Psychotic Disorder Practice Exam/Test (1-12)

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1. Which medication is most likely to be prescribed for an outpatient with a diagnosis of chronic undifferentiated schizophrenia and a history of medication noncompliance?

a) chlorpromazine (thorazine)
b) imipramine (tofranil)
c) lithium carbonate (lithane)
d) fluphenazine decanoate (prolixin decanoate)

2. A patient's medication order reads: "Thioridazine (mellaril) 200 mg orally four times a day and 100 mg orally as needed." Based on this order, the nurse should:

a) administer the medication as prescribed
b) question the physician about the order
c) administer the order for 200 mg orally four times a day but not for 100 mg orally as needed
d) administer the medication as prescribed but closely observe the patient for adverse effects

3. The extrapyramidal effects associated with antipsychotic agents can be controlled by which medication?

a) perphenazine (trilafon)
b) doxepin ( sinequan)
c) amantadine (symmetrel)
d) clorazepate dipotassium (tranxene)

4. Which non-antopsychotic medication is used to treat some patients with schizophrenia disorder?

a) phenelzine sulfate (nardil)
b) chlordiazepoxide (librium)
c) lithium carbonate
d) imipramine

Situation: T.S., a19 year old sophomore, walks into the college health center and asks to speak with a counselor or therapist. For the past month, she has been having difficulty concentrating, and her grades have declined because of this. She finds herself daydreaming, lost in her own thoughts, and feeling out of it both in class and out.
5. The nurse prepares to conduct the patient interview and initial evaluation. How should she begin?

a) hello, T., I'm R.N., a nurse here at the health center. I need to learn more about you and your reasons for coming in. Then we'll discuss how the health center can help you
b) Hi, T. My name is R. Why don't we sit and chat for awhile. How can I help you?
c) Ms. S., I'm the nurse assigned to interview you. If necessary, the psychiatrist also will evaluate you today. Otherwise, you'll see him another time
d) Ms. S., I'm Mrs. N., a nurse. You mentioned that you feel out of it. Can you tell me more about this?

6. T. begins to tell the nurse about herself. Which statement indicates possible difficulties in relating to others?

a) I miss my parents and friends at home very much and feel homesick
b) I have only two close friends at college and consider myself a shy person
c) my roommate at college is all right, but I don't consider her a shy person
d) I consider myself a loner and prefer reading and studying to going out and socializing

7. In recounting her family history, T. suddenly begins crying and says. "My mother was schizophrenic. She was in and out of the hospital for years. That's not what's wrong with me, is it?" The nurse should respond by saying:

a) what makes you think you're schizophrenic like your mother?
b) it's really too soon to tell, but heredity may play a role in schizophrenia
c) schizophrenia is a chronic illness, and since this is the first time you're having a problem, I doubt if you're schizophrenic
d) I'm not yet sure what your problem is

8. When T. returns to the health center 1 week later, she tells the nurse that she is not sure whether anything can be done to help her. How should the nurse respond?

a) you certainly are down in the dumps. You must have had a lousy week
b) I wish you would give us a chance. We really do have an excellent staff here
c) let's talk about the reasons you seem to be feeling so hopeless right now
d) that is a very self-defeating attitude. You can't be helped unless you want to be

9. T. tells the nurse that she feels she cannot handle her schoolwork. Her grades have gone from A's and B's to C's, and she even may be failing a course. T. asks the nurse if she should withdraw from all her classes. Which response is most helpful?

a) do you really think withdrawing from all your classes would be best right now?
b) we can discuss the choices you have and the pros and cons of each
c) I think you should discuss this with your professors before making such a decision
d) if you are feeling so overwhelmed by the demands of your classes, that might be the best thing to do

10. During one of her sessions with the nurse, T. mentions that her roommate borrowed her favorite dress without asking and then ruined it by spilling grease on it. She describes this episode in a matter-of-fact way and denies feeling angry about the incident. Then she adds, "I rarely get angry at anyone." To explore the patient's feelings, the nurse should say:

a) you are very nice person to feel angry about having your best dress ruined like that
b) I can't believe you aren't angry or at least annoyed by your roommate behavior. Why don't you level with me
c) I think I'd be angry about something like that. What were your thoughts when you first found out about it?
d) You know anger is a normal response to events like that. tell me how you really feel about what she did

11. T. eventually is able to admit that she was somewhat annoyed by her roommate's actions and recognizes that she feels uncomfortable getting angry even when she probably should. Which initial patient goal is most appropriate?

a) the patient will express her anger to her roommate regarding the ruined dress
b) the patient will be able to ask her roommate to replace the damaged dress
c) the patient will begin to identify and discuss with the nurse events that arouse her feelings of anger
d) the patient will demonstrate that she has learned to repress her angry feelings

12. T. continues her weekly sessions at the health center. She does not exhibit any psychotic symptoms, and her primary difficulties involve establishing and maintaining relationships with others and denying her anger. A medical diagnosis of personality disorder is considered. Based on the above symptoms and her knowledge of the disorder, the nurse would suspect the patient to have which type of personality disorder?

a) schizoid
b) schizotypal
c) borderline
d) antisocial


1) D
- fluphenazine decanoate (prolixin decanoate) is a long-acting ant-psychotic agent given by injection. Because it has a 4-week duration of action, fluphenazine is commonly prescribed for outpatients with a history of medication noncompliance. The antipsychotic agent chlorpromazine (thorazine) must be administered daily to maintain adequate plasma levels, which necessitates compliance with the dosage schedule. Imipramine (tofranil), a tricyclic antidepressant, and lithium carbonate (lithane), a mood stabilizer, are generally not used to treat patients with chronic schizophrenia.

2) B
- the nurse must question this order immediately. Thioridazine (mellaril) has an absolute dosage ceiling of 800 mg/day. Any dosage above this level places the patient at high risk for toxic pigmentary retinopathy, which cannot be reversed. The order, as written, allows for administering more than the maximum 800 mg/day; it should be corrected immediately, before the patient's health is jeopardized.

3) C
- Amantadine (symmetrel) is an anticholinergic drug used to relieve drug-induced extrapyramidal adverse effects, such as muscle weakness, involuntary muscle movement, pseudoparkisonism, and tardive dyskinesia. Other anticholinergic agents used for extrapyramidal reactions include benzotropine mesylate (cogentin), trihexyphenidyl (artane), biperiden (akineton), and diphenhydramine (benadryl). Perphenazine is an antipsychotic; doxepin, an antidepressant; and chlorazepate, an antianxiety agent. Because these medications have no anticholinergic or neurotransmitter effects, they do not alleviate extrapyramidal reactions.

4) C
- lithium carbonate, an antimania drug, is used to treat patients with cyclical schizoaffective (a psychotic disorder once classified under schizophrenia that produce affective symptoms, including maniclike activity). Lithium helps control the affective component of this disorder. Phenelzine sulfate (Nardil) is a monoamine oxidase inhibitor prescribed for patients who have not responded to other antidepressant drugs, such as imipramine. Chlordiazepoxide (librium), an antianxiety agent, is generally contraindicated in psychotic patients. imipramine, primarily classified as an antidepressant agent, also is used to treat patients with agoraphobia and those undergoing cocaine detoxification.

5) A
- each interview should begin with a clear statement of introduction that defines the purpose of the interview. Because the patient has come to the health center for the first time, informality, use of first names only, and an inviting to sit and chat are inappropriate. Also inappropriate are introductions with last names only, using clinical terminology, and abruptly mentioning the psychiatrist; this type of introduction is cold and distancing. Only after the nurse has introduced herself, defined her role, and told the patient what to expect from the interview should she begin exploring the patient's problem.

6) D
- the patient's self-description as a loner who prefers solitary activities, such as reading and studying, over socializing clearly suggests that she may be having difficulty relating to others. Shy persons who have established and maintained relationships may desire additional social skills but usually can relate meaningfully to others. Feeling homesick and missing family and friends is not unusual or abnormal; neither is not liking everyone.

7) A
- the nurse should explore the basis for T.'s fear that she may be schizophrenic because her response can provide clues to her current difficulties and self-concept. Once the nurse understands the patient's thoughts and feelings, she can better respond to her question. Although it is true that a diagnosis cannot yet be made and that heredity may be a factor in schizophrenia, giving the patient this information would probably not be helpful and does not encourage the patient to express concerns. Although schizophrenia is a chronic illness, the patient is in a vulnerable age-group (ages 15 to 35) for the onset of the disease. The nurse should not consider the patient schizophrenic until more data are obtained and the physician makes a positive diagnosis.

8) C
- by reflecting T.'s apparent hopelessness and inviting her to discuss her feelings, the nurse provides an opportunity for the patient to explore her perception of the situation. Acknowledging that T. is down in the dumps and attributing this to lousy week tells rather than asks the patient how she feels. Lecturing T. about how good the staff are or how her negative attitude will impede her progress denies her feelings and is judgmental and nontherapeutic.

9) B
- the nurse's role is to assist the patient in exploring and evaluating alternatives -- not to tell the patient what she thinks is best. Encouraging her to discuss the alternatives and helping her evaluate them promotes the patient's growth. Judgmental responses, such as "Do you really think..." or "I think you should..." belittle the patient by implying that the nurse knows best. These responses also fail to encourage the patient to explore all the possible choices. The nurse should not agree with the patient's decision until the situation has been discussed and understood.

10) C
- using self-disclosure in response to T.'s situation shows that the nurse emphatizes with the patient and relays that the negative feelings are acceptable. By encouraging the patient to discuss her thoughts, the nurse seeks to release T.'s underlying feelings. Promoting T.'s denial of anger by telling her that she must be a nice person is not helpful. Confrontational approaches, such as "Level with me" and "Tell me how you really feel," would put T. on the defensive and inhibit her expression of feelings.

11) C
- T. needs to learn that it is acceptable to express her anger before she learns to talk about her feelings. The nurse is a safe, supportive person with whom T. can begin this process. Once the patient can admit her feelings to herself, she can begin expressing them more directly to others. Repression (barring of unacceptable thoughts or painful experiences from consciousness) is not a desirable goal because the patient would expend much energy containing such thoughts and have difficulty focusing on day-to-day issues.

12) A
- Schizoid personality disorder is characterized by difficulty in forming social relationships and in expressing anger, preference for solitary activities, emotional detachment, daydreaming, and indecisiveness. Schizotypal personality is manifested by oddities of thinking, perception, speech, and behavior that are not severe enough to be labeled schizophrenia. Borderline personality marked by instability in several areas of development, is evidenced by unstable mood, poor relationships, impulsivity, and self-destructive behavior. The diagnosis of antisocial personality disorder is applied only to patients older than age 18 who have a history of conduct disorder before age 18. Conduct disorders are characterized by behaviors such as truancy, lying, problems in school, and running away.

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Mood Disorders Practice Exam/Test (24-30)

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Situation: Two days ago, M. arrived on the psychiatric unit, exhibiting extreme excitement, disorientation, incoherent speech, agitation, frantic, aimless physical activity, and grandiose delusions.

24. M. is in a manic episode. Which assessment finding is most characteristic of this stage of mania?

a) mild elation
b) hypomania
c) acute elation
d) delirium

25.Which nursing diagnostic category would hold the highest priority for M. at this time?

a) ineffective individual coping
b) hopelessness
c) potential for injury
d) personal identity disturbance

26. M. is assigned to a private room that is somewhat removed from the nurse's station. The primary reason for this room assignment is to:

a) decrease environmental stimuli
b) prevent the patient's excessive activity from disturbing others
c) deter the patient from interrupting the nurses
d) provide the patient with a quiet environment for thinking about his problems

Situation: K. is admitted to the acute psychiatric unit after 2 weeks of increasingly erratic behavior. She has not been sleeping, has lost 8 lb (3.6 kg), and is poorly groomed. She is hyperactive and loudly denies her need for hospitalization.

27. A priority nursing intervention for K. is to:

a) provide adequate hygiene
b) administer sedative medication
c) decrease environmental stimuli
d) involve her in unit activities

28. The physician plans to order lithium carbonate for K. Before beginning the lithium treatment regimen, the nurse performs a physical assessment. She is aware that lithium is contraindicated when a patient exhibit dysfunction of the:

a) renal system
b) reproductive system
c) endocrine system
d) respiratory system

29. The physician changes the medication order to lithium carbonate to 300 mg four times a day and chlorpromazine (thorazine) 100 mg four times a day. Which statement best explains the reason for ordering chlorpromazine?

a) a lower dose of lithium can be given
b) chlorpromazine helps control the manic symptoms until the lithium takes effect
c) joint administration makes both drugs more effective
d) joint administration decreases the risk of lithium toxicity

30. After 10 days on the unit, K. can tolerate short periods in the dayroom. One day, the nurse overhears her tell another patient that she is a journalist posting as a patient so that she can gather enough information to write an article about mental hospitals. The nurse should:

a) ignore K.'s delusion
b) confront K.
c) take K. back to her room
d) support K.'s denial of her illness


24) D
- mania is a mood of extreme euphoria. Delirium, the most severe state of mania, is manifested by extreme excitement, disorientation, incoherence, agitation, frantic activity, and grandiose delusions. At this stage, exhaustion, injury and death are possible. Mild elation and hypomania are synonymous terms that refer to a lesser state of hyperactivity. Acute elation, found in severe states of mania, is evidenced by feelings of exaltation, lability, flight of ideas, talkativeness, grandiosity, inappropriate dress and makeup, urgent activity, decreased appetite and sleep, and distractibility.

25) C
- M. is at risk for injury because of his severe hyperactivity, disorientation, and agitation. Although the nursing diagnostic categories of Ineffective individual coping, Hopelessness, and Personal identity disturbance are also appropriate, the patient's safety needs are the highest priority at this time. The nurse should take immediate action to protect the patient from injury.

26) A
- assigning M. to a room that is removed from the nurse's station helps to decrease environmental stimuli, thereby helping to reduce his level of hyperactivity. Although M.'s excessive activity may bother the nurses and other patients, the primary reason for this room assignment is to benefit M., not the others in the unit. Because a patient in any stage of mania has little or no capacity for introspection, a private room is not used for this purpose.

27) B
- the patient in this situation is at risk for injuring herself or others. Administering a sedative as an initial intervention helps protect both the patient and the nurse from injury. Decreasing environmental stimuli is an additional measure that, when combined with medicating the patient, can reduce dangerous hyperactivity. Providing for the patient's hygiene and grooming needs an appropriate nursing intervention, but it is not the initial priority. The overall goal is to reduce hyperactivity, so involvement in unit activities is contraindicated.

28) A
- lithium carbonate does not bind with plasma protein and is excreted exclusively through the kidneys; therefore, it is contraindicated in patients with renal system dysfunction. Lithium also is contraindicated in pregnant women and nursing mothers but not in those with reproductive disorders. Lithium can be used with caution in patients with thyroid or respiratory disorders.

29) B
- an effective serum lithium level is not achieved for 7 to 10 days. Administering chlorpromazine (thorazine) concomitantly helps control the manic symptoms during this time. Once a therapeutic lithium blood level is achieved, the chlorpromazine dosage can be reduced and discontinued. Chlorpromazine has no effect on lithium dosage. Because lithium and chlorpromazine do not have an additive effect, their efficacy is not increased when combined. Lithium toxicity is related to the body's sodium-fluid balance and would not affected by administration of chlorpromazine.

30) B
- once the intensity of the mania has diminished, the nurse can use therapeutic confrontation in response to the patient's denial of her illness. The nurse should approach the patient on a one-to-one basis and say something like, "I overheard you say you were a journalist posing as a patient. Why don't we sit and talk about the reasons for your admission and how you are doing now." While confronting but not arguing with K., the nurse can review the reasons she was admitted and present the reality of the situation. This is more therapeutic than ignoring the comment, isolating the patient, or supporting her denial.

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Mood Disorders Practice Exam/Test (16-23)

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Situation: C., age 36 and single, is brought to the local psychiatric hospital by her brother, who tells the nurse that she has been involved in a whirlwind of activity that began several months ago and that she seems out of control. She told friends that she was devoting all her time to writing a novel that was nearly complete, but at the same time, she began painting the interior of her seven-room home. When her friends tried to get her slow down, she increased her activities, taking little time to sleep or eat, and began spending huge amounts of money. Her admission was necessitated when she wrote a check for $500,000, with a bank balance of only $5.
At admission, C. is agitated, speaking loudly and challenging other patients. Her admitting diagnosis is bipolar reaction, manic phase.

16. Which approach would be most therapeutic in working with C.?

a) teaching the patient about banking procedures, then extending this approach to everyday issues
b) confronting the patient about all her inappropriate behavior
c) kindly but firmly guiding the patient into such activities as bathing and eating
d) showing the patient that she is in a controlled environment so that no difficulties arise later

17. C. lost 15 lb (6.8 kg) last week and now weighs 100 lb (45.4 kg). The nurse formulates a nursing diagnosis based on the diagnostic category Altered Nutrition: less than body requirements. Which goal is most appropriate initially?

a) the patient will consume an adequate diet
b) the patient will maintain her current weight of 100 lb
c) the patient will gain 1 lb (0.5 kg) per week
d) the patient will remain adequately hydrated

18. The best approach to meeting C.'s hydration and nutrition needs would be to:

a) leave finger foods and liquids in her room and let her eat and drink as she moves about
b) bring her to the dining room and encourage her to sit and eat with calm, quiet companions
c) explain mealtime routines and allow her to make her own decisions about eating
d) provide essential nutrition through high-calorie gavage feedings

19. The physician decides to start C. on lithium (Lithane) therapy. Which of the following best describes her dietary requirements while she is receiving this medication?

a) a high-calorie diet with reduced sodium and adequate fluid intake
b) a regular diet with normal sodium and adequate fluid intake
c) a low-calorie diet with reduced sodium and increased fluid intake
d) a regular diet with reduced sodium and adequate fluid intake

20. A few days later, C. tells the nurse, "I'm so ashamed of myself, I don't deserve to be here and be taken care of." Which action best demonstrates the nurse's understanding of the patient's needs?

a) expressing relief that C. has recognized the foolishness of her behavior
b) calling a team conference to increase protection against possible self-destructive behavior by C.
c) reporting to staff members that C. appears to be developing insight into her behavior
d) telling C. that she has done nothing that she should regret

21. C. would benefit most from which activity during the manic phase of her illness?

a) playing a game of badminton
b) attending the unit's weekly bingo game
c) putting together an intricate puzzle
d) drawing or painting in her room

22. One week after C. begins taking lithium, the nurse notes that her serum lithium level is 1 mEq/L. How should the nurse respond?

a) call the physician immediately to report the laboratory results
b) observe the patient closely for signs of lithium toxicity
c) withhold the next dose and repeat the blood work
d) continue administering the medication as ordered

23. Early signs of lithium toxicity include:

a) fine tremors, nausea, vomiting, and diarrhea
b) ataxia, confusion, and seizures
c) elevated white blood cell count and orthostatic hypotension
d) restlessness, shuffling gait, and involuntary muscle movements


16) C
- a soft, kind, but firm approach is least likely to provoke or anger the patient. Confronting the patient about her behavior is not recommended because, at this point, she cannot control her actions. Because the patient is n an agitated state, she is unable to listen or gain insight into her situation; trying to teach her about managing her money or her life is frustrating for both the nurse and the patient. Similarly, focusing on the controlled environment is ineffective while the patient remains agitated; however, this should be carried out later when the patient is less stressed.

17) B
- maintaining the patient's weight at stable level is an appropriate initial goal while the patient is acutely manic. Once the patient is less hyperactive, the goal can be changed to reflect a gradual weight gain. Goals that use such terms as adequate diet or adequate hydration are too vaguely stated to be evaluated.

18) A
- providing easily managed food and drink for the patient to consume as she moves about her room promotes nutrition while demonstrating acceptance of the patient's inability to cease activities long enough to eat in a conventional manner. Eating in the dining room would be too stimulating at this time and might escalate the patient's behavior as well as disturb others. The nurse should not allow the patient to make her own decisions about eating but should encourage her to eat at mealtimes; patients experiencing mania tend to be too "busy" to stop meals. Because the patient would probably view tube feedings as assaultive, they should be avoided unless no alternative is available.

19) B
- while receiving lithium, the patient should maintain a regular diet with adequate fluid intake (about 70 to 100 oz or 2 to 3 liters per day). Lithium is a salt, and its retention in the body is directly influenced by the body's sodium and fluid balance. Sodium depletion must be avoided because lithium will replace sodium in the cells, leading to lithium toxicity. Low-sodium diets and high- and low-calorie diets do not provide adequate balance for proper lithium regulation.

20) B
- the nurse should recognize that the patient is in the depressive phase of bipolar depression (manic-depressive disorder) and needs protection from herself because she is at risk for suicide. The nurse must always be alert for signs of self-destructive behavior and should inform the treatment team immediately so that protective measures, such as suicide precautions, can be instituted if necessary. Expressing relief at the patient's developed insight into her behavior and reporting to staff members that she is developing insight are serious misinterpretations that miss the underlying message. Although the nurse should help C. to recognize that her behavior is a function of her bipolar disorder and not a reflection of her as a person, telling her that she has done nothing she should regret is inappropriate because it devalues her feelings.

21) D
- drawing or painting in a quiet environment provides the patient with an outlet for excess energy and encourages sublimation of feelings (transferring unacceptable aggressive drives into a constructive activity). Badminton would only increase C.'s agitation and aggression because of its competitive nature. During acute mania, the patient would be overstimulated by the noise and activity of a bingo game. Because the patient finds sitting still and concentrating difficult, working on an intricate puzzle would be too frustrating and would increase her already low self-esteem.

22) D
- the serum lithium level should be maintained between 1 and 1.5 mEq/L during the acute manic phase; therefore, the nurse should continue administering the medication. In the absence of other signs of lithium toxicity, the nurse has no need to call the physician, withhold the medication, or repeat the blood work. Nevertheless, she should continue to monitor the patient's lithium level and watch for signs of toxicity if the level begins to rise.

23) A
- the nurse must remain alert for early signs of lithium toxicity, including fine tremors, nausea, vomiting, and diarrhea. When such symptoms are observed, the lithium should be withheld and the blood work repeated until the toxicity is reversed. Ataxia, confusion, and seizures indicate severe toxicity and require prompt medical management. An elevated white blood count, orthostatic hypotension, and extrapyramidal symptoms (involuntary muscle movements, restlessness, and shuffling gait) are side effects of phenothiazines, not lithium.

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