Nursing Care of Patients With Mental Health Disorders

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____ 1. A patient with schizophrenia has not bathed recently and a family member states that the patient has not been out of the house for 10 days. The patient tells the nurse, “They are trying to hurt me; don’t let them hurt me.” Which symptom is this patient demonstrating?

a.
Paranoid delusions
b.
Grandiose delusions
c.
Auditory hallucinations
d.
Persecutory hallucinations

____ 2. A patient is diagnosed as having a phobia. Which fear should the nurse expect to observe in this patient?

a.
Fear of poisonous spiders
b.
Fear of leaving the house during the day
c.
Fear of failing a test that one has not studied for
d.
Fear that a child playing in the street might get hurt

____ 3. A patient who is a war veteran states, “It should have been me that died. I’ll never forgive myself for leaving my buddy when he needed me.” The nurse recognizes this statement is most associated with which diagnosis?

a.
Bipolar depression
b.
Generalized anxiety
c.
Obsessive-compulsive disorder
d.
Post-traumatic stress disorder (PTSD)

____ 4. The spouse of an older male patient is concerned because since retiring the patient sits around the house, avoids eating, naps, and refuses to participate in sporting activities. Which disorder should the nurse recognize as being associated with these manifestations?

a.
Depression
b.
Bipolar disorder
c.
Conversion disorder
d.
Post-traumatic stress disorder (PTSD)

____ 5. A patient hospitalized for bipolar disorder is sitting in the corner of the room with the lights off, staring into space. Three hours later, the patient is in the same position. What should the nurse say to the patient?

a.
“Cheer up! Come on out and join us in a game!”
b.
“Come with me. I’d like you join our group for a while.”
c.
“You won’t make any progress if you stay in your room all the time.”
d.
“What’s the matter? Don’t you know you should be in your group right now?”

____ 6. The nurse is assisting with medication teaching for a patient who is prescribed lithium carbonate (Eskalith) for bipolar disorder. Which instruction by the nurse is most important?

a.
Instruct the patient to discontinue other antidepressant agents.
b.
Teach the patient that the lithium will help stabilize mood swings.
c.
Teach the patient side effects to report, such as nausea or weight gain.
d.
Explain to the patient and significant other the importance of regular blood tests.

____ 7. The nurse is caring for an older adult patient with a history of depression. Which comment by the patient indicates an immediate need for further assessment?

a.
“I am so old; all my friends have died.”
b.
“I am useless now; there is no reason to be alive.”
c.
“I retire in 6 months, and it will be all downhill from there.”
d.
“I am looking forward to seeing my husband in heaven someday.”

____ 8. A patient who has schizophrenia has a dull facial expression and speaks in a monotone voice, even though a visitor is making an effort to be jovial. What terminology should the nurse use to document this observation?

a.
Bored
b.
Depressed
c.
Flat affect
d.
Ambivalent attitude

____ 9. A patient with schizophrenia calls the nurse into the room and says, “Help me! The books are on fire!” Which response by the nurse is best?

a.
“I’ll get some water and put it out.”
b.
“That’s crazy; you know the books are not on fire!”
c.
“You don’t have any books; how could they be on fire?”
d.
“I do not see any fire. Here is your supper; it’s time to eat.”

____ 10. A patient with a mental illness says, “I have to go to the bank. The voices are telling me to go there.” Which response by the nurse is best?

a.
“Do you need money?”
b.
“I will call you a cab later. Right now, it is time for therapy.”
c.
“Why do you think the voices are telling you to go to the bank?”
d.
“I want to help you focus away from the voices. I am real, they are not.”

____ 11. A patient who experienced injuries from a motor vehicle crash 6 months ago continues to request prescriptions for an opioid analgesic. When assessing this patient for opioid dependency which finding is the nurse least likely to observe?

a.
The patient drops out of a Saturday night Bingo group.
b.
The patient continues to manage to get to work each day.
c.
The patient tried to quit using the opioid but couldn’t stop thinking about it.
d.
The patient has been to three or four physicians to obtain new prescriptions for the drug.

____ 12. The nurse is cautiously avoiding the temptation to take unused or wasted doses of narcotic medications when providing patient care. What percentages of nurses in the United States are chemically impaired?

a.
0% to 5%
b.
6% to 15%
c.
25% to 35%
d.
49% to 50%

____ 13. The nurse notes that another nurse colleague has been acting differently lately. The nurse often has red watery eyes and a runny nose. Today, the nurse was unhappy with the patient assignment and screamed, “Someone is going to pay for this!” What should the nurse who has observed this behavior do?

a.
Nothing; all nurses have stressful days sometimes.
b.
Tell the clinical manager exactly what was observed.
c.
Tell the clinical manager that the nurse is abusing drugs.
d.
Confront the nurse with the behavior and provide information about counseling.

____ 14. The nurse is providing care for a patient with symptoms of tardive dyskinesia from major tranquilizers. What treatment should the nurse anticipate?

a.
Use of anticholinergic agents
b.
Use of muscle relaxant agents
c.
Discontinuance of the tranquilizers
d.
Addition of rational emotive therapy to the treatment plan

____ 15. The nurse is completing a mental status examination for a newly admitted patient. In which part of the nursing process is the nurse functioning?

a.
Assessment
b.
Planning
c.
Implementation
d.
Evaluation

____ 16. The nurse is assisting with teaching a patient who has been started on fluphenazine (Prolixin). About which side effect should the nurse focus this teaching?

a.
Weight loss
b.
Hypoglycemia
c.
Photosensitivity
d.
Elevated blood pressure

____ 17. A patient cannot leave home without checking the coffee pot numerous times. This behavior makes the patient late to many functions. Which anxiety disorder should the nurse suspect the patient is experiencing?

a.
Phobia
b.
Generalized anxiety disorder (GAD)
c.
Post-traumatic stress disorder (PTSD)
d.
Obsessive-compulsive disorder (OCD)

____ 18. A patient who is withdrawing from alcohol is restless and reports seeing snakes on the ceiling. Vital signs are blood pressure 180/100 mm Hg, pulse 92 beats/min, and respirations 22 breaths/min. What should the nurse do first?

a.
Teach the patient a relaxation technique.
b.
Administer a dose of lorazepam (Ativan).
c.
Search the patient’s room for hidden alcohol.
d.
Administer an antihypertensive agent as ordered.

____ 19. The nurse assists with admission of a patient to the hospital with pancreatitis and a history of alcohol abuse. Why should the nurse observe the patient for agitation, tremors, and hallucinations?

a.
These are symptoms of alcohol withdrawal.
b.
These symptoms indicate possible cirrhosis of the liver.
c.
The patient may be using alcohol in the hospital setting.
d.
Patients with a history of alcohol abuse are at risk for mental illness.

____ 20. A patient is newly diagnosed with a trauma related disorder. Which medication should the nurse expect to be prescribed for this patient?

a.
Paroxetine (Paxil)
b.
Sertraline (Zoloft)
c.
Buspirone (Buspar)
d.
Alprazolam (Xanax)

____ 21. A patient with extreme anxiety is arriving for out-patient chemotherapy. What should the nurse do to help reduce the patient’s anxiety during this current treatment?

a.
Play a CD with nature sounds.
b.
Select a television station with a sporting event.
c.
Close the door to the room during the treatment.
d.
Remind the patient that anxiety is not going to make the treatment effective.

____ 22. A patient with depression is prescribed duloxetine (Cymbalta). What should the nurse instruct the patient about this medication?

a.
Take with fruit juice.
b.
Do not take with St. John’s wort.
c.
Stop the medication if experiencing adverse effects.
d.
Expect blood pressure to drop with this medication.

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

____ 23. The nurse is assisting with teaching a patient who is to begin taking a monoamine oxidase inhibitor (MAOI). Which foods should the nurse teach the patient to avoid? (Select all that apply.)

a.
Fish
b.
Wine
c.
Bread
d.
Pastas
e.
Aged cheese

____ 24. The nurse is assisting in the preparation of an educational seminar on anxiety disorders. Which anxiety disorders should the nurse make sure are included in this presentation? (Select all that apply.)

a.
Phobia
b.
Panic disorder
c.
Schizophrenia
d.
Unipolar depression
e.
Post-traumatic stress disorder
f.
Obsessive-compulsive disorder

____ 25. The nurse is assisting with data collection on a patient newly diagnosed with schizophrenia. Which observations should the nurse consider as being positive symptoms of schizophrenia? (Select all that apply.)

a.
Alogia
b.
Apathy
c.
Delusions
d.
Hallucinations
e.
Social isolation
f.
Disorganized behavior

____ 26. A patient has been prescribed fluoxetine (Prozac) to treat depression. What should be included in the nurse’s teaching about the drug? (Select all that apply.)

a.
“You need to take this drug only once a week.”
b.
“Take the prescribed dose in the early evening.”
c.
“A decreased interest in sexual activity may occur with this medication.”
d.
“You should not consume red wine, aged cheese, or other tyramine-rich foods.”
e.
“Do not expect immediate results; it usually takes 6 to 8 weeks for therapeutic effects to be felt.”
f.
“You may experience some nausea, vomiting, and anorexia, but these side effects will subside in time.”

____ 27. The nurse is reviewing the causes of anxiety with a patient diagnosed with an anxiety disorder. Which neurotransmitter abnormalities should the nurse include as causing symptoms of anxiety? (Select all that apply.)

a.
Increased substance P
b.
Increased epinephrine
c.
Increased somatostatin
d.
Decreased norepinephrine
e.
Decreased gamma-aminobutyric acid (GABA)

____ 28. The nurse is reviewing potential patient teaching needs. For which prescribed medications should the nurse plan to instruct patients to follow a tyramine-free diet? (Select all that apply.)

a.
Phenelzine (Nardil)
b.
Buspirone (Buspar)
c.
Isocarboxazid (Marplan)
d.
Valproic acid (Depakote)
e.
Lithium carbonate (Eskalith)

____ 29. A patient comes into the emergency department experiencing chest pain and feelings of impending doom. Which assessment findings should the nurse use to determine if this patient is experiencing a panic attack? (Select all that apply.)

a.
Shaking
b.
Neck pain
c.
Dissociation
d.
Vomiting brown emesis
e.
Occurs at 3 p.m. every day

____ 30. A patient with schizophrenia is returning from a CT scan of the brain followed by an electroencephalogram. Which diagnostic test findings should the nurse identify as supporting this patient’s diagnosis? (Select all that apply.)

a.
Enlarged ventricles
b.
Reduced amount of gray matter
c.
Areas of nerve de-myelinization
d.
Aneurysms of the cerebral vessels
e.
Diminished prefrontal cortex activity

____ 31. The nurse is assisting in planning care for a patient with extreme anxiety. Which interventions should the nurse include in this patient’s plan of care? (Select all that apply.)

a.
Maintain a calm environment.
b.
Encourage verbalization of feelings.
c.
Model and encourage positive self-talk.
d.
Encourage participation in competitive activities.
e.
Permit the patient to have time alone during acute anxiety events.

Chapter 57. Nursing Care of Patients With Mental Health Disorders

Answer Section

MULTIPLE CHOICE

1.ANS:D

Patients with paranoid schizophrenia tend to have delusions of persecution or grandeur. Patients experiencing persecutory delusions state that they feel tormented and followed by people. B. In delusions of grandeur, patients may state that they are God or the President of the United States. C. Hallucinations often accompany delusions but are not the same as delusions. The hallucinations can affect any of the five senses but are most commonly auditory followed by visual. A. Patients with paranoid schizophrenia talk about hearing “voices.”

PTS:1DIF:Moderate

KEY:Client Need: Psychosocial Integrity | Cognitive Level: Analysis

2.ANS:B

A phobia is an irrational fear of an object or situation—it is not normal to fear leaving the house. A. C. D. The fear of poisonous snakes, failing a test when unprepared, and a child getting hurt when playing in the street are reasonable things to fear.

PTS:1DIF:Moderate

KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

3.ANS:D

A behavior associated with PTSD is survivor guilt, which is the feeling of guilt expressed by those who have survived a tragedy. A survivor of an airline crash may say, “Why me? Why did I make it? I should have died too!” A. B. C. Survival guilt is not associated with bipolar depression, generalized anxiety, or obsessive-compulsive disorder.

PTS:1DIF:Moderate

KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

4.ANS:A

According to the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V), symptoms of major depression include either a depressed mood or anhedonia which is the loss of pleasure in things that are usually pleasurable along with additional symptoms such as change in appetite and sleep patterns. B. Bipolar disorder is also characterized by periods of mania as well as depression. C. Conversion disorder involves the conversion of a mental health problem into physical symptoms. D. PTSD occurs after a major trauma.

PTS:1DIF:Moderate

KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

5.ANS:B

Saying “Come with me. I’d like you to join our group for a while,” removes the patient from the situation and does not give him or her a choice. A is inappropriate. If the patient could cheer up, he or she would not be in the hospital. D. Asking what is the matter is also inappropriate—the patient does not likely know. C. Telling the patient he or she will not make any progress will cause feelings of guilt, which is not helpful.

PTS:1DIF:Moderate

KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

6.ANS:C

Lithium is an antimanic medication with a very narrow therapeutic range so toxic drug levels can easily develop. Lithium levels must be drawn regularly to assess that serum levels are in the therapeutic range. C. Reporting of side effects is important, but nausea and weight gain are not life-threatening. A. The patient should not discontinue other antidepressants unless instructed to do so by the physician. B. Lithium will stabilize mood swings, and it is important to tell the patient this, but not as important as advising the patient to have regular levels checked to avoid toxicity.

PTS:1DIF:Moderate

KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

7.ANS:B

Comments by any older adult referring to hopelessness or desire to die must be explored to assess suicide risk. A. C. These comments may require further assessment however is not as hopeless sounding as the statements about having no reason to be alive. C. Looking forward to seeing a spouse in heaven someday is a positive comment.

PTS:1DIF:Moderate

KEY:Client Need: Psychosocial Integrity | Cognitive Level: Analysis

8.ANS:C

Affect is the outward expression of mood—a patient who speaks in a monotone voice and has a dull expression has a flat affect. B. Depression is a medical diagnosis. A. D. Documenting boredom or ambivalent attitude is subjective and should be verified with additional assessment.

PTS:1DIF:Moderate

KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

9.ANS:D

The nurse needs to validate that the patient’s comment was heard but then needs to bring the patient back to reality by saying that it is time for a meal. A. Putting water on it is inappropriate—there is no fire. B. Telling a mental health patient he or she is crazy is inappropriate. C. The nurse cannot use logic such as saying that the patient does not have any books. A patient with schizophrenia may be unable to see logic.

PTS:1DIF:Moderate

KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

10.ANS:D

The nurse needs to validate the patient’s concern without exploring and focusing on the delusion. The patient needs to know what is real and what is not. B. Calling a cab and focusing on therapy does not validate the patient’s concern. C. Asking the patient about the voices encourages the patient to focus on the delusion. D. Asking about money might be appropriate for an older person with dementia, but a patient with schizophrenia needs to be brought back to reality.

PTS:1DIF:Moderate

KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

11.ANS:B

Being able to work each day is not an observation associated with opioid addiction. A. C. D. The patient with an addiction gives up important social or professional functions to use the substance, has tried at least once to quit but still obsesses about the substance, spends significant time obtaining the substance, and is unable to fulfill major role obligations at work, school, or home.

PTS:1DIF:Moderate

KEY:Client Need: Psychosocial Integrity | Cognitive Level: Analysis

12.ANS:B

According to the National Council of State Boards of Nursing, between 6 and 15 percent of nurses in the United States are chemically impaired. A. More than 5% of nurses are chemically impaired. C. D. The percentage of nurses who are chemically impaired is not above 15%.

PTS:1DIF:Moderate

KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

13.ANS:B

The nurse should document the behavior and inform the supervisor. A. Doing nothing could lead to harm to the nurse’s patients. C. Telling the manager that the nurse is using drugs is making an assumption. D. Confronting the nurse is not the role of a coworker. It is the job of the manager to follow up and ensure that the nurse is safe to provide patient care.

PTS:1DIF:Moderate

KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

14.ANS:A

Anticholinergic medications such as benztropine (Cogentin) or trihexyphenidyl (Artane) are used to combat the extrapyramidal side effects of the typical antipsychotics by helping return balance between dopamine, acetylcholine, and other neurotransmitters. B. D. Addition of rational emotive therapy or muscle relaxants will not affect the cause of the symptoms. C. Discontinuing the tranquilizers may help but may not be realistic if the patient needs them to control symptoms.

PTS:1DIF:Moderate

KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

15.ANS:A

A mental status examination is part of the assessment phase, though it may be done again during the evaluation phase to determine progress toward goals. B. C. An examination is not completed during the planning or implementation phases of the nursing process.

PTS:1DIF:Moderate

KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

16.ANS:C

Prolixin can cause photosensitivity, so the patient should be cautioned about sun protection. D. It can cause hypotension, not hypertension. A. B. It is not associated with weight loss or hypoglycemia.

PTS:1DIF:Moderate

KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

17.ANS:D

Repeatedly checking the coffee pot is an example of a compulsion which is a part of obsessive compulsive disorder (OCD). A. B. C. Compulsions are not manifestations associated with GAD, phobias, or PTSD.

PTS:1DIF:Moderate

KEY:Client Need: Psychosocial Integrity | Cognitive Level: Analysis

18.ANS:D

According to Maslow’s hierarchy, physiological symptoms must be attended to first. The patient’s blood pressure is at an unsafe level. A. B. Once the patient’s blood pressure is under control, then Ativan and relaxation may be helpful. C. Searching the room for alcohol is occasionally necessary, but a patient who has withdrawal symptoms is not likely using alcohol.

PTS:1DIF:Moderate

KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

19.ANS:A

Patients who are actively using drugs or alcohol when admitted to an inpatient setting, or who are cut off from their alcohol abruptly, can experience a condition called delirium tremens (DTs). In DTs, hyper-excitability can cause visual hallucinations, tremors, and possibly tonic-clonic seizures. B. These are not symptoms of cirrhosis. D. Patients with alcohol histories are at risk for cognitive changes, but not necessarily mental illness. C. If the patient were using alcohol in the hospital, he or she would not be experiencing DTs.

PTS:1DIF:Moderate

KEY:Client Need: Psychosocial Integrity | Cognitive Level: Analysis

20.ANS:D

Psychopharmacology for trauma related disorders may involve benzodiazepines which are antianxiety medications. Alprazolam (Xanax) is commonly used and is effective in most cases. Benzodiazepines are used for short-term treatment because of the strong potential for chemical dependency. A. B. C. Individuals who need longer term therapy for anxiety or who have chemical dependency tendencies may be treated with buspirone (Buspar), selective serotonin reuptake inhibitors (SSRIs) paroxetine (Paxil) or sertraline (Zoloft).

PTS:1DIF:Moderate

KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

21.ANS:A

A study was done that looked at the effect of nature based sounds to reduce agitation, anxiety level and physiological signs of stress in patients. The experimental group had significantly lower systolic blood pressure, diastolic blood pressure, anxiety and agitation levels than the control group. The use of music or nature based sounds incorporated into nursing care may help reduce anxiety. B. Selecting a program televising a sporting event might be too stressful for the patient. C. Closing the door to the treatment room might cause the patient to feel abandoned. D. Reminding the patient that anxiety is not going to make the treatment effective is threatening and is a negative statement. The patient should be counseled in positive self-talk.

PTS:1DIF:Moderate

KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

22.ANS:B

Many people take St. John’s wort, an OTC herbal supplement, for depression. Although it may be effective for some people with mild depression, it can interact with many prescribed medications that influence serotonin levels. If combined with prescription serotonin-type antidepressants, it can cause serotonin syndrome, an excess of serotonin resulting in agitation, confusion, diarrhea, muscle spasms, and even death. A. This medication does not need to be taken with fruit juice. C. This medication should not be abruptly stopped. D. This medication can cause systolic hypertension.

PTS:1DIF:Moderate

KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

MULTIPLE RESPONSE

23.ANS:B, E

When a patient taking a monoamine oxidase inhibitor (MAOI) consumes foods high in tyramine, the drug prevents the normal breakdown of tyramine, leading to excessive epinephrine levels. Hypertension can occur which can be severe enough to cause intracranial hemorrhage. Foods to be avoided include wine and aged cheese. A. C. D. Breads, pastas, and fish do not need to be restricted because of tyramine content.

PTS:1DIF:Moderate

KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

24.ANS:A, B, E, F

Phobias are the most common of the anxiety disorders. Additional disorders are panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, and post-traumatic stress disorder. D. Depression is a mood disorder. C. Schizophrenia is a brain disorder that is a group of illnesses, not one of the anxiety disorders.

PTS:1DIF:Moderate

KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

25.ANS:C, D, F

Positive symptoms of schizophrenia can be thought of as those symptoms that reflect an “excess” or distortion of normal functioning. Positive symptoms include hallucinations, delusions, disorganized thinking, and disorganized behavior. A. B. E. Negative symptoms include affective blunting or flattening, alogia, avolition, apathy, anhedonia, and social isolation.

PTS:1DIF:Moderate

KEY:Client Need: Psychosocial Integrity | Cognitive Level: Analysis

26.ANS:C, F

Teach patient who is taking a selective serotonin reuptake inhibitor (SSRI) that it will take 6 to 8 weeks for therapeutic effects to occur, and possibly longer with Prozac. Possible side effects include excitation, nausea and vomiting, decreased libido, anorexia, and weight loss. B. SSRIs should be administered before 3 p.m. to prevent excitation from affecting sleep. A. They are taken daily. D. Aged foods are avoided with monoamine oxidase inhibitors (MAOIs), not SSRIs.

PTS:1DIF:Moderate

KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

27.ANS:B, E

Anxiety, as explained by biological theory, is associated with increased epinephrine and norepinephrine, and decreased GABA. A. C. Increased substance P is associated with depression, and increased somatostatin is associated with Huntington’s disease. D. Anxiety is associated with increased and not decreased norepinephrine.

PTS:1DIF:Moderate

KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

28.ANS:A, C

Tyramine-free diet is required for patients taking monoamine oxidase inhibitor (MAOI) antidepressants including phenelzine (Nardil), tranylcypromine (Parnate), and isocarboxazid (Marplan). B. D. E. A tyramine-free diet is not required for patients taking buspirone (Buspar), valproic acid (Depakote), or lithium carbonate (Eskalith).

PTS:1DIF:Moderate

KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

29.ANS:A, C, E

Panic is a state of extreme fear that cannot be controlled; it may be referred to as a panic attack. Panic episodes are recurrent and occur unpredictably. Patients may present themselves at the emergency room because they believe they are having a heart attack or other significant physical illness. Patients must exhibit several episodes within a specified time frame to be given the diagnosis of panic disorder. Additional symptoms associated with panic disorder include dissociation and shaking. B. D. Neck pain and vomiting brown emesis are not manifestations of a panic disorder.

PTS:1DIF:Moderate

KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

30.ANS:A, B, E

The brains of patients with a diagnosis of schizophrenia show a significant loss of gray matter, enlarged ventricles, and diminished prefrontal cortex functioning. C. Nerve de-myelinization would not be visible through a CT scan or electroencephalogram. D. Aneurysms are not a normal finding in the patient with schizophrenia and would be considered an emergency.

PTS:1DIF:Moderate

KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

31.ANS:A, B, C

Nursing care for the patient with extreme anxiety includes maintaining a calm environment, encouraging verbalization of feelings, and encouraging positive self-talk. D. Activities should be encouraged however the patient should not be placed in a competitive situation since it can produce anxiety. E. The nurse should stay with the patient during an acute anxiety event because feeling abandoned can increase anxiety.

PTS:1DIF:Moderate

KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application