Items 41-100 Psychiatric Nursing

41. A client is admitted to the hospital for esophagitis with a secondary diagnosis of alcoholism. Which nursing diagnosis should the nurse consider a priority when planning the clients care?

A. Imbalanced nutrition: Less than body requirements B. Ineffective coping C. Risk for injury D. Disturbed sleep pattern

Rationale: C. This client is at increased risk for injury due to withdrawal from alcohol; therefore, Risk for injury would be the priority. All of the other diagnoses are also applicable to the situation, but are of lesser importance.

42. When intervening with a client who has severe or panic-level anxiety, it is essential for the nurse to: A. become aware of and control her own feelings of anxiety. B. have the client sit down and be quiet, and give detailed instructions to him. C. call security to restrain the client. D. leave the client alone so he well become quiet.

Rationale: A. To effectively deal with a clients anxiety, the nurse must first be aware of her own feelings and gain control over her own anxiety. Anxiety is communicated interpersonally; if not controlled, it can impede the nurses ability to assist the client. Giving detailed instructions to a client with severe or paniclevel anxiety would be ineffective because such a client cant focus. Direction and structure should be provided, but in simple, brief instructions stated in a calm and reassuring manner. Asking the client to sit down and be quiet would be inappropriate because the client may be able to reduce anxiety through physical activity. If the client loses control, safety measures may be required; however, less restrictive measures should always be attempted first. Also, there is no information in the situation indicating a need for physical restraints. A client experiencing severe anxiety or panic requires immediate attention. Leaving the client alone will only exacerbate his anxiety and may lead to loss of selfcontrol.

43. A nurse is working with a client who abuses alcohol. The client has been prescribed disulfiram (Antabuse). The nurse teaches the client that he should: A. avoid the use of alcohol B. eat foods high in tyramine C. take the disulfiram three times a day D. take the disulfiram when feeling the need for a drink.

Rationale: A. The person who drinks alcohol while taking disulfiram (Antabuse) becomes ill with nausea and vomiting, headache, palpitations, and tremor. Clients taking monoamine oxidase inhibitors must avoid tyramine-containing foods. Disulfiram should be taken as prescribed; the usual dose is once daily or three times weekly.

44. A client exhibits the need for progressively larger doses of a psychoactive substance to get the effect previously produced by smaller doses. The client is showing signs of: A. abuse B. addiction C. dependency D. tolerance

Rationale: D. This scenario describes a client who has developed a tolerance to his medication. Abuse involves the use of substances for reasons other than their specific functions; it is often accompanied by a variety of problems. Addiction involves a series of physiologic and psychological symptoms and dynamics related to the use of certain substances. Dependency involves a craving for the effect of a substance, which may be physical or psychological.

45. A client comes into the hospital for surgery and progresses well in the immediate postoperative period; however, approximately 36 hours after surgery, he develops the following symptoms: hypertension, diaphoresis, tremors, and hallucinations. The clients temperature is normal. The nurse suspects these symptoms as signs of: A. complications of surgery B. possible alcohol withdrawal C. possible drug allergy D. possible infection

Rationale: B. This client may have a history of alcohol abuse. The high blood pressure, tremors, and hallucinations all are symptoms of alcohol withdrawal delirium. Tremors and hallucinations are not expected signs of complications from surgery. A drug allergy would include rashes, itching, and possibly more severe symptoms of difficulty swallowing or breathing. An infection would cause a temperature elevation and would not be accompanied by tremors and hallucinations.

46. An elderly client with dementia is experiencing a disturbed sleep pattern. The client has received warm milk and a back rub as per the planned routine. The lights have been turned off. The client gets out of bed and is agitated. Which of the following is the best action for the nurse to take? A. Change the clients room, because his roommate may be keeping him up. B. Consider adding a night light. C. Continue the plan and return the client to bed. D. Leave the client alone; he will eventually get tired.

Rationale: B. A night light may help reduce sundown effect, which is characterized by the elder experiencing increased confusion at night. No evidence presented in the scenario supports changing the clients room. Putting an agitated client back to bed may increase his agitation. Leaving the client alone does not address his safety and rest needs.

47. The nurse should suspect opioid intoxication in a client with: A. dilated pupils, irritability, sweating B. pinpoint pupils, euphoria, elevated pulse C. rapid pulse, dilated pupils, red conjunctivae D. slurred speech, drowsiness, depressed respirations

Rationale: B. Common signs of opioid toxicity include pinpoint pupils, euphoria, and an elevated pulse rate. The findings in option A are indicative of amphetamine or cocaine intoxication. Option C includes common signs of marijuana intoxication. Option D covers findings associated with intoxication from sedatives.

48. A client with obsessive-compulsive disorder is treated with aversion therapy. This treatment is most consistent with which of the following conceptual frameworks? A. Behavioral framework B. Cognitive framework C. Psychobiologic framework D. Psychodynamic framework

Rationale: A. Behavioral frameworks focus on the idea that stimuli cause human behavior and the belief that persons are shaped by their environments. Treatments consistent with this framework are aversion therapy and behavior modification therapy. Aversion therapy is performed by introducing unpleasant or uncomfortable stimuli to interrupt or discourage a particular behavior. Cognitive frameworks focus on how thinking influences feelings and behaviors. Treatments more consistent with this framework include rational-emotive therapy cognitive restructuring. Psychobiologic frameworks focus on physical illness of defects (for example, infections, genetic problems, or biochemical problems). Psychopharmacologic therapies are consistent with this framework. Psychodynamic frameworks focus on developmental theories (for example, Freud and Erikson) and personality dynamics. Treatments consistent with this framework include psychoanalysis and hypnosis.

49. A client with obsessive-compulsive personality disorder will probably exhibit: A. an exaggerated sense of selfimportance B. a lack of concern about right and wrong C. rigidity and a moralistic attitude D. rigidity, temper tantrums, and impulsiveness

Rationale: C. Clients with obsessive-compulsive personality disorder typically exhibit a moralistic and judgmental attitude and are generally rigid. An exaggerated sense of selfimportance is seen in those with narcissistic personality disorder. A lack of concern about right and wrong is commonly attributed to antisocial personality disorder. Although rigidity is seen in clients with obsessivecompulsive disorder, temper tantrums and impulsiveness are not. Temper tantrums are common in histrionic personality disorder; impulsiveness, in borderline personality disorder.

50. A client who is taking sertraline hydrochloride, a serotonin reuptake inhibitor, complains of gastrointestinal upset with diarrhea. The nurse should tell the client that this is: A. a possible adverse reaction B. a temporary side effect C. an expected side effect D. an unrelated symptom

Rationale: A. Although this drug has a low incidence of side effects and adverse reactions, gastrointestinal upset and diarrhea are potential chronic side effects that may warrant a medication change.

51. State two coping mechanisms for dealing with anxiety is listed as one of the goals in the care plan of a bulimic client. Which statement by the client indicates that the goal has been met? A. I binged and purged twice during my home visit. B. I tried calling my friend when I felt anxious, and I went for a swim. C. I used deep breathing when travelling today. D. Writing in a journal was not helpful.

Rationale: B. Calling a friend and going for a swim are both positive coping strategies, and the client should be commended for using them. Although the statement in option A indicates that the client was unable to meet the goal, the information can serve as a basis for discussion about the clients feelings, situations, and thoughts. The focus should not be on failing to meet the goal, but on looking at contributing factors that thwarted her effort. Option C only mentions one coping measure (deep breathing), indicating partial achievement of the goal; however, the client should be praised for her effort. The client also tried journal writing as a coping mechanism, but apparently it was unsuccessful.

52. A client with a borderline personality disorder has two healing, closed, blistered areas (approximately 7 mm in size) on the palmar surface of his left hand. Which of the following interventions would be the nurses best initial response? A. Assess for self-mutilating behavior B. Call the psychiatric to see the client C. Do not address the blisters D. Perform wound care

Rationale: A. Further assessment is especially important because individuals with borderline personality disorder commonly engage in selfmutilating behavior as a means of acting out to deal with anxiety and anger. After assessing the client, the nurse should share this information with the psychiatrist and other appropriate members of the health care team. Not addressing the blisters would ignore the clients underlying problems with anxiety and anger. Because the wounds are healing and closed, wound care is probably unnecessary; however, the client needs further assessment for his self-destructive behaviors.

53. A client is mildly agitated walking to the exit of the hospital unit. When attempting to redirect an agitated and confused client, the nurse should take which approach? A. Approach the client calmly, explaining that you will touch him. B. Call the client from a distance in a loud voice. C. Change your activity so the client will be distracted. D. Quickly approach the client and take the client by the arm.

Rationale: A. A calmly stated explanation will be nonthreatening. It is important to tell the agitated client that you are going to touch him before doing so. A perceived threatening move will increase his agitation. A loud voice may be interpreted as a potential threat. Changing the activity may be too subtle to provide distraction in the agitated client. Quickly approaching the client and taking him by the arm may frighten him, increasing his agitation.

54. An obese client continues to gain weight. The nurse observes the client obtaining candy and snacks from other clients and plans to use confrontation in her interaction with the client. It will be important for the nurse to: A. ask the client why he is behaving in this manner. B. focus on the clients explanation of his behavior. C. inform the client that his 24-hour calorie totals will be reduced. D. point out the behavior as close to the snacking as possible.

Rationale: D. When using confrontation as a therapeutic technique, it is important to point out the problematic behavior as close as possible to the act. The nurse should strive to be specific and nonjudgmental, maintaining focus on the behavior. Asking why the client is behaving in this manner is generally not effective because the client probably is unaware of the reason. The nurse should focus on the actual behavior, not the clients explanation of the behavior, when using confrontation. Option D does not address the problem behavior and can easily be interpreted as a punitive action, which is countertherapeutic.

55. A client with a diagnosis of borderline personality disorder tells her nurse that she wishes the night shift nurses were as kind as the day shift nurses. This is an example of: A. confrontation B. defensiveness C. negativism D. splitting

Rationale: D. The client is exhibiting the coping mechanism of splitting, in which the individual views the world in terms of all bad vs. all good. Confrontation involves directly sharing feelings about negative behavior with another person. This is not example of defensiveness. The client in this situation does now view the day shift nurses in a negative manner.

56. The nurse has just been informed that a new client on the unit has a diagnosis of schizophrenia, paranoid type. Based on this limited information, the nurse knows that she will need to address which basic need first? A. Esteem and recognition B. Love and belonging C. Physiologic integrity D. Safety

Rationale: D. A client with paranoid schizophrenia generally feels unsafe in his environment and acts in a manner to promote his comfort, recognition, love, and belonging are not top priorities for an acutely ill client who is experiencing paranoid ideation. There is no information suggesting that the clients basic physiologic needs have not been met, so this is not a top priority.

57. The nurse is assessing the client for stressors. The most complete assessment would include which of the following? A. Life events, blood pressure, pulse, and presence of increased muscle tension. B. Life events, presence of anxiety, presence of fatigue, and physical illness. C. Life events, pulse, blood pressure, and presence of rapid, shallow respirations. D. Life events, subjective symptoms, previous coping strategies, and clinical signs.

Rationale: D. A thorough assessment of a client with stress should include a complete review of life events, subjective symptoms, clinical manifestations, and coping strategies. Options A and C fail to address subjective symptoms and coping strategies. Option B fails to address clinical manifestations and coping strategies.

58. A client with dementia accidentally knocks over a lamp. When his wife arrives and asks about the lamp, he explains that the cat knocked over the plant, which hit the lamp. This is an example of: A. confabulation B. confusion C. denial D. lack of insight

Rationale: A. Confabulation refers to a fabricated response by the client to compensate for an event he cant recall. Confusion is most likely related to a disturbed orientation. Denial involves an unconscious disavowing of thoughts, needs, or external reality. Lack of insight refers to ones judgment.

59. A nurse is caring for a child with depression. Psychopharmacology is one of the treatment modalities being used. Which of the following medication is most commonly used in childhood depression? A. Chlorpromazine (Thorazine) B. Fluoxetine (Prozac) C. Lithium carbonate (Eska-Lith) D. Methylphenidate (Ritalin)

Rationale: B. Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor commonly used to treat depression. Chlorpromazine is an antipsychotic medication. Lithium is used as a mood stabilizer in bipolar disorder and in the treatment of behavioral problems. Methylphenidate is used to treat attention deficit hyperactivity disorder.

60. The client exhibiting mistrust, guardedness, and restricted affect is showing signs of which personality? A. Antisocial personality disorder B. Dependent personality disorder C. Narcissistic personality disorder D. Paranoid personality disorder

Rationale: D. Paranoid personality disorder is characterized by suspiciousness and mistrust, jealously, guardedness, lack of emotional expression, and use of projection. Some of the characteristic features of antisocial personality disorder include emotional lability, controlling behavior, and an intense, dramatic, or overemphasized affect. Clients with dependent personality disorder typically are indecisive and have difficulty with independent behavior. Those with narcissistic personality disorder typically exhibit grandiose thinking, an exaggerated sense of self-importance, and attention-seeking behavior.

61. A client with delirium points to the coat rack in the room and asks the nurse, Why is that man standing over there? The nurse should document that the client: A. is suffering from delusions. B. had a hallucination. C. is experiencing illusions. D. had a panic attack.

Rationale: C. Illusions are sensory perceptions that have some basis in reality. The coat rack, the object in the corner, is the stimulus for this misperception. Delusions are false beliefs that remain despite contradictory evidence. Hallucinations are false sensory perceptions. Panic is an extreme state of anxiety in which the person feels that death is imminent.

62. A family has been told of the sudden death of their loved one. The nurse can expect that the grieving family initially will be: A. accepting B. angry C. crying D. disbelieving

Rationale: D. The first stage of grief is shock and disbelief. Denial is the defense mechanism used here and serves a therapeutic purpose. Crying usually occurs as the grieving family develops the pain of awareness, during the second stage of the grieving process. Anger usually comes later, and the nurse may have the anger directed toward her. Acceptance occurs in the final stage of grief.

63. A client is admitted to the hospital because suicidal thoughts. The nurse knows that the incidence of suicide is highest among which population? A. Children younger than age 10 B. Married adults C. Older, widowed men D. Single, young women

Rationale: C. The incidence of suicide increases with age in men, particularly among those who are divorce or widowed. Although the incidence has increased in children and adolescents in recent years, suicide is rare in children under age 10. The incidence of suicide is generally low among married adults. Among women, the incidence peaks between ages 45 and 54.

64. A client is being admitted to the unit for treatment of bipolar disorder, mania. The nurse would expect to assess which of the following physiologic symptoms in this client? A. Exhaustion and reduced appetite. B. Hypersexually and reduced appetite. C. Hypersomnolence and increased appetite. D. Hypoactivity and somnolence.

Rationale: A. Both exhaustion and reduced appetite are generally due to hyperactivity, a characteristic feature of someone in a manic state. The nurse would also expect the client to have insomnia, not somnolence. Hypersexually is a behavioral, not physiologic, response.

65. When assessing a client with paranoid schizophrenia, which findings should be the nurses immediate concern? A. Immobility, clanging, altered sleep patterns, and difficult family relationships. B. Problems with role-functioning, peculiar mannerisms, and decreased social competence. C. Stressful life events, altered sleep patterns, fatigue, and hostility. D. Paranoid delusions, increased suspiciousness, and hostility.

Rationale: D. Paranoia, suspiciousness, and hostility place the client and others at increased risk for violence and require the nurses immediate attention. Although the remaining assessment findings are important and applicable to the clients condition, they are not priorities.

66. A client with moderate anxiety is most likely to exhibit which of the following signs and symptoms? A. Hypervigilance and increased blood pressure B. Increased heart rate and decreased ability to concentrate C. Increased heart rate and decreased blood pressure D. Sweaty palms and increase salivation

Rationale: B. Moderate anxiety is typically accompanied by an increased heart rate along with signs of diminished ability to concentrate (selective inattention, difficulty remaining attentive, decreased learning ability). Hypervigilance, a state in which an individual scans his environment for threats, is more common in severe anxiety or panic episodes than in moderate anxiety. Besides increased heart rate, other physiologic manifestations of anxiety include increased blood pressure, sweaty palms, and dry mouth. Increased salivation is not associated with this disorder.

67. A client with bulimia complains of feeling helpless and having a black future and says, Whats the use? When planning care for this client, the nurse would consider which nursing diagnosis the top priority? A. Imbalanced nutrition: less than body requirements B. Anxiety C. Ineffective coping D. Risk for self-directed violence

Rationale: D. The verbalized helpless feelings, use of the term black to describe the future, and the hopeless comment of Whats the use? are good indicators that the client is depressed (depression is a common finding in bulimic clients) and may be at risk for suicide. This issue demands further attention. The diagnosis Imbalanced nutrition: less than body requirements does not directly address the clients current mental status and, therefore, is not a priority. Anxiety is a factor in this illness, but the data does not support this diagnosis. Although the clients coping skills are obviously lacking, Ineffective coping is not the priority diagnosis.

68. Which of the following substances are known to promote central nervous system stimulation? A. Alcohol and Demerol B. Cocaine and Dexedrine C. Demerol and cocaine D. Marijuana and alcohol

Rationale: B. Cocaine and Dexedrine (dextroamphetamine) are both CNS stimulants. Alcohol and Demerol (meperidine hydrochloride) are CNS depressants. Marijuana, a cannabinoid, has some CNS depressant effects.

69. Which of the following statements best describes the therapeutic nurse-client relationship? A. The nurse and client are committed to one another and care for each other. B. The nurse and client meet as needed by the client for the clients needs. C. The nurse and the client enter a goaldirected and purposeful interaction. D. The nurses and the clients needs and problems are the focus of the relationship.

Rationale: C. The therapeutic nurse-client relationship is purposely, goal-directed, and focused on the client. The length of the relationship, the meetings, focus, and termination are all defined at the onset. The basic principles of confidentiality apply to this relationship. The client and the nurse have specific roles and responsibilities. The nurse is the facilitator and professional helper, whereas the client is in the relationship to focus on specific needs and problems. The description given in option A is more consistent with an intimate relationship. The description in option B is more consistent with a social relationship. The description in option D is more consistent with a mutual friendship.

70. When caring for a client who has received naloxone (Narcan) for an overdose of opioids, the nurse should be chiefly concerned with which of the following? A. Acute withdrawal B. Dystonic reaction C. Future overdoses D. Narcan intoxication

Rationale: A. The nurse must be alert to the possibility that the client may experience an acute withdrawal. Dystonic reaction (dyskinesia) is a common manifestation of adverse extrapyramidal effects associated with the start of neuroleptic drug therapy. Although the possibility of future overdoses should be addressed, this is not a chief concern at this time. Narcan is a narcotic antagonist with a fast onset and short duration of action; intoxication is unlikely.

71. Which of the following behaviors would be an indication of substance abuse that requires further assessment? A. The client decides not to drink at a party because he is on antibiotics. B. The client is concerned about drinking but continues to do so. C. The client reports feeling tipsy after one glass of wine. D. The client substitutes alcohol-free beer when he wants a drink.

Rationale: B. Characteristics of substance abuse include the continued use of a substance despite the individuals awareness of problems associated with it. Such problems may include drinking when it is dangerous or when not recommended to do so. Option A shows good judgment on the part of the client; it does not indicate a problem with alcohol. Many clients feel the effects of alcohol after only one drink; this does not necessarily indicate a substance problem. The client in option D may be addicted to alcohol but is not currently abusing it because he has chosen an appropriate substitute.

72. A severely depressed client is admitted to the inpatient unit. Which action should the nurse take initially? A. Assist the client to meet her physiologic needs. B. Design a structured program of activities for the client. C. Involve the client in unit activities. D. Provide a group opportunity for the client to discuss her feelings.

Rationale: A. The clients physiologic needs must be met first. All of the other interventions are appropriate later.

73. A male client is reporting a decreased desire for sexual activity. Which of the following medications would the nurse consider to be related to the clients reports? A. Disulfiram (Antabuse) and testosterone therapy B. Antihistamines and steroid therapy C. Antihypertensives and steroid therapy D. Tricyclic antidepressants and antipsychotics

Rationale: D. Both tricyclic antidepressants and antipsychotics are known to decrease the desire for sex, in addition to exerting other effects that may influence ones sexual activity. Antabuse may delay orgasm. Testosterone may increase desire. Antihistamines influence lubrication. Steroids increase desire. Although antihypertensives can influence ones arousal or inhibit orgasm, the desire may still be present

74. Which of the following laboratory findings would be expected in a client with Wernicke-Korsakoff syndrome? A. Dopamine deficiency B. Serotonin deficiency C. Vitamin B1 deficiency D. Vitamin B12 deficiency

Rationale: C. Thiamine (vitamin B1) deficiency is seen in WernickeKorsakoff syndrome. Dopamine deficiency is associated with Parkinsons disease. Serotonin deficiency is associated with depression. Vitamin B12 deficiency is associated with various conditions, but not Wernicke-Korsakoff syndrome.

75. During his admission assessment, a depressed father states, I should have said something else to my daughter. The client repetitively remarks about the interaction and expresses apologies and feelings of guilt about the interaction with his daughter. The nurse recognizes this as a form of: A. anhedonia B. manipulation C. rumination D. somatization

Rationale: C. Ruminations are cognitive processes in which the client reviews a particular event (which he evaluates as negative) over and over. Anhedonia is used to describe the inability to enjoy those things that previously were a source of pleasure. Manipulation is a disruption in relatedness with others in which people are treated as objects to meet ones needs. Somatization is a focus on bodily functions.

76. When interacting with a client with a schizophrenic disorder, the nurse should remember to: A. avoid interactions whenever possible. B. have intensive 1-hour counseling sessions twice a day. C. speak loudly and clearly. D. use brief, simple statements.

Rationale: D. A client with a schizophrenic disorder may have difficulty with sorting information. Verbal interactions should be brief, using simple terms. The client probably already feels alone; avoiding him would only increase his anxiety. Long or multiple sessions are too intense for such a client. Unless the client is deaf, he can hear the nurse who speaks in a normal tone.

77. La belle indifference is a common manifestation of which disorder? A. Conversion disorder B. Dissociative disorder C. Posttraumatic stress syndrome D. Somatization disorder

Rationale: A. In conversion disorder, the client experiences a loss of physical functioning, which is an expression of psychological need or conflict. La belle indifference is a specific manifestation of conversion disorder in which the client expresses little concern or anxiety about the loss. For example, a client may become blind (no physiologic reason blindness can be found) after a traumatic event, but is not distressed by the blindness. Dissociative disorders are a collection of disturbances characterized as alterations in identity, memory, or consciousness. Posttraumatic stress syndrome (usually experienced after a psychologically traumatic event) involves the clients reexperiencing thoughts and feelings associated with the trauma through nightmares or flashbacks. Somatoform disorder is characterized by multiple physiologic complaints with no evidence of organic impairment; the individual commonly seeks medical attention and is often anxious about symptoms.

78. Which of the following behaviors by the alcoholics family demonstrates adequate knowledge about alcoholism? A. Accepting drinking by the client at various celebrations during the year. B. Allowing the client to experience the consequences of alcohol use. C. Frequently checking for alcohol around the house and making phone calls to validate actions. D. Helping the client maintain self-esteem by offering reasons for alcohol use.

Rationale: B. The alcoholic client must be allowed to experience the negative consequences of his actions to realize that alcohol is controlling his life. The best approach to successful treatment involves total abstinence and the development of better coping skills. Option C denies the client the opportunity to assume responsibility for his actions and to seek alternative means of coping. Option D is an example of enabling behavior, which actually impedes sobriety.

79. An 18-year-old man is admitted to the inpatient unit with a diagnosis of schizophrenia. As the nurse approaches him, she notices that he is grimacing and talking to the wall. The nurses first action should be to: A. ask him if he is hearing voices. B. ask him to walk in the hall. C. engage him in conversation. D. have him placed in seclusion

Rationale: A. The client may be experiencing auditory hallucinations, so asking whether he hears voices would be appropriate. After determining whether he is hallucinating, the nurse may ask him to walk in the hall or engage him in conversation as a way to bring him back to reality. Because he is not acting out aggressively or posing a risk to himself or others, there is no need for seclusion; besides, doing so at this time would only increase his anxiety.

80. A client reports having had his last drink of alcohol 2 days ago. The nurse knows that signs of impending alcohol withdrawal delirium are: A. abdominal cramping, runny nose, and restlessness. B. decreased pain response and extreme violent behavior. C. excessive eating and sleeping, muscle aches, and euphoria. D. tremors, anxiety, and visual hallucinations.

Rationale: D. Alcohol withdrawal syndrome (alcohol withdrawal delirium) usually occurs 48 to 72 hours after the last drink; its manifested by increased intensity of symptoms (anxiety, tremulousness, pronounced disorientation, insomnia, tachycardia, vomiting, visual hallucinations, and seizures).

81. A client who has just been informed of the death of a close relative begins to discuss the stages of death and dying identified by Kubler-Ross. The nurse would assess the clients behavior as a form of: A. disorientation B. intellectualize C. suppression D. failure to listen

Rationale: B. Intellectualization is a defense mechanism in which the individual uses his intellectual powers to blunt or avoid emotional stress. A client using this mechanism typically provides an explanation while showing no feeling or affective quality. Disorientation refers to an individuals inability to identify himself in relation to time, place, or person. Suppression is a defense mechanism in which an individual voluntarily excludes anxiety-producing feelings from awareness. Failure to listen is incorrect in this situation because the client has made some connection to the content of the communication, and therefore must have been listening to it.

82. The client states, I am low, how low can you go, Im going to get married. Yeah, Im going to marry Bill. Ive got lots of bills to pay after that last spree! Which observation is the nurse likely to document about this client? A. Circumstantiality was noted. B. Disorientation was noted. C. Flight of ideas was noted. D. Speech patterns using word salad was noted

Rationale: C. Flight of ideas, the swift shifting from one topic to the next, typically results from the manic clients easy distractibility. Circumstantial speech involves providing unnecessary, seemingly endless detail before getting to the point of the conversation. There are no data to suggest the client is disoriented. Word salad is a speech pattern that involves a series of unconnected words.

83. Which physiologic responses would the nurse expect to assess in a client with major depression? A. Anhedonia, increased appetite, and anger. B. Anhedonia, indecisiveness, and loneliness. C. Constipation, insomnia, and fatigue. D. Decreased appetite, apathy, and fatigue.

Rationale: C. Constipation, insomnia, and fatigue are all physiologic responses that can occur in someone with major depression. The symptoms listed in option A are a combination of behavioral, affective, and physiologic responses. The symptoms listed in option B are behavioral and cognitive responses. Those mentioned in option D are affective and physiologic responses.

84. Which of the following is associated with alterations in sexual identity? A. Exhibitionism B. Masturbation C. Promiscuity D. Transsexualism

Rationale: D. Transsexualism is a form of altered sexual identity in which one believes oneself to be of the sex opposite to ones anatomic gender. The other options listed are all unrelated to sexual identity. Exhibitionism is a form of paraphilia. Masturbation is self-stimulation for the purpose of reaching orgasm. Promiscuity is an alteration in sexual behavior.

85. Which of the following is the client communicating to the nurse when stating, I feel dead. A. The client is expressing a sense of depersonalization. B. The client is hallucinating. C. The client is speaking with a word salad. D. The client is trying to express sadness and depression.

Rationale: A. The clients communication is a form of depersonalization, a disturbance in thinking in which the person disengages from the self (as if in a dream). Hallucinations are sensory perceptual alterations, not a form of communication. There is no evidence of word salad (the stringing together of different, unrelated words) in this statement. The clients statement does not address affect (sadness, depression).

86. A school nurse teaches a sexual health education class. The nurse would plan to include which of the following concepts? A. All sexual behavior is appropriate. B. Sexuality begins to develop as you get older. C. Sexuality is part of ones personal identity. D. Masturbation is harmful.

Rationale: C. An effective sexual education program should communicate the importance of sexuality to personal identity. Although tolerance of alternative views is important, not all sexual behavior is appropriate. Humans grow and change throughout life, but our sexuality is present at birth. There are many myths about masturbation, including the inaccurate notion that it is harmful.

87. When planning care for a newly admitted client with obsessivecompulsive disorder, which of the following is essential to remember? A. Completion of rituals decreases anxiety. B. Interviewing should focus on reasons why the rituals are needed. C. Mistakes should not be tolerated. D. The cycle of rituals must be interrupted.

Rationale: A. The rituals performed by a client with obsessive-compulsive disorder are an attempt to decrease anxiety. If they are not allowed, the clients anxiety level will increase. As the clients treatment progresses, the need for rituals becomes less important. The focus of the interview should be on the client and her needs, rather than on the ritual itself. The nurse should be tolerant of mistakes. The client who has obsessive-compulsive disorder tends to be perfectionistic. Rituals should be maintained at the beginning of treatment until anxiety levels are sufficiently reduced.

88. A client with a documented history of delusional thoughts is admitted to the hospital. Which of the following information is most important for the nurse to gather during the initial assessment? A. Content of the delusional thoughts. B. Detailed account of thoughts. C. Medication compliance history. D. Orientation level.

Rationale: A. The nurse must be made aware of the specific type of delusion the client is having to ensure the safety of the client and others on the unit. Asking the client for a detailed account of his thoughts, which are delusional, would reinforce his nonreality. Medication compliance is an important issue, but the content of the delusional will help determine the level of safe care required. The client has a history of delusional thoughts; therefore, the nurse can assume he is disoriented.

89. When working with a client hospitalized with an eating disorder, the nurse should: A. monitor the type and amount of food consumed. B. observe the client for 15 minutes following meals. C. permit the client as much time as necessary to eat. D. weigh the client once a week.

Rationale: A. The client with an eating disorder must be monitored carefully to determine that her nutritional needs are being met. She should be observed for 1 hour after meals to prevent selfinduced vomiting. She should be given no more than 30 minutes to eat because she may dawdle over meals to gain attention. The client should be weighed daily at the same time, wearing the same amount of clothing.

90. A client reports a vague feeling of apprehension and states, I feel scared. He also has an increased pulse rate and blood pressure. Which of the following nursing diagnoses is most appropriate in this situation? A. Anxiety B. Fear C. Ineffective coping D. Disturbed sleep pattern

Rationale: A. Anxiety is defined as a vague and uneasy feeling, the source of which is often nonspecific or unknown to the individual. Increases in pulse rate and blood pressure are also common in anxiety. Fear is not vague; it is attributed to an identifiable source that can be subjectively validated. Ineffective coping reflects an impairment of adaptive behaviors and problem-solving abilities in meeting lifes demands and roles. The defining characteristics given in this question are not consistent with this diagnosis. A Disturbed sleep pattern is defined as a disruption of sleep time that causes discomfort or interferes with ones desired lifestyle. There is no information related to this diagnosis in the question.

91. The nurse knows that cues for potential aggression include: A. pacing and clenching fists. B. staying in bed. C. talking fast and muttering to oneself. D. visiting with other clients.

Rationale: A. Pacing and clenching of fists are signs of impending aggressive behavior. Staying in bed may be a sign of depression. Talking fast and muttering can signal anxiety. An angry and potentially aggressive client usually withdraws from others.

92. The nurse is caring for a client who is experiencing escalating levels of anxiety. The doctor orders medication to be given. Which medication would the nurse expect to administer in this situation? A. Alprazolam (Xanax) 0.5 mg p.o. t.i.d. B. Meclizine hydrochloride (Antivert) 25 mg p.o. t.i.d. C. Ranitidine hydrochloride (Zantac) 150 mg p.o. b.i.d. D. Sertraline hydrochloride (Zoloft) 50 mg p.o. every day.

Rationale: A. The nurse would expect to administer alprazolam, a benzodiazepine anxiolytic agent used to manage anxiety disorders or to provide short-term relief of anxiety symptoms. Meclizine hydrochloride is an antihistamine that is commonly used to manage nausea, vomiting, and dizziness associated with motion sickness and vertigo. Ranitidine hydrochloride is an H2-receptor antagonist used to treat various gastrointestinal problems (duodenal ulcers, gastroencephageal reflux disease, and benign gastric ulcers). Sertraline hydrochloride is a selective serotonin reuptake inhibitor used in the treatment of major depression.

93. When caring for a client with panic level anxiety, the nurse should consider which expected outcome to be a priority? A. The client will discuss his concerns for 10 minutes, three times a day. B. The client will verbalize a decreased level of anxiety by the end of the hospitalization. C. The client will verbalize a decreased level of anxiety within 2 hours. D. The client will state the name and dose of the anxiolytic medication.

Rationale: C. The ability to verbalize a decreased level of anxiety within 2 hours of a panic episode reflects that the clients need for immediate relief has been met. Option A may be appropriate when anxiety levels are not at the panic state. At this point, the client requires prompt intervention and a timely outcome; waiting until the end of hospitalization for validation that the clients anxiety level has decreased is inappropriate. The clients ability to state the name and dose of his medication would be appropriate in relation to the client teaching phase of nursing care. A client experiencing a panic level of anxiety will not be able to learn.

94. Which of the following is the most common reason for clients with personality disorders to enter the health care system? A. Because of their affective disorders or social or law enforcement entanglements. B. Because they are found to be insane. C. Because of their brief episodes with affective disorders. D. Because they seek treatment for their primary personality disorder.

Rationale: A. Clients with personality disorders commonly gain entry into the mental health system because of depression, suicide attempts, or brushes with social services or law enforcement agencies. Option B is untrue. Option C is incorrect because clients with personality disorders characteristically have longstanding, chronic problems and issues. Generally, clients do not seek treatment due to their lack of insight about the problem and the fact that, in most cases, there is no loss of touch with reality.

95. A clients history includes three documented episodes of hypomania. The nurse understands that hypomania: A. is a depressive state that is not considered full-blown depression. B. is a state of extreme excitement and euphoria that does not require hospitalization. C. is a state of mania that is less severe than a manic episode. D. is a state of slowed thinking with both sad and euphoric episodes.

Rationale: C. Hypomania is defined as a state of mania that is less severe than a manic episode. Dysthymia is a chronic depressed mood that is not as severe as major depression. Mania is a state of extreme excitement and euphoria. Hypomania is not characterized by slowed thinking or sad episodes.

96. Which of the following illustrates a common symptom of schizophrenia? A. During a discussion of the loss of a parent, the client is laughing uncontrollably. B. The admission history describes the clients affect as appropriate and the mood as depressed. C. The client has strong feelings about a decision to go to supervised housing. D. The client is an active participant in verbal groups on the unit.

Rationale: A. A client with schizophrenia characteristically has an inappropriate affect, as demonstrated by uncontrollable laughter upon hearing about a significant loss. Although the client may appear depressed (option b), his affect would most likely be inappropriate. Ambivalence and difficulty with decisions, rather than expression of strong feelings (option c), are more characteristic of schizophrenia. The client would probably be autistic or withdrawn rather than an active participant in a group (option d).

97. A client with schizophrenia states, The TV screen is constantly communicating with me. Which of the following would the nurse document? A. Delusions of grandeur B. Ideas of influence C. Ideas of reference D. Looseness of association

Rationale: C. Ideas of reference reflect a belief that either persons of objects are communicating with the individual. Delusions of grandeur reflect a fixed false belief about ones own importance. Ideas of influence reflect a belief that the individuals ideas are controlled externally. Looseness of association reflects a lack of logical progression or organization to ones thoughts.

98. A client is seen in the emergency department for chronic gastritis. In response to questions about the bruises on his arms, he says, I fell the other night on a wet kitchen floor. He reports some financial problems and poor sleep. These signs and symptoms are cues for the nurse to: A. assess the client using the Glasgow Coma Scales B. have the client complete an AIMS test. C. interview the client regarding substance abuse. D. investigate the clients home environment.

Rationale: C. Chronic gastritis accompanied by such assessment data as bruises, financial problems, and poor sleep may indicate substance abuse. The nurse should investigate this possibility further. A Glasgow Coma Scale is used to assess a clients level of consciousness. An AIMS test is given to assess motor problems in clients who are taking prescribed antipsychotic drugs. Investigating the clients home environment is not the role of an emergency department nurse.

99. When scenario best typifies a client with somatoform disorder? A. A client describes multiple gastrointestinal complaints without organic pathology. B. A client exhibits a morbid preoccupation with the fear of cancer. C. A client has recurrent episodes of intense anxiety that keep her from activities. D. A client recognizes an overwhelming and uncontrollable fear of episodes.

Rationale: A. A client with a somatoform disorder characteristically has multiple physiologic complaints with no evidence of organic impairment and commonly seeks medical attention. A client with hypochondriasis has a preoccupation with the fear of a serious disease (such as cancer) in the absence of organic problems. Typically, the clients fears are not relieved by reassurance and negative diagnostic results. Panic disorder is characterized by recurrent, unpredictable episodes of intense apprehension, fear, or terror, in which the episodes or attacks interfere with the clients normal functioning. Phobic disorders are described as persistent, irrational fears usually focused on specific objects (such as spiders), an activity, or situation. The individual recognizes that the fear is irrational but cant control it.

100. A client expressing suicidal thoughts suddenly becomes very calm and has a much improved outlook on life. The nurse recognizes that this behavior typically indicates: A. improved coping skills. B. increased self-esteem. C. an increased suicide risk. D. a positive response to treatment.

Rationale: C. A sudden lifting of mood in a suicidal client may signal that he has made the decision to act on his intention. Although the described behaviors may indicate that the client has developed improved coping skills and an increased self-esteem both viewed as positive response to treatment further assessment is needed before this can be determined. Normally, these changes are not sudden, though.