disorder.

Rationale 2: Sexual dysfunctions are frequent side effects of antidepressants and the client may be too embarrassed to initiate this discussion and quit taking the medication. Even though loss of libido may be a symptom of depression, it does not address the issue of the medication side effect. Cultural attitudes about sexual functioning are not directly related to the question. Antidepressants do not frequently contribute to sexual promiscuity when given to a person with a depressive disorder.

Rationale 3: Sexual dysfunctions are frequent side effects of antidepressants and the client may be too embarrassed to initiate this discussion and quit taking the medication. Even though loss of libido may be a symptom of depression, it does not address the issue of the medication side effect. Cultural attitudes about sexual functioning are not directly related to the question. Antidepressants do not frequently contribute to sexual promiscuity when given to a person with a depressive disorder.

Rationale 4: Sexual dysfunctions are frequent side effects of antidepressants and the client may be too embarrassed to initiate this discussion and quit taking the medication. Even though loss of libido may be a symptom of depression, it does not address the issue of the medication side effect. Cultural attitudes about sexual functioning are not directly related to the question. Antidepressants do not frequently contribute to sexual promiscuity when given to a person with a depressive disorder.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Incorporate the different perspectives clients have about pharmacology into treatment regimens.

Question 14

Type: MCSA

The nurse tells a psychotic client with alcohol dependence not to drink while taking the antipsychotic medication. How would the nurses supervisor evaluate this teaching statement?

1. There is no reason why the client cannot have one or two drinks per day.

2. It is not possible for a client with a psychotic disorder to be successful in staying sober.

3. It is a correct statement that should motivate the client to quit drinking.

4. Without treatment for the alcohol dependence, the client will be more likely to not take the medication.

Correct Answer: 4

Rationale 1: The alcohol dependence must be a part of the clients treatment plan or the client will likely not take the medication. Telling a client not to drink does not provide enough motivation to quit drinking. A person with alcohol dependence should not drink one or two drinks per day. It is possible for a client with a psychotic disorder to be successful at staying sober.

Rationale 2: The alcohol dependence must be a part of the clients treatment plan or the client will likely not take the medication. Telling a client not to drink does not provide enough motivation to quit drinking. A person with alcohol dependence should not drink one or two drinks per day. It is possible for a client with a psychotic disorder to be successful at staying sober.

Rationale 3: The alcohol dependence must be a part of the clients treatment plan or the client will likely not take the medication. Telling a client not to drink does not provide enough motivation to quit drinking. A person with alcohol dependence should not drink one or two drinks per day. It is possible for a client with a psychotic disorder to be successful at staying sober.

Rationale 4: The alcohol dependence must be a part of the clients treatment plan or the client will likely not take the medication. Telling a client not to drink does not provide enough motivation to quit drinking. A person with alcohol dependence should not drink one or two drinks per day. It is possible for a client with a psychotic disorder to be successful at staying sober.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Incorporate the different perspectives clients have about pharmacology into treatment regimens.

Question 15

Type: MCSA

The nurse knows that the client did not adhere to a medication plan in the past due to severe side effects. What information would be most important to include in the clients teaching?

1. The need to monitor all body changes on a continuous basis

2. Hopefulness about managing side effects

3. Reassurance that side effects will not occur

4. A detailed explanation of all potential side effects

Correct Answer: 2

Rationale 1: Side effects can be managed successfully and clients need to feel hopeful about their ability to work with the health care team in doing this. Although the client needs to know about potential side effects, the client should not be given only frightening information. Some side effects are a real possibility, and the nurse should not give false reassurance.

Rationale 2: Side effects can be managed successfully and clients need to feel hopeful about their ability to work with the health care team in doing this. Although the client needs to know about potential side effects, the client should not be given only frightening information. Some side effects are a real possibility, and the nurse should not give false reassurance.

Rationale 3: Side effects can be managed successfully and clients need to feel hopeful about their ability to work with the health care team in doing this. Although the client needs to know about potential side effects, the client should not be given only frightening information. Some side effects are a real possibility, and the nurse should not give false reassurance.

Rationale 4: Side effects can be managed successfully and clients need to feel hopeful about their ability to work with the health care team in doing this. Although the client needs to know about potential side effects, the client should not be given only frightening information. Some side effects are a real possibility, and the nurse should not give false reassurance.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Incorporate the different perspectives clients have about pharmacology into treatment regimens.

Question 16

Type: MCSA

A family member says to the nurse, I think my sister needs more medication because she says she cannot sit still and is moving her legs back and forth. The clients risperidone (Risperdal) was recently increased to 10 mg daily. What is the correct nursing response?

1. I will check with your sister because what you are describing sounds like a side effect called akathisia.

2. I will check to see what your sister has been prescribed because some clients get anxious when their medications are increased.

3. I will see if your sister has been prescribed a medication to counteract the dystonic reaction that she is having.

4. I will call the doctor and report that your sister is developing a tolerance to risperidone and the dose is not effective.

Correct Answer: 1

Rationale 1: Akathisia is the inability to sit still for more than a few minutes or the feeling of not being able to sit still. It is a side effect of antipsychotic medication that can be very distressing to the client. The nurse should assess the patient to determine if she has akathisia. It would not be typical for a client to get anxious just because the medications were increased. A dystonia would be an abnormal tonic muscle contraction. Risperidone is not addictive and clients do not develop tolerance to it.

Rationale 2: Akathisia is the inability to sit still for more than a few minutes or the feeling of not being able to sit still. It is a side effect of antipsychotic medication that can be very distressing to the client. The nurse should assess the patient to determine if she has akathisia. It would not be typical for a client to get anxious just because the medications were increased. A dystonia would be an abnormal tonic muscle contraction. Risperidone is not addictive and clients do not develop tolerance to it.

Rationale 3: Akathisia is the inability to sit still for more than a few minutes or the feeling of not being able to sit still. It is a side effect of antipsychotic medication that can be very distressing to the client. The nurse should assess the patient to determine if she has akathisia. It would not be typical for a client to get anxious just because the medications were increased. A dystonia would be an abnormal tonic muscle contraction. Risperidone is not addictive and clients do not develop tolerance to it.

Rationale 4: Akathisia is the inability to sit still for more than a few minutes or the feeling of not being able to sit still. It is a side effect of antipsychotic medication that can be very distressing to the client. The nurse should assess the patient to determine if she has akathisia. It would not be typical for a client to get anxious just because the medications were increased. A dystonia would be an abnormal tonic muscle contraction. Risperidone is not addictive and clients do not develop tolerance to it.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain acute extrapyramidal side effects to clients and families.

Question 17

Type: MCSA

The nurse observes a client on an antipsychotic medication and notes a pill-rolling movement of the fingers and a tremor of the extremities. The nurse documents this as what type of side effect?

1. Drug-induced parkinsonism

2. Dystonia

3. Anticholinergic effect

4. Tardive dyskinesia

Correct Answer: 1

Rationale 1: One form of EPSE is drug-induced parkinsonism characterized by tremors, rigidity, and pill-rolling movements of the fingers. Dystonia is an involuntary tonic muscle contraction. Anticholinergic side effects include blurred vision, dry mouth, urinary retention, and constipation. Tardive dyskinesia is involuntary nonrhythmic movements of the mouth, face, etc.

Rationale 2: One form of EPSE is drug-induced parkinsonism characterized by tremors, rigidity, and pill-rolling movements of the fingers. Dystonia is an involuntary tonic muscle contraction. Anticholinergic side effects include blurred vision, dry mouth, urinary retention, and constipation. Tardive dyskinesia is involuntary nonrhythmic movements of the mouth, face, etc.

Rationale 3: One form of EPSE is drug-induced parkinsonism characterized by tremors, rigidity, and pill-rolling movements of the fingers. Dystonia is an involuntary tonic muscle contraction. Anticholinergic side effects include blurred vision, dry mouth, urinary retention, and constipation. Tardive dyskinesia is involuntary nonrhythmic movements of the mouth, face, etc.

Rationale 4: One form of EPSE is drug-induced parkinsonism characterized by tremors, rigidity, and pill-rolling movements of the fingers. Dystonia is an involuntary tonic muscle contraction. Anticholinergic side effects include blurred vision, dry mouth, urinary retention, and constipation. Tardive dyskinesia is involuntary nonrhythmic movements of the mouth, face, etc.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain acute extrapyramidal side effects to clients and families.

Question 18

Type: MCSA

The spouse of a client on an antipsychotic medication asks the nurse why they routinely assess the client for movements, especially around the mouth and extremities. What nursing response is correct?

1. Abnormal involuntary movements can be an irreversible side effect of antipsychotic medications.

2. Antipsychotic medications can lead to this type of dystonia.

3. Abnormal involuntary movements can be easily treated and less annoying to the client.

4. Movements around the mouth herald the approaching medication tolerance that the client is developing.

Correct Answer: 1

Rationale 1: The nurse is assessing for tardive dyskinesia, an arrhythmic, involuntary movement that can be irreversible if not detected early. Antipsychotic medications do not lead to tolerance. Abnormal involuntary movements are not easily treated. Dystonia is a side effect characterized by muscle spasms.

Rationale 2: The nurse is assessing for tardive dyskinesia, an arrhythmic, involuntary movement that can be irreversible if not detected early. Antipsychotic medications do not lead to tolerance. Abnormal involuntary movements are not easily treated. Dystonia is a side effect characterized by muscle spasms.

Rationale 3: The nurse is assessing for tardive dyskinesia, an arrhythmic, involuntary movement that can be irreversible if not detected early. Antipsychotic medications do not lead to tolerance. Abnormal involuntary movements are not easily treated. Dystonia is a side effect characterized by muscle spasms.

Rationale 4: The nurse is assessing for tardive dyskinesia, an arrhythmic, involuntary movement that can be irreversible if not detected early. Antipsychotic medications do not lead to tolerance. Abnormal involuntary movements are not easily treated. Dystonia is a side effect characterized by muscle spasms.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain acute extrapyramidal side effects to clients and families.

Question 19

Type: MCSA

When in the course of treatment with an antipsychotic medication would the nurse be most likely to assess tardive dyskinesia?

1. Within 72 hours of initiation

2. After long-term use

3. Within 48 hours of initiation

4. After three or more weeks of treatment

Correct Answer: 2

Rationale 1: Tardive dyskinesia has a late onset during the course of treatment with antipsychotic medications.

Rationale 2: Tardive dyskinesia has a late onset during the course of treatment with antipsychotic medications.

Rationale 3: Tardive dyskinesia has a late onset during the course of treatment with antipsychotic medications.

Rationale 4: Tardive dyskinesia has a late onset during the course of treatment with antipsychotic medications.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:

Question 20

Type: MCMA

Which of the following are extrapyramidal side effects that the nurse would assess as symptoms of dystonia?

Standard Text: Select all that apply.

1. Decreased gastric motility and tachycardia

2. An inability to sit still

3. Forcing the back to arch and the neck to bend backward

4. Pulling the neck down into the shoulders

5. Spasms of the neck and back

Correct Answer: 2,3,4,5

Rationale 1: Decreased gastric motility and tachycardia. Decreased gastric motility and tachycardia may occur with a dopamine-acetylcholine imbalance in the extrapyramidal system.

Rationale 2: An inability to sit still. An inability to sit still is akathisia.

Rationale 3: Forcing the back to arch and the neck to bend backward. Forcing the back to arch and the neck to bend backward are examples of dystonia.

Rationale 4: Pulling the neck down into the shoulders. Pulling the neck into the shoulders is a type of dystonia.

Rationale 5: Spasms of the neck and back. Spasms of the neck and back are examples of dystonia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain acute extrapyramidal side effects to clients and families.

Question 21

Type: MCSA

The client is taking a medication to help cope with EPSEs but can not remember the name of the medication. The nurse would give the client information about which of the following medications that the client is receiving?

1. Risperidone (Risperdal)

2. Duloxetine (Cymbalta)

3. Loxapine (Loxitane)

4. Benztropine (Cogentin)

Correct Answer: 4

Rationale 1: Benztropine is an antiparkinson drug used to help manage the EPSEs of antipsychotic medications. Risperidone and loxapine are antipsychotic medications. Duloxetine is an antidepressant medication.

Rationale 2: Benztropine is an antiparkinson drug used to help manage the EPSEs of antipsychotic medications. Risperidone and loxapine are antipsychotic medications. Duloxetine is an antidepressant medication.

Rationale 3: Benztropine is an antiparkinson drug used to help manage the EPSEs of antipsychotic medications. Risperidone and loxapine are antipsychotic medications. Duloxetine is an antidepressant medication.

Rationale 4: Benztropine is an antiparkinson drug used to help manage the EPSEs of antipsychotic medications. Risperidone and loxapine are antipsychotic medications. Duloxetine is an antidepressant medication.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Compare and contrast a plan of care for taking these medications for an indefinite period of time versus a six-month period of time.

Question 22

Type: MCSA

The client reports difficulty remembering at home whether the client took the medication or just thought about taking the medication. Which of the following strategies would be most helpful for the nurse to suggest?

1. Obtaining and using a pill box

2. Wearing a rubber band to remember

3. Repeating the need to take the medications routinely

4. Putting the pill container near the breakfast table

Correct Answer: 1

Rationale 1: A pill box is the only method listed for which the patient can check the date and time to see whether or not the pill was taken.

Rationale 2: A pill box is the only method listed for which the patient can check the date and time to see whether or not the pill was taken.

Rationale 3: A pill box is the only method listed for which the patient can check the date and time to see whether or not the pill was taken.

Rationale 4: A pill box is the only method listed for which the patient can check the date and time to see whether or not the pill was taken.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Compare and contrast a plan of care for taking these medications for an indefinite period of time versus a six-month period of time.

Question 23

Type: MCSA

The nurse should monitor for which of the following in the client taking venlafaxine (Effexor)?

1. Increased weight

2. Prolonged QTc interval

3. Increased blood pressure

4. Tardive dyskinesia

Correct Answer: 3

Rationale 1: Sustained increased blood pressure has been noted in some clients, especially those on higher doses of venlafaxine. Weight, QTc intervals, and tardive dyskinesia are not typical side effects of venlafaxine.

Rationale 2: Sustained increased blood pressure has been noted in some clients, especially those on higher doses of venlafaxine. Weight, QTc intervals, and tardive dyskinesia are not typical side effects of venlafaxine.

Rationale 3: Sustained increased blood pressure has been noted in some clients, especially those on higher doses of venlafaxine. Weight, QTc intervals, and tardive dyskinesia are not typical side effects of venlafaxine.

Rationale 4: Sustained increased blood pressure has been noted in some clients, especially those on higher doses of venlafaxine. Weight, QTc intervals, and tardive dyskinesia are not typical side effects of venlafaxine.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Compare and contrast a plan of care for taking these medications for an indefinite period of time versus a six-month period of time.

Question 24

Type: MCSA

Which of the following laboratory studies are routinely done on patients taking second generation antipsychotic medications?

1. Hemoglobin and hematocrit

2. Renal functions

3. Thyroid functions

4. Serum glucose levels

Correct Answer: 4

Rationale 1: Second generation antipsychotic medications have a risk of insulin resistance contributing to diabetes, so serum glucose levels are routinely monitored. Hemoglobin, thyroid function, and renal function are not typically affected by the second generation antipsychotic medications.

Rationale 2: Second generation antipsychotic medications have a risk of insulin resistance contributing to diabetes, so serum glucose levels are routinely monitored. Hemoglobin, thyroid function, and renal function are not typically affected by the second generation antipsychotic medications.

Rationale 3: Second generation antipsychotic medications have a risk of insulin resistance contributing to diabetes, so serum glucose levels are routinely monitored. Hemoglobin, thyroid function, and renal function are not typically affected by the second generation antipsychotic medications.

Rationale 4: Second generation antipsychotic medications have a risk of insulin resistance contributing to diabetes, so serum glucose levels are routinely monitored. Hemoglobin, thyroid function, and renal function are not typically affected by the second generation antipsychotic medications.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Compare and contrast a plan of care for taking these medications for an indefinite period of time versus a six-month period of time.

Question 25

Type: MCSA

The client has been taking fluvoxamine (Luvox) for years, has been symptom-free for one year, and is now considering taking a drug holiday. What nursing teaching is necessary?

1. The client should be symptom-free for at least two years before trying to go off the medication

2. The client should let the prescriber make these decisions and should not suggest this

3. A drug holiday should be avoided due to discontinuation symptoms

4. This is worth trying since the client has been symptom-free for a year

Correct Answer: 3

Rationale 1: Fluvoxamine should be gradually tapered to avoid discontinuation symptoms. The client should discuss the drug holiday with the prescriber.

Rationale 2: Fluvoxamine should be gradually tapered to avoid discontinuation symptoms. The client should discuss the drug holiday with the prescriber.

Rationale 3: Fluvoxamine should be gradually tapered to avoid discontinuation symptoms. The client should discuss the drug holiday with the prescriber.

Rationale 4: Fluvoxamine should be gradually tapered to avoid discontinuation symptoms. The client should discuss the drug holiday with the prescriber.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Compare and contrast a plan of care for taking these medications for an indefinite period of time versus a six-month period of time.

Question 26

Type: MCSA

A client exhibiting which of the following antipsychotic side effects would require the nurses immediate intervention?

1. Neuroleptic malignant syndrome

2. Drowsiness

3. Parkinsonism

4. Impotence

Correct Answer: 1

Rationale 1: Neuroleptic malignant syndrome can be fatal. Parkinsonism, impotence, and drowsiness are not normally life-threatening conditions.

Rationale 2: Neuroleptic malignant syndrome can be fatal. Parkinsonism, impotence, and drowsiness are not normally life-threatening conditions.

Rationale 3: Neuroleptic malignant syndrome can be fatal. Parkinsonism, impotence, and drowsiness are not normally life-threatening conditions.

Rationale 4: Neuroleptic malignant syndrome can be fatal. Parkinsonism, impotence, and drowsiness are not normally life-threatening conditions.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Formulate nursing interventions to address the major side effects associated with psychotropic medications.

Question 27

Type: MCSA

Which of the following laboratory studies is performed because the client is taking lithium?

1. Hemoglobin

2. CBC

3. Liver function

4. Thyroid function

Correct Answer: 4

Rationale 1: A thyroid goiter and hypothyroidism are side effects of lithium; therefore, thyroid function studies are performed periodically. Lithium is not metabolized in the liver and so does not require liver function studies. A CBC and hemoglobin are not needed because lithium does not frequently alter blood counts.

Rationale 2: A thyroid goiter and hypothyroidism are side effects of lithium; therefore, thyroid function studies are performed periodically. Lithium is not metabolized in the liver and so does not require liver function studies. A CBC and hemoglobin are not needed because lithium does not frequently alter blood counts.

Rationale 3: A thyroid goiter and hypothyroidism are side effects of lithium; therefore, thyroid function studies are performed periodically. Lithium is not metabolized in the liver and so does not require liver function studies. A CBC and hemoglobin are not needed because lithium does not frequently alter blood counts.

Rationale 4: A thyroid goiter and hypothyroidism are side effects of lithium; therefore, thyroid function studies are performed periodically. Lithium is not metabolized in the liver and so does not require liver function studies. A CBC and hemoglobin are not needed because lithium does not frequently alter blood counts.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Formulate nursing interventions to address the major side effects associated with psychotropic medications.

Question 28

Type: MCSA

Clients taking an MAOI should be taught to avoid completely which of the following foods?

1. White wines, cottage cheese, and ice cream

2. Steak, potatoes, and corn

3. Bread, apples, and hamburgers

4. Liver, sauerkraut, and yogurt

Correct Answer: 4

Rationale 1: Clients taking MAOIs are taught to avoid foods containing tyramine, such as, liver, aged cheeses, red wines, sauerkraut, and yogurt. Additionally, caffeine, colas, chocolate, soy products, aged fish, and processed meats contain tyramine in high amounts. White wines, cottage cheese, ice cream, bread, apples, hamburgers, steak, potatoes, and corn are allowed.

Rationale 2: Clients taking MAOIs are taught to avoid foods containing tyramine, such as, liver, aged cheeses, red wines, sauerkraut, and yogurt. Additionally, caffeine, colas, chocolate, soy products, aged fish, and processed meats contain tyramine in high amounts. White wines, cottage cheese, ice cream, bread, apples, hamburgers, steak, potatoes, and corn are allowed.

Rationale 3: Clients taking MAOIs are taught to avoid foods containing tyramine, such as, liver, aged cheeses, red wines, sauerkraut, and yogurt. Additionally, caffeine, colas, chocolate, soy products, aged fish, and processed meats contain tyramine in high amounts. White wines, cottage cheese, ice cream, bread, apples, hamburgers, steak, potatoes, and corn are allowed.

Rationale 4: Clients taking MAOIs are taught to avoid foods containing tyramine, such as, liver, aged cheeses, red wines, sauerkraut, and yogurt. Additionally, caffeine, colas, chocolate, soy products, aged fish, and processed meats contain tyramine in high amounts. White wines, cottage cheese, ice cream, bread, apples, hamburgers, steak, potatoes, and corn are allowed.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Formulate nursing interventions to address the major side effects associated with psychotropic medications.

Question 29

Type: MCSA

Because of the risk of postural hypotension, the client on clozapine (Clozaril) should be taught which of the following?

1. To wear sunscreen if going outdoors

2. To rise slowly from a lying position

3. To check for involuntary movements of the mouth

4. To have weekly blood work

Correct Answer: 2

Rationale 1: Antipsychotic medications have a risk for postural hypotension that could lead to a fall if the client rises too quickly. Wearing a sunscreen is necessary due to photosensitivity, not hypotension. Blood work checks for agranulocytosis. Mouth movements are not caused by hypotension.

Rationale 2: Antipsychotic medications have a risk for postural hypotension that could lead to a fall if the client rises too quickly. Wearing a sunscreen is necessary due to photosensitivity, not hypotension. Blood work checks for agranulocytosis. Mouth movements are not caused by hypotension.

Rationale 3: Antipsychotic medications have a risk for postural hypotension that could lead to a fall if the client rises too quickly. Wearing a sunscreen is necessary due to photosensitivity, not hypotension. Blood work checks for agranulocytosis. Mouth movements are not caused by hypotension.

Rationale 4: Antipsychotic medications have a risk for postural hypotension that could lead to a fall if the client rises too quickly. Wearing a sunscreen is necessary due to photosensitivity, not hypotension. Blood work checks for agranulocytosis. Mouth movements are not caused by hypotension.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Formulate nursing interventions to address the major side effects associated with psychotropic medications.

Question 30

Type: MCSA

Which of the following would indicate that the client needs more teaching related to coping with constipation as a side effect of antipsychotic medications?

1. I will regularly use enemas.

2. I will walk and stay active.

3. I will include fiber daily in my diet.

4. I will have an adequate intake of fluid.

Correct Answer: 1

Rationale 1: The client should not use enemas regularly as a way to deal with constipation. Including fiber in the diet as well as adequate fluids are useful strategies to cope with constipation. Avoiding a sedentary lifestyle and being active help resolve constipation.

Rationale 2: The client should not use enemas regularly as a way to deal with constipation. Including fiber in the diet as well as adequate fluids are useful strategies to cope with constipation. Avoiding a sedentary lifestyle and being active help resolve constipation.

Rationale 3: The client should not use enemas regularly as a way to deal with constipation. Including fiber in the diet as well as adequate fluids are useful strategies to cope with constipation. Avoiding a sedentary lifestyle and being active help resolve constipation.

Rationale 4: The client should not use enemas regularly as a way to deal with constipation. Including fiber in the diet as well as adequate fluids are useful strategies to cope with constipation. Avoiding a sedentary lifestyle and being active help resolve constipation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Formulate nursing interventions to address the major side effects associated with psychotropic medications.

Kneisl, Contemporary Psychiatric-Mental Health Nursing, 3/e Test Bank

Copyright 2012 by Pearson Education, Inc.

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