TEST BANK FOR STAHL'S ESSENTIAL PSYCHOPHARMACOLOGY: NEUROSCIENTIFIC BASIS AND PRACTICAL APPLICATIONS 4TH EDITION

Stahl's Essential Psychopharmacology Neuroscientific Basis and Practical Applications TESTBANK/STUDY GUIDE Chapter 1 Chemical neurotransmission MULTIPLE CHOICE 1. A patient with depression mentions to the nurse, My mother says depression is a chemical disorder. What does she mean? The nurses response is based on the theory that depression primarily involves which of the following neurotransmitters? a. Cortisol and GABA b. COMT and glutamate c. Monamine and glycine d. Serotonin and norepinephrine ANS: D One possible cause of depression is thought to involve one or more neurotransmitters. Serotonin and norepinephrine have been found to be important in the regulation of depression. There is no research to support that the other options play a significant role in the development of depression. 2. A patient has experienced a stroke (cerebral vascular accident) that has resulted in damage to the Broca area. Which evaluation does the nurse conduct to reinforce this diagnosis? a. Observing the patient pick up a spoon b. Asking the patient to recite the alphabet c. Monitoring the patients blood pressure d. Comparing the patients grip strength in both hands ANS: B Accidents or strokes that damage Brocas area may result in the inability to speak (i.e., motor aphasia). Fine motor skills, blood pressure control, and muscle strength are not controlled by the Broca area of the left frontal lobe. 3. The patient diagnosed with schizophrenia asks why psychotropic medications are always prescribed by the doctor. The nurses answer will be based on information that the therapeutic action of psychotropic drugs is the result of their effect on: a. The temporal lobe; especially Wernickes area b. Dendrites and their ability to transmit electrical impulses c. The regulation of neurotransmitters especially dopamine d. The peripheral nervous system sensitivity to the psychotropic medications ANS: C Medications used to treat psychiatric disorders operate in and around the synaptic cleft and have action at the neurotransmitter level, especially in the case of schizophrenia, on dopamine. The Wernickes area, dendrite function, or the sensitivity of the peripheral nervous system are not relevant to either schizophrenia or psychotropic medications. 4. A student nurse mutters that it seems entirely unnecessary to have to struggle with understanding the anatomy and physiology of the neurologic system. The mentor would base a response on the understanding that it is: a. Necessary but generally for psychiatric nurses who focus primarily on behavioral interventions b. A complex undertaking that advance practice psychiatric nurses frequently use in their practice c. Important primarily for the nursing assessment of patients with brain traumacaused cognitive symptoms d. Necessary for planning psychiatric care for all patients especially those experiencing psychiatric disorders ANS: D Nurses must understand that many symptoms of psychiatric disorders have a neurologic basis, although the symptoms are manifested behaviorally. This understanding facilitates effective care planning. The foundation of knowledge is not used exclusively by advanced practice psychiatric nurses nor is it relevant for only behavior therapies or brain trauma since dealing with the results of normal and abnormal brain function is a responsibility of all nurses providing all types of care to the psychiatric patient. 5. A patient asks the nurse, My wife has breast cancer. Could it be caused by her chronic depression? Which response is supported by research data? a. Too much stress has been proven to cause all kinds of cancer. b. There have been no research studies done on stress and disease yet. c. Stress does cause the release of factors that suppress the immune system. d. There appears to be little connection between stress and diseases of the body ANS: C Research indicates that stress causes a release of corticotropin-releasing factors that suppress the immune system. Studies indicate that psychiatric disorders such as mood disorders are sometimes associated with decreased functioning of the immune system. Research does not support a connection between many cancers and stress. There is a significant amount of research about stress and the body. Research has shown that there are some connections between stress and physical disease. 6. A patient who has a parietal lobe injury is being evaluated for psychiatric rehabilitation needs. Of the aspects of functioning listed, which will the nurse identify as a focus of nursing intervention? a. Expression of emotion b. Detecting auditory stimuli c. Receiving visual images d. Processing associations ANS: D The parietal lobe is responsible for associating and processing sensory information that allows for functions such as following directions on a map, reading a clock, dressing self, keeping appointments, and distinguishing right from left. Emotional expression is associated with frontal lobe function. Detecting auditory stimuli is a temporal lobe function. Receiving visual images is related to occipital lobe function. 7. At admission, the nurse learns that some time ago the patient had an infarct in the right cerebral cortex. During assessment, the nurse would expect to find that the patient: a. Demonstrates major deficiencies in speech b. Is unable to effectively hold a spoon in the left hand c. Has difficulty explaining how to go about using the telephone d. Cannot use his right hand to shave himself or comb his own hair ANS: B The cerebral hemispheres are responsible for functions such as control of muscles. The right hemisphere mainly controls the motor and sensory functions on the left side of the body. Damage to the right side would result in impaired function on the left side of the body. The motor cortex controls voluntary motor activity. Brocas area controls motor speech. Cognitive functions are attributed to the association cortex. The right side of the bodys motor activity is controlled by the left cerebral cortex. 8. A patient with chronic schizophrenia had a stroke involving the hippocampus. The patient will be discharged on low doses of haloperidol. The nurse will need to individualize the patients medication teaching by: a. Including the patients caregiver in the education b. Being careful to stress the importance of taking the medication as prescribed c. Providing the education at a time when the patient is emotionally calm and relaxed d. Encouraging the patient to crush or dissolve the medication to help with swallowing The hippocampus plays a major role in short-term memory and, hence, in learning. Taking the medication as prescribed and providing the education at a time when the patient is calm and relaxed is information or considerations that all patients should be given. The medication does not necessarily need to be crushed or dissolved since the stroke would not have caused difficulty with swallowing. 9. The physician tells the nurse, The medication Im prescribing for the patient enhances the g-aminobutyric acid (GABA) system. Which patient behavior will provide evidence that the medication therapy is successful? a. The patient is actively involved in playing cards with other patients. b. The patient reports that, I dont feel as anxious as I did a couple of days ago. c. The patient reports that both auditory and visual hallucinations have decreased. d. The patient says that, I am much happier than before I came to the hospital. ANS: B GABA is the principle inhibitory neurotransmitter. The medication should provide an antianxiety effect. Alertness, psychotic behaviors, and mood elevation are not generally affected by g-aminobutyric acid. 10. The patients family asks whether a diagnosis of Parkinsons disease creates an increased risk for any mental health issues. What question would the nurse ask to assess for such a comorbid condition? a. Has your father exhibited any signs of depression? b. Does your father seem to experience mood swings? c. Have you noticed your father talking about seeing things you cant see? d. Is your dad preoccupied with behaviors that he needs to repeat over and over? ANS: A Serotonin and its close chemical relatives, dopamine and norepinephrine, are the neurotransmitters that are most widely involved in various forms of depression. Most researchers agree that the immediate cause of parkinsonism is a deficiency of dopamine and so a patient with Parkinsons disease should be monitored for depression, The other mental health disorders (bipolar disorder, hallucinations, and obsessive compulsive disorder) have not been connected to Parkinsons disease. 11. Which explanation for the prescription of donepezil (Aricept) would the nurse provide for a patient in the early stage of Alzheimers disease? a. It will increase the metabolism of excess GABA. b. Excess dopamine will be prevented from attaching to receptor sites. c. Serotonin deficiency will be managed through a prolonged reuptake period. d. The acetylcholine deficiency will be managed by inhibiting cholinesterase. Decreased levels of acetylcholine are thought to produce many of the behavioral symptoms of Alzheimers disease. The inhibiting action the drug has on cholinesterase will slow down the breakdown of acetylcholine and so delay the onset of symptoms. The other neurotransmitters (GABA, dopamine, and serotonin) are not currently believed to play a role in Alzheimers disease. 12. There remains a stigma attached to psychiatric illnesses. The psychiatric nurse makes the greatest impact on this sociological problem when: a. Providing educational programming for patients and the public b. Arranging for adequate and appropriate social support for the patient c. Assisting the patient to achieve the maximum level of independent functioning d. Regularly praising the patient for seeking and complying with appropriate treatment ANS: A Much of the stigma attached to psychiatric illness is due to a lack of understanding of the biologic basis of these disorders. Therefore, effective patient, family, and public teaching is an important function of the role of the psychiatric mental health nurse. While the remaining options are appropriate, they are not directed towards eliminating social stigma but rather empowering the patient. 13. The wife of a patient with paranoid schizophrenia tells the nurse, Ive learned that my husband has several close relatives with the same disorder. Does this problem run in families? The response based on recent discoveries in the field of genetics would be: a. Your children should be monitored closely for the disorder. b. Research tends to support a familiar tendency to schizophrenia. c. There is no concrete evidence; it is just as likely a coincidence. d. Only bipolar disorder has been identified to have a genetic component. ANS: B Familial tendencies appear with several psychiatric disorders including schizophrenia. To insinuate that the children are at such risk would not be supported by research. 14. A patient whose symptoms of mild depression have been managed with antidepressants is concerned about the affect of accepting a promotion that will require working the night shift. What will be the basis of the response the nurse gives to address the patients concern? a. The connection between a new job and possible depression does exist. b. The medication can be adjusted to manage any increase in depression. c. The interruption in normal wake-sleep patterns can influence mood disorders. d. The change in sleep routine can be managed with a healthy sleep hygiene routine. ANS: C Many psychiatric and medical disorders occur more frequently or are exacerbated when sleep patterns and biologic rhythms are disrupted. While the remaining options contain true information regarding the management of depression that is a result of sleep disruption, they do not effectively address the patients concern. 15. The nurse is discouraged because the patient exhibiting negative symptoms of schizophrenia has shown no improvement with the planned interventions to reduce the symptoms. The mentors remark that helps place the problem in perspective is: a. You arent responsible for the behavior of any other person. b. Patients can be perverse and cling to symptoms despite our efforts. c. Negative symptoms have been associated with genetic pathology. d. It will take several trail and error attempts to get the right combination care. ANS: C A complex disorder, such as schizophrenia, most likely has multiple contributing factors, including genetic predisposition, prenatal development, and the environment. Nurse frustration can be alleviated by helping the nurse realize that negative symptoms may be the result of actual brain dysfunction, rather than psychologically determined behaviors; thus the remaining options are not appropriate since they do not address the complexity of the problem. MULTIPLE RESPONSE 1. What assessment data would reinforce the diagnosis of temporal lobe injury in patient who experienced head trauma? Select all that apply. a. Inability to balance a checkbook b. Uncharacteristically aggressive c. Affect fluctuates dramatically d. Increased interest in sexual behaviors e. Difficulty remembering the names of family members ANS: C, D, E The temporal lobe is involved with memory as well as increased sexual focus and altered emotional responses. Personality and intellectual function is not centered in the temporal lobe. 2. A patient has begun experiencing dysfunction of the hypothalamus. What nursing interventions will the nurse include in the patients plan of care? Select all that apply. a. Reinforcing clear physical boundaries b. Assisting the patient with completing daily menus c. Learning about healthy sleep hygiene habits d. Monitoring and recording temperature every 4 hours e. Monitoring and recording blood pressure every 4 hours ANS: B, C, D The hypothalamus is responsible for regulation of sleep-rest patterns, body temperature, and physical drives of hunger. Social appropriateness and blood pressure is not controlled by the hypothalamus. 3. The nurse is preparing a patient for a positron emission tomography (PET) scan. Which instructions will the nurse include? Select all that apply. a. There will likely be a 30 to 45 minute wait between the injection and the beginning of the scan. b. A blindfold and earplugs may be used to help decrease reaction to the environment during the scan. c. Make every attempt to lie still during the scan because movement will affect the imaging produced. d. No food or fluids are to be ingested for at least 8 full hours before the scan and none during the scan. e. Staying awake during the scan is important since the results are altered when the patient is in any phase of the sleep state. ANS: A, B, C, E Appropriate patient preparation for a PET scan would include information regarding the time interval between injection of the isotope and the actual scan, the fact that steps will be taken to minimize the effects of sights and sounds during the scan, lying still is critical to achieving a quality image, and that being asleep during the scan will alter the results. It is not necessary to fast before or during the scan. 4. A patient with schizophrenia is described as having difficulty with executive functions. What patient dysfunction can the nurse expect to assess behaviorally? Select all that apply. a. Invades the personal space of others frequently b. Consistently fails to bring money when going to buy snacks c. Cannot remember the names of staff who often provide care d. Requires repeated reinforcement on how to make a sandwich e. Frequently speaks of hurting himself or of hurting other patients ANS: A, B, D Executive functions include reasoning, planning, prioritizing, sequencing behavior, insight, flexibility, judgment, focusing on tasks, responding to social cues, and attending in appropriate ways to incoming stimuli. Memory is not considered an executive function and risk for harm to self and others is not generally a diagnosis appropriate for such a patient. 5. The unit physicians have ordered magnetic resonance imaging (MRI) tests for the following patients. For which patients would the nurse decline to make test arrangements without further discussion with the physician? Select all that apply. a. A patient who is claustrophobic b. A patient who is breastfeeding c. A patient who has an allergy to iodine d. A patient who had a total knee replacement e. A patient who is taking a neuroleptic medication ANS: A, D Patients with claustrophobia are often unable to complete this type of study, because the MRI machine is enclosed, and patients are required to remain motionless. Metal implants are contraindications for MRIs since metal affects the scan. Breastfeeding, iodine sensitivity, and neuroleptic medication therapy are not contraindications for an MRI. Chapter 2 Transporters, receptors, and enzymes as targets of psychopharmacological drug action 1. The somatic nervous system provides sensory and motor innervation for: A) peripheral nerves. B) abdominal viscera. C) secretory glands. D) smooth muscle. 2. ANS.A The proteins and other materials used by the axon are synthesized and then flow down the axon through its cytoplasm. A) in the cell body B) by Nissl bodies C) through dendrites D) across synapses 3. ANS.A Supporting cells of the nervous system, such as Schwann cells, satellite cells, and types of glial cells, function to provide neurons with: A) local protection. B) control functions. C) membrane permeability. D) integrative metabolism. 4. ANS.A Neurons are characterized by the ability to communicate with other neurons and body cells through: A) astrocytes. B) axon hillocks. C) nodes of Ranvier. D) action potentials. ANS.D 5. Chemical synapses rely on in order to provide communication between neurons. A) diffusion B) gap junctions C) satellite cells D) transmitter molecules 6. ANS.D The blood-brain and CSF-brain barriers control the chemical environment of the brain by allowing easy entrance to only a few chemicals that include: A) oxygen. B) protein. C) glutamate. D) potassium. 7. ANS.A The perception of where a stimulus is in space and in relation to body parts is a function of the: A) occipital lobe. B) parietal lobe. C) hypothalamus. D) prefrontal cortex. 8. ANS.B The pia mater is a connective tissue sheath that covers the spinal cord and also contains: A) spinal fluid. B) fibrocartilage. C) blood vessels. D) segmental nerves. ANS.B 9. Which of the following is the neurotransmitter for most postganglion sympathetic neurons? A) Enkephalin B) Glutamic acid C) Catecholamines D) Acetylcholine 10. ANS.C In contrast to the sympathetic nervous system, the functions of the parasympathetic nervous system include: A) sweating. B) anabolism. C) pupil dilation. D) vasoconstriction. 11. ANS.B Which of the following substances provides the majority of the fuel needs of the neurologic system? A) Glycogen B) Glucose C) Amino acids D) Triglycerides 12. ANS.B A 60-year-old woman has been recently diagnosed with multiple sclerosis, a disease in which the oligodendrocytes of the patients central nervous system (CNS) are progressively destroyed. Which physiologic process within the neurologic system is most likely be affected by this disease process? A) Oxygen metabolism B) Neurotransmitter synthesis C) Nerve conduction D) Production of cerebrospinal fluid ANS.C 13.A neuron has been hyperpolarized. How will this affect the excitability of the neuron? A) The neuron will have a membrane potential farther from the threshold. B) The neuron will be more difficult to repolarize after firing. C) The membrane potential of the neuron will be closer to the threshold. D) The neurons excitability will be significantly increased. 14. ANS.A A pregnant womans most recent ultrasound is suggestive of spina bifida, and her primary care provider has subsequently order further diagnostic testing. The pathophysiologic effects of this disease are due to: A) malformation of the mesoderm. B) abnormal closure of the neural tube. C) lesions in the dorsal root ganglia. D) hypertrophy of the primary vesicles. 15. ANS.B Which of the following messages is most likely to be carried by general somatic afferent (GSA) neurons? A) The sensation of cold when touching ice B) The message to move a finger and thumb C) The message to move the larynx during speech D) Information about the position of a joint 16. ANS.A Which of the following processes is most likely to occur as a result of a spinal reflex? A) Peristalsis of the small and large bowel B) Control of oculomotor function in changing light levels C) Pain sensation from a potentially damaging knee movement D) Withdrawal of a hand from a hot stove element ANS.D 17. A patient has required mechanical ventilation following a traumatic head injury sustained in a motorcycle crash, during which he sustained damage to his respiratory center. Which of the patients brain structures has been injured? A) Brain stem B) Midbrain C) Diencephalon D) Frontal lobe 18. ANS.A A patient with a diagnosis of epilepsy has required surgical removal of part of her prefrontal cortex. Which of the following effects should her family and care team anticipate? A) Lapses in balance and coordination B) Deficits in regulation of the endocrine system C) Sensory losses D) Changes in behavior and judgment 19. ANS.D A patients primary care provider has prescribed a b-adrenergic receptor blocker. Which of the following therapeutic effects do the patient and care provider likely seek? A) Reduction in heart rate and blood pressure B) Slowing of gastrointestinal motility C) Increase in mental acuity D) Decreased production of gastric acid 20. ANS.A Neurotrophic factors contribute to the maintenance of homeostasis in which of the following ways? A) By catalyzing the effects of neurotransmitters B) By increasing the sensitivity of receptors on postsynaptic cells C) By promoting the growth and survival of neurons D) By selectively increasing or decreasing the release of neurotransmitters ANS. C Chapter 3 Ion channels as targets of psychopharmacological drug action 1. A nurse is teaching a medication class to a group of psychiatric patients. One of them asks the nurse why he has so much more trouble learning now when hes in his 60s than he did when he was younger. Which of the following concepts would the nurse integrate into the response? A) The extrapyramidal motor system B) The amygdala C) Neuroplasticity D) Psychoneuroimmunology 2. ANS.C Which of the following would a nursing instructor identify when describing the area of the brain involved with verbal language function, including areas for both receptive and expressive speech? A) Right hemisphere B) Parietal lobe C) Occipital lobe D) Left hemisphere 3. ANS.D A nurse is developing a plan of care for a patient experiencing expressive aphasia. The nurse incorporates knowledge that the patient most likely has sustained damage to which of the following? A) The postcentral gyrus B) Brocas area C) Basal ganglia D) The hippocampus 4. ANS.B The nurse is caring for an older adult who has experienced damage to the frontal lobe after an automobile accident. The nurse anticipates that the patient will have difficulty with which of the following? A) Smell B) Concept formation C) Receptive speech D) Hearing 5. ANS.B The nurse is caring for a patient who has experienced damage to the parietal lobes of the brain. The nurse anticipates that the patient with have difficulty with which of the following? A) Perceiving sensory input B) Calculating a math problem C) Seeing objects in front of him D) Speaking fluently 6. ANS.B A patient has been diagnosed with memory dysfunction associated with Alzheimers disease. The nurse determines that damage to the patients brain includes deterioration of temporal lobe structures and the nerves of which of the following? A) Basal ganglia B) Limbic system C) Frontal lobe D) Hippocampus 7. ANS.D The nurse is caring for a hospitalized patient who has a disorder of the hypothalamus. When developing the patients plan of care, in which of the following areas would the nurse anticipate a problem? A) Sleep B) Constipation C) Speech D) Motor activity 8. ANS.A A patient who is scheduled to undergo a sleep deprivation electroencephalogram (EEG) in the morning is experiencing moderate anxiety about the procedure. Based on an understanding of this test, which of the following would the nurse avoid? A) Explaining in depth what to expect during the upcoming procedure B) Administering a benzodiazepine medication prescribed for anxiety C) Taking a thorough history of her use of prescribed and illicit drugs D) Giving her a noncaffeinated beverage of her choice 9. ANS.B A nursing instructor asks a student to explain the influence of chronobiology on depression. Which of the following would the student include when responding? A) The exact location of genes leads to identifying the gene responsible for causing depression. B) A break in the corpus coliseum blocks information exchange between the right and left hemispheres. C) Damage to the posterior areas of the parietal lobe leads to altered discriminative sensory function. D) Internal and external triggers can elicit biologic rhythm changes indicative of clinical depression. 10. ANS.D When describing the various neurotransmitters, which of the following would the nurse identify as the primary cholinergic neurotransmitter? A) Dopamine B) Acetylcholine C) Norepinephrine D) Serotonin 11. ANS.B A group of nursing students are reviewing the various neurotransmitters. The students demonstrate understanding when they identify which of the following as a neuropeptide? A) Melatonin B) Serotonin C) Glutamate D) Gamma-aminobutyric acid 12. ANS.A The nurse is assessing a patient experiencing anxiety and observes increased sweating and gooseflesh. The nurse understands that these are the result of which substance? A) Acetylcholine B) Norepinephrine C) Serotonin D) Histamine 13. ANS.B A nurse is developing a plan of care for a patient diagnosed with schizophrenia. The nurse integrates knowledge of this disorder, identifying which neurotransmitter as being primarily involved? A) Acetylcholine B) Dopamine C) Norepinephrine D) Serotonin ANS.B 14.A group of students are reviewing information about neurotransmitter subtypes. The group demonstrates understanding of the information when they identify which neurotransmitter as having muscarinic and nicotinic receptors? A) Serotonin B) Gamma-aminobutyric acid (GABA) C) Dopamine D) Acetylcholine 15. ANS.D A nurse is involved in gathering information about the inheritance of mental disorders using population genetics. Which of the following would the nurse be least likely to be evaluating? A) Concordance rates B) Occurrence in first-degree relatives C) Risk factor analysis D) Adoptions studies 16. ANS.C A nurse is reading a journal article about psychoneuroimmunology. Which information would the nurse most likely find? Select all that apply. A) Neurotoxins role in receptor site damage B) Hypothalamicpituitarythyroid axis disruption C) Static activity of natural killer cells in response to stress D) Hypothalamic damage leading to immune dysfunction E) Interruption in the typical circadian rhythm cycle 17. ANS.A,B,D A patient is scheduled for a challenge test. Which of the following would the nurse include when explaining this test to the patient? A) Intravenous administration of a substance to induce symptoms B) Application of electrodes to the scalp for monitoring C) Evaluation electrical impulses recorded on graph paper D) Exposure to a flashing strobe light to elicit abnormal activity 18. ANS.A A patient with depression tells the nurse that he is to have a test that involves the recording of an electroencephalogram (EEG) throughout the night. The nurse most likely identifies this testing as which of the following? A) Sleep deprivation EEG B) Polysomnography C) Evoked potentials D) Functional magnetic resonance imaging 19. ANS.B A group of nursing students are reviewing the role of serotonin in psychiatric disorders. The students demonstrate a need for additional study when they identify which disorder as being associated with its dysfunction? A) Depression B) Obsessive-compulsive disorder C) Panic disorder D) Schizophrenia 20. ANS.D When describing neuronal transmission, an instructor describes the area where the electrical intracellular signal becomes a chemical one. The instructor is describing which of the following? A) Soma B) Synaptic cleft C) Terminal D) Receptor site ANS.B Chapter 4 Psychosis and schizophrenia MULTIPLE CHOICE 1. A newly admitted patient has the diagnosis of catatonic schizophrenia. Which behavior observed in the patient supports that diagnosis? a. Uses a rhyming form of speech b. Refuses to eat any unwrapped foods c. Laughs when watching a sad movie d. Maintains an immobilized state for hours ANS: D Catatonic schizophrenia is characterized by extremes of psychomotor activity ranging from frenzied behavior to immobilization and may include echopraxia and posturing. Paranoid thinking is characteristic of paranoid schizophrenia. Inappropriate affect and clanging are seen in disorganized schizophrenia. 2. What would be an appropriate short-term outcome for a patient diagnosed with residual schizophrenia who exhibits ambivalence? a. Decide their own daily schedule. b. Decide which unit groups they will attend. c. Choose which clinic staff member to work with. d. Choose between two outfits to wear each morning. ANS: D An early step would be to make choices about nonthreatening matters when presented with limited alternatives. The remaining options represent decisions that are too complicated for the patient to make initially. 3. What is the priority nursing diagnosis for a catatonic patient? a. Ineffective coping b. Impaired physical mobility c. Impaired social interaction d. Risk for deficient fluid volume ANS: D The highest priority for the patient is maintenance of basic physiologic needs, such as hydration. Mobility is of lesser physiological importance than fluid volume. The remaining options do not have priority over a physiological need. 4. Which nursing diagnosis is appropriate for a patient who insists being called Your Highness and demonstrates loosely associated thoughts? a. Risk for violence b. Defensive coping c. Impaired memory d. Disturbed thought processes ANS: D Delusions and loose associations suggest disturbed thought processes. The other options are not supported by data in the scenario. 5. Which initial short-term outcome would be appropriate for a patient who was admitted expressing delusional thoughts? a. Accept that delusion is illogical. b. Distinguish external boundaries. c. Explain the basis for the delusions. d. Engage in reality-oriented conversation. ANS: D Delusions are not reality oriented; thus an appropriate outcome would be that patient will engage in reality-oriented conversation rather than discussing delusional beliefs. Delusions are fixed, false beliefs. Patients rarely accept anyone using logic to dispute them. Data are not present to suggest boundary disturbance. Explaining the delusion is not progress; it suggests the patient still holds to the belief. 6. Which of the following interventions should the nurse plan to use to reduce patient focus on delusional thinking? a. Confronting the delusion b. Refuting the delusion with logic c. Exploring reasons the patient has the delusion d. Focusing on feelings suggested by the delusion ANS: D Focusing on feelings suggested by the delusion will help meet patient needs and help the patient stay based in reality. This technique fosters rapport and trust while discouraging the belief without challenging or refuting it. 7. Which assessment observation supports a patients diagnosis of disorganized schizophrenia? a. Reports suicidal ideations b. Last relapse was 6 years ago c. Consistent inappropriate laughing d. Believes that the government is out to get me ANS: C The presence of disorganization and inappropriate affect identifies this disorder as disorganized schizophrenia. The symptoms of residual schizophrenia have long periods of remission. Schizoaffective disorder presents with severe mood disorders along with symptoms of schizophrenia. Paranoid schizophrenia is characterized by persecutory or grandiose delusions. 8. A patient tried to gouge out his eye in response to auditory hallucinations commanding, If thine eye offends thee, pluck it out. The nurse would analyze this behavior as indicating: a. Derealization b. Inappropriate affect c. Impaired impulse control d. Inability to manage anger ANS: C Command hallucinations may be so intense that the patient cannot control the impulse to do what the hallucination tells him to do; thus the patient has impaired impulse control. This is not an anger management problem. Derealization is a feeling that the environment is distorted or unreal and not suggested in the scenario. No evidence of inappropriate affect is given. 9. An appropriate intervention for a patient with an identified nursing diagnosis of situational low self-esteem would be: a. Providing large muscle activities to relieve stress b. Attempting to determine triggers to hallucinations c. Engaging patient in activities designed to permit success d. Encouraging verbalization of feelings in a safe environment ANS: C All are useful interventions for a patient with schizophrenia; however, engaging the patient in specifically designed activities is the only option that addresses improving self-esteem. 10. A 19-year-old patient is admitted for the second time in 9 months and is acutely psychotic with a diagnosis of undifferentiated schizophrenia. The patient sits alone rubbing her arms and smiling. She tells the nurse her thoughts cause earthquakes and that the world is burning. The nurse assesses the primary deficit associated with the patients condition as: a. Social isolation b. Disturbed thinking c. Altered mood states d. Poor impulse control The nurse interprets the patients statements that were not reality-based as indicating disturbed thought processes. Social isolation is not the primary patient problem. No data exist to support the other options. 11. A patient has been admitted with disorganized type schizophrenia. The nurse observes blunted affect and social isolation. He occasionally curses or calls another patient a jerk without provocation. The nurse asks the patient how he is feeling, and he responds, Everybody picks on me. They frobitz me. The patients communication exhibits: a. A neologism b. Loose associations c. Delusional thinking d. Circumstantial speech ANS: A A newly coined word having meaning only for the patient is called a neologism (meaning, new word). It is associated with autistic thinking. The patients speech does not show associative looseness or circumstantiality. The use of a neologism is not delusional in and of itself, but it suggests delusional thinking may be present. 12. A patient has been admitted with disorganized type schizophrenia. The nurse asks the patient how he is feeling, and he responds, Everybody picks on me. They frobitz me. The best response for the nurse to make would be: a. Thats really too bad that you are being treated that way. b. Who do you mean when you say everybody? c. What difference does frobitzing make? d. Why do they frobitz? ANS: B This response will help clarify the patients thinking and change the focus from global to specific. In this situation, sympathizing with the patient is a nonproductive response. The remaining options appear to accept the neologism thus supporting the patients delusional thinking. 13. Which patient behavior would support the diagnosis of residual schizophrenia with negative symptoms? a. Communicating using only rhyming phases b. Claims that worms are crawling in my brain c. Maintaining both arms suspended awkwardly overhead d. Shows no emotion when telling the story of a sisters recent death Blunted affect is considered a negative symptom. The other symptoms would be classified as positive symptoms. 14. By discharge, which outcome is appropriate for a patient who hears voices telling him he is evil? a. Respond verbally to the voices. b. Verbalize the reason the voices say he is evil. c. Identify events that increase anxiety and promote hallucinations. d. Integrate the voices into his personality structure in a positive manner. ANS: C An appropriate outcome for a patient with hallucinations is recognition of events that precede the onset of hallucinations. Trigger events or situations usually cause increased feelings of anxiety. The remaining options are neither desirable nor appropriate. 15. Which response by the nurse would best assist a patient in de-escalating aggressive behavior? a. Tell me whats going on. b. Why are you getting so upset? c. If you throw something, you will be restrained. d. Its time for group therapy. You can talk there. ANS: A Using how, what, and when to gather information is a nonthreatening approach. It will promote patient verbalization and explanation of events without causing the patient to become defensive. Mentioning restraints sounds threatening even though it may be meant to remind the patient of limits.Why questions are demanding and threatening to patients. Sending the patient into group therapy sidesteps the problem. 16. A 34-year-old male admitted with catatonic schizophrenia has been mute and motionless for several days while at home prior to admission. He still appears stuporous in the hospital. Which nursing intervention would be an initial priority? a. Orienting the patient to the unit b. Reinforcing reality with the patient c. Establishing a nonthreatening relationship d. Assessing the patient for physical problems ANS: D Patients who are mute and motionless and inattentive to environmental stimuli are at risk for a number of physical problems. Further, they are unable to communicate existing problems. The nurse must make thorough and astute assessments before creating plans to meet the patients needs. A patient who is stuporous may not be able to attend to information given about unit rules and protocols. While establishing a therapeutic nurse-patient relationship is an important intervention, it does not have priority according to Maslows hierarchy. Because the patient is mute, one can only suspect lack of reality orientation. While an appropriate intervention, it is not the priority according to Maslows hierarchy. 17. Which response is appropriate when a patients mother expresses guilt over causing my child to be schizophrenic? a. I can see how you would be upset over this turn of events. b. New findings suggest this disorder is biological in nature. c. Dont be so hard on yourself; your daughter needs you to be strong. d. Its difficult to see what produces stress for the child at the time its occurring. ANS: B Many individuals in the mental health field attribute the development of schizophrenia to multiple causes centering on biological theories. The remaining options do little to provide the mother with new information. 18. Which response demonstrates both empathy and understanding of the relationship genetics has to the development of schizophrenia in twins? a. In fraternal twins, the chance of the other twin developing the disorder is quite small. b. Studies show that 50% of twins develop schizophrenia when it is present in the other twin. c. No one can say what will happen, so we will hope for the best for you and both of your sons. d. You poor woman! I wish I could tell you that your other son he will be free of the disorder. ANS: A Current research supports the correct option, whereas the remaining options are not factual and show expressed sympathy rather than empathy. 19. The wife of a patient diagnosed with paranoid schizophrenia asks, Ive been told that my husbands illness is probably related to imbalanced brain chemicals. Can you be more specific? The response based on the dopamine hypothesis is: a. Breakdown of dopamine produces LSD, which in large amounts produces psychosis. b. An increase in the brain chemical dopamine explains the presence of delusions and hallucinations. c. Decreased amounts of the brain chemical dopamine explain the presence of delusions and hallucinations. d. An increase in the brain chemical dopamine explains the presence of lack of motivation and disordered affect. ANS: B The statement is correctly based on the dopamine hypotheses while the remaining options are neither known to be true nor based on that theory 20. What is the basis for the reduction in disturbed thought processes when a patient is administered haloperidol (Haldol)? a. Reduction in the number of brain cells that crave dopamine b. Dopamine receptors are blocked, making dopamine less available c. Dopamine receptors are enhanced, making more dopamine available d. Medication causes an increased cellular production of dopamine ANS: B Excess dopamine is responsible for symptoms of psychosis such as delusions and hallucinations. Blocking dopamine receptors will result in reduction of primary symptoms. The other options do not reflect the action of typical antipsychotic medications. 21. During a treatment team meeting, the point is made that a patient with schizophrenia has recovered from the acute psychosis but continues to demonstrate apathy, avolition, and blunted affect. The nurse who relates these symptoms to serotonin (5HT2) excess will suggest that the patient receive: a. Haloperidol (Haldol) b. Chlorpromazine (Thorazine) c. Olanzapine (Zyprexa) d. Phenelzine (Nardil) ANS: C Olanzapine is an atypical antipsychotic. Atypical antipsychotic medications are more effective than typical antipsychotics in blocking serotonin receptors and reducing the negative symptoms of schizophrenia. Haloperidol (Haldol) and chlorpromazine (Thorazine) are typical antipsychotic medications while phenelzine (Nardil) is an MAOI antidepressant. 22. What response would be anticipated when a patient who received chlorpromazine (Thorazine) for 15 years to treat schizophrenia is switched to Seroquel (quetiapine)? a. Development of pseudoparkinsonism b. Development of dystonic reactions c. Improvement in tardive dyskinesia d. Worsening of anticholinergic symptoms ANS: C Atypical antipsychotics have been noted to block oral dyskinesia and improve tardive dyskinesia as well as improve both positive and negative symptoms of schizophrenia. Pseudoparkinsonism and dystonic reactions are associated with typical antipsychotic medication. Anticholinergic symptoms are not intense with the use of atypical antipsychotic medication. 23. A patient admitted with the diagnosis of schizophreniform disorder R/O organic pathology. Based on this information, the nurse can expect that the patient will: a. Be scheduled for a magnetic resonance imaging (MRI) test b. See a mental health specialist for extensive psychological testing c. Have an immunologic assay performed within 2 days of the admission d. Participate in a dexamethasone suppression test (DST) administered by the staff ANS: A The MRI will reveal structural changes in the brain that might be responsible for symptoms of psychosis (e.g., abscess, tumor). Psychologic testing may be performed but will be less definitive in ruling out organic pathology. Immunologic studies are not indicated. The DST is related to depression. 24. In planning aftercare for a patient with schizophrenia and whose insurance benefits have been exhausted, the nurse who is concerned about overcoming negative symptoms will make provisions for the patient to have stimulation, structure, socialization, and support. Which option would best incorporate these factors? a. Day hospitalization b. Attending a psychosocial club c. Living with his elderly mother d. Spending free time in the mall ANS: B A psychosocial club is organized to provide the 4 Ss and is not costly to patients. Day hospitalization would not be possible because of the lack of insurance benefits. Living with his mother might fall short of stimulation and support. Spending time in the mall lacks structure, socialization, and support. 25. A patient with catatonic schizophrenia has been standing with his left arm upraised and his right foot off the floor for the majority of the last 20 hours, eating only when allowed to eat standing up. Which nursing intervention has priority for this patient? a. Providing high-calorie drinks hourly b. Assessing for lower extremity edema bid c. Taking the patient to activities therapy once daily d. Encouraging the patient to sit or lie down for 30 minutes hourly ANS: B Patients who maintain one position for long periods of time should be assessed for dependent edema. In this case, the nurse would look for edema of the lower extremities and would be concerned about the pressure exerted by standing on one foot for long periods of time. Such encouragement would probably be met with resistance by the patient. High-calorie drinks would be necessary if the patient failed to eat at meals. The patient probably would not be able to cognitively process what is required to participate in activities. 26. Which nursing action best addresses the needs of a paranoid patient who believes the food is poisoned? a. Explaining that others eat the food and are not harmed b. Allowing the patient to select food from vending machines c. Encouraging the patient to discuss why someone would poison the food d. Taking steps to prevent the patient from verbalizing the delusional thoughts ANS: B Patients who think hospital food is being poisoned will sometimes eat wrapped foods that have not been opened, and occasionally, they may eat food brought from the outside by a trusted person. Delusions are fixed, false beliefs that cannot be refuted by logic. The patient will probably state that the others have been given the antidote to the poison. Encouraging discussion about the delusion is not therapeutic. Although it is wise to minimize the amount of discussion about delusions, refusing to allow the patient to speak about the delusions will not foster a therapeutic alliance. 27. Prior to discharge, the nurse plans to teach the patient and family about relapse. Which items will the nurse include in the teaching? a. Recognizing warning signs of relapse b. Using street drugs judiciously and only in small amounts c. Lowering medication dosage to manage emerging side effects d. Notifying the nurse of warning signs present for more than one month ANS: A The patient and family must be aware of signs of impending relapse. These signs are usually similar to those that the patient experienced prior to hospitalization and will be patient-specific. The nurse should be notified ASAP, rather than waiting two weeks. Patients should never adjust medication dosage. Street drug use often precipitates relapse since many street drugs are dopaminergic. 28. Because of the cognitive disturbances associated with schizophrenia, which technique will be useful as the nurse teaches a patient about self-management? a. Use only verbal instruction. b. Teach material in small segments. c. Offer opportunities for making numerous choices. d. Plan the teaching for a time when the patient has been recently medicated. ANS: B Patients with cognitive disturbances should be taught small blocks of information at a time and given frequent reinforcement. Both verbal and visual materials should be used since processing of verbal stimuli may be more impaired. Teaching should be scheduled when the patient is most alert. A large number of choices may be confusing for the person, but a few simple choices may be included. 29. The wife of a patient newly diagnosed with paranoid schizophrenia is concerned that her husband will be this sick for the rest of his life. What information can the nurse provide to the wife? a. This disorder generally responds well with treatment and follow-up. b. All types of schizophrenia by their nature are chronic relapsing disorders. c. Outcomes are related to the patients pre-hospital symptoms of disorganization. d. The typical outcome for this diagnosis is that total remission is not achievable. ANS: A The prognosis for paranoid schizophrenia is good with appropriate treatment and effective follow-up. The remaining options are not correct when considering this type of schizophrenia 30. A patient is exhibiting auditory hallucinations in addition to being forgetful and easily confused. Which diagnosis does the nurse base this patients interventions on? a. Social isolation b. Deficient knowledge c. Situational low self-esteem d. Impaired cognitive functioning ANS: D Schizophrenia may alter cognitive functioning, including memory, retention, attention, and the processing of incoming information. Altered cognition accounts for many of the symptoms mentioned in the scenario. Knowing that cognition is altered, the nurse can adjust plans to take the deficits into account. The patient is not exhibiting symptoms that would warrant any of the other options. 31. A patient experiences intrusive, insulting auditory hallucinations. Which independent behavioral technique can the nurse teach the patient to employ when the voices are troublesome? a. Introduce a distraction like reading. b. Use positive talk to offset the insults. c. Sing or whistle to compete with the voices. d. Increase the daily dose of an antipsychotic medication. ANS: C This action provides an alternative to listening to the voices and gives the patient a sense of control. The patient should not adjust medication independently. Reading will not be particularly effective, because the voices are uncontested in a quiet atmosphere. Positive talk is generally used to positively affect self-esteem. 32. A patient with schizophrenia tells the nurse as they sit in the day room, I hear voices telling me bad things. The most therapeutic response the nurse can make is: a. Tell me what the voices are saying. b. I believe you hear voices, but I dont hear them myself. c. The voices are not real. Theyre a product of your imagination. d. Do you think the voices would go away if we went into your room to talk? ANS: B By voicing his or her own reality related to the voices, the nurse does not deny the patients experiences but helps the patient distinguish actual voices from those resulting from internal stimulation. Discussing what the voices are saying serves only to validate the reality of the voices. Challenging the voices will cause the patient to defend his perceptions and thereby reinforce the importance of the hallucination. Asking to move validates the reality of the voices and is not a helpful action since the voices go where the patient goes. 33. A patient tells the nurse, When Im in the day room, I hear people whispering about me, and that makes me want to punch them. What direction will the nurse provide the staff regarding interacting with this patient? a. To minimize the need to whisper, utilize nonverbal techniques when possible. b. Stay physically close to this patient and use touch as a tool to interact with him. c. Treat this patient matter-of-factly. Be direct; dont talk about him or others in his presence. d. Interact with this patient only when necessary. The fewer interactions, the fewer misinterpretations there will be. ANS: C This approach is important when providing care for a patient who is misinterpreting reality and is suspicious of the motives of others. Ostracizing the patient is non- therapeutic. Patients often misinterpret touch as threatening. This might promote loss of control. Using nonverbal communication techniques would be nontherapeutic as it would increase patient anxiety and promote loss of control. 34. A patient with schizophrenia is medication compliant and has well-controlled symptoms. He has, however, never been successful in holding a job because of poor social skills and lack of understanding of basic job skills. The nurse case manager should consider referring the patient: a. For cognitive therapy b. To assertiveness training c. To a day hospital program d. For psychosocial rehabilitation ANS: D Psychosocial rehabilitation helps patients readjust to community living by promoting development of necessary skills. Social skills training and job skills training programs are usually available. The patient does not need the more intensive services found in a day hospital. Cognitive therapy will not offer the needed community living skills training. Assertiveness training is only a small portion of the community living skills the patient needs. 35. A patient prescribed an antipsychotic medication develops a high fever, unstable blood pressure, and muscle rigidity. Her next dose of medication is due. The nurse should: a. Administer the medication and monitor the vital signs every 4 hours. b. Give a lower dose of the medication for 24 hours and monitor the blood pressure. c. Prepare to administer a prn dose of the anticholinergic drug benztropine (Cogentin). d. Hold the medication and immediately describe the patients symptoms to the doctor. ANS: D These symptoms could be related to a possibly fatal disorder called neuroleptic malignant syndrome (NMS), and the nurse should hold the medication and contact the doctor immediately. The other options are inappropriate in light of the seriousness of the situation. MULTIPLE RESPONSE 1. Which interventions will the nurse implement to preserve milieu safety when a patient becomes agitated? Select all that apply. a. Project confidence and control. b. Provide a show of force when appropriate. c. Ask the agitated patient why they are feeling so aggressive. d. Move to within 5 feet of the patient to help contain their movement. e. Provide the patient with several options as means of de-escalating the crisis. ANS: A, B, E The correct options demonstrate that the staff is in control without unnecessarily challenging the patient. Asking why is often interpreted as being challenging and often serves to future agitate the patient. Eight feet is considered to be the therapeutic distance between patient and staff in this type of situation. 2. Which interventions will the nurse implement to assure effective staff crises management skills? Select all that apply. a. Schedule regular staff crises simulations. b. Encourage the staff to discuss the details of unit crises. c. Attempt to identify staff who are ineffective during crises. d. Review documentation that describe the details of unit crises. e. Review unit crises management policies for needed updates. ANS: A, B, D, E The correct options empower the staff while improving/maintaining their crises management skills. The failures of the process should be identified without blaming staff for ineffective crises management.