Psychiatric Medications NCLEX Practice Quiz: 75 Questions | 2022 latest update

Psychiatric Medications NCLEX Practice Quiz: 75 Questions 1. 1. Question Jose is diagnosed with amphetamine psychosis and was admitted to the emergency room. Nurse Ronald would most likely prepare to administer which of the following medication? o A. Librium o B. Valium o C. Ativan o D. Haldol Incorrect Correct Answer: D. Haldol The nurse would prepare to administer an antipsychotic medication such as Haldol to a client experiencing amphetamine psychosis to decrease agitation & psychotic symptoms, including delusions, hallucinations & cognitive impairment. Haloperidol is a first-generation (typical) antipsychotic medication that is used widely around the world. Food and Drug Administration (FDA) approved the use of haloperidol is for schizophrenia, Tourette syndrome (control of tics and vocal utterances in adults and children), hyperactivity (which may present as impulsivity, difficulty maintaining attention, severe aggressivity, mood instability, and frustration intolerance), severe childhood behavioral problems (such as combative, explosive hyperexcitability), intractable hiccups. It is a typical antipsychotic because it works on positive symptoms of schizophrenia, such as hallucinations and delusions. • Option A: Chlordiazepoxide is a long-acting benzodiazepine and is an FDA approved medication for adults with mild-moderate to severe anxiety disorder, preoperative apprehension and anxiety, and withdrawal symptoms of acute alcohol use disorder. It is also FDA approved for pediatric patients greater than six years old for anxiety. Chlordiazepoxide has anti-anxiety, sedative, appetite-stimulating, and weak analgesic actions. • Option B: Diazepam is an anxiolytic benzodiazepine, first patented and marketed in the United States in 1963. It is a fast-acting, long-lasting benzodiazepine commonly used in the treatment of anxiety disorders, as well as alcohol detoxification, acute recurrent seizures, severe muscle spasm, and spasticity associated with neurologic disorders. In the setting of acute alcohol withdrawal, diazepam is useful for symptomatic relief of agitation, tremor, alcoholic hallucinosis, and acute delirium tremens. • Option C: Lorazepam has common use as the sedative and anxiolytic of choice in the inpatient setting owing to its fast (1 to 3 minute) onset of action when administered intravenously. Lorazepam is also one of the few sedative-hypnotics with a relatively clean side effect profile. Lorazepam is FDA approved for short-term (4 months) relief of anxiety symptoms related to anxiety disorders, anxiety-associated insomnia, anesthesia premedication in adults to relieve anxiety, or to produce sedation/amnesia, and treatment of status epilepticus. 2. 2. Question Which of the following liquids would nurse Leng administer to a female client who is intoxicated with phencyclidine (PCP) to hasten excretion of the chemical? • A. Shake • B. Tea • C. Cranberry Juice • D. Grape juice Incorrect Correct Answer: C. Cranberry Juice An acid environment aids in the excretion of PCP. The nurse will definitely give the client with PCP intoxication cranberry juice to acidify the urine to a ph of 5.5 & accelerate excretion. PCP begins to cause symptoms at a dose of 0.05mg/kg, and a dose of 20 mg or more can cause seizures, coma, and death. It is mainly metabolized by the liver, and 10% is excreted in the kidneys. Inhalation (the most common route of administration) and intravenous routes of administration produce symptoms in 2 to 5 minutes. Oral ingestion produces symptoms in 30 to 60 minutes. • Option A: Most patients survive PCP intoxication with supportive care. Airway, breathing, circulation, and hemodynamic monitoring are essential to the care of patients with PCP toxicity. Intubation with ventilatory support may be required for airway protection. Sedation with medication and physical restraints may be required to control agitation, violent behavior, and psychosis due to PCP intoxication. Placing the patient in a calm environment such as a quiet room with the lights dimmed may be helpful. Benzodiazepines are the preferred medication for chemical sedation in patients with PCP toxicity. • Option B: Patients with mild symptoms can be discharged one to 2 hours after they become symptom-free and have no other medical complications or behavioral issues that need to be addressed. Patients with severe symptoms or medical complications should be admitted to a monitored bed. Patients who are asymptomatic who present to the emergency department after PCP use should be observed for at least 6 hours before being discharged. • Option D: PCP is available as a powder, crystal, liquid, and tablet. It produces both stimulation and depression of the CNS. PCP is a non-competitive antagonist to the NMDA receptor, which causes analgesia, anesthesia, cognitive defects, and psychosis. PCP blocks the uptake of dopamine and norepinephrine, leading to sympathomimetic effects such as hypertension, tachycardia, bronchodilation, and agitation. PCP can also cause sedation, muscarinic, and nicotinic signs by binding to acetylcholine receptors and GABA receptors. Sigma receptor stimulation by PCP causes lethargy and coma. 3. 3. Question When developing a plan of care for a female client with acute stress disorder who lost her sister in a car accident. Which of the following would the nurse expect to initiate? • A. Facilitating progressive review of the accident and its consequences. • B. Postponing discussion of the accident until the client brings it up. • C. Telling the client to avoid details of the accident. • D. Helping the client to evaluate her sister’s behavior. Incorrect Correct Answer: A. Facilitating progressive review of the accident and its consequences The nurse would facilitate progressive review of the accident and its consequence to help the client integrate feelings & memories and to begin the grieving process. Help patients reframe any destructive cognitions (eg, beliefs that they acted terribly and are terrible people or are weak for being so distraught, that life is hopeless or worthless, or that the world is totally unsafe). • Option B: Support self-esteem; help patients understand that their reaction to the trauma is a normal reaction to an abnormal situation, not a sign of weakness or psychopathology. Reassure and help survivors concerning immediate needs, such as rest, food, shelter, social support, or a sense of belonging to a community (some feel cut off and detached). • Option C: Promote coping mechanisms. Avoid prompting discussion of issues that cannot be resolved; avoid abreaction in groups and the resulting contagion effect; respect defenses, and do not force reality on people who cannot handle it yet; keep in mind that debriefing may be harmful. Discuss the experience with patients who want to talk about it, and avoid pressuring those who do not wish to discuss it. • Option D: Check to see if children feel that they somehow caused the death or disaster or if they have other misunderstandings, and take pains to reassure them or correct any misunderstanding; do not assume children are fine just because they are not saying anything. Let them know it is all right to talk about unpleasant feelings (including sadness and anger) and listen to them; sharing personal feelings of sadness with them is all right as well. 4. 4. Question The nursing assistant tells nurse Ronald that the client is not in the dining room for lunch. Nurse Ronald would direct the nursing assistant to do which of the following? • A. Tell the client he’ll need to wait until supper to eat if he misses lunch. • B. Invite the client to lunch and accompany him to the dining room. • C. Inform the client that he has 10 minutes to get to the dining room for lunch. • D. Take the client a lunch tray and let the client eat in his room. Incorrect Correct Answer: B. Invite the client to lunch and accompany him to the dining room. The nurse instructs the nursing assistant to invite the client to lunch & accompany him to the dining room to decrease manipulation, secondary gain, dependency and reinforcement of negative behavior while maintaining the client’s worth. Staff working with manipulative patients are best prepared when they establish firm rules that are rigidly interpreted and consistently enforced among all members of the health care team. Frequent discussions regarding the patient’s progress can help reduce staff frustration and isolation and minimize the patient’s attempts at staff splitting. • Option A: Discussing realistic expectations of time and resources available with the patient is of paramount importance. This establishes boundaries and forms a solid foundation on which to build future rapport. The patient will learn that you can be trusted because you will practice with integrity. By putting forth realistic expectations, you can mitigate many manipulative behaviors exhibited in the healthcare setting. • Option C: One of the best ways to become accountable for exemplary care is to advocate for the patient’s autonomy. Giving the patient choices regarding his or her care restores a sense of control that is imperative to feeling secure. Many times the lack of a routine or schedule prompts a patient to allege that the nurse is neglectful. Formulating a schedule and faithfully notifying the manipulative patient of changes will demonstrate that you believe he or she is worthy of your time and efforts. • Option D: There are many specific interventions that may be put into place by an interdisciplinary team caring for a patient who exhibits manipulative behavior. For example, designating one caregiver to be the patient’s contact will result in more consistent care. Having two staff members present for all patient interactions will ensure that any claims of misconduct can be evaluated for validity by multiple healthcare professionals. 5. 5. Question The initial nursing intervention for the significant-others during shock phase of a grief reaction should be focused on: • A. Presenting the full reality of the loss of the individuals. • B. Directing the individual’s activities at this time. • C. Staying with the individuals involved. • D. Mobilizing the individual’s support system. Incorrect Correct Answer: C. Staying with the individuals involved. This provides support until the individual’s coping mechanisms and personal support systems can be immobilized. Assess the patient’s ability to make decisions. Grief may limit a person’s cognitive ability that is needed in decision-making and problem-solving. Know the availability of support systems for the patient. If the patient’s main support is the object of perceived loss, the patient may need help in naming other sources of support. • Option A: Review and point out strengths and progress to date. Reviewing a patient’s progress is very helpful and provides perspective in the whole process. Communicate therapeutically with patient and family members and allow them to verbalize feelings. Sharing feelings with a healthcare provider may help the patient find significance in the experience of loss. • Option B: Encourage significant others to manage their own self-care needs for rest, sleep, nutrition, leisure activities, and time away from the patient. Alteration in normal activities is evident during this time of stress. Care should be taken to treat these symptoms so that emotional reconstitution is not complicated by illness. • Option D: Initiate a process that provides additional support and resources. The patient and family may benefit from spiritual support resources. Support the patient and significant others share mutual fears, concerns, plans, and hopes for each other. Keeping secrets won’t do any help during this time. These times of stress can be used as an opportunity for growth and family development. 6. 6. Question Joy’s stream of consciousness is occupied exclusively with thoughts of her father’s death. Nurse Ronald should plan to help Joy through this stage of grieving, which is known as: • A. Shock and disbelief • B. Developing awareness • C. Resolving the loss • D. Restitution Incorrect Correct Answer: C. Resolving the loss Resolving a loss is a slow, painful, continuous process until a mental image of the dead person, almost devoid of negative or undesirable features emerges. The individual is preoccupied with the loss, the lost person or object is idealized, the mourner may even imitate the lost person. Eventually, the preoccupation decreases, usually in a year or perhaps more. • Option A: The initial reaction to a loss is a stunned, numb feeling accompanied by a refusal to acknowledge the reality of the loss in an attempt to protect the self against overwhelming stress. • Option B: As the individual begins to acknowledge the loss, there may be crying, feelings of helplessness, frustration, despair, and anger that can be directed at self or others, including God or the deceased person. • Option D: Participation in the rituals associated with death, such as a funeral, wake, family gathering, or religious ceremonies that help the individual accept the reality of the loss and begin the recovery process. 7. 7. Question When taking a health history from a female client who has a moderate level of cognitive impairment due to dementia, the nurse would expect to note the presence of: • A. Accentuated premorbid traits • B. Enhance intelligence • C. Increased inhibitions • D. Hypervigilance Incorrect Correct Answer: A. Accentuated premorbid traits A moderate level of cognitive impairment due to dementia is characterized by increasing dependence on environment & social structure and by increasing psychological rigidity with accentuated previous traits & behaviors. There are some cases in which the cause of mild cognitive impairment is due to the effects of a treatable illness or disease. However, researchers have now determined that for most patients with mild cognitive impairment (MCI), the MCI is a point along the pathway to dementia. The MCI is considered the stage between the mental changes that are seen in normal aging and early-stage dementia. • Option B: Example of memory and thinking problems that might be seen in someone with mild cognitive impairment including memory loss. Forgets recent events, repeats the same questions and the same stories forgets the names of close friends and family members, forgets appointments or planned events, forgets conversations, misplaces items often. • Option C: The patient struggles with planning and problem solving and has a hard time making decisions. May struggle, but can complete complex tasks such as paying bills, taking medications, shopping, cooking, household cleaning, driving. • Option D: Some gradual mental (cognitive) decline is seen with normal aging. For example, the ability to learn new information may be reduced, mental processing slows, speed of performance slows, and the ability to become distracted increases. However, these declines due to normal aging do not affect overall functioning or ability to perform activities of daily living. Normal aging does not affect recognition, intelligence, or long-term memory. 8. 8. Question What is the priority care for a client with dementia resulting from AIDS? • A. Planning for remotivation therapy. • B. Arranging for long-term custodial care. • C. Providing basic intellectual stimulation. • D. Assessing pain frequently. Incorrect Correct Answer: C. Providing basic intellectual stimulation This action maintains for as long as possible, the client’s intellectual functions by providing an opportunity to use them. Frequently orient the client to reality and surroundings. Allow the client to have familiar objects around him or her; use other items, such as a clock, a calendar, and daily schedules, to assist in maintaining reality orientation. • Option A: Teach prospective caregivers how to orient the client to time, person, place, and circumstances, as required. These caregivers will be responsible for client safety after discharge from the hospital. Give positive feedback when thinking and behavior are appropriate, or when the client verbalizes that certain ideas expressed are not based on reality. Positive feedback increases self-esteem and enhances the desire to repeat appropriate behavior. • Option B: Instruct family members in the disease process, what can be expected, and assist with providing a list of community resources for support. Once diagnosis of AD is made, the family should be prepared to make long-term plans in order to discuss problems before they arise. Choices for resuscitation, legal competency and guardianship including financial responsibility needed to be addressed. The care of a person with AIDS is expensive and time-consuming, as well as energy-draining and emotionally devastating for the family. Community resources can help delay the need for placement in a long-term care facility and may help defray some costs. • Option D: Assess the patient’s ability for thought processing every shift. Observe the patient for cognitive functioning, memory changes, disorientation, difficulty with communication, or changes in thinking patterns. Changes in status may indicate a progression of deterioration or improvement in condition. Assess the level of cognitive disorders such as a change to orientation to people, places and times, range, attention, thinking skills. Provide the basis for the evaluation or comparison that will come, and influence the choice of intervention. 9. 9. Question Jerome who has an eating disorder often exhibits similar symptoms. Nurse Lhey would expect an adolescent client with anorexia to exhibit: • A. Affective instability • B. Dishered, unkempt physical appearance • C. Depersonalization and derealization • D. Repetitive motor mechanisms Incorrect Correct Answer: A. Affective instability Individuals with anorexia often display irritability, hospitality, and a depressed mood. Anorexia nervosa is an eating disorder defined by restriction of energy intake relative to requirements, leading to significantly low body weight. Patients will have an intense fear of gaining weight and distorted body image with the inability to recognize the seriousness of their significantly low body weight. • Option B: Patients will report symptoms such as amenorrhea, cold intolerance, constipation, extremity edema, fatigue, and irritability. They may describe restrictive behaviors related to food like calorie counting or portion control, and purging methods, for example, self-induced vomiting or use of diuretics or laxatives. Many exercise compulsively for extended periods of time. Patients with anorexia nervosa develop multiple complications related to prolonged starvation and purging behaviors. • Option C: Depersonalization/derealization disorder is a type of dissociative disorder that consists of persistent or recurrent feelings of being detached (dissociated) from one’s body or mental processes, usually with a feeling of being an outside observer of one’s life (depersonalization), or of being detached from one’s surroundings (derealization). The disorder is often triggered by severe stress. Diagnosis is based on symptoms after other possible causes are ruled out. Treatment consists of psychotherapy plus drug therapy for any comorbid depression and/or anxiety. • Option D: Stereotyped motor behaviors are defined as repetitive, often rhythmic, movements that are topographically alike and that serve no obvious purpose or function (Lewis & Bodfish, 1998). Repetitive behaviors are diagnostic for autism spectrum disorders and common in related neurodevelopmental disorders such as intellectual disability. 10. 10. Question The primary nursing diagnosis for a female client with a medical diagnosis of major depression would be: • A. Situational low self-esteem related to altered role • B. Powerlessness related to the loss of idealized self • C. Spiritual distress related to depression • D. Impaired verbal communication related to depression Incorrect Correct Answer: D. Impaired verbal communication related to depression Depressed clients demonstrate decreased communication because of a lack of psychic or physical energy. The common features of all depressive disorders are sadness, emptiness, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function. Initially, provide activities that require minimal concentration (e.g., drawing, playing simple board games). Depressed people lack concentration and memory. Activities that have no “right or wrong” or “winner or loser” minimizes opportunities for the client to put himself/herself down. • Option A: Assess the self-esteem level of the patient. Signs of low self-esteem include withdrawal from social relationships, feeling of inadequacy, neglect of personal hygiene and dress, and rejecting self which all may indicate a negative thought pattern. Allow the patient to engage in simple recreational activities, advancing to more complex activities in a group environment. The patient may feel overwhelmed at the start when participating in a group setting. • Option B: The investigation into depressive symptoms begins with inquiries of the neurovegetative symptoms which include changes in sleeping patterns, appetite, and energy levels. Positive responses should elicit further questioning focused on evaluating for the presence of the symptoms which are diagnostic of major depression. • Option C: Assess what spiritual practices have offered comfort and meaning to the client’s life when not ill. Evaluates neglected areas in the person’s life that, if reactivated, might add comfort and meaning during a painful depression. Suggest that the spiritual leader affiliated with the facility contact the client. Spiritual leaders are familiar with dealing with spiritual distress and can offer comfort to the client. 11. 11. Question When developing an initial nursing care plan for a male client with a Bipolar I disorder (manic episode) nurse Ron should plan to? • A. Isolate his gym time. • B. Encourage his active participation in unit programs. • C. Provide foods, fluids, and rest. • D. Discourage his participation in programs. Incorrect Correct Answer: C. Provide foods, fluids, and rest The client in a manic episode of the illness often neglects basic needs, these needs are a priority to ensure adequate nutrition, fluid, and rest. Decreasing environmental stimulation may assist the client to relax; the nurse must provide a quiet environment without noise, television, and other distractions; finger foods or things the client can eat while moving around are the best options to improve nutrition. • Option A: A primary nursing responsibility is to provide a safe environment for the client and others; for clients who feel out of control, the nurse must establish external controls emphatically and nonjudgmentally. The nurse can direct their need for movement into socially acceptable, large motor activities such as arranging chairs for a community meeting or walking. • Option B: When less manic, the client might join one or two other clients in quiet, non stimulating activities (e.g., drawing, board games, cards). As mania subsides, involvement in activities that provide a focus and social contact becomes more appropriate. Competitive games can stimulate aggression and can increase psychomotor activity. When possible, provide an environment with minimum stimuli (e.g., quiet, soft music, dim lighting). Reduction in stimuli lessens distractibility. • Option D: Solitary activities requiring short attention spans with mild physical exertion are best initially (e.g., writing, taking photos, painting, or walks with staff). Solitary activities minimize stimuli; mild physical activities release tension constructively. 12. 12. Question Grace is exhibiting withdrawn patterns of behavior. Nurse Johnny is aware that this type of behavior eventually produces a feeling of: • A. Repression • B. Loneliness • C. Anger • D. Paranoia Incorrect Correct Answer: B. Loneliness The withdrawn pattern of behavior presents the individual from reaching out to others for sharing the isolation produces a feeling of loneliness. Prolonged loneliness can affect mental health, too. It can make any symptoms you’re already dealing with worse, for one. But it can also factor into the development of serious mental health conditions, including depression. Loneliness may not feel very comfortable, but it’s a transient emotional state that specifically relates to your needs for connection and belonging. Once you meet those needs, you’ll probably feel less lonely. • Option A: Repression is a type of psychological defense mechanism that involves keeping certain thoughts, feelings, or urges out of conscious awareness. The goal of this form of defense is to keep unacceptable desires or thoughts out of the conscious mind in order to prevent or minimize feelings of anxiety. This process involves pushing painful or disturbing thoughts into the unconscious in order to remain unaware of them. The concept was first identified and described by Sigmund Freud, who was most famous for the development of psychoanalysis. • Option C: Anger is an emotion characterized by antagonism toward someone or something you feel has deliberately done you wrong. Anger can be a good thing. It can give you a way to express negative feelings, for example, or motivate you to find solutions to problems. But excessive anger can cause problems. Increased blood pressure and other physical changes associated with anger make it difficult to think straight and harm your physical and mental health. • Option D: Paranoia involves intense anxious or fearful feelings and thoughts often related to persecution, threat, or conspiracy. Paranoia occurs in many mental disorders, but is most often present in psychotic disorders. Paranoia can become delusions, when irrational thoughts and beliefs become so fixed that nothing (including contrary evidence) can convince a person that what they think or feel is not true. When a person has paranoia or delusions, but no other symptoms (like hearing or seeing things that aren’t there), they might have what is called a delusional disorder. Because only thoughts are impacted, a person with delusional disorder can usually work and function in everyday life, however, their lives may be limited and isolated. 13. 13. Question One morning a female client on the inpatient psychiatric service complains to nurse Hazel that she has been waiting for over an hour for someone to accompany her to activities. Nurse Hazel replies to the client “We’re doing the best we can. There are a lot of other people in the unit who need attention too.” This statement shows that the nurse’s use of: • A. Defensive behavior • B. Reality reinforcement • C. Limit-setting behavior • D. Impulse control Incorrect Correct Answer: A. Defensive behavior The nurse’s response is not therapeutic because it does not recognize the client’s needs but tries to make the client feel guilty for being demanding. Another non-therapeutic communication technique is defending or trying to protect a person, place, or idea from a verbal attack. An example of this may be a client saying something negative about a doctor and the nurse saying, ‘The doctor is only looking out for you.’ This basically tells the patient that their critique is unfounded and that the patient shouldn’t express their feelings or opinions. Defending only serves to reinforce the patient’s opinion and shut down further communication. • Option B: One of the many different ways in which people can learn is through a process known as operant conditioning (also known as instrumental conditioning). This involves learning through reinforcement or punishment. The type of reinforcement used can play an important role in how quickly a behavior is learned and the overall strength of the resulting response. • Option C: Limit setting allows the boundaries of the therapeutic relationship to be established and provides the consumer with a clear understanding of what is and isn’t acceptable behavior and what the consequences of their actions will be. It also allows for consistency across staff interactions with the consumer aiding in reducing agitation and confusion. Clear, effective limit setting is a part of the therapeutic relationship that all staff should develop with consumers in their care. • Option D: The ability to control impulses, or more specifically control the desire to act on them, is an important factor in personality and socialization. Deferred gratification, also known as impulse control is an example of this, concerning impulses primarily relating to things that a person wants or desires. 14. 14. Question A nursing diagnosis for a male client with a diagnosed multiple personality disorder is chronic low self-esteem probably related to childhood abuse. The most appropriate short-term client outcome would be: • A. Verbalizing the need for anxiety medications. • B. Recognizing each existing personality. • C. Engaging in object-oriented activities. • D. Eliminating defense mechanisms and phobia. Incorrect Correct Answer: B. Recognizing each existing personality The client must recognize the existence of the sub-personalities so that interpretation can occur. Review intervention guidelines for each personality disorder in this chapter. All clients are individuals, even within the same diagnostic category. However, guidelines for specific categories are helpful for planning. Identify behavioral limits and behaviors that are expected. Client needs a clear structure. Expect frequent testing of limits initially. Maintaining limits can enhance feelings of safety in the client. • Option A: Regardless of the clinical setting, the nurse must provide structure and limit setting in the therapeutic relationship; in a clinic setting, this may mean seeing the client for scheduled appointments of a predetermined length rather than whenever the client appears and demands the nurse’s immediate attention. • Option C: Minimizing unstructured time by planning activities can help clients to manage time alone; clients can make a written schedule that includes appointments, shopping, reading the paper, and going for a walk. • Option D: Cognitive restructuring is a technique useful in changing patterns of thinking by helping clients to recognize negative thoughts and feelings and to replace them with positive patterns of thinking; thought stopping is a technique to alter the process of negative or self-critical thought patterns. 15. 15. Question A 25-year-old male is admitted to a mental health facility because of inappropriate behavior. The client has been hearing voices, responding to imaginary companions, and withdrawing to his room for several days at a time. Nurse Monette understands that the withdrawal is a defense against the client’s fear of: • A. Phobia • B. Powerlessness • C. Punishment • D. Rejection Incorrect Correct Answer: D. Rejection An aloof, detached, withdrawn posture is a means of protecting the self by withdrawing and maintaining a safe, emotional distance. When confronted by stressful events, people sometimes abandon coping strategies and revert to patterns of behavior used earlier in development. Anna Freud called this defense mechanism regression, suggesting that people act out behaviors from the stage of psychosexual development in which they are fixated. For example, an individual fixated at an earlier developmental stage might cry or sulk upon hearing unpleasant news. • Option A: Patients with a specific phobia experience high levels of anxiety and panic attacks along with excessive and unreasonable fear due to either exposure or anticipation of exposure to a feared stimulus. As a result, these patients will try to avoid the anxiety-provoking stimulus to any extent possible. The fear or anxiety experienced is out of proportion to the actual danger posed by the specific object or situation. The fear or anxiety experienced is out of proportion to the actual danger posed by the specific object or situation. • Option B: The opposite of power is powerlessness. Powerlessness refers to the expectancy that people’s behaviors cannot determine the outcomes or reinforcements that they seek. Powerlessness may further be explained as the lack of strength or the absence of power. People experiencing powerlessness may feel out of control and have no solution to regain control. Subsequent to feeling out of control comes the lack of capability to be in command of most aspects of one’s life. Powerlessness also can be considered as the absence of complete authority or status to affect how others will act toward others. It is viewed by some that, when confronting powerlessness, individuals may be able to affect or change the negative behaviors (e.g., compulsions and addictions) of either themselves or others. • Option C: Punishment is a term used in operant conditioning to refer to any change that occurs after a behavior that reduces the likelihood that that behavior will occur again in the future. While positive and negative reinforcements are used to increase behaviors, punishment is focused on reducing or eliminating unwanted behaviors. 16. 16. Question When asking the parents about the onset of problems in young client with the diagnosis of schizophrenia, Nurse Linda would expect that they would relate the client’s difficulties began in: • A. Early childhood • B. Late childhood • C. Adolescence • D. Puberty Incorrect Correct Answer: C. Adolescence The usual age of onset of schizophrenia is adolescence or early childhood. The first schizophrenic episode usually occurs during early adulthood or late adolescence. Individuals often lack insight at this stage; therefore few will present directly to seek help for their psychotic symptoms. Common presentations include a relative noticing social withdrawal, personality changes or uncharacteristic behavior; deliberate self-harm or suicide attempts; calling the police to report their delusional symptoms or referral via the criminal justice system. • Option A: Though the prevalence of the disease varies globally, estimates are that schizophrenia affects approximately 1% of adults, whereas prevalence in the US is 0.6% to 1.9%. Men are slightly more likely to be diagnosed and have an earlier onset than women, while African-Caribbean migrants and their descendants also have a higher incidence. • Option B: Though the prevalence of the disease varies globally, estimates are that schizophrenia affects approximately 1% of adults, whereas prevalence in the US is 0.6% to 1.9%. Men are slightly more likely to be diagnosed and have an earlier onset than women, while African-Caribbean migrants and their descendants also have a higher incidence. • Option D: In schizophrenia, the prognosis is dependent on several factors. Insidious onset, childhood or adolescent onset, poor premorbid adjustment, and cognitive impairment are indicative of a poor prognostic outcome whereas acute onset, female sex, and living in a developed country signal comparatively better prognostic factors. 17. 17. Question Jose, who has been hospitalized with schizophrenia tells Nurse Ron, “My heart has stopped and my veins have turned to glass!” Nurse Ron is aware that this is an example of: • A. Somatic delusions • B. Depersonalization • C. Hypochondriasis • D. Echolalia Incorrect Correct Answer: A. Somatic delusions Somatic delusion is a fixed false belief about one’s body. Of the delusional symptoms, somatic delusions-those that pertain to the body-are rather rare. Somatic delusions are defined as fixed false beliefs that one’s bodily function or appearance is grossly abnormal. They are a poorly understood psychiatric symptom and pose a significant clinical challenge to clinicians. • Option B: Depersonalization is described as feeling disconnected or detached from one’s self. Individuals may report feeling as if they are an outside observer of their own thoughts or body, and often report feeling a loss of control over their thoughts or actions. • Option C: Illness anxiety disorder (IAD) is a recent term for what used to be diagnosed as hypochondriasis, or hypochondria. People diagnosed with IAD strongly believe they have a serious or life-threatening illness despite having no, or only mild, symptoms. Yet IAD patients’ concerns are to them very real. Even if they go to doctors and no illnesses are found, they are generally not reassured and their obsessive worry continues. • Option D: Echolalia is the unsolicited repetition of vocalizations made by another person (when repeated by the same person, it is called palilalia). In its profound form, it is automatic and effortless. 18. 18. Question In recognizing common behaviors exhibited by a male client who has a diagnosis of schizophrenia, nurse Josie can anticipate: • A. Slumped posture, pessimistic outlook, and flight of ideas • B. Grandiosity, arrogance, and distractibility • C. Withdrawal, regressed behavior, and lack of social skills • D. Disorientation, forgetfulness, and anxiety Incorrect Correct Answer: C. Withdrawal, regressed behavior, and lack of social skills These are the classic behaviors exhibited by clients with a diagnosis of schizophrenia. Traditionally, symptoms have divided into two main categories: positive symptoms which include hallucinations, delusions, and formal thought disorders, and negative symptoms such as anhedonia, poverty of speech, and lack of motivation. • Option A: Negative symptoms refer to reduced or lack of ability to function normally. For example, the person may neglect personal hygiene or appear to lack emotion (doesn’t make eye contact, doesn’t change facial expressions, or speaks in a monotone). Also, the person may lose interest in everyday activities, socially withdraw or lack the ability to experience pleasure. • Option B: Delusions are false beliefs that are not based in reality. For example, you think that you’re being harmed or harassed; certain gestures or comments are directed at you; you have exceptional ability or fame; another person is in love with you, or a major catastrophe is about to occur. Delusions occur in most people with schizophrenia. • Option D: Disorganized thinking is inferred from disorganized speech. Effective communication can be impaired, and answers to questions may be partially or completely unrelated. Rarely, speech may include putting together meaningless words that can’t be understood, sometimes known as word salad. 19. 19. Question One morning, nurse Diane finds a disturbed client curled up in the fetal position in the corner of the dayroom. The most accurate initial evaluation of the behavior would be that the client is: • A. Physically ill and experiencing abdominal discomfort. • B. Tired and probably did not sleep well last night. • C. Attempting to hide from the nurse. • D. Feeling more anxious today. Incorrect Correct Answer: D. Feeling more anxious today The fetal position represents regressed behavior. Regression is a way of responding to overwhelming anxiety. Validate observations by asking the patient, “Are you feeling anxious now?” Anxiety is a highly individualized, normal physical and psychological response to internal or external life events. • Option A: Assess physical reactions to anxiety. Anxiety also plays a role in somatoform disorders, which are characterized by physical symptoms such as pain, nausea, weakness, or dizziness that have no apparent physical cause. Recognize awareness of the patient’s anxiety. Since a cause of anxiety cannot always be identified, the patient may feel as though the feelings being experienced are counterfeit. Acknowledgment of the patient’s feelings validates the feelings and communicates acceptance of those feelings. • Option B: Use presence, touch (with permission), verbalization, and demeanor to remind patients that they are not alone and to encourage expression or clarification of needs, concerns, unknowns, and questions. Being supportive and approachable promotes communication. Consider the patient’s use of coping strategies that the patient has found effective in the past. This enhances the patient’s sense of personal mastery and confidence. • Option C: Observe how the patient uses coping techniques and defense mechanisms to cope with anxiety. Asking questions requiring informative answers helps identify the effectiveness of coping strategies currently used by the patient. This approach may help the patient feel like he or she is contributing to patient care. Coping strategies may include reading, journaling, or physical activity such as taking a walk. Defense mechanisms are used by people to preserve the ego and manage anxiety. Some defense mechanisms are highly adaptive in managing anxiety, such as humor, sublimation, or suppression. Other defense mechanisms may lead to less adaptive behavior, especially with long-term use. These defense mechanisms include displacement, repression, denial, projection, and self-image splitting. 20. 20. Question Nurse Bea notices a female client sitting alone in the corner smiling and talking to herself. Realizing that the client is hallucinating. Nurse Bea should: • A. Invite the client to help decorate the dayroom. • B. Leave the client alone until he stops talking. • C. Ask the client why he is smiling and talking. • D. Tell the client it is not good for him to talk to himself. Incorrect Correct Answer: B. Leave the client alone until he stops talking This provides a stimulus that competes with and reduces hallucination. Decrease environmental stimuli when possible (low noise, minimal activity). Decrease the potential for anxiety that might trigger hallucinations. Helps calm the client. Be alert for signs of increasing fear, anxiety or agitation. Might herald hallucinatory activity, which can be very frightening to client, and client might act upon command hallucinations (harm self or others). • Option A: Explore how the hallucinations are experienced by the client. Exploring the hallucinations and sharing the experience can help give the person a sense of power that he or she might be able to manage the hallucinatory voices. Help the client to identify the needs that might underlie the hallucination. What other ways can these needs be met? Hallucinations might reflect needs for anger, power, self-esteem, and sexuality. • Option C: Keep to simple, basic, reality-based topics of conversation. Help the client focus on one idea at a time. Client’s thinking might be confused and disorganized; this intervention helps the client focus and comprehend reality-based issues. Work with the client to find which activities help reduce anxiety and distract the client from hallucinatory material. Practice new skills with the client. If clients’ stress triggers hallucinatory activity, they might be more motivated to find ways to remove themselves from a stressful environment or try distraction techniques. • Option D: Accept the fact that the voices are real to the client, but explain that you do not hear the voices. Refer to the voices as “your voices” or “voices that you hear”. Validating that your reality does not include voices can help the client cast “doubt” on the validity of their voices. Engage the client in reality-based activities such as card playing, writing, drawing, doing simple arts and crafts or listening to music. Redirecting the client’s energies to acceptable activities can decrease the possibility of acting on hallucinations and help distract from voices. 21. 21. Question When being admitted to a mental health facility, a young female adult tells Nurse Mylene that the voices she hears frighten her. Nurse Mylene understands that the client tends to hallucinate more vividly: • A. While watching TV • B. During mealtime • C. During group activities • D. After going to bed Incorrect Correct Answer: D. After going to bed Auditory hallucinations are most troublesome when environmental stimuli are diminished and there are few competing distractions. Be alert for signs of increasing fear, anxiety or agitation. Might herald hallucinatory activity, which can be very frightening to client, and client might act upon command hallucinations (harm self or others). Explore how the hallucinations are experienced by the client. Exploring the hallucinations and sharing the experience can help give the person a sense of power that he or she might be able to manage the hallucinatory voices. • Option A: Help the client to identify the needs that might underlie the hallucination. What other ways can these needs be met? Hallucinations might reflect needs for anger, power, self-esteem, and sexuality. Help the client to identify times that the hallucinations are most prevalent and frightening. Helps both nurse and client identify situations and times that might be most anxiety-producing and threatening to the client. • Option B: Stay with clients when they are starting to hallucinate and direct them to tell the “voices they hear” to go away. Repeat often in a matter-of-fact manner. The client can sometimes learn to push voices aside when given repeated instructions. especially within the framework of a trusting relationship. • Option C: Decrease environmental stimuli when possible (low noise, minimal activity). Decrease the potential for anxiety that might trigger hallucinations. Helps calm the client. Work with the client to find which activities help reduce anxiety and distract the client from a hallucinatory material. Practice new skills with the client. If clients’ stress triggers hallucinatory activity, they might be more motivated to find ways to remove themselves from a stressful environment or try distraction techniques. 22. 22. Question Nurse John recognizes that paranoid delusions usually are related to the defense mechanism of: • A. Projection • B. Identification • C. Repression • D. Regression Incorrect Correct Answer: A. Projection Projection is a mechanism in which inner thoughts and feelings are projected onto the environment, seeming to come from outside the self rather than from within. Projection is a defense mechanism that involves taking our own unacceptable qualities or feelings and ascribing them to other people. For example, if you have a strong dislike for someone, you might instead believe that they do not like you. Projection works by allowing the expression of the desire or impulse, but in a way that the ego cannot recognize, therefore reducing anxiety. • Option B: Identification with the aggressor is a defense mechanism proposed by Sandor Ferenczi and later developed by Anna Freud. It involves the victim adopting the behavior of a person who is more powerful and hostile towards them. By internalizing the behavior of the aggressor the ‘victim’ hopes to avoid abuse, as the aggressor may begin to feel an emotional connection with the victim which leads to feelings of empathy. • Option C: Repression is another well-known defense mechanism. Repression acts to keep information out of conscious awareness. However, these memories don’t just disappear; they continue to influence our behavior. For example, a person who has repressed memories of abuse suffered as a child may later have difficulty forming relationships. • Option D: When confronted by stressful events, people sometimes abandon coping strategies and revert to patterns of behavior used earlier in development. Anna Freud called this defense mechanism regression, suggesting that people act out behaviors from the stage of psychosexual development in which they are fixated. For example, an individual fixated at an earlier developmental stage might cry or sulk upon hearing unpleasant news. According to Freud, an individual fixated at the oral stage might begin eating or smoking excessively, or might become very verbally aggressive. A fixation at the anal stage might result in excessive tidiness or messiness. 23. 23. Question When planning care for a male client using paranoid ideation, nurse Jasmin should realize the importance of: • A. Giving the client difficult tasks to provide stimulation. • B. Providing the client with activities in which success can be achieved. • C. Removing stress so that the client can relax. • D. Not placing any demands on the client. Incorrect Correct Answer: B. Providing the client with activities in which success can be achieved. This will help the client develop self-esteem and reduce the use of paranoid ideation. As the client progresses, provide the client with graded activities according to the level of tolerance e.g., (1) simple games with one “safe” person; (2) slowly add a third person into “safe”. Gradually the client learns to feel safe and competent with increased social demands. • Option A: If a client is found to be very paranoid, solitary or one-on-one activities that require concentration are appropriate. The client is free to choose his level of interaction; however, concentration can help minimize distressing paranoid thoughts or voices. • Option C: Teach the client to remove himself briefly when feeling agitated and work on some anxiety relief exercises (e.g., meditations, rhythmic exercise, deep breathing exercise). Teach client skills in dealing with anxiety and increasing a sense of control. Useful coping skills that the client will need include conversational and assertiveness skills. These are fundamental skills for dealing with the world, which everyone uses daily with more or less skill. • Option D: Remember to give acknowledgment and recognition for positive steps the client takes in increasing social skills and appropriate interactions with others. Recognition and appreciation go a long way to sustaining and increasing a specific behavior. Useful coping skills that the client will need include conversational and assertiveness skills. These are fundamental skills for dealing with the world, which everyone uses daily with more or less skill. 24. 24. Question Nurse Gerry is aware that the defense mechanism commonly used by clients who are alcoholics is: • A. Displacement • B. Denial • C. Projection • D. Compensation Incorrect Correct Answer: B. Denial Denial is a method of resolving conflict or escaping unpleasant realities by ignoring their existence. Denial is probably one of the best-known defense mechanisms, used often to describe situations in which people seem unable to face reality or admit an obvious truth (e.g., “He’s in denial”). Denial is an outright refusal to admit or recognize that something has occurred or is currently occurring. People living with drug or alcohol addiction often deny that they have a problem, while victims of traumatic events may deny that the event ever occurred. • Option A: Displacement involves taking out our frustrations, feelings, and impulses on people or objects that are less threatening. Displaced aggression is a common example of this defense mechanism. Rather than express our anger in ways that could lead to negative consequences (like arguing with our boss), we instead express our anger towards a person or object that poses no threat (such as our spouse, children, or pets). • Option C: Projection is a defense mechanism that involves taking our own unacceptable qualities or feelings and ascribing them to other people.3 For example, if you have a strong dislike for someone, you might instead believe that they do not like you. Projection works by allowing the expression of the desire or impulse, but in a way that the ego cannot recognize, therefore reducing anxiety. • Option D: Overachieving in one area to compensate for failures in another. The term compensation refers to a type of defense mechanism in which people overachieve in one area to compensate for failures in another. For example, individuals with poor family lives may direct their energy into excelling above and beyond what is required at work. 25. 25. Question Within a few hours of alcohol withdrawal, nurse John should assess the male client for the presence of: • A. Disorientation, paranoia, tachycardia • B. Tremors, fever, profuse diaphoresis • C. Irritability, heightened alertness, jerky movements • D. Yawning, anxiety, convulsions Incorrect Correct Answer: C. Irritability, heightened alertness, jerky movements Alcohol is a central nervous system depressant. These symptoms are the body’s neurological adaptation to the withdrawal of alcohol. Alcohol withdrawal symptoms occur when patients stop drinking or significantly decrease their alcohol intake after long-term dependence. Withdrawal has a broad range of symptoms from mild tremors to a condition called delirium tremens, which results in seizures and could progress to death if not recognized and treated promptly. • Option A: Alcohol withdrawal can range from very mild symptoms to severe form, which is named delirium tremens. The hallmark is autonomic dysfunction resulting from the excitation of the central nervous system. Mild signs/symptoms can arise within six hours of alcohol cessation. If symptoms do not progress to more severe symptoms within 24 to 48 hours, the patient will likely recover. • Option B: Mild symptoms can be insomnia, tremulousness, hyperreflexia, anxiety, gastrointestinal upset, headache, palpitations. Moderate symptoms include alcohol withdrawal seizures (rum fits) that can occur 12 to 24 hours after cessation of alcohol and are typically generalized in nature. There is a 3% incidence of status epilepticus in these patients. About 50% of patients who have had a withdrawal seizure will progress to delirium tremens. • Option D: Delirium tremens is the most severe form of alcohol withdrawal, and its hallmark is that of an altered sensorium with significant autonomic dysfunction and vital sign abnormalities. It includes visual hallucinations, tachycardia, hypertension, hyperthermia, agitation, and diaphoresis. Symptoms of delirium tremens can last up to seven days after alcohol cessation and may last even longer. 26. 26. Question Mr. Marquez reports losing his job, not being able to sleep at night, and feeling upset with his wife. Nurse John responds to the client, “You may want to talk about your employment situation in group today.” The Nurse is using which therapeutic technique? • A. Observations • B. Restating • C. Exploring • D. Focusing Incorrect Correct Answer: D. Focusing The nurse is using focusing by suggesting that the client discuss a specific issue. Sometimes during a conversation, patients mention something particularly important. When this happens, nurses can focus on their statement, prompting patients to discuss it further. Patients don’t always have an objective perspective on what is relevant to their case; as impartial observers, nurses can more easily pick out the topics to focus on. • Option A: Observations about the appearance, demeanor, or behavior of patients can help draw attention to areas that might pose a problem for them. Observing that they look tired may prompt patients to explain why they haven’t been getting much sleep lately; making an observation that they haven’t been eating much may lead to the discovery of a new symptom. • Option B: Restating is repeating the main idea expressed. The nurse repeats what the client has said in approximately or nearly the same words the client has used. Client: “I can’t sleep. I stay awake all night.” Nurse: “You have difficulty sleeping.” • Option C: Exploring delves further into a subject or idea. When clients deal with topics superficially, exploring can help them examine the issue more fully. Examples of exploring include: “Tell me more about that.” and “Would you describe it more fully?” 27. 27. Question Tony refuses his evening dose of Haloperidol (Haldol), then becomes extremely agitated in the dayroom while other clients are watching television. He begins cursing and throwing furniture. Nurse Oliver first action is to: • A. Check the client’s medical record for an order for an as-needed I.M. dose of medication for agitation. • B. Place the client in full leather restraints. • C. Call the attending physician and report the behavior. • D. Remove all other clients from the dayroom. Incorrect Correct Answer: D. Remove all other clients from the dayroom. The nurse’s first priority is to consider the safety of the clients in the therapeutic setting. Modify the environment. Decrease noise and distractions, or relocate. Check yourself. Do not raise your voice, show alarm or offense, or corner, crowd, restrain, criticize, ignore or argue with the person. Take care not to make sudden movements out of the person’s view. • Option A: Listen to the frustration. Find out what may be causing the agitation, and try to understand. Provide reassurance. Use calming phrases such as: “You’re safe here;” “I’m sorry that you are upset;” and “I will stay until you feel better.” Let the person know you are there. • Option B: See the client’s primary care physician to rule out any physical causes or medication-related side effects. Utilize safety measures to protect clients or others, if the client believes they need to protect themselves against a specific person. Precautions are needed. During an acute phase, a client’s delusional thinking might dictate to them that they might have to hurt others or self in order to be safe. External controls might be needed. • Option C: Do not touch the client; use gestures carefully. Suspicious clients might misinterpret touch as either aggressive or sexual in nature and might interpret it as a threatening gesture. People who are psychotic need a lot of personal space. If nursing interventions (quiet environment and firm limit setting) and chemical restraints (tranquilizers–e.g., haloperidol [Haldol]) have not helped dampen escalating manic behaviors, then seclusion might be warranted. 28. 28. Question Junnel, who is manic, but not yet on medication, comes to the drug treatment center. The nurse would not let this client join the group session because: • A. The client is disruptive. • B. The client is harmful to self. • C. The client is harmful to others. • D. The client needs to be on medication first. Incorrect Correct Answer: A. The client is disruptive. Group activity provides too much stimulation, which the client will not be able to handle (harmful to self) and as a result will be disruptive to others. Decrease environmental stimuli (e.g., by providing a calming environment or assigning a private room). Helps decrease escalation of anxiety and manic symptoms. • Option B: Frequently assess client’s behavior for signs of increased agitation and hyperactivity. Early detection and intervention of escalating mania will prevent the possibility of harm to self or others, and decrease the need for seclusions. • Option C: Redirect agitation and potentially violent behaviors with physical outlets in an area of low stimulation (e.g., punching bag). Can help to relieve pent-up hostility and relieve muscle tension. Remain neutral as possible; Do not argue with the client. The client can use inconsistencies and value judgments as justification for arguing and escalating mania. • Option D: Chart, in nurse’s notes, behaviors; interventions; what seemed to escalate agitation; what helped to calm agitation; when as-needed (PRN) medications were given and their effect; and what proved most helpful. Staff will begin to recognize potential signals for escalating manic behaviors and have a guideline for what might work best for the individual client. 29. 29. Question Dervid, an adolescent boy, was admitted for substance abuse and hallucinations. The client’s mother asks Nurse Armando to talk with his husband when he arrives at the hospital. The mother says that she is afraid of what the father might say to the boy. The most appropriate nursing intervention would be to: • A. Inform the mother that she and the father can work through this problem themselves. • B. Refer the mother to the hospital social worker. • C. Agree to talk with the mother and the father together. • D. Suggest that the father and son work things out. Incorrect Correct Answer: C. Agree to talk with the mother and the father together. By agreeing to talk with both parents, the nurse can provide emotional support and further assess and validate the family’s needs. Observe family interactions and SO dynamics and level of support. Substance abuse is a family disease, and how the members act and react to the patient’s behavior affects the course of the disease and how the patient sees himself. Many unconsciously become “enablers,” helping the individual to cover up the consequences of the abuse. • Option A: Review family history; explore roles of family members, circumstances involving drug use, strengths, areas for growth. Determines areas for focus, potential for change. Explore how the SO has coped with the patient’s habit, (denial, repression, rationalization, hurt, loneliness, projection). The person who enables also suffers from the same feelings as the patient and uses ineffective methods for dealing with the situation, necessitating help in learning new and effective coping skills. • Option B: Assess the current level of functioning of family members. Affects an individual’s ability to cope with a situation. Determine the extent of enabling behaviors being evidenced by family members; explore with each individual and patient. Enabling is doing for the patient what he or she needs to do for self (rescuing). People want to be helpful and do not want to feel powerless to help their loved one stop substance use and change the behavior that is so destructive. However, the substance abuser often relies on others to cover up their own inability to cope with daily responsibilities. • Option D: Identify and discuss sabotage behaviors of family members. Even though family member(s) may verbalize a desire for the individual to become substance-free, the reality of interactive dynamics is that they may unconsciously not want the individual to recover because this would affect the family member(s)’ own role in the relationship. Additionally, they may receive sympathy and attention from others (secondary gain). 30. 30. Question What is Nurse John likely to note in a male client being admitted for alcohol withdrawal? • A. Perceptual disorders • B. Impending coma • C. Recent alcohol intake • D. Depression with mutism Incorrect Correct Answer: A. Perceptual disorders Frightening visual hallucinations are especially common in clients experiencing alcohol withdrawal. This symptom usually begins within 12 to 24 hours after your last drink, and may last as long as 2 days once it begins. If this happens, you hallucinate (see or feel things that are not real). It is common for people who are withdrawing from alcohol to see multiple small, similar, moving objects. Sometimes the vision is perceived to be crawling insects or falling coins. It is possible for an alcohol withdrawal hallucination to be a very detailed and imaginative vision. • Option B: Delirium tremens commonly begins two to three days after the last alcohol drink, but it may be delayed more than a week. Its peak intensity is usually four to five days after the last drink. This condition causes dangerous shifts in your breathing, your circulation and your temperature control. It can cause your heart to race dangerously or can cause your blood pressure to increase dramatically, and it can cause dangerous dehydration. Delirium tremens also can temporarily reduce the amount of blood flow to your brain. Symptoms can include confusion, disorientation, stupor or loss of consciousness, nervous or angry behavior, irrational beliefs, soaking sweats, sleep disturbances and hallucinations. Alcohol withdrawal is common, but delirium tremens only occur in 5% of people who have alcohol withdrawal. Delirium tremens is dangerous, killing as many as 1 out of every 20 people who develop its symptoms. • Option C: After withdrawal is complete, it is essential that you not begin drinking again. Alcohol treatment programs are important because they improve your chances of successfully staying off of alcohol. Only about 20 per