POTENTIAL CONCEPTS 5D - 211

CONCEPTS: BEHAVIORAL SIGNS AND SYMPTOMS AND NURSING DIAGNOSIS

1. With the diagnosis of a possible pervasive development autistic disorder, the nurse would find it most unusual for
a 3-year-old to demonstrate:
a. Ritualistic behavior c. An attachment to odd objects
b. An interest in music d. A responsiveness to the parents

2. A 7-year-old third grader is brought to the clinic by her mother who tells the nurse that her child has been having
trouble in school, has difficulty concentrating, and is falling behind in her school work since she and her husband
separated 6 months ago. The mother reports that lately her daughter has not been eating her dinner and she
often hears her crying in her room. The nurse realizes that the child:
a. Feels different from her classmates.
b. Is working through her feelings of loss.
c. Would probably be happier living with her father.
d. Probably blames herself for her parents’ breakup.

3. A young college student tells the nurse in the school’s health service that his girlfriend’s period is late and they
both think she is pregnant. The client, with a broad smile on his face, stares loudly and angrily, “If she is pregnant
I will drop out of school, marry her, and get a full-time job.” The nurse’s best initial assessment of the client’s
verbal and nonverbal behavior would be that they are:
a. Uniform. c. Appropriate.
b. Consistent. d. Incongruent.

4. A client with a known history of opiate addiction is treated for multiple stab wounds to the abdomen. After surgical
repair the nurse notes that the client’s pain does not seem to be relieved by the prescribed IM Meperidine
hydrochloride (Demerol) injections. The nurse recognizes that the failure to achieve pain relief from the Demerol
injections indicates that the client is probably experiencing the phenomenon of:
a. Tolerance. c. Physical addiction.
b. Habituation. d. Psychological addiction.

5. When making an assessment of a client’s hallucinatory behavior, the nurse realizes that the most common type of
hallucination is:
a. Visual. b. Tactile. c. Auditory. d. Olfactory.

6. A client with the diagnosis of schizophrenia repeatedly says to the nurse, “no moley, jandu!” The statement “No
moley, jandu” is an example of:
a. Echolalia. b. Concretism. c. A neologism. d. Paleologic thinking.

7. A young client is admitted with a diagnosis of acute schizophrenia. The family relates that one day the client
looked at a linen sheet on a clothesline and thought it was a ghost. The nurse recognizes that this was:
a. An illusion. b. A delusion. c. A confabulation. d. A hallucination.

8. A young male client with the diagnosis of schizophrenia states that he cannot eat because someone has taken his
stomach. The nurse recognizes this is an example of:
a. An illusion. b. A hallucination. c. Depersonalization. d. A somatic delusion.

9. Many clients with schizophrenia often experience opposing emotions simultaneously. The nurse recognizes this
phenomenon as;
a. Double bind b. Ambivalence c. Loose associations. d. Inappropriate affect.

10. While the nurse is assisting a client with the diagnosis of schizophrenia with morning care, the client suddenly
throws off the covers and starts shouting, “My body is disintegrating; I am being pinched.” The term that best
describes the client’s behavior is:
a. Paranoid ideation. c. Loose association.
b. Depersonalization. d. Ideas of reference.

11. A client presents at emergency services stating, “The FBI is trying to kill me.” The client is dressed in soiled
clothes, wears no shoes, has on a pair of sunglasses, and has body odor. The client’s symptoms are most typical
of:
a. Shared paranoia. c. Paranoid schizophrenia
b. Paranoid disorder. d. Paranoid personality.

12. A male client’s statement about a microcomputer implanted in his ear by a foreign agent would help the nurse
recognize that the client is experiencing:
a. Illusions. b. Hallucinations. c. Neologistic thinking. d. Delusional thoughts.

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 13. The nurse recognizes that a paranoid client’s accusations are an example of:
a. A delusion. c. A hallucination.
b. A neologism d. An idea of reference.

14. A disturbed client is admitted for psychiatric evaluation. In taking the nursing history, the nurse asks why the client
came to the hospital. The client states, “They lied about me. They said I murdered my mother. You killed her. She
died before I was born.” The nurse recognizes that the client is experiencing:
a. Ideas of grandeur. c. Persecutory delusions.
b. Confusing illusions. d. Auditory hallucinations.

15. When the nurse is communicating with a client with substance-induced persisting dementia, the client cannot
remember facts and fills in the facts with imaginary information. The nurse is aware that this is typical of:
a. Concretism. c. Flight of ideas.
b. Confabulation. d. Associative looseness.

16. When taking health history from a client with moderate dementia, the nurse would expect to note the presence of:
a. Hypervigilance. c. Enchanced intelligence.
b. Increased inhibition. d. Accentuated premorbid traits.

17. The most basic therapeutic tool used by the nurse to assist a client’s psychological coping is the:
a. Self. c. Client’s intellect.
b. Milieu. d. Helping process.

18. In an attempt to remain objective and support a client during a crisis, the nurse uses imagination and
determination to project the self into the client’s emotions. The nurse accomplishes this by using the technique
known as:
a. Empathy. b. Sympathy. c. Projection. d. Acceptance.

19. Following a traumatic event a client is extremely upset and exhibits pressured and rambling speech. A therapeutic
technique that the nurse can use when a client’s communication rambles is:
a. Touch. b. Silence. c. Focusing. d. Summarizing.

20. A client with an inoperable occipital lobe tumor has been experiencing rather frightening visual hallucinations
especially when alone. The nurse can best help the client cope with these hallucinations by planning to:
a. Move the client to a four-bed room closer to the nurse’s station.
b. Suggest that the client turn on the radio to television when alone.
c. Have family or friends remain with the client until the hallucinations stop.
d. Suggest that the client not be alone and work out a schedule for visitors.

21. Which of these activities would be appropriate for a patient who is delusional?
a. Participating in a table tennis tournament.
b. Visiting a nature preserve with eight other patients.
c. Reading a book in the room.
d. Creating a design with a variety of materials.

22. While a patient is having an acute anxiety attack, which of these attitudes by the nurse would be appropriate when
interacting with the patient?
a. Be calm and reassuring. c. Be stern and professional.
b. Be friendly and concerned. d. Be nurturing and cheerful.

23. A patient is admitted to the psychiatric unit for treatment of depression. The nurse should expect the patient to
have which of these symptoms?
a. Insomnia and hard stools.
b. Confusion about time and place.
c. Distortion in vision and hearing.
d. Psychogenic paralysis and anesthesia of the body parts.

RELATED CONCEPTS: COMMON BEHAVIORAL SIGNS AND SYMPTOMS

24. Disturbances in perception:

Illusion – misperception of an actual external stimuli.
Hallucination – false sensory perception in the absence of external stimuli.

25. Disturbances in thinking

Neologism – pathological coining of new words
Circumstantiality – over inclusion of details
Word salad – incoherent mixture of words and phrases
Verbigeration – meaningless repetition of words or phrases
Perseveration – persistence of a response to a previous question
Echolalia – pathological repetition of words of others
Flight of ideas – shifting of one topic from one subject to another in a somewhat related way
Looseness of association – shifting of a topic from one subject to another in a completely unrelated way

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 Clang association – the sound of the word gives direction to the flow of thought
Delusion – false belief which is inconsistent with one’s knowledge and culture

26. Disturbances of affect

Inappropriate affect – disharmony between the stimuli and the emotional reaction
Blunted affect – severe reduction in emotional reaction
Flat affect – absence or near absence of emotional reaction
Apathy – dulled emotional tone
Ambivalence – presence of two opposing feelings
Depersonalization – feeling of strangeness towards ones self
Derealization – feeling of strangeness towards the environment

27. Disturbances in Motor Activity

Echopraxia – the pathological imitation of posture/action of others
Waxy flexibility – maintaining the desired position for long periods of time without discomfort

28. Disturbances in memory

Confabulation – filling in of memory gaps
Amnesia – inability to recall past events
Anterograde amnesia – loss of memory of the immediate past
Retrograde amnesia – loss of memory of the distant past
Deja vu – feeling of having been to place which one has not yet visited
Jamais vu – feeling of not having been to a place which one has visited

The format of this material is an innovation ® registered under Philippine laws.