Psychiatric Nursing Practice Test 5 (Exam Mode)

The nurse should first ACKNOWLEDGE that the voices are real to the patient and then, PRESENT REALITY by telling the patient that you do not hear anything. The third part of the nursing intervention in hallucination is LESSENING THE STIMULI by either staying with the patient or removing the patient from a highly stimulating place. Telling the client that the voices is part of his illness is not therapeutic. People with schizophrenia do not think that they are ILL. Letter C and D disregards the client’s concern and therefore, not therapeutic.

When disorders of perception and thoughts came in, The only feasible diagnosis a doctor can make is among the choices is schizophrenia. A,B and D can occur in normal individuals without altering their perceptions. Schizophrenia is characterized by disorders of thoughts, hallucination, delusion, illusion and disorganization.

The problem of the patient is his behavior. A is done for patient who has insomnia or severe anxiety. B is a therapy that promotes growth by providing a contact, either a person or an environment who will facilitate the growth of an individual. It is a humanistic psychotherapeutic model approach. D is done on clients who are in crisis like trauma, post traumatic disorders, raped or accidents.

Anafranil is an anti depressant, effects are noticeable within 1 to 2 weeks.

A lithium level of 1.0 mEq/L after 10 days of lithium therapy indicates an anticipated therapeutic blood level of the drug. This means that the client's lithium level is within the expected range for therapeutic effectiveness. This level suggests that the client is receiving the appropriate dosage of lithium to manage their condition. It is important for the nurse to monitor the lithium levels regularly to ensure that they remain within the therapeutic range and to prevent toxicity.

Haldol is a neuroleptic, Specific to these neuroleptics are the EPS. The client will likely be hypotensive than hypertensive because neuroleptics causes postural hypotension, The client will complaint of dry mouth due to its anticholinergic properties. Dizziness and drowsiness are side effects of neuroleptics but not oversedation.

This question will give the nurse idea WHEN will the withdrawal occur. Withdrawal occurs 5 to 10 hours after the last intake of alcohol. This is a crucial and mortality is very high during this period. Client will undergo delirium tremens, seizures and DEATH if not recognize earlier by the nurse. B is very judgmental, C is non specific, whether it is a beer or a wine It is still alcohol and has the same effects. D is a valuable question to determine the chronic effects of alcohol ingestion but asking letter A can broaden the line between life and death.

According to brunner and suddarths MS nursing, The normal therapeutic level of lithium is .6 to 1.2 meq/L. Some books will say .5 to 1.5 meq/L.

A counselor is much more of a listener than a speaker. She encourage the client to express feelings and concerns as to formulate necessary response and facilitate a channel to express anger, disappointments and frustrations.

too obvious, no need to rationalize.

Regular blood check up is required for patients taking clozaril. As frequent as every 2 weeks. Clozapine can cause bone marrow depression, therefore, frequent blood counts are necessary.

The levels of lithium in the body are dependent on sodium. The higher the sodium, The lower the levels of lithium. Clients should have an adequate intake of sodium to prevent sudden increase in the levels of lithium leading to toxicity and death.

Thorazine is a neuroleptic. Desired effect evolve on controlling the client’s psychoses. Letter A is the side effect of the drug, which is not desired. B and D
indicates that the drug is not effective in controlling the client’s agitation, restlessness and disorders of perception.

This is a sign of light lithium toxicity. Increasing fluid intake will cause dilutional decrease of lithium level. Restriction of sodium will cause dilutional increase in lithium level.

Clozapine is a dreaded aypical antipsychotic because it causes severe bone marrow depression, agranulocytosis, infection and sore throat. WBC count is important to assess if the clients immune function is severely impaired. The first presenting sign of agranulocytosis is SORE THROAT.

The child is 16 years old, In the stage of IDENTITY VS. ROLE CONFUSION. The most significant persons in this group are the PEERS. B refers to children in the school age while C refers to the young adulthood stage of INTIMACY VS. ISOLATION. The child is not dying and the situation did not even talk about the child’s belief therefore, calling the priest is unnecessary.

Tranylcypromine sulfate (Parnate) is a monoamine oxidase inhibitor (MAOI) antidepressant. MAOIs can interact with tyramine, a substance found in certain foods, leading to a hypertensive crisis. A hypertensive crisis is characterized by a sudden and severe increase in blood pressure, which can be life-threatening. Therefore, the client should be cautioned about consuming foods containing tyramine while taking tranylcypromine sulfate to avoid this potentially dangerous reaction.

2 anti depressants cannot be given at the same time unless the other one is tapered while the other one is given gradually.

If a client can do ADLs , there is no reason for that client to be hospitalized.

The client shows typical sign and symptoms of DEPRESSION. Moving slowly, gazes on the floor, blank stares and showing flat affect. The highest priority among depressed client is assessing any suicide plans or ideation for the nurse to establish a no suicide contract early on or, in any case client do not participate in a no suicide contract, a 24 hour continuous
monitoring is established.

Tertiary prevention involves rehabilitation. Client is now being assisted to perform ADLs at his optimum functioning. Remember that all kinds of rehabilitatory and palliative management is included in tertiary prevention.

The client shows sign of motor restlessness, which is specific for Akathisia or MAKATI SYA.

As a nurse manager, you should be able to work with the team. A,B,C are not specific of a nurse manager. They can be done by an ordinary R.N.

As I said, symptoms of PD will never show alteration in cognitive functioning. They are much more of SOCIAL Disturbances rather than PSYCHOLOGICAL.

Anorexia with nausea and vomiting is a clinical manifestation that would alert the nurse to lithium toxicity. This is because lithium toxicity can cause gastrointestinal symptoms such as anorexia, nausea, and vomiting. These symptoms may indicate that the lithium levels in the body are too high, leading to toxicity. Increasingly agitated behavior, markedly increased food intake, and sudden increase in blood pressure are not specific manifestations of lithium toxicity.

Aside from tonometry or IOP measurement, Client should undergo regular ECG schedule. Most TCAs cause tachycardias and ECG changes, an ECG should be done before
the client takes the medication.

This is the only statement of the client that contains a specific and technical plan. B,D are all indicative of suicidal ideation but it contains
no specific plans to carry out the objective. Letter A admits the client thinks of hurting himself, but not doing it because it scares him, therefore, it is not indicative of suicidal ideation.

The nurse should recognize that this is an early s/s of lithium toxicity. Taking the clients vital signs will not confirm diarrhea,
vomiting or restlessness. Notifying the physician is unnecessary at this point and the physician will likely to withhold the medication.

Neuroleptic malignant syndrome is a side effect of neuroleptics. This is characterized by fever, increase in blood pressure and warm, diaphoretic skin.

Elavil is an TC antidepressant. It should not cause insomnia. Hypertension are specific of MAOI anti depressants when tyramine is ingested. Due to the anticholinergic s/e of TCAs, Urinary retention is an adverse effect.

we are talking about what should the nurse do first. ASSESSMENT involves early recognition of clients needs. A,B,C are all involve in the intervention phase of the nursing process.

Heroin is a narcotic. Together with morphine, meperidine, codeine and opiods, they are DEPRESSANTS and will cause decrease respiration,
constricted pupils and pallor due to vasoconstriction.

An advocate role is shown when the nurse defends the rights of the client. Interceding in behalf of the patient should not be done by a nurse. Counter transference can
develop in that case and we should avoid that. Only the family and the health attorney of the patient can intercede or speak for the patient.

The ego is responsible for distinguishing what is REAL and what is NOT. It is the one that balances the ID and super ego. B and D
is a characteristic of the SUPER EGO which is the CONTROLLER of instincts and drives and serve as our CONSCIENCE or the MORAL ARM. The ID is our DRIVES and INSTINCTS that is mediated by the EGO and controlled by the SUPER EGO.

The client already had stroke, TPA stands for TRANSPLASMINOGEN ACTIVATOR which are thrombolytics, dissolving clots formed in the vessels of the brain. We are just preventing COMPLICATIONS here.

Flight of ideas is a condition in which patient talks continuously and then switching to unrelated topic. An example is “ Ang ganda ng bulaklak na ito no budek? Rose ito hindi ba? Kilala mo ba si jack yung boyfriend ni rose? Grabe yung barko no ang laki laki tapos lumubog lang. Dapat sana nag seaman ako eh, gusto kasi ng nanay ko. “. Loose association is somewhat similar but the switch in
topic is more obvious and completely unrelated. Example “ Ang cute nung rabbit, paano si paul kasi tanga eh, papapatay ko yan kay albert. Ang ganda nung bag na binigay ni jenny, tanga nga lang yung aswang dun sa kanto. Pero bakit ka ba andito? Wala akong pagkain, Penge ako kotse aakyat ako everest.”

A,C,D are all alteration in perception. A refers to a person thinking that everyone is talking about him. C and D are all sensory alterations. The difference is that, in hallucination, there is no need for a stimuli. In illusion, a stimuli [ A phone cord ] is mistakenly identified by the client as something else [ Snake ]

Orientation phase is synonymous with CONTRACT ESTABLISHMENT. Here, the nurse will establish regular meeting of schedule, agreements and giving the client information that there is a TERMINATION. Letter A and B assesses the client’s coping skills, which is in the working phase and so is letter B. In working phase, The nurse assesses the coping
skills of the client and formulate plans and intervention to correct deficiencies. Although assessment is also made in the orientation phase, COPING SKILLS are assessed in the working phase.

A,B and C are all positive symptoms of schizophrenia. Negative symptoms includes anhedonia, anergia, associative looseness and Asocial behavior.

Panic is the only level of anxiety that leads to personality disorganization.

This is high in tyramine, and therefore, removed from patients diet to prevent hypertensive crisis.

The client is never sick of anything but we are detecting the POSSIBILITY by giving yearly mammography. Remember that all kinds of tests, case findings and treatment belongs
to the secondary level of prevention.

this is the only question that determines the effects of the problem on the client and the ways she is dealing with it. Letter A can only be answered by FINE
and close further communication. B is unrelated to coping strategies. Letter C, asking the client what do you think can help you right now is INAPPROPRIATE for the nurse to ask. The client is in the hospital because she needs help. If she knows something that can help her with her problem she shouldn’t be there.

Tofranil is a neuroleptic. It is well known that this is the antipsychotic that increases the IOP and contraindicated in patients with glaucoma. Hypertension is not specific with TOFRANIL. All neuroleptics can cause NMS or the neuroleptic malignant syndrome.

In psychiatric nursing, The epitome of all nursing goal should focus on facilitating GROWTH of the client.

A and B are similar, therefore , removed them first. Recognizing that most antidepressants exerts their effects within 2-3 weeks will lead you to letter C.

There is no such nursing diagnosis as A , looking at C and D, they are much more compatible to schizophrenia which is not a characteristic of an ANTI SOCIAL P.D
which is shown in the situation. Remember that Personality Disorder is FAR from Psychoses. When client exhibits altered thought process or sensory alteration, It is not anymore a personality disorder but rather, a sign and symptom of psychoses.

Telling the client that there is a TERMINATION PHASE should be in the ORIENTATION PHASE, however, in preparing the client for the TERMINATION, it should be done in the working phase.
The nurse will start to lessen the number of meetings to prevent development of transference or counter transference.

Hypotension, dizziness and lethargy are side effects of anti parkinson drugs like levodopa and carbidopa.

When you take zoloft, mag zozoloft ka nalang sa buhay. Because it causes erectile dysfuntion and decrease libido. Letter B and C are specific of TCAs.
Zoloft will exert its effects as early as 1 week.

Clozapine causes AGRANULOCYTOSIS and bone marrow depression. Early s/s includes fever and sore throat. The medication is to be withheld this time or the patient might develop severe infection leading to death.