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An individual who recently celebrated his 65th birthday is planning to retire from the job he has held for the last 35 years. His place of employment is providing information on how to adjust to the change in lifestyle. The industrial nurse leading the workshop is aware that if the individual does experience an adjustment disorder, it will likely be related to:
A. loss of identity and purpose.
B. concern about finances.
C. boredom from having few interests.
D. loneliness from having to spend time alone.
- A. loss of identity and purpose.
- Rationale: Identity and purpose are often associated with one's job. When one retires, loss of identity and purpose often occur, which requires adaptation. If adaptation does not occur, adjustment disorder may result. Options 2, 3, and 4 are not the most frequent causes of postretirement adjustment disorder.
A patient who has adjustment disorder with depressed mood has been given the nursing diagnosis of risk for self-directed violence. Which patient outcome would best address this diagnosis? Patient will:
A. notify nurse if he feels more depressed.
B. verbalize no suicidal ideations while hospitalized.
C. keep a journal describing any self-destructive thoughts.
D. not harm self while in the hospital.
- D. not harm self while in the hospital.
- Rationale: This "no harm" outcome is the most definitive and the most desirable of all those listed.
Which of the following questions asked by the nurse would be effective in gaining data about a patient's coping skills?
A. "Can you tell me about your family and available support system?"
B. "What has happened in your life recently?"
C. "How do you think others your age would handle this?"
D. "How have you handled events like this in the past?"
- D. "How have you handled events like this in the past?"
- Rationale: This question asks directly about the coping skills used in the past. After this lead-in the nurse can question
- further to find out how effective the coping skills were. This option is the only question that relates specifically to adequacy of coping skills.
4. Which of these actions taken by inexperienced health care professionals would block grief resolution when a patient experiences a loss?
A. Attempting to obtain detailed information about the loss
B. Feeling empathy for the patient
C. Failing to recognize cultural custom
D. Seeking assistance from the pastoral care department
- C. Failing to recognize cultural custom
- Rationale: Cultural practices dealing with grief and loss differ. Failure to incorporate
- the significance of cultural practices into the treatment plan may impede
- resolution of the patient's grieving. 1. Talking about the loss helps the
- patient come to terms with it. 2. Empathy is a helpful response. 4. Obtaining
- help from qualified persons to assist with grief resolution is valuable if the
- patient approves of their involvement.
5. Which of these observations suggests an improvement in a patient who was diagnosed with adjustment disorder with depressed mood?
A. Asking to participate with a group preparing a meal on the unit
B. Walking to the medicine room to get prn medications
C. Visiting with the minister during visiting hours
D. Attending group therapy
A. Asking to participate with a group preparing a meal on the unit
- Rationale: The desire to actively participate with others in meal preparation demonstrates that the patient is less depressed. Most depressed patients prefer solitude. 2. Use of prn medication suggests continuation of symptoms. 3. This is not an indicator of improvement. 4. Group therapy is part of the treatment program, not an optional activity.
A patient, age 54, is preparing for discharge from outpatient therapy, having
been diagnosed and treated for adjustment disorder with anxious mood. Which
statement indicates that the patient has developed an adequate strategy for
coping with the problem of disturbed sleep pattern?
A. "I know I must take a sleeping medication in order to sleep."
B. "Listening to relaxation tapes helps me get to sleep."
C. "I sleep better after I drink a small glass of wine."
D. "When I can't sleep, I will call my friend, who is always willing to listen to me."
- B. "Listening to relaxation tapes helps me get to sleep."
- Rationale: Listening to relaxation tapes indicates the patient has learned an effective method to cope with the
- problem of disturbed sleep. 1. Continued use of hypnotics is to be discouraged. 3. Use of alcohol will not improve sleep disturbance. 4. This method of dealing with sleep disturbance may cost the patient a friend.
1. Appropriate discharge criteria for a patient with chronic anxiety disorder are that the patient will:
A. Identify situations and events that trigger anxiety
B. Experience no more anxiety
C. Suppress anxiety symptoms and focus on the future
D. Recognize the need to take medications for life to control anxiety
A. Identify situations and events that trigger anxiety.
(this multiple choice question has been scrambled)
2. Which nursing diagnosis would be most useful for patients with anxiety
disorders when the following defining characteristics have been identified:
avoidance, poor concentration, nightmares, hypervigilance, exaggerated startle
response, detachment, numbing, and flashbacks?
C. Disturbed sensory perception
D. Post-trauma syndrome
- D. Post-trauma syndrome
- Rationale: Circumscribed anxiety disorders including post-trauma syndrome and rape-trauma syndrome are related to specific antecedent traumatic events. The defining characteristics given are those of post-trauma syndrome. Pervasive disorders have no clearly identifiable antecedent even and have defining characteristics that include many physiological sympathetic and parasympathetic symptoms along with behavioral, affective, and cognitive symptoms. Options 1, 2, and 3 each address only a single aspect and are therefore of limited usefulness when compared with option 4.
3. The nurse must plan health teaching for a patient with generalized anxiety disorder who is taking lorazepam (Ativan). Which topic should be included?
A. Tyramine-free diet
B. Caffeine restriction
C. Skin care to prevent breakdown
D. Dietary restriction of tryptophan
- B. Caffeine restriction
- Rationale: Caffeine is a central nervous system stimulant that acts as an antagonist to the benzodiazepine lorazepam. Daily caffeine intake should be reduced to the amount contained in one cup of coffee.
4. The patient tells the nurse he feels as though something terrible is going to happen to him and displays symptoms of increased vital signs, dilated pupils, urinary frequency, rigid muscles, and decreased hearing. The nurse would assess these findings as being indicative of anxiety at the level of:
- C. Severe
- Rationale: In severe anxiety autonomic symptoms are pronounced, and sensory perceptions are decreased because the individual has entered the fight-or-flight stage of response.
5. Which statement made by a patient who washes his or her hands compulsively identifies the thinking typical of a patient with obsessive-compulsive disorder?
A. "I know I'll get my hands clean eventually; it just takes time."
B. "I need a milder soap that won't damage my hands so much."
C. "I feel so much better when my hands are clean. I can get on to do other things."
D. "I feel driven to wash my hands, although I don't like doing it."
- D. "I feel driven to wash my hands, although I don't like doing it."
- Rationale: The individual who uses obsessive-compulsive rituals generally acknowledges that the ritualistic behavior is not constructive and that he or she does not like doing it.
6. A patient was admitted with a diagnosis of agoraphobia with panic attacks. Which of the following symptoms would the nurse expect the patient to experience during a panic attack?
C. Feigned fears
- A. Paresthesias
- Rationale: According to the DSM-IV-TR criteria, paresthesias are often present during a panic attack. 2. Diarrhea, rather than constipation is seen. 3. During a panic attack the patient is not feigning fear; the sensations are very real. 4. Hypertension would be expected.
7. A patient has a history of pain related to at least four different sites that cannot be explained by a known general medical condition. The nurse analyzes this as most closely related to the medical diagnosis of:
A. somatoform disorder.
B. pain syndrome.
C. generalized anxiety disorder.
D. obsessive-compulsive disorder.
- A. somatoform disorder.
- Rationale: These symptoms meet the DSM-IV-TR criteria for somatization disorder. 2. These symptoms are not associated with pain syndrome because there is no association with a medical condition. 3. GAD does not include complaints related to multiple organ systems. 4. Data do not support the presence of obsessions or compulsions.
8. A patient was driving an auto along a deserted country road when a moderate earthquake caused the bridge she was passing over to collapse, which inadvertently caused her to be trapped in her car for several hours. A year later she still has nightmares about the event, and reexperiences the feelings of fear and isolation associated with being trapped in the car in swirling water up to her neck. She avoids driving over bridges. She indicates that her relationships have not been "normal" since the event because she is so tense. The data collected are consistent with the symptoms of:
B. panic attacks
C. generalized anxiety disorder
D. post-traumatic stress disorder
- D. post-traumatic stress disorder
- Rationale: PTSD follows exposure to a traumatic event. Symptoms include those described in the scenario as well as persistent symptoms of arousal and avoidance of stimuli associated with the traumatic event.
9. Which piece of subjective data obtained during the nurse's psychiatric assessment of a patient experiencing severe anxiety would indicate the possibility of posttraumatic stress disorder?
A. "I keep washing my hands over and over."
B. "My legs feel weak most of the time."
C. "I'm afraid to go out in public."
D. "I keep reliving the rape."
- D. "I keep reliving the rape."
- Rationale: After a psychologically traumatic event, the person may reexperience the event via dreams or flashbacks.
10. When the nurse has diagnosed a patient as experiencing panic-level anxiety, an intervention that should be implemented immediately is to
A. teach relaxation techniques.
B. place the patient in four-point restraint.
C. reduce stimuli.
D. gather a show of force.
- C. reduce stimuli.
- Rationale: Patients experiencing panic-level anxiety are unable to focus on reality, ruling out option 1. Although the patient is completely disorganized, violence may not be imminent, ruling out options 2 and 4. Reducing stimuli is helpful because the patient is unable to screen stimuli. A simplified environment reduces demands on the patient and supports reintegration.
11. Which of the following is a criterion for evaluation of the anxiety level in patients with an anxiety disorder?
A. Ability to be assertive
B.Ability to determine appropriateness of own behavior
C.Attention span and concentration
- C.Attention span and concentration
- Rationale: The ability to concentrate and attend to reality is increased slightly in mild anxiety and decreased in moderate, severe, and panic-level anxiety. The other options are not relevant as evaluation criteria; for example, patients with anxiety disorders are often aware of the "oddness" of their symptoms. Anxiety level cannot be measured by assertiveness. Sleep pattern is not a reliable indicator of anxiety. One may have insomnia for reasons other than anxiety.
12. For planning purposes, the nurse caring for a patient with obsessive-compulsive disorder should know that an effective treatment for obsessive-compulsive disorder is
B. group therapy
- D. clomipramine
- Rationale: The medication clomipramine has been effective in reducing obsessive-compulsive behavior in a large number of patients with this disorder. The other treatment strategies have been evaluated as being less successful.
1. Which of the following interventions should the nurse incorporate in the care plan of a patient with dementia to support short-term memory?
A. Daily activity schedule
B. Activities using large muscles
C. Simple word games
D. A discussion group
- A. Daily activity schedule
- Rationale: A daily activity schedule helps remind the patient of what to do and when to do it. A written schedule helps support recent memory. Options 2, 3, and 4 are appropriate activities but do not directly address the support of recent memory.
2. A 45-year-old male has been admitted with a diagnosis of delirium of unknown etiology. The nurse would expect to assess:
A. fluctuating level of consciousness.
B. gait abnormalities.
C. apathetic affect.
D. negative thought content.
- A. fluctuating level of consciousness.
- Rationale: Disturbances of consciousness that tend to fluctuate during the course of the day are a primary symptom of delirium. The other options are not expected in delirium.
3. A patient with dementia is unable to name ordinary objects. Instead, he describes the function, for example, "the thing you cut meat with." The nurse should assess this as:
- B. agnosia.
- Rationale: Agnosia is the failure to identify objects despite intact sensory function. 1. Apraxia is the inability to carry out purposeful, complex movements and use objects properly. 3. Aphasia refers to inability to speak (expressive) or inability to comprehend what is said or written (receptive). 4. Amnesia is inability to remember a significant block of information.
4. Which of the following descriptions of patient experience and behavior can be assessed as an illusion? A patient
A. states, "I keep hearing a man's voice telling me to run away."
B. looks at the shadows on a wall and tells the nurse she sees frightening faces on the wall.
C. becomes anxious whenever the nurse leaves her bedside.
D. tries to hit the nurse when vital signs are being taken.
- B. looks at the shadows on a wall and tells the nurse she sees frightening faces on the wall.
- Rationale: An illusion is a misinterpreted sensory perception.
5. Which of the following would the nurse assess as an example of cognitive impairment?
A. Crying when the occasion calls for laughter
B. Inability to name a familiar object
- B. Inability to name a familiar object
- Rationale: Inability to name an object is called agnosia. Naming an object requires a high level of cortical functioning. Agnosia is an example of cognitive impairment.
6. An action the nurse can advise a family to take in the home setting to enhance safety for the family member with Alzheimer's disease is
A. placing throw rugs on tile or wooden floors.
B. instructing patient on cooking safety.
C. allowing patient to smoke unattended.
D. having patient wear an identification bracelet with name, address, and telephone number
- D. having patient wear an identification bracelet with name, address, and telephone number
- Rationale: Patients with Alzheimer's disease are prone to wander. If the patient wanders out of the home, an identification bracelet will facilitate his or her safe return.
7. With respect to evaluation of outcomes and goals for the patient with Alzheimer's disease, the nurse should be aware of the need for
A. changing expectations for the patient as patient abilities deteriorate.
B. identifying stressors that impact negatively on the patient.
C. simplifying the environment to reduce sensory perceptual alterations.
D. changing interventions when goals are unmet.
- A. changing expectations for the patient as patient abilities deteriorate.
- Rationale: A patient whose course of illness is predictably downward will need to have goals and outcomes correspondingly adjusted to lower levels. This is true of a patient with Alzheimer's disease. Option 1 is the only one that deals with goal and outcome planning. Option 2 deals with assessment, and options 3 and 4 deal with interventions.
8. Which of the following is an appropriate nursing intervention for a patient with dementia who develops a catastrophic reaction?
A. Employ negative responses to the behavior.
B. Use touch to communicate.
C. Eliminate or reduce environmental stimulation.
D.Maintain close personal boundaries.
- C. Eliminate or reduce environmental stimulation.
- Rationale: Reducing stimulation is calming and will allow the patient to focus his or her limited intellectual skills on regaining control. 1. Behavioral responses to the patient should be positive. 2. Touch can easily be misinterpreted as a threat. 4. Patients need increased personal space during catastrophic reactions.
9. The husband of a patient with moderately advanced Alzheimer's disease tells the nurse his wife becomes greatly distressed several times a week as she tells him she sees strangers walking around in the house. She thinks these strangers are taking her things. The nurse should advise the husband to:
A. try to talk his wife out of these ideas by using logic.
B. try diverting her by suggesting an activity.
C. search the house with her and show her that no strangers are there.
D. put locks on doors and windows to increase her sense of security.
- B. try diverting her by suggesting an activity.
- Rationale: It is important not to reinforce hallucinations or delusions. A useful strategy is to listen briefly and then attempt to divert the individual by focusing on a real activity.
10. An objective sign that frequently accompanies the subjective symptoms of delirium is:
A. reduced awareness.
B. disorganized thinking.
C. psychomotor retardation.
D. disturbed sleep-wake cycle
- D. disturbed sleep-wake cycle
- Rationale: Patients with delirium often demonstrate day-night sleep reversal. Regarding option 1, awareness fluctuates. Regarding option 2, thinking matches level of awareness, with logical alternating with illogical. Regarding option 3, psychomotor agitation is often seen as plucking at the bed sheets or nightgown.
11. Which of the following nursing techniques are appropriate for successful interaction with a patient who has been diagnosed with Alzheimer's disease
A. Giving all directions at one time to increase understanding
B. Correcting errors made by the patient by speaking to him in a loud, clear voice
C. Encouraging communication and maintaining a calm demeanor
D. Setting strict time limits and repeatedly rephrasing misunderstood questions
- C. Encouraging communication and maintaining a calm demeanor
- Rationale: These interventions will create a positive emotional climate and preserve patient self esteem. 1. Directions should be given in step-by-step fashion. 2. Activities should not be judged, and the patient should be addressed in a well-modulated voice. 4. Patients with dementia usually need increased time to perform a task, and direction should not be rephrased, only repeated.
12. The nurse notes that an elderly patient has fluctuating levels of awareness. She seems anxious. She tells the nurse she saw her granddaughter standing at the foot of the bed during the night. Later the nurse sees her moving her hands as though picking things out of the air. The nurse should suspect:
C. bipolar disorder.
- A. delirium
- Rationale: The symptoms presented are consistent with the symptoms of delirium.
13. When the nurse gives anticipatory guidance to the family of a patient with early Alzheimer's disease, which behavioral problem common to that stage of the disease should be mentioned?
A. Violent outbursts
B. Emotional disinhibition
C. Inability to carry on an in-depth conversation
D. Inability to eat and drink enough to meet body requirements
- C. Inability to carry on an in-depth conversation
- Rationale: Families should be made aware that the patient will have difficulty concentrating and following or carrying on in-depth or lengthy conversations. The other symptoms are usually seen at later stages of the disease.
1. During the nursing assessment of a patient that was newly admitted to the eating disorders unit, the nurse asks the patient, "How do you feel about being here today?" The purpose of this question is to:
A. reduce the patient's anxiety level from moderate to mild.
B. encourage the patient to communicate openly with the nurse.
C. determine the patient's willingness to engage in treatment.
D. assess the patient's level of feelings of guilt and shame.
- C. determine the patient's willingness to engage in treatment.
- Rationale: This question will give the nurse data about the patient's feelings about entering treatment. Generally, patients who are willing to become involved derive greater benefits. 1. The question will not alter the patient's level of anxiety. 2. The goal of nursing assessment is to gather specific data. 4. This question is not designed to gather this information.
2. The nurse, who works with patients who have eating disorders, is involved in teaching patients and family members about the disorder, including its symptoms and management. What is the rationale for including family in this teaching?
A. Eating disorders are usually caused by dysfunctional family interaction.
B. Knowledge promotes power and reduces fear and anxiety.
C. Family members need to learn to monitor the eating pattern of the identified patient.
D. Having an understanding of the disorder will prevent other family members from developing a similar problem
- B. Knowledge promotes power and reduces fear and anxiety.
- Rationale: Having an understanding of an illness and knowing what to expect decreases fear and anxiety and empowers patients and families to cope more effectively. 1. Eating disorders have multicausal etiology. 3. This is not a family responsibility. 4. This is no guarantee of illness prevention.
3. A patient with anorexia nervosa engages in manipulative behavior. She tells the nurse, "I can't get weighed this morning because I drank a glass of juice a few minutes before breakfast. " The best approach by the nurse would be:
A. "I'm pleased that you took in some calories."
B. "We can get around this, if you'll eat a doughnut, too."
C. "The rule is 'weigh before eating;' now we have to put it off until tomorrow."
D. "This is record weight day. Please step on the scale."
- D. "This is record weight day. Please step on the scale."
- Rationale: This response is calm, matter-of-fact and firm. The nurse is not permitting the patient to be manipulative, nor is she setting up a situation in which a power struggle is likely to arise. Option 1 praises the patient for her behavior. Option 2 is manipulative on the part of the nurse. Option 3 suggests the patient will not be weighed according to schedule.
4. The nurse is performing a physical assessment of a patient with bulimia nervosa. What assessment findings would confirm patient use of purging behaviors?
A. Sore tongue and buccal lesions
B. Enlarged parotid glands and dental erosions
C. Runny nose and reddened conjunctiva
D. Circumoral pallor and crusted nares
- B. Enlarged parotid glands and dental erosions
- Rationale: Repeated purging causes enlarged parotid glands. Dental erosions result from contact of the teeth with the hydrochloric acid of stomach fluids.
5. Which of these personality traits would the nurse evaluate as being common among individuals with eating disorders?
A. Excellent coping skills
B. Security in social relationships
D. Interoceptive deficits
- D. Interoceptive deficits
- Rationale: Individuals with eating disorders are often unable to identify and respond to bodily sensations such as hunger or fullness. 1. Individuals with eating disorders often have inadequate coping skills. 2. People with eating disorders characteristically have insecure interpersonal relationships. 3. Most persons with eating disorders are compliant individuals.
6. What behavior on the part of the nurse caring for a patient with anorexia nervosa would indicate a need for supervision?
A. Being consistent and reliable
B. Using an acceptant, nonjudgmental manner
C. Being matter-of-fact and neutral
D. Being flexible about limits for the patient
- D. Being flexible about limits for the patient
- Rationale: The nurse who does not provide consistent, appropriate limits may be compensating for feeling angry with the patient. The other options reflect desirable nurse behaviors.
7. Which of these measures should be initiated first for a new patient with anorexia nervosa who displays malnutrition, extreme weight loss, weakness, and fatigue?
A. Determining electrolyte levels
B. Placing on suicide precautions
C. Providing a nutritious meal
D. Placing on bed rest with bathroom privileges
- A. Determining electrolyte levels
- Rationale: Electrolyte imbalances are common in patients with eating disorders. Determining present electrolyte levels is necessary to planning replacement therapy. 2. No data are given suggesting suicidal ideation. 3. It is likely the patient will refuse food during the admission process. 4. Bed rest may be necessary but is not the priority for determining treatment for electrolyte replacement.
8. Nursing assessment of a bulimic patient often reveals
A. clubbing of the fingers.
D. thin, brittle hair.
- B. hoarseness.
- Rationale: Repeated vomiting may cause hoarseness. The other options are signs of anorexia and are not usually seen in bulimia.
9. When a patient with anorexia nervosa is admitted for treatment, the nurse's priority interventions will be directed toward
A. teaching assertiveness.
B. sharing information on self-help groups.
C. supervision of patient activities.
D. developing a friendship with the patient
- C. supervision of patient activities.
- Rationale: Priority interventions are those that support restoration of weight and normalization of eating patterns. This requires close supervision of the patient's eating and prevention of exercise, purging, and so forth. Options 1 and 2 are long-term treatment interventions. Option 4 is inappropriate; the relationship developed should be a therapeutic relationship.
10. While performing the assessment of a patient with the binge-purge type of bulimia, the nurse should be particularly alert for signs and symptoms of
D. fluid volume excess.
- B. hypokalemia.
- Rationale: Purging promotes excessive loss of potassium, resulting in eventual hypokalemia.
11. An early step for the nurse to take in developing the nurse-patient relationship with a patient with anorexia nervosa is:
A. recommending a therapeutic group.
B. formulating a nurse-patient contract.
C. intense confrontation to attack denial.
D. excluding the family from treatment
- B. formulating a nurse-patient contract.
- Rationale: A contract is formulated early in therapy to give the patient the opportunity to participate in treatment. This increases the patient's sense of control. By establishing contractual behavioral limits, manipulation and power struggles can be minimized.
12. When a patient with an eating disorder asks to be excused from the meal to use the restroom, the best response by the nurse would be:
A. "Only if you eat your pork chop first."
B. "Yes, we can go to the bathroom together."
C. "No one leaves the table during meals."
D. "No, I know you want to vomit and that's not permitted."
- B. "Yes, we can go to the bathroom together."
- Rationale: Close observation is necessary to prevent patients with eating disorders from purging during and after meals. Patients should be accompanied to the bathroom and observed while in the bathroom to prevent purging.
13. Which of these finding would the nurse attribute to purging?
A. Excessive facial hair
B. Elevated blood pressure
D. Dental enamel erosion
- D. Dental enamel erosion
- Rationale: Dental enamel is damaged by the acidity of the gastric contents during the purging experience. Options 1, 2, and 3 are not considered to be related to purging.
14. The priority nursing diagnosis that should be completed for a patient who restricts food and is 15% underweight is:
A. risk for injury.
B. disturbed thought processes.
C. ineffective coping.
D. imbalanced nutrition: less than body requirements.
- D. imbalanced nutrition: less than body requirements.
- Rationale: The priority diagnosis relates to a physical problem that is life threatening.
15. A behavior modification approach that would be appropriate to use with a patient with anorexia nervosa is:
A. encouraging the patient to participate in art therapy.
B. instituting a structured meal and snack plan.
C. requiring one-to-one supervision for 1 hour after meals.
D. restriction to the unit until the patient has gained 5 pounds
- D. restriction to the unit until the patient has gained 5 pounds
- Rationale: This is the only behavior modification technique listed in the options. It makes use of positive reinforcement, for example, rewarding the patient for desired behavior.
1. In planning care for a newly admitted patient with depression, the highest priority for the nurse is:
A. orienting the patient to the unit.
B. encouraging expression of feelings.
C. providing a safe environment.
D. meeting the patient at an appropriate affective level
- C. providing a safe environment.
- Rationale: Safety is the highest priority. The other interventions are appropriate but of lesser importance than this basic need.
2. Which of the following is a priority assessment for the patient with major depression?
A. Nutritional status
B. Fluid and electrolyte balance
C. Suicidal ideation
D. Mood and affect
- C. Suicidal ideation
- Rationale: Safety needs take priority over the other needs listed as options. Assess presence of suicidal ideation and determine and implement means to provide patient safety.
3. A priority nursing intervention for a patient who underwent his first electroconvulsive therapy (ECT) treatment a half hour ago would be:
A. monitoring vital signs.
B. offering oral fluids.
C. encouraging group interaction.
D. evaluating ECT effectiveness.
- A. monitoring vital signs.
- Rationale: Stabilization of the patient is the priority; therefore monitoring vital signs would be the priority intervention. Other interventions would be appropriate at varying times post-ECT. 2. Fluids can be offered after the patient awakens and is able to be up, usually within 30 minutes to an hour after treatment. 3. The post-ECT patient is typically sleepy and confused and unable to participate in group activities for an hour or more. 4. ECT effectiveness is evaluated after several treatments.
4. A 60-year-old man who comes to the health clinic for his annual flu shot tells the nurse he feels tired all the time, finds little pleasure in things anymore, and has difficulty sleeping. The best nursing intervention would be to:
A. have him remain in the clinic until evaluated by a mental health professional.
B. instruct him in how to manage these typical complaints associated with aging.
C. explore his psychiatric history and further assess his current mental status.
D. explain that this is not a psychiatric clinic and provide a follow-up referral.
- C. explore his psychiatric history and further assess his current mental status.
- Rationale: The patient is demonstrating signs of depression that the nurse should explore further. 1. The nurse should perform a basic assessment before referring. 2. These are not typical signs of aging; they are indicative of depression. 4. The nurse should perform a mental status examination before referring.
5. To plan care for a patient with severe major depressive disorder, the nurse will make it a priority to:
A. avoid creating a stressful situation by asking for patient participation.
B. assess patient cognition and ability to participate in planning.
C. include teaching about the possibility of developing mania.
D. advise the patient that electroconvulsive therapy (ECT) may be indicated.
- B. assess patient cognition and ability to participate in planning.
- Rationale: Cognition may be impaired in major depression; the patient is encouraged to participate in care planning only to the extent of his or her capabilities. 1. Patients should have input into care planning to the greatest extent possible. 3. No evidence is given that mania is a concern. 4. ECT is a collaborative intervention to be determined with the physician.
6. What characteristic usually manifested by an individual during a manic episode can be used positively as a part of nursing intervention?
B. Clang association
C. Flight of ideas
D. Poor concentration
- A. Distractibility
- Rationale: Distractibility assists the nurse to direct the patient toward more appropriate, constructive activities.
7. What can a nurse do to avoid feelings of frustration when establishing a relationship and working with a severely depressed patient? Expect the patient to
A. be receptive to the plans for nursing care.
B. be withdrawn and disinterested in a relationship.
C. show signs of improvement after several scheduled sessions.
D. show gratitude for attention
- B. be withdrawn and disinterested in a relationship.
- Rationale: A depressed person often feels undeserving of the attention of health care staff. Patients often reject the overtures of staff and appear not to respond to nursing interventions.
8. A depressed patient who is receiving a tricyclic antidepressant tells the nurse, "My mood is a little better, but I'm so sleepy all the time that I can't do much of anything." The nurse should
A. tell the patient that the sleepiness will probably wear off in about 6 weeks.
B. suggest to the physician that the medication be administered in one bedtime dose.
C. withhold the drug until the physician examines the patient.
D. perform a mental status examination on the patient.
- B. suggest to the physician that the medication be administered in one bedtime dose.
- Rationale: Many tricyclic antidepressants can be given safely in a daily single dose. The drowsiness that is so annoying by day can help the patient's sleep pattern.
9. The side effects of lithium the nurse can expect the patient to demonstrate when the serum lithium level is within the therapeutic range include:
A. extreme thirst and vomiting.
B. polyuria and fine hand tremor.
C. ataxia and orthostatic hypotension.
D. confusion, restlessness, and sleeplessness
- B. polyuria and fine hand tremor.
- Rationale: Because patients on lithium drink so much, polyuria is expected. A fine hand tremor is often present at therapeutic serum lithium levels. The other options present symptoms that are usually seen when the patient is experiencing lithium toxicity.
10. A student nurse caring for a depressed patient reads the following in the patient's medical record: "This patient clearly shows the vegetative signs of depression." What can the student expect to observe?
A. Suicidal ideation
B. Feelings of hopelessness, helplessness, and worthlessness
C. Constipation, anorexia, and sleep disturbance
D. Anxiety and psychomotor agitation
- C. Constipation, anorexia, and sleep disturbance
- Rationale: Vegetative signs of depression are alterations in body processes necessary to support life and growth.
11. Information given to a depressed patient and his or her family when the patient is begun on tricyclic antidepressant therapy should include
A. the need to avoid exposure to bright sunlight.
B. the fact that mood improvement may take 7 to 28 days.
C. instructions to restrict sodium intake to 1 g daily.
D. the need to maintain a tyramine-free diet.
- B. the fact that mood improvement may take 7 to 28 days.
- Rationale: Improvement in mood may not be noticed by the patient for 3 to 4 weeks, and the full effect may take 6 to 8 weeks. To avoid discouragement, the patient should frequently be reassured that the medication works slowly.
12. What initial nursing intervention is appropriate to take in the immediate post-electroconvulsive therapy (ECT) treatment period?
A. Place the patient in the lateral position.
B. Repeatedly stimulate the patient to respond.
C. Assist the patient to sit up, then ambulate.
D. Begin forcing fluids
- A. Place the patient in the lateral position.
- Rationale: During the immediate posttreatment period, the patient is recovering from general anesthesia. Placing patients on their side prevents aspiration in the event that the swallowing and gag reflexes are slow to return.
13. Seclusion is being considered for a severely hyperactive, aggressive manic patient. Which rationale explains the usefulness of this intervention?
A. It permits uninterrupted nursing intervention time with other patients.
B. It assists in limit setting, enabling the patient to learn to follow unit rules.
C. It is an effective way of protecting the patient until medication can take effect.
D. It provides reduction of environmental stimuli that impact negatively on the patient
- D. It provides reduction of environmental stimuli that impact negatively on the patient
- Rationale: Seclusion is used when less restrictive measures have failed to help the patient maintain control. One of its benefits is to reduce overwhelming environmental stimuli impacting on an extremely distractible individual.
14. A parameter that should be observed when planning activities for a manic patient is
A. promote group activities.
B. avoid competitive activities.
C. discourage solitary activities.
D. require attendance at the community meetings.
- B. avoid competitive activities.
- Rationale: Group and competitive activities provide more stimulation than is therapeutic for a manic patient. A quiet, nonstimulating environment is desirable.
15. A patient who lives at home and is on maintenance doses of lithium should be advised to maintain an adequate dietary intake of
- D. sodium.
- Rationale: Lithium concentration increases in the body when sodium is lost. To avoid lithium toxicity, normal sodium intake is necessary.
16. A patient who has been diagnosed with seasonal affective disorder asks the nurse, "Will I ever feel better?" The best response, based on understanding of this psychopathology, is:
A."Your low mood will probably spontaneously improve in 6 months to a year."
B."Usually people who have seasonal mood swings feel better in the spring and summer when there is more light."
C."Unfortunately, the antidepressant medications are not particularly effective in treating this disorder."
D."Most people with this disorder feel better during the fall and winter as they experience the pleasure of the holiday season."
- B."Usually people who have seasonal mood swings feel better in the spring and summer when there is more light."
- Rationale: Seasonal affective disorder is a depression occurring in conjunction with a seasonal change, most often beginning in fall and winter and remitting in spring in the northern hemisphere.
17. Based on the patient's behaviors and ideation, which of the following personality types would the nurse interviewing a patient with major depression be most likely to identify?
- D. Dependent
- Rationale: Patients with depression frequently have dependent personalities. Individuals with dependent personalities are prone to develop depression when they feel overwhelmed. 1. Egocentric personality types would be focused on self at the expense of others. 2. This personality type is seen more in patients with schizoid and paranoid disorders. 3. Narcissistic personality is seen in persons with histrionic and narcissistic disorders.
18. A patient with depression is pacing and pulling at her clothing constantly. She wrings her hands and cannot sit for longer than 5 minutes, even at meals. The nurse would document this behavior as:
B. hypomanic activity.
C. psychomotor agitation.
D. catatonic excitement.
- C. psychomotor agitation.
- Rationale: Psychomotor agitation is marked by increased, purposeless, repetitive motor activity often performed with a sense of urgency. The description of the patient's behavior is consistent with this definition.
19. Nursing care of the depressed and the manic patient are similar in that both call for
A. providing challenging group interactions.
B. limiting stimulation.
C. observation of intake and sleep pattern.
D. suicide and escape precautions.
- C. observation of intake and sleep pattern.
- Rationale: Physical needs of patients with mood disorders include being at risk for altered nutrition and altered sleep patterns. Assessment data should be routinely gathered about these possible problems.
20. A principle of value when interacting with a patient who is experiencing a manic episode is:
A. use a calm, matter-of-fact approach.
B. avoid mentioning limits.
C. do not interrupt patient.
D. encourage joking.
- A. use a calm, matter-of-fact approach.
- Rationale: A calm, matter-of-fact approach minimizes the need for the patient to respond defensively and avoids power struggles. Using this approach, the nurse conveys both control of the situation and empathy.
21. To plan effective care for a depressed patient, the nurse must be aware of what relationship between emotional pain and apathy?
A.There is no relationship.
B.Apathy produces emotional pain.
C.Extreme emotional pain causes "shut down," resulting in apathy.
D.Emotional pain produces anxiety, which, in turn, produces apathy
- C.Extreme emotional pain causes "shut down," resulting in apathy.
- Rationale: Because of their emotional pain, depressed individuals vacillate between sadness and apathy. When the pain becomes too great, patients shut down emotionally and become apathetic. Finally, apathy becomes continually present.
22. During the interview with a depressed person, it is important for the nurse to assess for impaired social interactions to determine:
A. disruptions in relationships with others.
B. need for diversional activities therapy.
C. patient ability to make decisions about care.
D. need for patient to participate in a "no-harm" contract with staff
- A. disruptions in relationships with others.
- Rationale: Assessing for impaired social interactions will give the nurse information about whether relationships with significant others are intact or disrupted. Often the depressed person has withdrawn to the extent that formerly supportive relationships have been disrupted, leaving the patient without situational support.
23. A depressed patient is admitted following a suicide attempt. She had taken an overdose of sedatives and was found by her husband. Presently she states that she is too tired to consider signing a no-harm contract and that she is angry that her spouse thwarted her attempt. What, if any, level of suicide precautions should the nurse recommend?
A. No precautions
B. Routine observation appropriate for all patients
C. Every-15-minute observation by staff
D. One-to-one continuous supervision by staff
- D. One-to-one continuous supervision by staff
- Rationale: One-to-one constant supervision is appropriate for suicidal patients who are considered at high risk: those who still have suicidal ideation, are angry that an attempt failed, refuse to participate in own care by agreeing to talk with staff before harming self, and so forth.
24. Which symptom related to disordered communication is the nurse most likely to assess in a patient who is having a manic episode?
B. Flight of ideas
C. Loose associations
- B. Flight of ideas
- Rationale: Flight of ideas is a continuous flow of speech marked by jumping from topic to topic.
25. A patient with bipolar disorder is to be discharged on a maintenance dose of lithium. The nurse plans teaching to foster compliance. Which factor will be of least consequence in developing the teaching plan?
A. Lithium side effects are unpleasant.
B. The patient enjoys feeling energetic.
C. The patient feels well and denies the possibility of relapse.
D. Auditory hallucinations tell the patient he/she is being poisoned.
- D. Auditory hallucinations tell the patient he/she is being poisoned.
- Rationale: Although manic patients may experience perceptual distortions during the early acute stage of illness, these have usually disappeared by discharge. The other factors are entirely relevant.
26. The nurse who presents a psychoeducation program to patients with bipolar disorder and their families mentions that the signs of impending relapse include:
A. sleep disturbance and racing thoughts.
B. diarrhea, thirst, and gross tremor.
C. complacency with the status quo and agreeability.
D. sense of pleasure in feeling well, optimistic outlook
- A. sleep disturbance and racing thoughts.
- Rationale: Relapse symptoms are congruent with early symptoms of a manic episode. They include sleeping less and experiencing racing thoughts and having boundless energy. Option 2 relates to lithium side effects. Options 3 and 4 are not consistent with relapse and return of manic symptoms.
1. A patient with a personality disorder told the nurse during the interview that he believes that people in general do not like him, and may even wish to harm him. This thinking can be assessed as showing evidence of the use of
- A. projection.
- Rationale: The patient with paranoid personality disorder may unconsciously use the defense mechanism projection to keep anxiety under control. The use of projection allows the individual to disown his own unacceptable feelings, attitudes, or ideas by attributing them to others.
2. A nurse wishing to assess a patient's interpersonal relationships would obtain most data by asking:
A. "How would you describe yourself?"
B. "Describe your relationship with friends."
C. "Do you have any persistent worries?"
D. "Tell me about any strange or unusual things that have ever happened to you."
- B. "Describe your relationship with friends."
- Rationale: Option 2 is the only query that pertains to interpersonal relations.
3. Which of the following would the nurse expect to observe in a patient diagnosed with schizotypal personality disorder?
A. Brief psychotic episodes in response to stress
B. Intense, stormy relationships
C. Incorrect interpretation of external events
D. Lack of tender feelings toward others
- C. Incorrect interpretation of external events
- Rationale: Incorrect interpretation of external events and a belief that all events refer to the self are typical of patients with schizotypal personality disorder. 1. This is more often seen with schizoid disorder. 2. This is more often seen with borderline personality disorder. 4. This would be seen in paranoid personality disorder.
4. Which of the following would the nurse analyze as indicating improvement in a patient with a diagnosis of high risk for self-mutilation related to feelings of abandonment and impulsivity?
A. Patient controls self-destructive impulses when feeling empty or upset.
B. Patient vows never to get involved in a close relationship again.
C. Patient expresses deep rage at the ending of a relationship.
D. Patient suppresses feelings of abandonment
- A. Patient controls self-destructive impulses when feeling empty or upset.
- Rationale: Controlling the impulse to self-mutilate or self-destruct would be indicative of improved ability to tolerate distressing thoughts. Ordinarily the patient would impulsively act out the urge. Option 2 is not a desired outcome. Option 3 does not suggest improved management of feelings. Option 4 is not a desired outcome.
5. A patient admitted for psychiatric examination ordered by the court following arrest for embezzlement from his workplace has a history of blaming others for his problems and becoming defensive and angry when criticized. He expresses no remorse for his actions, but claims his actions were justified because his company did not pay him what he is worth. The nurse would correctly determine that this patient displays symptoms most closely associated with:
A. avoidant personality disorder.
B. schizotypal personality disorder.
C. antisocial personality disorder.
D. borderline personality disorder.
- C. antisocial personality disorder.
- Rationale: Patients with antisocial personality disorder typically show no remorse and justify their actions as being right for them, despite being socially unacceptable. 1. Such a person would have difficulties with interactions. 2. This person behaves bizarrely and has few interactions with others. 4. This person has intense, angry relationships, is impulsive, and may self-mutilate.
6. When a patient demonstrates behaviors and verbalizations indicating a lack of guilt feelings, desired outcomes will be facilitated by interventions that:
A. provide external limits on patient behavior.
B. foster discussion of rationales for behavior.
C. encourage interactions with vulnerable patients.
D. require participation in activities therapies.
- A. provide external limits on patient behavior.
- Rationale: When patients are unable to determine appropriate behavioral limits, staff must set clear limits and enforce them. This ensures the safety of the patient and others. The other options are either inappropriate (2 and 3) or unrelated to the topic (4).
7. Which of the following behaviors would the nurse expect to observe while interacting with a 43-year-old woman diagnosed with narcissistic personality disorder?
A. Attention seeking
B. Empathy towards others
C. Lack of trust in others
D. Labile affect
- A. Attention seeking
- Rationale: Patients with narcissistic personality disorder are grandiose and display a constant need for admiration from others. 2. Patients with narcissistic personality disorder display little empathy. 3. It is patients with schizoid personality disorder for whom trust is a major issue. 4. Labile affect is more prominent in patients with borderline personality disorder.
8. When caring for a patient with dependent personality disorder, the behavior the nurse would positively reinforce would be:
A. choosing which outfit to wear.
B. asking another patient for advice.
C. sitting next to the nurse at community meeting.
D. concealing anger with a member of the family.
- A. choosing which outfit to wear.
- Rationale: Dependent patients find it difficult to make even simple decisions. They often ask advice; thus independently choosing her own attire is a behavior to be reinforced. The other options are behaviors that reflect dependent needs and are not desirable.
9. The problem that is most likely to occur when a nurse sets unrealistically high goals for an antisocial patient is
A. the nurse becomes frustrated and angry with the patient when goals are not met.
B. the nurse adopts various acting out behaviors used by the patient.
C. the patient's acting out behaviors intensify in response to frustration over inability to meet the expectations of others.
D. the patient experiences anger and directs it inward
- A. the nurse becomes frustrated and angry with the patient when goals are not met.
- Rationale: Change comes slowly even when appropriate goals are set with the patient. When goals are unattainable, staff become discouraged or frustrated with lack of progress. Regarding option 2, when a nurse adopts the behaviors used by an antisocial patient, it is not related to lack of progress toward goals. Regarding option 3, the antisocial patient is usually uncaring about the opinions of others. Regarding option 4, antisocial patients act out feelings, instead of turning them inward.
10. A nursing diagnosis appropriate to consider for a patient with any of the personality disorders is:
B. impaired social interaction.
C. disturbed personal identity.
D. disturbed sensory perception
- B. impaired social interaction.
- Rationale: Without exception, individuals with personality disorders have problems with social interaction with others; hence the diagnosis "impaired social interaction." For example, some individuals are suspicious and lack trust, others are dependent, still others are manipulative.
11. Which assessment would a nurse be most likely to make when working with a patient with a personality disorder?
A. Patient behavior demonstrates similarity to cultural norms for behavior.
B. Patient behavior causes little distress to self or others.
C. Patient behavior is inflexibly dysfunctional.
D. Patient seeks an intense relationship with nurse.
- C. Patient behavior is inflexibly dysfunctional.
- Rationale: Personality disorders involve lifelong, inflexible, dysfunctional, or deviant patterns of behavior causing distress to others, and in some cases, to self.
12. For which of the following behaviors would it be most essential for the nurse to use limit setting?
- D. Manipulation
- Rationale: Manipulation involves getting one's needs met at the expense of others. Because manipulation violates the rights of others, limit setting is absolutely necessary. Limit setting may be used with dependent and avoidant behavior, occasionally, but other therapeutic techniques are also useful.
13. The nurse working with a patient who has borderline personality disorder must consider in advance strategies for intervening in:
A. grief and social isolation.
B. withdrawal and social avoidance.
C. mood shifts, impulsivity, and manipulation.
D. thought disorder, grandiosity, and overreaction
- C. mood shifts, impulsivity, and manipulation.
- Rationale: Characteristic behaviors of individuals with borderline personality disorder include rapid mood shifts, impulsive acting out, manipulation of others, as well as problems with identity, dependency, self-mutilation, and unstable, intense interpersonal relationships.
14. The nurse caring for an individual with schizoid personality disorder would expect to assess:
A. impulsive, restless, aggressive behavior.
B. magical thinking and suspicious, odd behavior.
C. distrustful, cold, often angry behaviors.
D. few interactions with others and little verbalization
- D. few interactions with others and little verbalization
- Rationale: Individuals with schizoid personality disorder do not want to be involved in relationships. They are shy and introverted, speak little, and prefer fantasy and daydreaming to being involved with real people.
15. The distinguishing characteristic the nurse is likely to assess in a patient with antisocial personality disorder that is absent in most other personality disorders is:
A. exhibiting guilt and remorse.
B. responding well to neuroleptics.
C. disregarding the rights of others.
D. responding to kindly, gentle suggestions
- C. disregarding the rights of others.
- Rationale: Individuals with antisocial personality disorders have no concern for what is right or wrong or for the rights of others. They frequently violate others' rights and frequently break laws in their "Me first " thinking. These individuals exhibit no guilt or remorse, show no improvement from neuroleptics, and walk all over anyone who is not able to set firm limits.
16. When planning limit setting for a manipulative patient, which of the following steps would be omitted
A. Establishing realistic limits
B. Making sure limits are enforceable
C. Making patient aware of limits and consequences of violating limits
D. Allowing staff to use own judgment in event the patient exceeds limits
- D. Allowing staff to use own judgment in event the patient exceeds limits
- Rationale: When a plan for limit setting is established, all staff must be committed to follow the plan implicitly.
Schizophrenia or Other Psychotic Disorders
1. The nurse would evaluate that a patient who has auditory hallucinations has improved when the patient can:
A. tell the nurse what the voices say.
B. tell the voices to be quiet.
C. validate what is real.
D. do what the voices command
- C. validate what is real.
- Rationale: Improvement would be evaluated when the patient can validate with the nurse, or others, what is real. 1. Reporting what the voices say does not indicate improvement. 2. Telling the voices to be quiet is a technique for managing hallucinations and does not indicate improvement. 4. Doing as the voices command is not a sign of improvement, in fact, it can be dangerous.
2. A newly admitted patient has the diagnosis of catatonic schizophrenia. The nurse would expect to assess:
A. psychomotor symptoms.
B. intense suspiciousness.
C. inappropriate affect.
D. clanging communication
- A. psychomotor symptoms.
- Rationale: Catatonic schizophrenia is characterized by extremes of psychomotor activity ranging from frenzied behavior to immobilization and may include echopraxia and posturing. 2. Paranoid thinking is characteristic of paranoid schizophrenia. 3 and 4. Inappropriate affect and clanging are seen in disorganized schizophrenia.
3. The community mental health nurse working with a patient who has schizophrenia is meeting with the patient and family to evolve a plan of care for the patient when she leaves the hospital. The patient's mother remarks, "I get so tied up in the symptoms, that I'm afraid I'll miss noticing when progress is made." The best response for the nurse would be:
A. "We'll be setting up criteria for measuring progress."
B. "Don't worry, I'll be here to evaluate outcomes."
C. "I'll be teaching you about nursing diagnoses."
D. "Having a relative with schizophrenia is overwhelming."
- A. "We'll be setting up criteria for measuring progress."
- Rationale: This response reinforces the collaboration necessary for planning and implementing care in the community. It reassures that ongoing evaluation is part of the process. 2. This statement, meant to be reassuring, interferes with collaboration. 3. This is an unnecessary measure. 4. This statement does not address outcome measurement.
4. A patient smiles and giggles while telling the nurse, "My mother died yesterday." The nurse can make the assessment that the patient is displaying:
C. associative looseness.
D. inappropriate affect.
- D. inappropriate affect.
- Rationale: Speaking of a sad topic while laughing exemplifies inappropriate affect. 1. Autism is characterized by having little concern for external reality. 2. Ambivalence is the simultaneous presence of opposite emotions. 3. Associative looseness is characterized by stringing unrelated topics together.
5. A nurse who works in the posthospitalization clinic for patients with schizophrenia should assess each patient for signs and symptoms of impending relapse such as
A. weight gain and loss of libido.
B. loss of appetite and increased sedation.
C. increased ability to concentrate and plan.
D. difficulty sleeping and feeling tense.
- D. difficulty sleeping and feeling tense.
- Rationale: Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increase in bizarre or magical thinking.
6. A newly admitted patient is mute and immobile. The patient will hold her limbs in whatever position is imposed. This symptom would be documented as:
A. waxy flexibity.
- A. waxy flexibity.
- Rationale: A patient is said to have waxy flexibility when he/she remains for a long period of time in a position that has been imposed upon him/her.
7. A male patient with the diagnosis of paranoid schizophrenia loses control, punches the door and throws his coffee down the hallway. Which of the following actions will the nurse take to help the patient regain control?
A. Speak loudly and quickly to the patient
B. Move to within two feet of the patient
C. Keep his or her hands visible at his or her side
D. Give a detailed explanation of rules
- C. Keep his or her hands visible at his or her side
- Rationale: Keeping one's hands visible and assuming an open posture is important for defusing any patient who is threatening to lose control or who has lost control, but it is especially important if the patient is suspicious of the motives of others, as most paranoid schizophrenic patients are. 1. The nurse should speak calmly and slowly enough to be clearly understood. 2. The patient needs increased bodily space. Two feet is too close. 4. Explanations should be brief and clear.
8. Which nursing diagnosis listed below is of highest priority for a stuporous catatonic patient?
B. Impaired verbal communication
C. Ineffective denial
D. Feeding self-care deficit
- D. Feeding self-care deficit
- Rationale: Physical needs must be met to preserve life. Self-care deficit related to immobility as evidenced by inability to feed self is the priority diagnosis.
9. To establish a relationship with a severely socially withdrawn patient who has schizophrenia, the nurse should
A. sit with the patient several times a day for short periods, accept silence, state when nurse will return.
B. arrange to spend 1 hour each day with the patient, ask questions about what the patient is thinking or experiencing, avoid silences.
C. sit beside the patient, place hand on patient's arm occasionally, ask if patient would like you to leave if patient does not respond within 10 minutes.
D. sit facing the patient, tell patient that although he or she is unwilling to talk, you will read aloud from the daily newspaper to promote orientation.
- A. sit with the patient several times a day for short periods, accept silence, state when nurse will return.
- Rationale: A severely withdrawn patient should be met "at the patient's own level " with silence being accepted. Short contacts are helpful to minimize both the patient's and the nurse's anxiety.
10. A schizophrenic patient approaches the nurse and says, "The voices are bothering me. They're yelling and telling me I'm bad. Can't you hear them?" The most helpful reply for the nurse to make would be
A."Do you hear the voices often?"
B."Have you been taking your medication regularly?"
C."Forget the voices and ask some other patients to play cards with you."
D."I can't hear the voices, but I can see that you're upset."
- D."I can't hear the voices, but I can see that you're upset."
- Rationale: The nurse should honestly say that he or she does not hear the voices the patient hears. Yet, for the patient, the experience is real. Acknowledging the patient's distress encourages the patient to identify feelings associated with the experience.
11. If a patient developed extrapyramidal symptoms (EPS), the nurse would interpret this as resulting from:
A. overabundance of dopamine in the extrapyramidal system.
B. use of a low-potency, high-dosage antipsychotic.
C. dopamine depletion in response to antipsychotic medication administration.
D. high doses of antidepressant medications.
- C. dopamine depletion in response to antipsychotic medication administration.
- Rationale: Typical antipsychotic medications reduce symptoms of psychosis by blocking dopamine receptors. However, the extrapyramidal system requires sufficient dopamine for smooth motor movements. When dopamine is depleted due to medication administration, extrapyramidal symptoms result. 1. The opposite is true. 2. Symptoms are not dosage-related. 4. EPS are not commonly seen with use of antidepressant medications.
12. The parents of a 17-year-old who has been diagnosed with schizophrenia ask the nurse what the future will be like for their child. The nurse's answer should be predicated on knowledge that the course of the illness is usually:
A. a steady, downward decline.
B. positive following recovery from the first episode.
C. characterized by alternating acute and stable phases.
D. totally different for each individual patient.
- C. characterized by alternating acute and stable phases.
- Rationale: Most patients with schizophrenia experience alternating acute and stable phases throughout life. Complete and permanent remission is rare.
13. A patient has received standard antipsychotics for a year. His hallucinations are less intrusive, but the patient remains apathetic, has poverty of thought, cannot work, and is socially isolated. To address these symptoms, the nurse might expect the psychiatrist to prescribe
- B. olanzapine.
- Rationale: Olanzapine is an atypical antipsychotic that targets both positive and negative symptoms of schizophrenia. Options 1 and 4 are standard antipsychotics that target only positive symptoms. Option 3 is an antihistamine.
14. Interventions a nurse would implement when caring for a patient who has paranoid schizophrenia with poor ego boundaries include
A. staying physically close during interactions.
B. touching the patient often.
C. prolonged interactions.
D. eliminating physical contact.
- D. eliminating physical contact.
- Rationale: Having personal space invaded intensifies anxiety, which in turn causes increased ego boundary problems.
15. A patient displays disorganized, difficult-to-understand speech, behavioral disorganization, and a silly, inappropriate affect. The patient prefers to sit alone and be uninvolved in unit activities, and often appears to be listening and responding to unseen stimuli. The nurse assesses that this patient's behavior most closely conforms to the characteristic behavior of:
- C.disorganized schizophrenia.
- Rationale: The presence of disorganization and inappropriate affect characterizes the disorganized type of schizophrenia.
16. A young patient with schizophrenia is standing in his pajamas next to the shower. The nurse observes that he seems dazed and indecisive. The most helpful nursing intervention would be to say:
A. "It's time for you to take your shower."
B. "Take off your pajamas and step into the shower."
C. "Is something the matter?"
D. "Why are you waiting to get into the shower?"
- B. "Take off your pajamas and step into the shower."
- Rationale: Preoccupied patients or patients who have cognitive dysfunction may have problems with executive functioning. They may be unable to determine what to do even in simple situations. When this occurs, they require simple, concrete directions.
17. A patient with schizophrenia who has been hospitalized for 3 days is observed to be anxious and delusional. How can the nurse intervene to help the patient focus less on the delusions?
A. Arrange time for patient to read and listen to music.
B. Plan activities that require mental concentration.
C. Engage in noncompetitive physical or craft activity.
D. Discuss patient's goals for improved functioning
- C. Engage in noncompetitive physical or craft activity.
- Rationale: Engaging in a physical activity of some sort will help distract the patient and shift focus to something reality oriented. Making sure the activity is noncompetitive will reduce anxiety. 1 and 2. The patient can remain focused on delusions while appearing to be reading, listening to music, or engaged in "concentrating" on some other activity such as a crossword puzzle. 4. It may be too soon to discuss personal goals if the patient is fully focused on delusions.
18. A patient who has been diagnosed as having paranoid schizophrenia is highly suspicious and delusional. He hears voices telling him terrorists are plotting to assassinate him. He refuses to eat, saying the food is poisoned. The nursing response that best addresses his needs when he tells the nurse about his delusion would be:
A. "How is it that you are so important that terrorists want to kill you?"
B. "Your thinking is distorted because your brain chemicals are out of balance."
C. "Your story is so fantastic that I cannot believe it's true."
D. "It must be frightening to think you are being targeted."
- D. "It must be frightening to think you are being targeted."
- Rationale: This option focuses on the feelings the patient may be experiencing, rather than the content of the delusion. It is empathetic and fosters rapport and trust. Option 1 is challenging and anxiety-provoking and would cause the patient to cling to the delusion. Option 2 would be dismissed by the patient, who does not believe he is ill. 3. Because this statement is challenging, the patient would probably respond defensively or will simply ignore the speaker, who he will believe doesn't care to understand.
1. A patient who is a pedophile tells the nurse that he is feeling a huge amount of guilt and shame over molesting a child. He is concerned about the impact on his family and states that the family would be better off without him. The nurse should:
A. explore feelings in greater depth.
B. set limits on patient disclosure.
C. consider instituting suicide precautions.
D. provide prn anxiolytic medication.
- C. consider instituting suicide precautions.
- Rationale: Patients who describe guilt, shame, and the idea that others would be better off without them are at risk for suicide. The nurse should report the data and the assessment and institute suicide precautions.
2. Which question would be preferable to ask at or near the beginning of the interview with a patient diagnosed as having sexual dysfunction?
A. "Is there a family history of sexual dysfunction?"
B. "Were you sexually abused as a child or adolescent?"
C. "What makes you think you have a sexual dysfunction?"
D. "Why did you come for treatment at this time?"
- D. "Why did you come for treatment at this time?"
- Rationale: This question is the least threatening of those listed as options. The principle is that one begins by seeking background information; then, as patient comfort increases, the nurse may seek more specific information about sexual concerns.
3. While a nurse is volunteering at a soup kitchen, she observes a known pedophile leaving the bathroom with a small child while the others are eating. The nurse's responsibility in this situation is:
A. as a mandated reporter, the nurse must report the incident to the authorities.
B. to protect the child without involving self with the perpetrator.
C. to let the staff of the soup kitchen handle the situation.
D. to avoid jumping to conclusions by watching and waiting.
- A. as a mandated reporter, the nurse must report the incident to the authorities.
- Rationale: In every state nurses are mandated reporters of child abuse. The nurse is obligated legally and morally to report the incident so proper authorities can follow up.
4. A patient has been diagnosed with gender identity disorder. The characteristic assessment find the nurse would expect is:
A. discomfort with biological sex.
B. an intense sexual urge focused on an object.
C. compromised sexual response cycle.
D. need to humiliate partner during sex.
- A. discomfort with biological sex.
- Rationale: An individual with gender identity disorder feels trapped in a body of the "wrong" sex and at odds with the roles associated with that gender.
5. A 56-year-old man has been feeling great tension since losing his job. He leaves home one morning, and while sitting in the park feeding birds, impulsively publicly exposes himself to a group of mothers and children. This behavior should be assessed as:
- Rationale: Exhibitionism is obtaining sexual pleasure from exposing one's genitalia to unsuspecting strangers.
6. The nurse manager is interviewing nurses to staff a unit that will admit and treat patients experiencing sexual dysfunction. Which qualification would be most important for a nurse working with this specific group to have?
A. Previous experience working with individuals with sexual dysfunction
B. A keen awareness of personal feelings about sexuality
C. The belief that all types of sexual dysfunction can be corrected
D. Understanding that the prognosis for most sexual dysfunction disorders is guarded
- B. A keen awareness of personal feelings about sexuality
- Rationale: The nurse who is aware of his or her personal feelings and views about sexual issues can assist a patient with a sexual disorder. Lack of clarity about one's feelings and views clouds the nurse's focus. 1. Previous experience may prove to be helpful, but is not the most important qualification. 3. Thinking that all types of sexual dysfunction can be corrected is unrealistic. 4. Thinking that the prognosis for most sexual dysfunction disorders is poor shows lack of information.
7. The physician mentions to the nurse that a patient is "an ego-syntonic pedophile." The nurse understands that the statement that best expresses the feelings of an ego-syntonic pedophile is:
A. "I know what I do is wrong, but I am comfortable the way I am."
B. "Being this way makes me so miserable that I want to get help."
C. "If parents supervised their children more closely, molestation would stop."
D. "I decided on my own that I needed help. No one sent me here."
- A. "I know what I do is wrong, but I am comfortable the way I am."
- Rationale: An ego-syntonic pedophile is cognitively aware that the behavior is inappropriate, but is not troubled by it and shows no remorse. Options 2 and 3 suggest the pedophile's behavior is ego-dystonic, that is, unacceptable to the ego. Option 4 uses rationalization.
8. A patient seen in outpatient therapy described symptoms indicative of scatologia. He acknowledges that he has a problem and asks for help in avoiding a repeat of these behaviors. Which information should be included in the patient's teaching plan?
A.Triggers must be identified that provoke the inappropriate behavior.
B.Making obscene phone calls relates to his hatred of women.
C.The obscene message is generally not a problem to the receiver of the call.
D.The etiology of this disorder is usually related to dysfunctional parenting.
- A.Triggers must be identified that provoke the inappropriate behavior.
- Rationale: The patient must come to recognize what triggers the occurrence of making obscene phone calls. When triggers are recognized, the patient can employ strategies to help him substitute healthier behaviors. No data are available to support options 2, 3 and 4.
9. A couple is in marriage counseling for the initial visit because of the husband's decreased interest in an intimate relationship with his wife. He admitted that his job is a constant source of worry and that he feels "tied in knots all the time." They admit that any mention of sex results in a verbal battle. Which of these patient outcomes is realistic for this initial session?
A.The husband will be able to focus on body feelings during intimacy rather than anxiety.
B.Both partners will express their perception of the problem in the presence of the therapist.
C.Both partners will discuss job concerns creating stress in their lives and strategies for change.
D.The wife will talk openly about her feelings of inadequacy.
- B.Both partners will express their perception of the problem in the presence of the therapist.
- Rationale: Learning how each party views the problem will be essential to helping them. 1. Sensate focusing is a premature outcome at this time. 3. Discussion concerning stress and strategies for change will take place at a future session. 4. Talking openly about feelings of inadequacy is too sensitive for an initial outcome.
10. A new staff nurse tells the clinical nurse specialist, "I'm unsure about my role when patients bring up sexual problems." The clinical nurse specialist should give clarification by saying, "All nurses
A. qualify as sexual counselors. Each has knowledge about the biopsychosocial aspects of sexuality throughout the life cycle."
B. should be able to screen for sexual dysfunction and give basic information about sexual feelings, behaviors, and myths."
C. should defer questions about sex to other health care professionals because of their limited knowledge of sexuality."
D. who are interested in sexual dysfunction can provide sex therapy for individuals and couples."
- B. should be able to screen for sexual dysfunction and give basic information about sexual feelings, behaviors, and myths."
- Rationale: The basic education of nurses provides information sufficient to qualify the generalist to assess for sexual dysfunction and to perform health teaching. Taking a detailed sexual history and providing sex therapy requires additional training in sex education and counseling.
11. The patient's medical record documents the diagnosis of sexual masochism. The nurse understands this to mean the patient derives sexual pleasure:
A. from inanimate objects.
B. when sexually humiliated by a partner.
C. from inflicting pain on a partner.
D. from touching a nonconsenting person.
- B. when sexually humiliated by a partner.
- Rationale: Sexual masochism is sexual pleasure derived from being humiliated, beaten, or otherwise made to suffer.
12. As nurses perform screening assessments of sexual function or dysfunction, which problem will be seen as the most frequently occurring
C. Sexual aversion disorder
D. Hypoactive sexual desire disorder
- D. Hypoactive sexual desire disorder
- Rationale: Lack of sexual desire is the most common disorder seen among couples requesting sex therapy.
Somatoform & Dissociative Disorders
1. The nurse assessing a patient with a somatoform disorder will probably note that the
A. verbalizes emotional needs easily.
B. denies the need for anxiolytic medication.
C. assumes increasing responsibility within the family.
D. exaggerates or misinterprets physical symptoms
- D. exaggerates or misinterprets physical symptoms
- Rationale: The patient has an unconscious need to focus on physical symptoms in order to feel more comfortable.
2. Which intervention should the nurse select to help a patient with chronic pain disorder cope more effectively?
B. Relaxation techniques
C. Response prevention
D. Systemic desensitization
- B. Relaxation techniques
- Rationale: Pain is increased when the patient experiences muscle tension. Relaxation can diminish the patient's perceptions of the intensity of pain.
3. Select the nursing diagnosis that could be developed for the patient with a somatoform disorder who has little energy to expend on activities or interactions with friends.
A. Self-care deficit
B. Impaired social interaction
C. Ineffective coping
D. Disabled family coping
- B. Impaired social interaction
- Rationale: When patients focus their psychic and physical energy on somatic symptoms, they have little energy to expend on social or diversional activities. Such a patient needs nursing assistance to become involved in social interactions.
4. The spouse of a patient who has hypochondriasis tells the nurse, "I'm at my wit's end. Just when I think we're on sound financial ground, he gets sick and takes time off. I work a full time and a part-time job and do all the work at home as well as taking care of him." Based on this data, the nurse should consider the nursing diagnosis
A. Defensive coping
B. Ineffective denial
C. Decisional conflict
D. Caregiver role strain
- D. Caregiver role strain
- Rationale: The caregiver is feeling and expressing difficulty in performing the family caregiver role. Data are not present to suggest the other options.
5. The nurse who is addressing memory problems with a patient with a dissociative disorder can be most effective if he or she:
A. reorients the patient to time, place, and person at every contact.
B. observes for cues that the patient is ready to receive information.
C. instructs the patient not to be overly concerned with memory loss because no organic pathology exists.
D. tells the patient of the events surrounding the memory loss at the initial therapy session.
- B. observes for cues that the patient is ready to receive information.
- Rationale: The patient's memory loss serves a protective function for the patient. He or she should not be forced to give it up too quickly. Patients usually provide clues to readiness.
6. An assessment question a nurse might ask to help identify secondary gains is:
A. "What can't you do now that you were formerly able to do?"
B. "How many doctors have you seen in the last year?"
C. "Whom do you talk to when you're upset?"
D. "Did you suffer abuse as a child?"
- A. "What can't you do now that you were formerly able to do?"
- Rationale: Option 1 will help the nurse see how the disorder has affected the patient's life and may provide clues to "payoffs" the patient is receiving by virtue of assuming the sick role.
7. The husband of a patient who has been diagnosed with dissociative identity asks the nurse if he is in any way at fault for his wife's illness. The nurse's reply should be predicated on the knowledge that dissociative identity disorder is thought to be related to:
A. faulty learning.
B. severe childhood trauma.
C. genetic predisposition.
D. intentional production of symptoms
- B. severe childhood trauma.
- Rationale: Many authorities believe dissociative identity disorder is a coping mechanism resulting from severe childhood trauma, usually sexual or physical, in which the child develops other personalities to deal with pain, fear, or danger.
8. In order to assist a patient with a somatoform disorder to increase self-esteem, an appropriate nursing intervention would be to:
A. focus attention on the patient as a person rather than on the symptom.
B. encourage the patient to use avoidant interactional patterns rather than assertive patterns.
C. set large goals so the patient can see positive gains.
D. discuss the patient's childhood to link present behaviors with past traumas.
- A. focus attention on the patient as a person rather than on the symptom.
- Rationale: Focusing on the patient directs attention away from the symptom. This approach eventually reduces the patient's need to gain attention via physical symptoms. 2. Assertive communication raises self-esteem. 3. Small goals insure success and reinforce self-esteem.4. This intervention has no bearing on self-esteem.
9. The symptom the nurse can expect a patient with dissociative fugue to manifest is:
A. the notion that some part of the body is ugly or disproportionate.
B. a feeling of detachment from one's body.
C. worry about having a serious disease.
D. travel away from home and assumption of a new identity.
- D. travel away from home and assumption of a new identity.
- Rationale: Dissociative fugue involves unplanned travel away from one's usual quarters and either confusion about identity or assumption of a new identity. The person does not seem to be wandering, but behaves purposefully. Option 1 relates to body dysmorphic disorder. Option 2 relates to depersonalization disorder. Option 3 relates to hypochondriasis.
10. Which nursing diagnosis might the nurse wish to explore and possibly establish for a patient with hypochondriasis?
B. Ineffective denial
C. Decisional conflict
D. Deficient diversional activity
- D. Deficient diversional activity
- Rationale: Most patients who are focused on their physical symptoms ignore other aspects of life. Rarely do they engage in diversional activity, a need if the patient's life is to regain balance.
11. When working with a patient who has dissociative amnesia, the nurse should plan to begin by:
A.taking measures to prevent identity diffusion.
B.setting mutual goals for behavioral changes.
C.helping the patient develop a realistic self-concept
D.identifying and supporting patient strengths.
- D.identifying and supporting patient strengths.
- Rationale: Strengths serve as the foundation for later therapeutic work to promote more adaptive coping; thus identifying and supporting strengths is a fundamental initial intervention.
12. A principle that should be applied when providing care for a patient with conversion disorder is:
A. give attention to the patient, not the symptom.
B. structure care to provide time for rituals.
C. facilitate progressive review of the trauma.
D. permit dependence while symptom is present
- A. give attention to the patient, not the symptom.
- Rationale: Often patients with conversion disorder think that their symptom makes them interesting and that they are not interesting as persons. The nurse should matter-of-factly accept the symptom without focusing on it and direct attention to the person as an individual. Option 2 refers to care of a patient with OCD. Option 3 refers to care of a patient with PTSD. Option 4 is undesirable.
Substance Related Disorders
1. The nurse is working with a 40-year-old male patient diagnosed with chronic alcoholism and his wife. The wife describes how she has cut off all outside relationships over the past 20 years while focusing her life on trying to help her husband remain sober. Based on this, the nurse assesses the wife's behavior as an indication of:
- A. enmeshment.
- Rationale: Enmeshment refers to lack of differentiation. Enmeshed individuals have diffuse boundaries and describe living for the other individual, as the wife did in this scenario. 2. This description of the wife's behavior goes beyond normal concern. 3. The wife may consider herself a martyr, but the nurse will assess this as enmeshment. 4. This behavior does not fit the definition of introversion.
2. Milieu management for a patient who has ingested a hallucinogen should create an environment that is:
A. simple and safe.
B. active and noisy.
C. stimulating and colorful.
D. confrontive and challenging
- A. simple and safe.
- Rationale: Since the individual who has ingested a hallucinogen is probably experiencing feelings of unreality and altered sensory perceptions, the best environment is one that does not add to the stimulation. A simple, safe environment is a better choice than an environment with any of the characteristics listed in the other options. Options 2 and 4 especially would contribute to a "bad trip."
3. The probable occurrence of withdrawal symptoms in a patient with a history of long-term alcohol abuse is most accurately assessed by determining:
A. the blood alcohol level at the time of admission.
B. drinking history, quantity consumed, and time of last drink.
C. experiences following previous cessation of drinking.
D. the kind of alcoholic beverage last consumed
- B. drinking history, quantity consumed, and time of last drink.
- Rationale: This data will provide the best estimate of the likelihood of withdrawal and the time at which withdrawal symptoms are likely to occur. Option 1 relates to degree of intoxication. Option 3 could be useful information but is only retrospective and unrelated to the current situation. Option 4 is not particularly useful.
4. A patient who has been clinically depressed for the past year has responded poorly to antidepressants. The statement that would be of greatest concern relative to the development of dual diagnosis is:
A."My life has lost all its color and pleasure."
B."I can't take it anymore. I'm going to end it."
C."When I drink things look better, and I feel almost human."
D."I can't seem to get any work done. I'm always so tired."
- C."When I drink things look better, and I feel almost human."
- Rationale: The individual has the mental disorder diagnosis at present. For dual diagnosis the individual must have a substance-related problem. Option 3 suggests that drinking is becoming attractive, putting her at high risk for dual diagnosis. The other options relate to the depression.
5. The community mental health nurse is conducting a community health education series on substance abuse. Which of the following descriptions of abuse or addiction should the nurse plan to include?
A. Abuse and addiction are interchangeable terms.
B. Abuse is characterized by physical dependence, whereas addiction is characterized by psychologic dependence.
C. Both abuse and addiction are disease entities with severe withdrawal symptoms.
D. Addiction is characterized by both psychological and physiological withdrawal symptoms
- D. Addiction is characterized by both psychological and physiological withdrawal symptoms
- Rationale: This is an accurate description of addiction, whereas abuse refers to misuse of a substance leading to problems in psychological, biological, cognitive/perceptual or spiritual/belief dimensions of life. The terms in option 1 are not interchangeable. Options 2 and 3 give inaccurate information.
6. A patient with severe and persistent paranoid schizophrenia and crack abuse tells the nurse, "I don't think I'll ever get straight. Maybe I don't even want to. Being schizophrenic is such a drag. The voices are such downers, always insulting and berating me, but when I use crack, I like the good feeling I get." The nursing diagnosis the nurse should consider is:
A. spiritual distress related to separation from religious ties.
B .risk for violence related to poor impulse control.
C. impaired adjustment related to failure to intend to change behavior.
D. disturbed thought process related to use of mind-altering drugs
- C. impaired adjustment related to failure to intend to change behavior.
- Rationale: Data are present to suggest that the patient does not intend to change his abuse of cocaine, making option 3 an appropriate nursing diagnosis. Data are not present to suggest any of the other options.
7. A patient asks the nurse, "How would I know if I were dependent on alcohol?" The nurse should respond by telling her that dependence is defined by:
A. a compulsion to use the drug.
B. a loss of control over use of the drug.
C. a physiological need to use the drug.
D. continued use despite adverse consequences
- C. a physiological need to use the drug.
- Rationale: Dependence is marked by physiological need for the substance. The other options refer to psychological need.
8. Indicators that would support the nurse's suspicion that a patient has been using inhalants are:
A. perforated nasal septum and hypertension.
B. drowsiness, euphoria, and constipation.
C. confusion, mouth ulcers, and ataxia.
D. pinpoint pupils and respiratory rate 12
- C. confusion, mouth ulcers, and ataxia.
- Rationale: Inhalants are usually CNS depressants, giving rise to confusion and ataxia. Mouth ulcers come from the irritation of buccal mucosa by the inhalant.
9. During the admission interview, a patient mentions to the nurse that he had increased the amount of oxycodone because the smaller dose "just wasn't doing it for me anymore." The nurse assesses this phenomenon as resulting from:
- A. tolerance.
- Rationale: Tolerance, the physiological adaptation to the effect of a drug resulting in needing more of the substance to gain the desired effect, develops quickly in opioid use.
10. At a meeting for family members of alcoholic individuals, one woman describes trying her best to help her husband keep his job by calling the employer and lying when her husband was too intoxicated to go to work. The nurse assesses this behavior as:
C. role reversal.
- B. codependent.
- Rationale: Codependence refers to participating in behaviors that maintain the addiction or allow it to continue without holding the user accountable for his/her actions.
11. The optimal time in the continuum of care to begin group therapy for a patient with dual diagnosis is:
A. during inpatient treatment.
B. at the point of transfer to outpatient treatment.
C. never, as group therapy is not effective for patients with dual diagnosis.
D. when the patient has successfully completed withdrawal from the substance of choice
- A. during inpatient treatment.
- Rationale: In a therapeutic milieu, much of the therapy is undertaken in groups. If the patient does not attend inpatient groups, he/she will miss education about substances, mental illness, and medication at a minimum.
12. Which goal for treatment of alcoholism is primary?
A. Develop alternate coping strategies.
B. Learn about dependence and recovery.
C. Achieve physiological stability.
D. Develop a peer support system
- C. Achieve physiological stability.
- Rationale: The individual must have completed withdrawal and achieved physiological stability before he/she is able to address any of the other treatment goals.
13. A patient admitted for treatment of pneumonia has a history of substance abuse. Twenty-four hours after admission he exhibits tremulousness, anorexia, hypertension, and confusion. The nurse analyzes these symptoms as being indicative of:
A. acute intoxication.
B. delirium tremens.
C. alcoholic hallucinations.
D. Wernicke-Korsakoff syndrome
- B. delirium tremens.
- Rationale: These signs of alcohol withdrawal syndrome are called delirium tremens. The patient may demonstrate withdrawal symptoms beginning 24 to 72 hours after his last drink. The other options are unrelated to alcohol withdrawal.