NUR 356 Exam 4 Practice Questions
Family members of a client ask the nurse to explain the difference between schizoid and avoidant personality disorders. Which is the appropriate nursing reply? A. "Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone." B. "Clients diagnosed with schizoid personality disorder exhibit odd, bizarre, and eccentric behavior, whereas clients diagnosed with avoidant personality disorder do not." C. "Clients diagnosed with avoidant personality disorder are eccentric, and clients diagnosed with schizoid personality disorder are dull and vacant." D. "Clients diagnosed with schizoid personality disorder have a history of psychotic thought processes, whereas clients diagnosed with avoidant personality disorder remain based in reality."
A. "Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone." Rationale: Clients diagnosed with avoidant personality disorder desire intimacy but fear it, whereas clients diagnosed with schizoid personality disorder prefer to be alone.
A nurse is assessing a client who has a history of alcohol use disorder. Which of the following questions should the nurse include to determine how the use of alcohol affects the client's psychosocial behaviors? A. "Has alcohol use affected your performance at work?" B. "Do you take any over the counter medications?" C. "Do you receive treatment for any mental health disorders?" D. "What type of alcohol do you drink?"
A. "Has alcohol use affected your performance at work?" Rationale: Inquiring about work performance is appropriate to include in a psychosocial assessment related to substance use disorder. Understanding if the client has any other mental health diagnosis aides in the planning of care but is not specifically psychosocial. Understanding type doesn't address the psychosocial behavior of the client.
A home health nurse is speaking to a group of acute care nurses about domestic violence. Which of the following statements by one of the acute care nurses indicates a need for clarification? A. "I have heard that abusers think of themselves as very important and have high self-esteem." B. "Domestic violence escalates during pregnancy." C. "I know that abusers lack social support and social skills." D. "I have heard that abusers keep their victims isolated from others."
A. "I have heard that abusers think of themselves as very important and have high self-esteem." Rationale: Victimizers typically have low self-esteem and diminished feelings of self-worth. They may show a different type of personality to the community than the one shown to the partner. They keep their partners isolated from others and this potentiates the cycle of abuse.
A nurse is assessing a child and suspects child abuse. Which assessment finding support the nurse's assumption? A. A circular burn on the child's arm B. A bump on the child's forehead C. Redness on the child's legs D. The child does not want to listen to instructions
A. A circular burn on the child's arm Rationale: A circular burn is not a normal finding and can indicate a burn from a cigarette or other smoked substance. Bruising is an expected finding if a child is active these will be in consistent areas that would indicate falls during play. Children that are active may present with bumps on head from falls. A child that has been abused may rather than acting out be subdued and fearful.
A group of nurses is discussing how food is used in their families and the effects this might have on their ability to work with clients diagnosed with eating disorders. Which nurse is most likely to be most effective with these clients? A. A nurse that refuses to engage in power struggles over food B. A nurse that allows her children to be "picky" eaters C. A nurse that stresses the importance of balanced meals daily D. A nurse that grew up in a house with very little food
A. A nurse that refuses to engage in power struggles over food Rationale: The nurse who refuses to engage in power struggles is likely to be the most effective when working with clients with eating disorders. The nurse understands that the client's issues are related to control rather than food consumption.
A nurse is educating staff on personality disorders. Which statement by the staff indicates understanding? A. Antisocial personality disorder can start as conduct disorder B. It is very easy to categorize the clients based on their disorder C. All clients with personality disorders were the victims of abuse D. All clients with personality disorders take advantage of others
A. Antisocial personality disorder can start as conduct disorder Rationale: APD can start as conduct disorder while in childhood. The different disorders overlap and can be difficult for even prescribers to identify. These disorders have signs that you look for and will create a plan of care based on what behaviors and thoughts the client has.
Which of the following is an FDA approved medication for the pharmacological intervention of Autism Spectrum Disorder (ASD)? A. Aripiprazole B. Zoloft C. Methylphenidate D. Prozac
A. Aripiprazole Rationale: The two medications for ASD approved by the FDA are risperidone and aripiprazole. These medications target aggression, self injury, temper tantrums, and quick changes in mood.
A nurse is admitting a 14-year-old with conduct disorder. What would the nurse anticipate finding in this assessment? A. Bullying of others B. Vulnerable demeanor C. Repetitive counting D. Ritualistic activities
A. Bullying of others Rationale: Conduct disorder involves bullying and mistreatment of others as well as illegal and elicit behavior. These children often engage in behavior that is coercive and criminal. These clients will escalate into adulthood and can be diagnosed later in life with cluster B personality disorders as they continue to take advantage of others.
A patient has anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and has lost 25% of body weight. The serum potassium is 2.7 mg/dL. This patient is at risk of what complication? A. Cardiac arrhythmia B. Increased bone density C. Increased heart rate D. Possible decrease in cortisol
A. Cardiac arrhythmia Rationale: This patient presents with imbalanced nutrition related to not eating. The patient has hypokalemia which will result in changes in ECG. This client will also have bradycardia, elevated cortisol and osteopenia.
A nurse questions the order to begin nourishing an emaciated client slowly. The prescriber explains the reason behind this choice is: A. Clients may die from being nourished too quickly B. Introducing food slowly encourages client compliance C. There is no medical justification for this D. Introducing nourishment quickly causes client anxiety
A. Clients may die from being nourished too quickly Rationale: Nourishing the client too quickly causes an electrolyte shift and can cause death.
A nurse is caring for a client who has schizophrenia. The client states, "The weather channel lady loves me and she is going to quit her show to be with me!" The nurse should document that the client is experiencing which of the following types of delusions? A. Erotomanic B. Persecution C. Control D. Somatic
A. Erotomanic Rationale: A client that is experiencing erotomania thinks that someone else loves them or that they are in love with the other party. These clients will maintain this delusion. This behavior can lead to stalking or other inappropriate actions on the part of the psychotic client.
An unlicensed assistive personnel (UAP) is working with clients that have diagnosis of obsessive compulsive disorder. The UAP understands the reason not to stop the carrying out of compulsions is: A. If this is not done therapeutically the client will have an escalation in anxiety B. The RNs don't trust the UAPs C. Stopping compulsions is not part of the treatment plan D. The obsessions are the client's problems not the compulsions
A. If this is not done therapeutically the client will have an escalation in anxiety Rationale: The clients with OCD get relief by carrying out compulsions and if this is not discontinued therapeutically it will increase anxiety and set the client back in therapy. Both the obsession and the compulsions are problems and need to be addressed properly. A UAP is part of the healthcare team and should understand the roles that each member play and that this is not a discriminatory intervention on the part of the nurse.
A client is experiencing command hallucinations and appears to be frightened. Which of the following actions are appropriate nursing interventions? A. Keep the client physically safe B. Ignore the client's feelings in response to altered perceptions C. Assure the client that they are not experiencing something real D. Inform the client that their hallucinations are just bad dreams
A. Keep the client physically safe Rationale: Validate the patient's feelings. Keep them physically safe. Determine what the hallucination is telling them to do and provide reality testing PRN.
A nurse is admitting an older adult client who has a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment? A. Mental status examination (MSE) B. Scale for Assessment of Negative Symptoms (SANS) C. Abnormal Involuntary Movements Scale (AIMS) D. Brief Patient Health Questionnaire (Brief PHQ)
A. Mental status examination (MSE) Rationale: The use of an MSE assists in identifying deterioration in mental status and brain damage, which are findings associated with cognitive disorders. SANS- schizophrenia, AIMS-tardive dyskinesia, brief PHQ- depression.
A client with anorexia nervosa is at increased risk for which of the following? A. Osteopenia B. Increased testosterone C. Hyperglycemia D. Hypertension
A. Osteopenia Rationale: A client with anorexia nervosa is at risk for decreased bone density, osteoporosis and osteopenia. Osteopenia is a condition that begins as you lose bone mass and your bones get weaker. This happens when the inside of your bones become brittle from a loss of calcium.
A nurse is performing an admission assessment for an adolescent client with a diagnosis of schizophrenia. Which of the following findings should the nurse identify as a positive symptom? A. Somatic Delusions B. Anhedonia C. Waxy Posture (immobile posturing) D. Anergia
A. Somatic Delusions Rationale: Delusions are example of a positive symptom. Anhedonia, waxy posture, and anergia are negative symptoms. Positive symptoms, which include delusions, hallucinations, disorganized thoughts, and disorganized speech; can cause you or someone you love to lose touch with reality. Negative schizophrenia refers to behaviors or emotions that are deficient or lacking in people with schizophrenia
A client prescribed sertraline asks about alternative therapies to treat the depression that she is experiencing regarding her current family situation. Which statement by the student nurse indicates a need for intervention? A. St John's wort is an excellent treatment for depression B. Electroconvulsive therapy (ECT) works well with some types of depression C. Over the counter medications can interact with your current antidepressant medication D. Family therapy may help you address your feelings
A. St John's wort is an excellent treatment for depression Rationale: St John's wort is taken by some to reduce feelings of depression, but it can interact and cause dangerous side effects with many psychotropic medications. ECT can be very effective in depression and is used after medication has been attempted and is not successful. Antidepressants may interact with many OTC medications.
After an adolescent diagnosed with attention-deficit/hyperactivity disorder (ADHD) begins methylphenidate therapy, the nurse notes that the adolescent loses 10 pounds in a 2-month period. Which is the best explanation for this weight loss? A. The pharmacological action of methylphenidate causes a decrease in appetite. B. Hyperactivity seen in ADHD causes increased caloric expenditure. C. Side effects of methylphenidate cause nausea; therefore, caloric intake is decreased. D. Increased ability to concentrate allows the client to focus on activities rather than food.
A. The pharmacological action of methylphenidate causes a decrease in appetite. Rationale: The pharmacological action of Ritalin causes a decrease in appetite that often leads to weight loss. Methylphenidate (Ritalin) is a central nervous symptom stimulant that serves to increase attention span, control hyperactive behaviors, and improve learning ability for clients diagnosed ADHD.
The nurse working with a client diagnosed with Bulimia Nervosa asks the client to recall a time in life when food could be consumed without purging. Which best explains the purpose of the nurse's question? A. To emphasize that the client is capable of consuming food without purging B. To incorporate specific foods into the meal plan to reflect pleasant memories C. To encourage autonomy in the treatment plan D. To gain insight into the disorder
A. To emphasize that the client is capable of consuming food without purging Rationale: The nurse is identifying the client's previous successful coping strategies. The nurse will utilize the data to develop interventions to help the client employ prior coping skills to replace maladaptive eating behaviors. This is cognitive-behavioral therapy.
The following are all common comorbid psychiatric disorders prevalent with ADHD, except: A. Anxiety B. Depression C. Obsessive compulsive disorder D. Substance use disorders
C. Obsessive compulsive disorder Rationale: Common comorbid psychiatric disorders are prevalent with ADHD. Oppositional defiant disorder: Conduct disorder, anxiety, depression, bipolar disorder, substance use disorders.
The nurse tells the parents of an adolescent diagnosed with anorexia nervosa, "The social worker will be contacting you to schedule a family meeting." One of the client's parents states, "Why is that necessary? Our child is the one who needs treatment." Which response by the nurse is best? A. "We expect every client and their family to attend two family sessions." B. "Family intervention and support are important in managing eating disorders." C. "The sessions are used to educate all family members about eating disorders." D. "During the meeting you will be able to resolve conflicts with your child."
B. "Family intervention and support are important in managing eating disorders." Rationale: Family meetings focus on the needs of the client and their family. The nurse should educate the family on the importance of family involvement and support in the treatment of anorexia nervosa. Although conflicts can be identified during a family meeting, resolution of conflicts requires family therapy beyond the inpatient setting.
A child has been diagnosed with autism spectrum disorder (ASD). The distraught mother cries out, "I'm such a terrible mother. What did I do to cause this?" Which nursing reply is most appropriate? A. "Researchers really don't know what causes autistic disorder, but the relationship between autistic disorder and fetal alcohol syndrome is being explored." B. "Poor parenting doesn't cause autism. Research has shown that abnormalities in brain structure and/or function are to blame. This is beyond your control." C. "Research has shown that the mother appears to play a greater role in the development of this disorder than does the father." D. "Lack of early infant bonding with the mother has shown to be a cause of autistic disorder. Did you breastfeed or bottle feed?"
B. "Poor parenting doesn't cause autism. Research has shown that abnormalities in brain structure and/or function are to blame. This is beyond your control." Rationale: ASD is believed to be caused by abnormalities in brain structure and/or function, not poor parenting. ASD occurs in approximately 6 per 1000 children and is about four times more likely to occur in boys.
A client is pacing the hall near the nurse's station, swearing loudly. An appropriate initial intervention for the nurse would be to address the client by name and say: A. "Please quiet down." B. "You seem upset. Would you like to tell me about it?" C. "Hey, why are you so upset?" D. "You need to go to your room to get control of yourself."
B. "You seem upset. Would you like to tell me about it?" Rationale: This response is the most therapeutic. You should never use the why when capable of avoiding it.
The nurse has taken report for the evening shift on an adolescent inpatient unit. Which client should the nurse address first? A. A client diagnosed with Oppositional Defiant Disorder being sexually inappropriate with staff B. A client diagnosed with Conduct Disorder who is verbally abusing a peer in the milieu C. A client diagnosed with Conduct Disorder who is demanding special attention from staff D. A client diagnosed with ADHD who has a history of self-mutilation
B. A client diagnosed with Conduct Disorder who is verbally abusing a peer in the milieu Rationale: A client diagnosed with Conduct Disorder who is verbally abusing a peer in the milieu creates risk for injury to others.
A nurse is caring for a client who has a new prescription for risperidone. Which of the following rating scales should the nurse complete prior to administering the first dose of risperidone? A. Beck's Depression Inventory B. Abnormal Involuntary Movement Scale C. Hamilton Depression Scale D. The Body Attitude Test
B. Abnormal Involuntary Movement Scale Rationale: Risperidone, an antipsychotic, can cause tardive dyskinesia, involuntary movements that may include the tongue, lips, and face. The nurse should perform the AIMS assessment prior to initiating treatment with risperidone and then at regularly scheduled intervals thereafter.
Symptoms of amphetamine withdrawal include: A. Tremors, nausea/vomiting, malaise, weakness, and tachycardia B. Anxiety, depressed mood, irritability, and craving for the substance C. Fighting, grandiosity, hypervigilance, and pupillary dilation D. Aggressiveness, slurred speech, nystagmus, and a flushed face
B. Anxiety, depressed mood, irritability, and craving for the substance Rationale: The client with amphetamine withdrawal may experience anxiety, depressed mood, irritability, craving for the substance, fatigue, insomnia or hypersomnia, psychomotor agitation, paranoid and suicidal ideation.
A nurse is planning care for a client who has a diagnosed anxiety disorder. Which of the following intervention should the nurse implement to promote occupational functioning? A. Help the client to identify prior accomplishments B. Assist the client in identifying triggers C. Identify the client's spirituality D. Encourage the client to identify positive self attributes
B. Assist the client in identifying triggers Rationale: This client may want to use their spirituality in aiding with relaxation, but the identification of spirituality will not in itself reduce the anxiety. This client needs to be able to identify stressors. If the client can identify some things that cause stress this client can learn to function day to day.
People living with bulimia nervosa tend to be: A. Underweight B. Average weight C. Obese D. Morbidly obese
B. Average weight Rationale: People with bulimia tend to be average or slightly overweight
A nurse assessing a client with post-traumatic stress disorder (PTSD) would expect the client to report which finding? A. Increased appetite B. Fatigue C. Manipulative behavior D. Hypersomnia
B. Fatigue Rationale: Clients with PTSD will have fatigue from loss of sleep. These clients regularly have flashbacks and nightmares and as such they will not sleep or report not sleeping well. These clients tend to have a loss of appetite and do not regularly take advantage of anyone else.
A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first? A. Provide a structured schedule for the client B. Identify stressors that precipitate rituals C. Instruct the client on meditation D. Discuss alternative coping strategies with the client
B. Identify stressors that precipitate rituals Rationale: This is the priority intervention when taking the nursing process approach to client care. The other interventions should be carried out after stressors are identified. The schedule should not be set until the client's stressors are identified.
A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens (Severe alcohol withdrawal symptoms such as shaking, confusion, and hallucinations). Which of the following actions should the nurse take first? A. Administer clonidine B. Lower the bed and raise the side rails C. Obtain a medical history D. Complete CIWA scale
B. Lower the bed and raise the side rails Rationale: The greatest risk to the client is injury from a fall; therefore, the first action by the nurse is to raise the side rails of the bed. The nurse should obtain a medical history and CIWA scale after making sure the client is safe; therefore, this is not a priority action. The nurse should administer diazepam when the client is safe and after obtaining a CIWA; therefore, this is not a priority action.
What is the difference between conduct disorder (CD) and oppositional defiance disorder (ODD)? A. CD is mild and involves inattention B. ODD does not involve physical aggression C. CD is only present in boys D. ODD is only diagnosed before age 5
B. ODD does not involve physical aggression Rationale: ODD is present in conduct disorder; however, CD also has physical aggression, drug use and illegal activity . Neither of these disorders is only present in 1 gender. Both disorders are present in the adolescent period.
Personality traits most likely to be documented regarding a patient demonstrating characteristics of an obsessive-compulsive personality disorder are: A. Affable, generous B. Perfectionist, inflexible C. Dramatic speech, impulsive D. Suspicious, holds grudges
B. Perfectionist, inflexible Rationale: OCP patients typically like things in a very orderly fashion and are inflexible in their ritualistic behaviors. These clients believe that the problems that they encounter are not their fault, but the fault of others. These clients are not impulsive as they like to have things set up and planned out.
A client is diagnosed with PTSD. Which treatment modality exposes the client to repeated and prolonged mental recounting of the traumatic event? A. Cognitive therapy B. Prolonged exposure therapy C. Group therapy D. Eye movement desensitization and reprocessing
B. Prolonged exposure therapy Rationale: Prolonged exposure therapy is a type of behavioral therapy similar to implosion therapy or flooding. It can be conducted in an imagined or real (in vivo) situation. In the imagined situation, the individual is exposed to repeated and prolonged mental recounting of the traumatic experience. In vivo exposure involves systematic confrontation, within safe limits, of trauma-related situations that are feared and avoided. This intense emotional processing of the traumatic event serves to neutralize the memories so that they no longer result in anxious arousal or escape and avoidance behaviors.
A nurse is assessing a 5-year-old client with autism spectrum disorder. For which of the following manifestations will the nurse assess? A. Sedation B. Repetitive hand gestures C. Somatic illness problems D. Elation
B. Repetitive hand gestures Rationale: Repetitive actions are a common feature of autism spectrum disorder. The client with autism will not be overly emotional or sedate. The client will not experience somatic illness due to autism, but GI and seizure disorders are common concurrent diagnosis.
A nurse is planning care for a client who has antisocial personality disorder. Which of the following actions should the nurse plan to take? A. Give positive feedback when client is assertive with staff or clients. B. Set limits to prevent exploitation of other clients. C. Discourage flamboyant or seductive behaviors. D. Monitor the client closely to prevent self-mutilation.
B. Set limits to prevent exploitation of other clients. Rationale: A trademark feature of APD is exploitation of others. These clients must have clear boundaries set. These clients are more in tune with appropriate behavior and are not as likely to be overly dramatic.
Personality traits most likely to be documented regarding a patient demonstrating characteristics of a paranoid personality disorder are: A. Affable, generous B. Suspicious, holds grudges C. Dramatic speech, impulsive D. Perfectionist, inflexible
B. Suspicious, holds grudges Rationale: PPD clients suspect others to have ulterior motives and tend to hold grudges for imagined slights. These clients do not do well in social situations and tend to avoid them. These clients are more traditionally closed off and will not be generous with others.
Which finding is the nurse most likely to assess in a child diagnosed with separation anxiety disorder? A. The child has a history of antisocial behaviors. B. The child's mother is diagnosed with an anxiety disorder. C. The child previously had an extroverted temperament. D. The child's parents have inconsistent parenting styles.
B. The child's mother is diagnosed with an anxiety disorder. Rationale: A child whose mother is diagnosed with an anxiety disorder has a greater risk of developing an anxiety disorder. Research indicates that there is a hereditary influence in the development of separation anxiety disorder. More children with relatives who manifest anxiety problems develop anxiety disorders than those without.
The client states "I just can't fall asleep". The nurse responds, "You are having difficulty falling asleep?" Why is the nurse using the restating technique? A. The nurse wants the client to know they understand B. The nurse is allowing the client to elaborate or clear up misunderstanding C. The nurse is keeping the conversation going D. The nurse wants to focus on one idea
B. The nurse is allowing the client to elaborate or clear up misunderstanding Rationale: Establishes priority with nursing goals and interventions related to therapeutic interaction. Using the client's words or close to is restating. This technique allows the client to be able to elaborate or clear up any miscommunications with nursing. This also gives the feedback that their concerns are being heard
A patient tells the nurse, "I don't like you, you look like my grandmother." This is an example of what concept? A. Staff splitting B. Transference C. Manipulation D. Delusion
B. Transference Rationale: The client is demonstrating negative transference. This client has negative thoughts toward the nurse.
Jane is a 4-year-old who wakes up screaming in her room, she is frantic, states she wants her mom who had to leave hours ago to go home. All of the therapeutic techniques may be effective except: A. Offering hope and age appropriate humor. B. Turning off the lights to calm her down. C. Active listening to the client, recognizing their fears. D. Making observations around the room, discussing them with the client to calm her down.
B. Turning off the lights to calm her down. Rationale: While working with pediatric clients it is important to be aware of anxiety. This client is experiencing fear and anxiety and the nurse must use therapeutic communication in the interaction.
Consider this comment to three different nurses by a patient diagnosed with antisocial personality disorder, "Another nurse said you don't do your job right." Collectively, these interactions can be assessed as: A. Insightful B. Guilt-producing C. Manipulative D. Detached
C. Manipulative Rationale: The patient is demonstrating manipulation with this statement. This behavior is a hallmark of the cluster B personality disorders. This is technically defined as "splitting".
You are the night nurse who has just gotten report on the following patients. Prioritize which of the patients you would see first. A. 29 year old male admitted for pyelonephritis and S.I. who is currently feeling depressed and on suicide precautions B. 88 year old female admitted for altered mental status placed on fall precautions C. 70 year old male who is a post-surgical hip fracture with a history of dementia D. 45 year old male with gall stones and GAD with complaints of anxiety
C. 70 year old male who is a post-surgical hip fracture with a history of dementia Rationale: This patient is at high risk for falls AEB his history of dementia and recent surgery.
A nurse is reviewing the medical histories of four clients. Which of the following clients will be most likely to develop extrapyramidal symptoms from medication therapy? A. A client with depression taking selective serotonin reuptake inhibitors B. A client with schizoaffective disorder taking an atypical antipsychotic C. A client with schizophrenia taking a first-generation antipsychotic D. A client with anxiety disorder taking an anxiolytic medication
C. A client with schizophrenia taking a first-generation antipsychotic Rationale: A client who has schizophrenia and is taking first generation antipsychotic medication can develop extrapyramidal manifestations, such as acute dystonia, Parkinsonism, akathisia, and tardive dyskinesia. First generation = typical antipsychotics = more potent = have more side effects
A nurse is caring for a client who is cognitively impaired. Which of the following rooms will provide a therapeutic environment for this client? A. A room adjacent to the nursing station B. A room without a window C. A room containing personal belongings nearby without contrabands D. A room with dim lighting
C. A room containing personal belongings nearby without contrabands Rationale: A room that contains several of the client's personal belongings assists in maintaining personal identity and provides a therapeutic environment. This will aide in the therapeutic care and minimize anxiety and distress in the client. This client should be monitored but a lot of added stimuli may cause the client to become distressed and exhibit unwanted behaviors.
A nurse is attempting to differentiate between the symptoms of anorexia nervosa and the symptoms of bulimia. Which statement delineates the difference between these two disorders? A. Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not. B. Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not. C. Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not. D. Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not.
C. Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not. Rationale: Bulimic clients tend to have some nutrient absorption prior to their purging however, clients with anorexia do not intake the food and thus have a lack of nutrients to their bodies.
The nurse is reviewing the plan of care for a 15-year-old client diagnosed with anorexia nervosa. The treatment team plans to implement cognitive behavior therapy (CBT). Which is the best rationale for the use of CBT for clients diagnosed with anorexia nervosa? A. Recognize maladaptive eating patterns as defense mechanisms. B. Promote autonomy and control overeating behaviors. C. Eliminate emotional components of maladaptive eating patterns. D. Allow client to establish goals of the treatment plan.
C. Eliminate emotional components of maladaptive eating patterns. Rationale: CBT strives to eliminate the emotional components associated with unhealthy eating patterns by confronting irrational thinking patterns and associated feelings
The nurse is reviewing the plan of care for a 15-year-old client diagnosed with anorexia nervosa. The treatment team plans to implement cognitive behavior therapy (CBT). Which is the best rationale for the use of CBT for clients diagnosed with anorexia nervosa? A. Recognize maladaptive eating patterns as defense mechanisms. B. Promote autonomy and control overeating behaviors. C. Eliminate emotional components of maladaptive eating patterns. D. Allow client to establish goals of the treatment plan.
C. Eliminate emotional components of maladaptive eating patterns. Rationale: CBT strives to eliminate the emotional components associated with unhealthy eating patterns by confronting irrational thinking patterns and associated feelings.
Possible predisposing factors to Schizoid personality disorder include all of the following except: A. Bleak childhood B. Notable childhood negligence C. Having overly protective parents D. Hereditary factors
C. Having overly protective parents Rationale: Predisposing factors to schizoid personality disorders include possible hereditary factors and many descriptions of a cold lacking childhood.
A client taking phenelzine has a blood pressure of 210/119, a HR of 104 bpm, and diaphoresis. The nurse discovers the client has recently taken over the counter medication for allergies and a cold. The nurse recognizes this client is experiencing: A. Hypertension B. Neuroleptic Malignant Syndrome C. Hypertensive crisis D. Serotonin Syndrome
C. Hypertensive crisis Rationale: Hypertensive crisis brought on by over the counter cold medication. Clients on MAOI should be counselled not to take any OTC medications prior to consulting their physician.
The nurse working in an acute care psychiatric facility is working with clients that have personality disorders. The nurse knows that cluster A personality disorders (odd, eccentric) tend to exhibit what behaviors? A. Dramatic B. Dependency C. Indifference to social situations D. Splitting between healthcare providers
C. Indifference to social situations Rationale: Cluster A trademarks are odd, eccentric and indifferent to social situations. These clients do not seek out interaction and when in social situations may not interact in an appropriate manner. They exhibit some magical thinking or paranoia and are not perceived by others positively.
Which nursing intervention is the priority when caring for a child diagnosed with conduct disorder? A. Modify the environment to decrease stimulation and provide opportunities for quiet reflection. B. Convey unconditional acceptance and positive regard. C. Recognize escalating aggressive behaviors and intervene before violence occurs. D. Provide immediate positive feedback for appropriate behaviors.
C. Recognize escalating aggressive behaviors and intervene before violence occurs. Rationale: The client's behaviors create risk of other-directed violence. The nurse's priority is safety.
Which of the following defense mechanisms describes the underlying cause of somatic symptom disorder? A. Denial of depression B. Suppression of grief C. Repression of anxiety D. Displacement of anger
C. Repression of anxiety Rationale: This group of disorders is caused by avoidance and repression of feelings. The reason the client experiences symptoms is that they do not deal with their feelings and anxiety.
Rank the following nursing interventions based on priority of a patient diagnosed with bulimia nervosa A. Draw Blood for CBC and CMP B. Asses for depression C. Obtain Vitals D. Perform ECG E. Teach and encourage on self-care activities
D, C, A, B, E Rationale: The priority here is the ECG because patients with Bulimia nervosa are at high risk for low potassium, which can lead to ECG changes and life threatening arrythmias. Next you would obtain vitals to determine the patient's current level of hemodynamic stability which can also be affected by the client's altered electrolyte imbalance. Third, you draw blood to monitor electrolytes. Forth, depression is assessed and common amongst individuals with BN. Last you would promote and perform education for the patient for long term goals.
Of the following populations, which would Tourette's be most common in? A. 2 year old boys B. 2 year old girls C. 6-7 year old girls D. 6-7 year old boys
D. 6-7 year old boys Rationale: Onset may be as early as 2 years but occurs most commonly around age 6 or 7. The disorder is more common in boys than in girls.
The clearest indication of success in behavior modification related to eating disorders would be... A. A client inducing vomiting at a smaller frequency B. A client claiming they have gained some needed weight C. A client showing patterns of an improved mood D. A client showing and demonstrating that they have perceptions of control over their life and treatments
D. A client showing and demonstrating that they have perceptions of control over their life and treatments Rationale: For a successful behavior modification, the client must perceive that they are in control of the treatment, recognize options and goals, in accordance with their healthcare providers.
A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client? A. A seclusion room until the client's activity level becomes more subdued B. A semi-private room with a roommate who has a similar diagnosis C. A private room away from the nursing station D. A private room in a quiet location that can easily be monitored
D. A private room in a quiet location that can easily be monitored Rationale: A private room in a quiet location is ideal for a client with mania. The client may easily become overstimulated by the number of people and activities in a nursing care unit. A private room can be used for time-out during the day and to settle down to sleep at night.
A clearly underweight client presents constant descriptions of distorted body images and denies that they ever binge eat. You can assume that the client is suffering from: A. Bulimia nervosa B. Binge-eating disorder C. Obesity D. Anorexia nervosa
D. Anorexia nervosa Rationale: The distortion in body image by clients diagnosed with anorexia nervosa is manifested by thoughts that they are fat when they are obviously underweight or even emaciated.
A nurse is caring for a client who with an eating disorder. The nurse is demonstrating which of the following ethical concepts when they allow the client to refuse to drink a between meal protein and calorie supplement? A. Fidelity B. Beneficence C. Veracity D. Autonomy
D. Autonomy Rationale: Autonomy respects the rights of clients to refuse medication or treatment. The nurse is allowing the client to make the decision not to participate in this treatment at this time.
A 28-year-old client with body dysmorphic disorder (BDD) tells the nurse that they plan to have a surgical procedure that will affect their appearance. The nurse understands that this plan is an effort to A. Suppress intrusive thoughts B. Deal with multiple physical complaints C. Treat associated depression D. Cure the imagined defect
D. Cure the imagined defect Rationale: With BDD the client has a perceived defect, they will seek to alter this defect through means such as plastics procedures. These clients seek extreme measures to cure this defect that only they see.
A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes washing their hands and completing ritualistic tasks. Which nursing intervention would best address this client's problem? A. Lock the room to discourage ritualistic behavior. B. Report the behavior to the psychiatrist to obtain an order for medication dosage change. C. Distract the client with other activities whenever ritual behaviors begin. D. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.
D. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors. Rationale: Discussing triggers will enable the client to address and deal with obsessions and compulsions. Distracting the client will increase the anxiety. Discuss the triggers to be able to assist the client in their therapeutic recovery.
The most important short term goal of a client with avoidant personality disorder would be to: A. Express feelings verbally B. Stop initiating arguments C. Acknowledge own behavior D. State a positive personality trait
D. State a positive personality trait Rationale: The client with avoidant personality disorder has low self esteem and self worth. This client will be increasingly inhibited. The nurse should encourage and support the client and give reassurance and help them with encourage them in building their self esteem.
A nurse is teaching a male client who has a depressive disorder about escitalopram. Which of the following information should the nurse include in the teaching? A. This medication may cause muscle rigidity temporarily B. You will notice an improvement in mood within 2-3 days C. A fever is a common side effect of this medication D. This medication may cause an inability to orgasm
D. This medication may cause an inability to orgasm Rationale: Escitalopram is an SSRI. SSRIs may cause sexual dysfunction, including anorgasmia, impotence, or decreased libido. Fever and muscle rigidity are medical emergencies with this medication, this medication will take 4-6 weeks to reach full effect.
A patient with a substance abuse problem makes statements such as, "I don't have a problem with (substance)" or "I can quit any time I want to." The patient also does not perceive any problems related to use of the substance and is unable to admit the impact of the disease on his or her life patterns and functioning. What nursing diagnosis would you assign to this patient?
Denial Rationale: Denial is defined as a "conscious or unconscious attempt to disavow the knowledge or meaning of an event to reduce anxiety and/or fear, leading to the detriment of health." The patient with substance abuse disorder may be in denial about their addiction and downplay any associated problems or impairments in social or occupational functioning related to the addiction.
The following are characteristics of which cluster B personality disorder: Arrogance, grandiosity, lack of empathy, and sensitive to criticism.
Narcissistic Personality Disorder Rationale: Narcissistic personality disorder is a cluster B personality disorder with characteristics such as arrogance, grandiosity, lack of empathy, and sensitive to criticism.
This is a potentially fatal complication that results in the introduction of fluids and carbohydrates for patients who are malnourished.
Refeeding syndrome Rationale: Refeeding syndrome is a potentially fatal complication resulting from aggressive initiating of feedings that results in the introduction of fluids and carbohydrates for patients who are malnourished.
