Week 4.

Bipolar Disorders, OCD, Schizophrenia, PTSD, Anxiety Disorder

Name: _______________________ Section: ___________ Date: ___________

Multiple Choice.

1. A client with bipolar disorder has only been prescribed an antidepressive

medication. Which risk factor should the nurse consider to be the highest?
A. No change
B. Manic episode
C. Compulsive behaviors
D. Increased anxiety

RATIONALE: B. A client with bipolar disorder (BPD) who is prescribed

antidepressive medication has a high risk of having a manic episode in
response to the antidepressant; to avoid this possibility, most clients with
BPD who need an antidepressant will also take mood stabilizers.
Compulsive behaviors and increased anxiety are not directly related to
antidepressive medications.

2. A client diagnosed with obsessive-compulsive disorder is admitted to a

psychiatric unit. The client has an elaborate routine for toileting activities.
Which would be an appropriate initial client outcome during the first week of
hospitalization?
A. The client will refrain from ritualistic behaviors during daylight hours.
B. The client will wake early enough to complete rituals prior to breakfast.
C. The client will participate in 3 unit activities by day 3.
D. The client will substitute a productive activity for rituals by day 1.

RATIONALE: B. During the first week, we wouldn't ask them to stop their
compulsions or change their routine. Having goals are fine, but first they
need to be started on medication and treatment prior to talking about
their feelings and dealing with their anxiety. Assimilating to a schedule is
first in acute care. Allow them to continue with their rituals for a short
period of time.

3. A paranoid client presents with bizarre behaviors, neologisms, and thought

insertion. Which nursing action should be prioritized to maintain this client's
safety?
A. Assess for medication noncompliance
B. Note escalating behaviors and intervene immediately
C. Interpret attempts at communication
D. Assess triggers for bizarre, inappropriate behaviors
 RATIONALE: B. The nurse should note escalating behaviors and intervene
immediately to maintain this client's safety. Early intervention may
prevent an aggressive response and keep the client and others safe.

4. The nurse is caring for a 30-year-old woman 3 months after the woman's
assault. Her symptoms include a sense of detachment, altered sense of
reality, spontaneous memories of the assault, recurring distressing dreams,
psychological distress, and an inability to return to her apartment. Which risk
factor should lead the nurse to suspect that the patient is experiencing
posttraumatic stress disorder (PTSD)?
A. Experiencing an extremely stressful event
B. Exhibiting depersonalization
C. Avoiding situations related to the trauma
D. Experiencing flashbacks

RATIONALE: A. Risk factors for PTSD include the severity of the stressor
event and additional stressors immediately following the event.
Depersonalization, avoiding situations related to the trauma, and
flashbacks are clinical manifestations of PTSD, not risk factors.

5. A client is prescribed alprazolam (Xanax) for acute anxiety. What client

history should cause a nurse to question this order?
A. History of alcohol dependence
B. History of personality disorder
C. History of schizophrenia
D. History of hypertension

RATIONALE: A. The nurse should question a prescription of alprazolam

(Xanax) for acute anxiety if the client has a history of alcohol
dependence. Alprazolam is a benzodiazepine used in the treatment of
anxiety and has an increased risk for physiological dependence and
tolerance. A client with a history of substance abuse may be more likely
to abuse other addictive substances and/or combine this drug with
alcohol.

6. A highly agitated client paces the unit & states, I could buy & sell this place.
The clients mood fluctuates from fits of laughter to outbursts of anger. Which
is the most accurate documentation of this clients behavior?
A. Rates mood 8/10. Exhibiting looseness of association. Euphoric.
B. Mood euthymic. Exhibiting magical thinking. Restless.
C. Mood labile. Exhibiting delusions of reference. Hyperactive.
D. Agitated & pacing. Exhibiting grandiosity. Mood labile.

RATIONALE: D. The nurse should document that this clients behavior is

Agitated & pacing. Exhibiting grandiosity. Mood labile. The client is
 exhibiting mood swings from euphoria to irritability. Grandiosity refers to
the attitude that ones abilities are better than everyone else's.

7. A client is newly diagnosed with obsessive-compulsive disorder and spends

45 minutes folding clothes and rearranging them in drawers. Which nursing
intervention best addresses this client's problem?
A. Distract the client with other activities whenever ritual behaviors begin.
B. Report the behavior to the psychiatrist to obtain an order for medication
dosage increase.
C. Lock the room to discourage ritualistic behavior.
D. Discuss the anxiety-provoking triggers that precipitate the ritualistic
behaviors.

RATIONALE: D. Never distract clients with OCD with other activities.

8. A person is directing traffic on a busy street while shouting & making

obscene gestures at passing cars. The person has not slept or eaten for 3
days. What features of mania are evident?
A. Increased muscle tension and anxiety
B. Vegetative signs and poor grooming
C. Poor judgment and hyperactivity
D. Cognitive deficit and sad mood

RATIONALE: C. Hyperactivity (directing traffic) & poor judgment (putting

self in a dangerous position) are characteristic of manic episodes. The
distractors do not specifically apply to mania.

9. The nurse is assessing a child diagnosed with posttraumatic stress disorder

(PTSD). Which finding should be the priority?
A. History of suicide attempts
B. Changes in sleeping patterns
C. History of traumatic brain injury
D. Lack of social support

RATIONALE: B. Identification of PTSD in children is improved when they

are questioned directly about their experiences. Assessment of younger
children involves questioning the child and/or the parents about
significant changes in behavior and sleeping patterns. Lack of social
support, history of traumatic brain injury, and history of suicide attempts
are vital information for other patient populations but are not critical for
the pediatric population.

10. A nursing instructor is teaching about specific phobias. Which student

statement should indicate that learning has occurred?
 A. "These clients do not recognize that their fear is excessive and rarely seek
treatment."
B. "These clients have a panic level of fear that is overwhelming and
unreasonable."
C. "These clients experience symptoms that mirror a cerebrovascular
accident (CVA)."
D. "These clients experience the symptoms of tachycardia, dysphagia, and
diaphoresis."

RATIONALE: B. The nursing instructor should evaluate that learning has

occurred when the student knows that clients experiencing phobias have
a panic level of fear that is overwhelming and unreasonable. Phobia is
fear cued by a specific object or situation in which exposure to the stimuli
produces an immediate anxiety response.

11. A client diagnosed with schizoaffective disorder is admitted for social

skills training. Which information should be taught by the nurse?
A. The side effects of medications
B. Deep breathing techniques to decrease stress
C. How to make eye contact when communicating
D. How to be a leader

RATIONALE: C. The nurse should plan to teach the client how to make
eye contact when communicating. Social skills, such as making eye
contact, can assist clients in communicating needs and maintaining
connectedness.

12. The nurse is evaluating the treatment plan for a patient with
obsessive-compulsive disorder (OCD). Which patient action demonstrates
successful response to nursing care?
A. The patient verbalizes increased social interaction and a decrease in
missed events.
B. The patient describes normal roles that they are not performing because
of the disorder.
C. The patient understands their reactions to environmental triggers.
D. The patient understands that complete healing from OCD will occur within
6 months.

RATIONALE: A. The patient verbalizing increased social interaction and a

decrease in missed events due to the performance of ritualistic behaviors
is an expected treatment outcome and indicates a successful response to
nursing care. The patient describing normal roles that they are not
performing because of the disorder and the patient understanding their
reactions to environmental triggers will promote effective coping but do
not indicate a successful response to nursing care. Patients should
 understand that complete healing from OCD will likely take many years
for most patients and will not occur in 6 months.

13. A client diagnosed with bipolar disorder is distraught over insomnia

experienced over the last 3 nights & a 12-pound weight loss over the past 2
weeks. Which should be this clients priority nursing diagnosis?
A. Knowledge deficit R/T bipolar disorder AEB concern about symptoms
B. Altered nutrition: less than body requirements R/T hyperactivity AEB
weight loss
C. Risk for suicide R/T powerlessness AEB insomnia & anorexia
D. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights

RATIONALE: B. The nurse should identify that the priority nursing

diagnosis for this client is altered nutrition: less than body requirements
R/T hyperactivity AEB weight loss. Because of the clients rapid weight
loss, the nurse should prioritize interventions to ensure proper nutrition &
physical health.

14. A 16-year-old-client diagnosed with paranoid schizophrenia

experiences command hallucinations to harm others. The client's parents ask
a nurse, "Where do the voices come from?" Which is the appropriate nursing
reply?
A. "Your child has a chemical imbalance of the brain which leads to altered
thoughts."
B. "Your child's hallucinations are caused by medication interactions."
C. "Your child has too little serotonin in the brain causing delusions and
hallucinations."
D. "Your child's abnormal hormonal changes have precipitated auditory
hallucinations."

RATIONALE: A. The nurse should explain that a chemical imbalance of the

brain leads to altered thought processes. Hallucinations, or false sensory
perceptions, may occur in all five senses. The client who hears voices is
experiencing an auditory hallucination.

15. A client has a history of excessive fear of water. What is the term that
a nurse should use to describe this specific phobia, and under what subtype
is this phobia identified?
A. Aquaphobia, a natural environment type of phobia
B. Aquaphobia, a situational type of phobia
C. Acrophobia, a natural environment type of phobia
D. Acrophobia, a situational type of phobia
RATIONALE: A. The nurse should determine that an excessive fear of
water is identified as aquaphobia which is a natural environment type of
phobia. Natural environment-type phobias are fears about objects or
 situations that occur in the natural environment such as a fear of heights
or storms.

16. A patient with posttraumatic stress disorder (PTSD) wishes to include

nonpharmacologic therapy as part of the treatment regimen. Which form of
nonpharmacologic therapy allows the patient to develop effective coping
skills in a safe, controlled environment?
A. Cognitive-behavioral therapy
B. Body-centered therapy
C. Dual-attention stimulus
D. Exposure therapy

RATIONALE: D. Exposure therapy allows the patient to develop effective

coping skills in a safe, controlled environment. Cognitive-behavioral
therapy, body-centered therapy, and dual-attention stimulus do not
provide this for the patient.

17. A patient reports irritated, dry, and bleeding skin on their hands. While
talking to the patient, the nurse orienting to the unit observes the patient go
to the sink and wash their hands five times. Which action by the orienting
nurse should cause the preceptor to provide teaching?
A. Administering selective serotonin reuptake inhibitor (SSRI) as ordered
B. Teaching the patient alternative coping mechanisms
C. Interrupting the patient's hand washing ritual
D. Referring the patient for cognitive-behavioral therapy (CBT)

RATIONALE: C. Referral for cognitive-behavioral therapy (CBT),

administering an SSRI as ordered, and teaching the patient coping
mechanisms are all appropriate nursing interventions. Interrupting the
patient may increase the patient's anxiety and telling the patient that it is
not necessary to wash their hands so often may increase the patient's
feelings of shame. If a patient with OCD is admitted to the hospital, the
hospital staff may need to collaborate with the patient to accommodate
the rituals until the patient experiences relief from anxiety. Administration
of medicines to lower anxiety and re-evaluation of the patient's response
to the medication are the responsibility of the nurse in collaboration with
the healthcare provider and the patient.

18. A patient diagnosed with bipolar disorder is dressed in a red leotard &
brightly colored scarves. The patient says, "I'll punch you, munch you,
crunch you" while twirling & shadowboxing. Then the patient says gaily, Do
you like my scarves? Here, they are my gift to you. How should the nurse
document the patients mood?
A. Labile and euphoric
B. Irritable and belligerent
 C. Highly suspicious and arrogant
D. Excessively happy and confident

RATIONALE: A. The patient has demonstrated angry behavior & pleasant,

happy behavior within seconds of each other. Excessive happiness
indicates euphoria. Mood swings are often rapid & seemingly without
understandable reason in patients who are manic. These swings are
documented as labile. Irritability, belligerence, excessive happiness &
confidence are not entirely correct terms for the patient's mood. A high
level of suspicion is not evident.

19. After establishing a therapeutic relationship, the nurse is counseling a

patient with obsessive-compulsive disorder (OCD) regarding adaptive coping
strategies. Which action should the nurse teach a patient to do instead of
performing a ritual?
A. Take a deep breath.
B. Meditate.
C. Count to ten.
D. Drink a glass of water.

RATIONALE: B. Nurses can help patients reframe how they think about
their disease and help them reframe thought processes to reduce ritual
performance, such as helping the patient meditate instead of performing a
ritual. Taking a deep breath, counting to ten, or drinking a glass of water
would not be sufficient to reframe the way of thinking of a patient with
OCD.

20. How would a nurse differentiate a client diagnosed with panic disorder
from a client diagnosed with generalized anxiety disorder (GAD)?
A. GAD is acute in nature, and panic disorder is chronic.
B. Chest pain is a common GAD symptom, whereas this symptom is absent
in panic disorders.
C. Hyperventilation is a common symptom in GAD and rare in panic disorder.
D. Depersonalization is commonly seen in panic disorder and absent in GAD.

RATIONALE: D. The nurse should recognize that a client diagnosed with

panic disorder experiences depersonalization, whereas a client diagnosed
with GAD would not. Depersonalization refers to being detached from
oneself when experiencing extreme anxiety.

21. A patient wishes to incorporate exposure therapy into the treatment

regimen. The nurse should understand that exposure therapy helps the
patient in which way?
A. To face fears
 B. To mix several types of therapy, including cognitive-behavioral (CBT) and
body-centered therapy
C. To focus internally on the traumatic event
D. To focus on a different external stimulus

RATIONALE: A. Exposure therapy enables the patient to face fears. Eye-

movement desensitization and reprocessing (EMDR) is a form of
psychotherapy that contains elements of several types of therapy,
including CBT and body-centered therapy. One element of EDMR is dual-
attention stimulus, which allows the patient to reprocess or reappraise the
trauma by focusing internally on the traumatic event or another stressor
while simultaneously focusing on a different external stimulus.

22. Parents ask a nurse how they should reply when their child, diagnosed
with paranoid schizophrenia, tells them that voices command him to harm
others. Which is the appropriate nursing reply?
A. "Tell him to stop discussing the voices."
B. "Ignore what he is saying, while attempting to discover the underlying
cause."
C. "Focus on the feelings generated by the hallucinations and present
reality."
D. "Present objective evidence that the voices are not real."

RATIONALE: C. The most appropriate response by the nurse is to instruct

the parents to focus on the feelings generated by the hallucinations and
present reality. The parents should maintain an attitude of acceptance to
encourage communication but should not reinforce the hallucinations by
exploring details of content. It is inappropriate to present logical
arguments to persuade the client to accept the hallucinations as not real.

23. The nurse is leading a group therapy session for clients with bipolar
disorder. During the session, a client with bipolar I disorder becomes
increasingly restless and starts constantly interrupting and criticizing other
members of the group. The client ignores the nurse's repeated requests to
stop the disruptive behavior. Which type of bipolar episode is the client likely
experiencing?
A. Manic
B. Disruptive
C. Depressive
D. Cyclothymic

RATIONALE: A. The client is likely experiencing a manic bipolar state.

Mania is an abnormal and persistent period of increased, expanded, or
irritable mood that is characterized by increased energy for a period of
time. A depressive state is characterized by five or more symptoms in a
 2-week period that demonstrate either a depressed mood or a decrease in
pleasure or interest in daily activities. Cyclothymic disorder is
characterized by at least 2 years of chronic fluctuating periods of
hypomanic and depressive behaviors.

24. A patient recently diagnosed with obsessive-compulsive disorder

(OCD) requires cognitive-behavioral therapy (CBT). Because it has
evidentiary support, which type of cognitive-behavioral therapy (CBT) should
the nurse expect the patient to receive?
A. Exposure and response prevention
B. Interpersonal therapy
C. Dialectical behavior therapy
D. Eye movement desensitization and reprocessing therapy

RATIONALE: CBT that relies primarily on behavioral techniques such as

exposure and response prevention (ERP) is recommended because it has
evidentiary support. Interpersonal therapy, dialectical behavior therapy,
and eye movement desensitization and reprocessing therapy are not
indicated for the treatment of OCD.

25. Which treatment should a nurse identify as most appropriate for

clients diagnosed with generalized anxiety disorder (GAD)?
A. Long-term treatment with diazepam (Valium)
B. Acute symptom control with citalopram (Celexa)
C. Long-term treatment with buspirone (BuSpar)
D. Acute symptom control with ziprasidone (Geodon)

RATIONALE: C. The nurse should identify that an appropriate treatment

for clients diagnosed with GAD is long-term treatment with buspirone.
Buspirone is an anxiolytic medication that is effective in 60% to 80% of
clients with GAD. It takes 10 to 14 days for alleviation of symptoms but
does not have the dependency concerns of other anxiolytics.

26. The nurse suggests that a patient with posttraumatic stress disorder
(PTSD) should include exercise in the treatment regimen. Which aspect of
PTSD can be reduced effectively through exercise?
A. Suicidal thoughts
B. Negative feelings
C. Aggressive behavior
D. Somatic symptoms

RATIONALE: B. Nurses should help patients with PTSD to identify safe

physical outlets for negative feelings, such as exercise. Exercise may not
be effective for treating suicidal thoughts, aggressive behavior, or somatic
symptoms.
27. The nurse is teaching colleagues about cyclothymic disorder. Which
statement should the nurse include?
A. "It involves a single manic episode."
B. "It is a mood disorder similar to major depression but of mild to moderate
severity."
C. "It is a form of depression that occurs in the fall and winter."
D. "It involves a mood range from moderate depression to hypomania."

RATIONALE: D. Cyclothymic disorder involves a mood range from

moderate depression to hypomania. Bipolar I disorder is characterized by
at least one manic episode; the manic episode may have been preceded
by and may be followed by hypomanic or major depressive episodes.

28. A nurse is assessing a client diagnosed with paranoid schizophrenia.

The nurse asks the client, "Do you receive special messages from certain
sources, such as the television or radio?" Which potential symptom of this
disorder is the nurse assessing?
A. Thought insertion
B. Paranoid delusions
C. Magical thinking
D. Delusions of reference

RATIONALE: D. The nurse is assessing for the potential symptom of

delusions of reference. A client who believes that he or she receives
messages through the radio is experiencing delusions of reference. When
a client experiences these delusions, he or she interprets all events within
the environment as personal references.

29. A patient with obsessive-compulsive disorder (OCD) requires

hospitalization for the treatment of the disorder. Which action should the
nurse implement to alleviate the anxiety associated with this situation?
A. Validate the patient's feelings without encouraging the patient's belief in a
distorted reality.
B. Encourage the patient to have health conversations with family members.
C. Remove triggers associated with the patient's obsession or compulsion.
D. Encourage the patient to participate in individual or family behavioral
therapy or counseling.

RATIONALE: For patients who are hospitalized for treatment of OCD or for
any other reason, steps need to be taken to reduce environmental
stimulation, which includes removal or hiding of any triggers associated
with the patient's obsession or compulsion. Validating the patient's
feelings without encouraging the patient's belief in a distorted reality,
encouraging patients to have health conversations with their family
 members, and encouraging patients to participate in individual or family
behavioral therapy or counseling are all important for the well-being of
the patient, but they will not be useful to decrease the stress associated
with a hospitalization.

30. A cab driver, stuck in traffic, suddenly is lightheaded, tremulous,

diaphoretic, and experiences tachycardia and dyspnea. An extensive workup
in an emergency department reveals no pathology. Which medical diagnosis
is suspected, and what nursing diagnosis takes priority?
A. Generalized anxiety disorder and a nursing diagnosis of fear
B. Altered sensory perception and a nursing diagnosis of panic disorder
C. Pain disorder and a nursing diagnosis of altered role performance
D. Panic disorder and a nursing diagnosis of anxiety

RATIONALE: D. The nurse should suspect that the client has exhibited
signs/symptoms of a panic disorder. The priority nursing diagnosis should
be anxiety. Panic disorder is characterized by recurrent, sudden onset
panic attacks in which the person feels intense fear, apprehension, or
terror.

31. Which collaborative process of initial monitoring should the nurse

implement for a client who has been prescribed lithium?
A. Testing lithium serum levels every 1-3 days
B. Arranging for therapy sessions every 1-3 days
C. Arranging for blood urea nitrogen (BUN) and creatinine levels every 1-3
days
D. Testing sodium levels every 1-3 days

RATIONALE: A. The window between lithium toxicity and therapy is short,

and close monitoring is required.

32. A client diagnosed with schizophrenia tells a nurse, "The

'Shopatouliens' took my shoes out of my room last night." Which is an
appropriate charting entry to describe this client's statement?
A. "The client is experiencing command hallucinations."
B. "The client is expressing a neologism."
C. "The client is experiencing a paranoid delusion."
D. "The client is verbalizing a word salad."

RATIONALE: B. The nurse should describe the client's statement as

experiencing a neologism. A neologism is when a client invents a new
word that is meaningless to others but may have symbolic meaning to the
client. Word salad refers to a group of words that are put together
randomly.
33. Which behavior is a characteristic of dissociation experienced by
patients with posttraumatic stress disorder (PTSD)?
A. Emotional numbing and loss of sense of reality
B. Blocking certain elements of the traumatic event
C. Blocking emotions related to the traumatic event
D. Strong sense of agitation and poor concentration

RATIONALE: C. Dissociation, in which the individual blocks emotions

related to the traumatic event, may occur in patients with PTSD.
Dissociation is not associated with a strong sense of agitation and poor
concentration, emotional numbing and loss of sense of reality, or blocking
certain elements of the traumatic event altogether.

34. How would a nurse differentiate a client diagnosed with obsessive-

compulsive disorder (OCD) from a client diagnosed with obsessive-
compulsive personality disorder?
A. Clients diagnosed with OCD experience both obsessions and compulsions,
and clients diagnosed with obsessive-compulsive personality disorder do
not.
B. Clients diagnosed with obsessive-compulsive personality disorder
experience both obsessions and compulsions, and clients diagnosed with
OCD do not.
C. Clients diagnosed with obsessive-compulsive personality disorder
experience only obsessions, and clients diagnosed with OCD experience
only compulsions.
D. Clients diagnosed with OCD experience only obsessions, and clients
diagnosed with obsessive-compulsive personality disorder experience only
compulsions.

RATIONALE: A. A client diagnosed with OCD experiences both obsessions

and compulsions. Clients diagnosed with obsessive-compulsive personality
disorder exhibit a pervasive pattern of preoccupation with orderliness,
perfectionism, and mental and interpersonal control.

35. The behavioral health nurse is assessing a client with bipolar disorder.
Which finding indicates that the client is in a state of hypomania?
A. The client feels powerless and is coping with the use of alcohol.
B. The client expresses euphoric feelings of being on top of the world.
C. The client is experiencing hallucinations.
D. The client demonstrates flight of ideas.

RATIONALE: B. Hypomania is less extreme compared with mania and

does not involve manifestations of psychosis such as hallucinations. The
client may feel like they are "on top of the world." Flight of ideas and
 hallucinations align with mania. Powerlessness and coping with alcohol
may be observed with depression.

36. A nursing instructor is teaching about the medications used to treat

panic disorder. Which student statement indicates that learning has
occurred?
A. "Clonazepam (Klonopin) is particularly effective in the treatment of panic
disorder."
B. "Clozapine (Clozaril) is used off-label in long-term treatment of panic
disorder."
C. "Doxepin (Sinequan) can be used in low doses to relieve symptoms of
panic attacks."
D. "Buspirone (BuSpar) is used for its immediate effect to lower anxiety
during panic attacks."

RATIONALE: A. The student indicates learning has occurred when he or

she states that clonazepam is a particularly effective treatment for panic
disorder. Clonazepam is a type of benzodiazepine that can be abused and
lead to physical dependence and tolerance. It can be used on an as-
needed basis to reduce anxiety and its related symptoms.

37. During an admission assessment, a nurse asks a client diagnosed with

schizophrenia, "Have you ever felt that certain objects or persons have
control over your behavior?" The nurse is assessing for which type of thought
disruption?
A. Delusions of persecution
B. Delusions of influence
C. Delusions of reference
D. Delusions of grandeur

RATIONALE: B. The nurse is assessing the client for delusions of influence

when asking if the client has ever felt that objects or persons have control
of the client's behavior. Delusions of control or influence are manifested
when the client believes that his or her behavior is being influenced. An
example would be if a client believes that a hearing aid receives
transmissions that control personal thoughts and behaviors.

38. The nurse is caring for an older patient who is a veteran with
posttraumatic stress disorder (PTSD). Which manifestation is reported more
often by older veteran patients compared with younger veterans?
A. Depression
B. Hostility
C. Guilt
D. Somatic symptoms
 RATIONALE: D. Older veteran patients report more somatic complaints;
fewer typical PTSD general symptoms; and less depression, hostility, and
guilt than younger veterans do.

39. A person was online continuously for over 24 hours, posting rhymes on
official government websites and inviting politicians to join social networks.
The person has not slept or eaten for 3 days. What features of mania are
evident?
A. Increased muscle tension and anxiety
B. Poor judgment and hyperactivity
C. Vegetative signs and poor grooming
D. Cognitive deficits and paranoia

RATIONALE: B. Hyperactivity (activity without sleep) and poor judgment

(posting rhymes on government websites) are characteristic of manic
episodes. The distracters do not specifically apply to mania.

40. A patient diagnosed with bipolar disorder is dressed in a red leotard

and bright scarves. The patient twirls and shadow boxes. The patient says
gaily, "Do you like my scarves? Here; they are my gift to you." How should
the nurse document the patient's mood?
A. Euphoric
B. Suspicious
C. Irritable
D. Confident

RATIONALE: A. The patient has demonstrated clang associations and

pleasant, happy behavior. Excessive happiness indicates euphoria.
Irritability, belligerence, excessive happiness, and confidence are not the
best terms for the patient's mood. Suspiciousness is not evident

41. A person was directing traffic on a busy street, rapidly shouting, "To
work, you jerk, for perks" and making obscene gestures at cars. The person
has not slept or eaten for 3 days. Which assessment findings will have
priority concern for this patient's plan of care?
A. Insulting, aggressive behavior
B. Pressured speech and grandiosity
C. Hyperactivity; not eating and sleeping
D. Poor concentration and decision making

RATIONALE: C. Hyperactivity, poor nutrition, hydration, and not sleeping

take priority in terms of the needs listed above because they threaten the
physical integrity of the patient. The other behaviors are less threatening
to the patient's life.
42. A patient diagnosed with acute mania has distributed pamphlets about
a new business venture on a street corner for 2 days. Which nursing
diagnosis has priority?
A. Risk for injury
B. Ineffective coping
C. Impaired social interaction
D. Ineffective therapeutic regimen management

RATIONALE: A. Although each of the nursing diagnoses listed is

appropriate for a patient having a manic episode, the priority lies with the
patient's physiological safety. Hyperactivity and poor judgment put the
patient at risk for injury.

43. During the assessment, the nurse observes a client who was a victim
of a home invasion abruptly stand up and begin to run out of the room in
response to hearing a loud bang. What should be the nurse's initial response?
A. The client thought there was an earthquake.
B. The client was reacting to the loud noise as a form of a flashback.
C. The client wanted to check the cause for the loud noise.
D. The client thought the assessment was concluded.

RATIONALE: B. Flashbacks are the recurrence of images, sounds, smells,

or feelings from a traumatic event that are triggered by daily events such
as a door banging. The client's reaction to hearing a loud bang from a
door could have made the client recall being at home during the home
invasion. The client most likely did not think that the assessment was
concluded or that there was an earthquake. The client would not have
abruptly begun to run out of the room if checking for the source of the
loud noise.

44. A patient diagnosed with bipolar disorder becomes hyperactive after

discontinuing lithium. The patient threatens to hit another patient. Which
comment by the nurse is appropriate?
A. "Stop that! No one did anything to provoke an attack by you."
B. "If you do that one more time, you will be secluded immediately."
C. "Do not hit anyone. If you are unable to control yourself, we will help
you."
D. "You know we will not let you hit anyone. Why do you continue this
behavior?"

RATIONALE: C. When the patient is unable to control his or her behavior

and violates or threatens to violate the rights of others, limits must be set
in an effort to de-escalate the situation. Limits should be set in simple,
concrete terms. The incorrect responses do not offer appropriate
 assistance to the patient, threaten the patient with seclusion as
punishment, and ask a rhetorical question.

45. A patient demonstrating characteristics of acute mania relapsed after

discontinuing lithium. New orders are written to resume lithium twice daily
and begin olanzapine (Zyprexa). What is the rationale for the addition of
olanzapine to the medication regimen? It will:
A. Minimize the side effects of lithium.
B. Bring hyperactivity under rapid control.
C. Enhance the antimanic actions of lithium.
D. Be used for long-term control of hyperactivity.

RATIONALE: B. Manic symptoms are controlled by lithium only after a

therapeutic serum level is attained. Because this takes several days to
accomplish, a drug with rapid onset is necessary to reduce the
hyperactivity initially. Antipsychotic drugs neither enhance lithium's
antimanic activity nor minimize the side effects. Lithium will be used for
long-term control.

46. A patient diagnosed with bipolar disorder has rapidly changing mood
cycles. The health care provider prescribes an anticonvulsant medication. To
prepare teaching materials, which drug should the nurse anticipate will be
prescribed?
A. Phenytoin (Dilantin)
B. Risperidone (Risperdal)
C. Clonidine (Catapres)
D. Carbamazepine (Tegretol)

RATIONALE: D. Some patients with bipolar disorder, especially those who

have only short periods between episodes, have a favorable response to
the anticonvulsants carbamazepine and valproate. Carbamazepine seems
to work better in patients with rapid cycling and in severely paranoid,
angry manic patients. Phenytoin is also an anticonvulsant but not used for
mood stabilization. Risperidone is not an anticonvulsant. See relationship
to audience response question.

47. The exact cause of bipolar disorder has not been determined;
however, for most patients:
A. Several factors, including genetics, are implicated.
B. Brain structures were altered by stress early in life.
C. Excess sensitivity in dopamine receptors may trigger episodes.
D. Inadequate norepinephrine reuptake disturbs circadian rhythms.

RATIONALE: A. The best explanation at this time is that bipolar disorder is

most likely caused by interplay of complex independent variables. Various
 theories implicate genetics, endocrine imbalance, environmental
stressors, and neurotransmitter imbalances.

48. A patient diagnosed with bipolar disorder commands other patients,

"Get me a book. Take this stuff out of here," and other similar demands. The
nurse wants to interrupt this behavior without entering into a power struggle.
Which initial approach should the nurse select?
A. Distraction: "Let's go to the dining room for a snack."
B. Humor: "How much are you paying servants these days?"
C. Limit setting: "You must stop ordering other patients around."
D. Honest feedback: "Your controlling behavior is annoying others."

RATIONALE: A. The distractibility characteristic of manic episodes can

assist the nurse to direct the patient toward more appropriate,
constructive activities without entering into power struggles. Humor
usually backfires by either encouraging the patient or inciting anger. Limit
setting and honest feedback may seem heavy-handed and may incite
anger.

49. What should the nurse plan for a client diagnosed with posttraumatic
stress disorder who has experienced symptoms for 4 months?
A. Guidelines on conducting activities of daily living
B. Information on the treatments available
C. Referral to local employment agency
D. Information on the need for adequate exercise

RATIONALE: B. The nurse should plan to provide the client with

information on the treatments available for posttraumatic stress disorder.
Information on exercise and activities of daily living will most likely not
help the client's symptoms. Referral to the local employment agency may
or may not be necessary.

50. The nurse receives a laboratory report indicating a patient's serum

level is 1 mEq/L. The patient's last dose of lithium was 8 hours ago. This
result is:
A. Within therapeutic limits.
B. Below therapeutic limits.
C. Above therapeutic limits.
D. Invalid because of the time lapse since the last dose.

RATIONALE: A. Normal range for a blood sample taken 8 to 12 hours after

 Prepared by: Dr. Jhonnifer A. Abarao,
DHCM, MAN, USRN, RN, LPT, CHA,

“Not all angels have wings … some have scrubs.” —Unknown