Adaptive Quizzing for the NCLEX-RN Exam - Mental Health Disorders and Addictions

A nurse, understanding the possible cause of alcohol-induced amnestic disorder, should take into consideration that the client is probably experiencing which imbalance?

Thiamine deficiency Rationale: The deficiency of thiamine (vitamin B 1) is thought to be a primary cause of alcohol-induced amnestic disorder. Reduced iron intake, increased serotonin, and riboflavin malabsorption are all unrelated to alcohol-induced amnestic disorder.

A salesman with a history of heavy drinking is on a detoxification unit. He asks the nurse's permission to skip the Alcoholics Anonymous (AA) meeting held each day. What is the nurse's initial response?

"What are your feelings about going to AA meetings?" Rationale: The question "What are your feelings about going to AA meetings?" forces the client to face what going to AA meetings means to the client. The question "What is it that you dislike about going to AA meetings?" focuses the client on negative aspects; also, the client may be unable to answer this question. The response "It's all right to wait until you feel like going to AA meetings" reinforces avoidance, which delays dealing with the problem; the client may never feel like going to AA meetings. Although the response "An important part of your treatment is attending AA meetings" is true, it does not explore the client's feelings.

A client is found to have a mood disorder, hypomanic episode. To support the diagnosis, the nurse should identify the signs and symptoms associated with this disorder. Select all that apply.

- Distractibility - Flight of ideas Rationale: These individuals have a short attention span; their attention is easily drawn to unimportant or irrelevant external stimuli. These individuals shift from one idea or topic to another and express their thoughts in a rapid flow of speech. These individuals have an inflated self-esteem or grandiosity. These individuals have a decreased need for sleep. These individuals have psychomotor agitation or an increase in goal-directed activity.

A nurse is assessing a child with suspected autism. At what age does the nurse determine that the signs of autism initially may be evident?

2 years Rationale: By 2 years of age the child should demonstrate an interest in others, communicate verbally, and possess the ability to learn from the environment. Before the age when these skills develop, autism is difficult to diagnose. Usually by 3 years the signs of autism become more profound. Autism can be diagnosed long before a child is 6 years old. Infantile autism may occur in an infant of 1 to 3 months, but at this age it is difficult to diagnose.

A client with the diagnosis of bulimia nervosa, purging type, is admitted to the mental health unit after an acute episode of bingeing. Which clinical manifestation is most important for the nurse to assess?

Dehydration Rationale: The nurse should be alert for dehydration caused by fluid loss through vomiting in the binge-purge cycle. Weight gain is not expected because purging frequently follows a binge. Hyperactivity is not expected because many individuals with bulimia withdraw and vomit after a binge. Hyperglycemia is not expected because of the vomiting that follows a binge.

A client with a history of atrial fibrillation has a stroke, and vascular dementia (multiinfarct dementia) is diagnosed. In a comparison of assessment findings in clients with vascular dementia and dementia of the Alzheimer type, which factor is unique to vascular dementia?

Abrupt onset of symptoms Rationale: The signs and symptoms associated with vascular dementia have an abrupt onset (days to weeks) because of the occlusion of small arteries or arterioles in the cortex of the brain. Dementia of the Alzheimer type is associated with a gradual (years), progressive loss of function. Both vascular dementia and dementia of the Alzheimer type are associated with this deficit in function. Memory impairment may or may not be a symptom of vascular dementia, it depends on which part of the brain is affected. Alzheimer disease usually results in memory impairment, but the client does not have abrupt onset of symptoms. Difficulty making decisions is a major part of Alzheimer disease, but may not be manifested with vascular dementia, depending on which part of the brain is affected. Inability to use words to communicate is a typical symptom of Alzheimer disease, but with vascular dementia, the client may have trouble speaking or understanding speech.

A nurse is providing information about Alcoholics Anonymous (AA) meetings to a client with a history of alcohol abuse. What will be required when the client attends AA meetings?

Acknowledging an inability to control the alcoholism Rationale: A major premise of AA is that to be successful in achieving sobriety, clients with an alcohol abuse problem must acknowledge their inability to control the use of alcohol. There are no rules of attendance or speaking at meetings, although both actions are strongly encouraged. Maintaining controlled drinking after 6 months is not part of the AA program; this group strongly supports total abstinence for life.

A nurse is discussing Alcoholics Anonymous (AA) with a client. What behavior expected of members of AA should the nurse include in the discussion?

Acknowledging an inability to control the problem Rationale: A major premise of AA is that to be successful in achieving sobriety, clients with alcohol abuse problems must acknowledge their inability to control their drinking. There are no rules about speaking at meetings, although members are encouraged strongly to do so. There are no rules of attendance at meetings, although members are encouraged strongly to attend as often as possible. Maintaining controlled drinking after 6 months is not part of AA; this group strongly supports total abstinence for life.

When being admitted to a mental health facility, a young male adult tells the nurse that the voices he hears frighten him. The nurse knows that clients tend to hallucinate more vividly at what point in their routine?

After going to bed Rationale: Auditory hallucinations are most troublesome when environmental stimuli are diminished and there are few competing distractions. Before meals, during group activities, and during television watching are all times of relatively high, competing environmental stimuli.

A nurse decides to use the CAGE screening questionnaire with a client admitted for substance abuse. What is the client abusing?

Alcohol Rationale: The CAGE questionnaire is one of the simplest and most reliable screening tools for alcohol abuse. CAGE is an acronym for the key words ( Cut down, Annoyed, Guilty, and Eye-opener) in the four questions asked of people suspected of abusing alcohol. The CAGE questionnaire is not designed to screen clients for barbiturate, hallucinogen, or multiple drug abuse.

A mental health nurse is admitting a client with anorexia nervosa. When obtaining the history and physical assessment, the nurse expects the client's condition to reveal what?

Amenorrhea Rationale: Amenorrhea results from endocrine imbalances that occur when fat stores are depleted. The client is dehydrated; edema is not expected. Constipation, not diarrhea, may occur because of lack of fiber in the diet. Hypotension, not hypertension, may occur because of dehydration.

A mental health nurse is admitting a client with anorexia nervosa. When obtaining the history and physical assessment, the nurse expects the client's condition to reveal which symptom?

Amenorrhea Rationale: Amenorrhea results from endocrine imbalances that occur when fat stores are depleted. The client is dehydrated; edema is not expected. Constipation, not diarrhea, may occur because of lack of fiber in the diet. Hypotension, not hypertension, may occur because of dehydration.

A 24-year-old woman states that she no longer enjoys any of the activities that she once found fun and pleasurable, such as socializing, sports, and hobbies. What term should the nurse use to describe this condition?

Anhedonia Rationale: Anhedonia is the inability to experience pleasure in events or activities that once were enjoyable. Anergia is lethargy and a decreased level of energy. Grandiosity is a symptom seen during manic episodes in which an individual displays an inflated self-esteem. Learned helplessness is a theory proposing that depression occurs when an individual believes that he or she has no control over life situations. This results in the individual's giving up and becoming passive and dependent.

A nursing assistant interrupts the performance of a ritual by a client with obsessive-compulsive disorder. What is the most likely client reaction?

Anxiety Rationale: Because the compulsive ritual is used to control anxiety, any attempt to prevent the action will increase anxiety. Underlying hostility is considered part of the disorder itself, not a reaction to an interruption of the ritual. Aggression is possible only if the anxiety reaches a panic level and causes the person to express anger overtly. Withdrawal is not a pattern of behavior associated with obsessive-compulsive disorder.

A female client with obsessive-compulsive disorder has become immobilized by her elaborate handwashing and walking rituals. Which feelings does the nurse recall are often the basis of obsessive-compulsive disorder?

Anxiety and guilt Rationale: Ritualistic behavior seen in this disorder is aimed at controlling feelings of anxiety and guilt by maintaining an absolute set pattern of action. Although the person with an obsessive-compulsive disorder may be angry and hostile, the feelings of anger and hostility do not precipitate the rituals. Although the person with an obsessive-compulsive disorder may be embarrassed and ashamed by the ritual or feel hopeless and powerless to the ritual, the basic feelings precipitating the rituals are usually anxiety and guilt.

What does the nurse recall is the major defense mechanism used by an individual with a phobic disorder?

Avoidance Rationale: The person transfers anxieties to activities or objects, usually inanimate objects, which are then avoided to decrease anxiety. Splitting is the compartmentalization of opposite affective states and the inability to integrate the positive and negative aspects of others or self. Regression, the return to an earlier, more comfortable level of development, is not the defense mechanism used by someone with a phobia. Conversion, the transfer of a mental conflict to a physical symptom, is not the defense mechanism used by someone with a phobia.

The nurse would recognize which behavior as being characteristic of the panic phase of crisis behavior?

Being physically immobile Rationale: Being unable to physically move is a psychomotor characteristic of extreme panic, which is a characteristic of crisis behavior. Sobbing for no apparent reason, reporting great difficulties falling asleep, and startling easily to loud noises and being touched are behaviors seen in lesser degrees of anxiety.

The nurse is assigned to work with a 20-year-old client on an inpatient unit. In assessing the woman, the nurse notes that she is mute, does not show any type of movement, is unresponsive, and appears unaware of her surroundings. What is the best term for the nurse to use to describe these symptoms?

Catatonia Rationale: Catatonia is the term to describe stupor, rigidity, or extreme flexibility of the limbs; excitability; confusion; and lack of verbal expression. Alogia is a term used to describe an inability to speak or near-absence of speech. Echopraxia is the term for the mimicking or repetition of the actions of another person. Affective flattening is the term for blunted or constricted facial expression.

While a client is attending an Alcoholics Anonymous (AA) meeting, a nurse talks with the client's spouse about the purpose of AA. What is the priority goal of this self-help group?

Changing destructive behavior Rationale: The purpose of a self-help group is for individuals to develop their strengths and new, constructive patterns of coping. Developing functional relationships, identifying how people present themselves to others, and understanding patterns of interaction within the group are purposes of group therapy.

When planning for a client's care during the detoxification phase of acute alcohol withdrawal, what need should the nurse anticipate?

Checking on the client frequently Rationale: During detoxification frequent checks help ensure safety and prevent suicide, which is a real threat. Bright light is preferable to dim light because it minimizes shadows that may contribute to misinterpretation of environmental stimuli (illusions). The client who is going through the detoxification phase of acute alcohol withdrawal usually does not lose his sense of hearing, so there is no need to shout. Restraints may upset the client further; they should be used only if the client is a danger to himself or others.

An 84-year-old woman is admitted to the hospital with a diagnosis of dementia of the Alzheimer type. What does the nurse know about this disorder?

Cognitive problem that is a slow and relentless deterioration of the mind Rationale: Dementia of the Alzheimer type accounts for 80% of dementias in older adults; it may be due to a neurotransmitter deficiency and is characterized by a steady decline in intellectual function, including memory deficits, disorientation, and decreased cognitive ability. More than 90% of people with dementia of the Alzheimer type are older than 50 years. It is an organic, not functional, disorder. Dementia of the Alzheimer type is difficult to diagnose and often is made when other causes of the dementia have been ruled out.

An older adult is admitted for evaluation of anemia and unsteady gait. While obtaining a health history, the nurse notes that the client seems to make up stories to fill in for memory lapses. How should the nurse document what the client is doing?

Confabulating Rationale: Confabulation is the filling in of memory gaps as a protective mechanism. Lying is false or dishonest behavior that is conscious and deliberate and is used in an attempt to deceive or mislead; there is no evidence of this behavior. Denying is a refusal to believe or accept reality and is used as a protective defense mechanism; there is no evidence of this behavior. Fantasizing is a more-or-less connected series of mental images, such as those that occur in daydreams, that usually involve some unfulfilled desire; there is no evidence of this behavior.

A nurse is planning care for a client with substance-induced persisting dementia resulting from long-term alcohol use. Which nutritional problem, in addition to the effect of alcohol on brain tissue, has contributed to substance-induced persisting dementia?

Deficiency of thiamine Rationale: Substance-induced persistent dementia is caused by a prolonged deficiency of vitamin B1 (thiamine) and the direct toxic effect of alcohol on brain tissue. Increase in serotonin, reduction in iron intake, and malabsorption of riboflavin are problems that are unrelated to substance-induced persisting dementia caused by alcoholism.

Despite repeated nursing interventions to improve reality orientation, a client insists that he is the commander of an alien spaceship. What is the client experiencing?

Delusion Rationale: A delusion is a fixed false belief. An illusion is a false sense interpretation of an external stimulus. Confabulation is the client's attempt to fill gaps in memory with imaginary events. A hallucination is a false sensory perception with no external stimulus.

During a one-on-one interaction with a client with paranoid-type schizophrenia, the client says to the nurse, "I've figured out how foreign agents have infiltrated the news media. They want to shut me up before I spill the beans." How should the nurse describe this statement when documenting this client's response?

Delusions of persecution Rationale: Thoughts of being pursued by powerful agents because of one's special attributes or powers are fixed false beliefs and are referred to as delusions of persecution. There is no evidence to indicate that there are nihilistic delusions of total or partial nonexistence. There is also no evidence to support that external forces are controlling the client (delusions of control) or that the client has false beliefs of being a famous figure (delusions of grandeur).

Addicted clients commonly expect discrimination and lack of empathy from others. How can the nurse best overcome these expectations?

Demonstrating a nonjudgmental attitude Rationale: Behaviors that reflect acceptance and consistency are the best approaches to overcoming these client expectations. What the nurse does is a better indicator of acceptance than the words or explanations that are verbalized. The nurse's actions over time are better indicators of acceptance than is verbal reassurance. Confrontational measures increase anxiety and are not therapeutic.

A client with obsessive-compulsive disorder performs a specific ritual. Why should the nurse give the client time to perform the ritual?

Denying this activity may precipitate an increased level of anxiety. Rationale: The repeated thought or act defends the client against severe anxiety; the client does not want to perform the ritual but feels compelled to do so to keep anxiety at a controllable level. Compulsive behaviors are not autonomous choices. The client is compelled to perform the activity to reduce anxiety. Anxiety reduction, not anger, is the motivation for performing the ritual. Rituals are not activities that enhance self-esteem; they control anxiety. The client may be ashamed of the rituals that cannot be stopped.

A female client is admitted to the hospital after attempting suicide. She reveals that her desire for sex has diminished since her child's birth 3 years ago. What is most directly related to the client's loss of interest in sex?

Depression Rationale: Decreased sexual desire is a major symptom of clinical depression. Other vegetative signs of depression include changes in bowel elimination, eating habits, and sleeping patterns. Although depression is often related to unmet dependency needs, the decreased sexual desire is associated with the depression, not the unmet dependency needs. The sexual difficulties are associated with the depression, and the depression, not the sexual difficulties, may be the major cause of marital stress. Also, there are no data indicating marital stress. Role confusion, not identity confusion, is usually associated with depression.

The nurse is caring for a client with vascular dementia. What does the nurse identify as the cause of this problem?

Disruptions in cerebral blood flow, resulting in thrombi or emboli Rationale: Vascular dementia results from the sudden closure of the lumen of arterioles, causing infarction of the brain tissue in the affected area. Inadequate nutrition may be one of the factors that bring about a general decline of health; however, there is no direct evidence that avitaminosis can cause primary degenerative dementia. Severe emotional trauma may contribute to primary degenerative dementia but does not necessarily cause it. Neural degeneration leads to permanent, not transient, changes.

The nurse is caring for a client with vascular dementia. What does the nurse identify as the cause of this problem?

Disruptions in cerebral blood flow, resulting in thrombi or emboli Rationale: Vascular dementia results from the sudden closure of the lumen of arterioles, causing infarction of the brain tissue in the affected area. Inadequate nutrition may be one of the factors that bring about a general decline of health; however, there is no direct evidence that avitaminosis can cause primary degenerative dementia. Severe emotional trauma may contribute to primary degenerative dementia but does not necessarily cause it. Neural degeneration leads to permanent, not transient, changes.

A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive disorder (OCD). Before providing care for this client, what should the nurse remember about clients with OCD?

Do not want to repeat the ritual but feel compelled to do so Rationale: The repeated thought or act defends the client against even higher, more severe levels of anxiety. Clients usually do recognize that the ritual serves little or no purpose. Rituals are usually followed rigidly; setting limits on or altering a ritual increases anxiety. Preventing the client from performing the ritual may precipitate a panic level of anxiety.

What does a nurse recall that language development in the autistic child resembles?

Echolalia Rationale: The autistic child repeats sounds or words spoken by others, which is echolalia. Stuttering is a speech disorder in which the same syllable is repeated, usually at the beginning of a word. Scanning speech is associated with neurological disorders, not autism. Pressured speech is rapid, tense, and difficult to interrupt. This is associated with anxiety, not autism.

After a cocaine binge an individual is found unconscious and is admitted to the hospital with acute cocaine toxicity. What should the initial nursing action be directed toward?

Establishing a patent airway Rationale: The client is unconscious and unable to meet physical needs; a patent airway, breathing, and circulation are essential needs. Understanding and support are important once the client's physical condition has stabilized. Maintaining a drug-free environment will be a priority later in the treatment program. Establishment of a therapeutic relationship will increase in importance once the client's physical condition has stabilized.

A nurse knows that children with attention deficit-hyperactivity disorder (ADHD) may be learning disabled. What impact does this disability have on their education?

Experience perceptual difficulties that interfere with learning Rationale: ADHD interferes with the ability to perceive and respond to sensory stimuli, resulting in a deficit in interpreting new sensory data. This makes learning difficult. It is not true that children with ADHD have intellectual deficits that interfere with learning; there is no cognitive impairment present. It is not necessarily true that children with ADHD are not self-directed learners or that they perform two grade levels below their age norm.

A client is admitted to the psychiatric hospital after many self-inflicted nonlethal injuries over the preceding month. Of which level of suicidal behavior is the client's behavior reflective?

Gestures Rationale: A suicidal gesture involves superficial, nonlethal injuries; the client has no intent to die as a result of the injuries. A suicidal threat is a person's verbal statement of intent to commit suicide; there is no action. Suicidal ideation is a person's thoughts regarding suicide; there is no definitive intent or action expressed. A suicide attempt is an actual implementation of a severe self-injurious act; there is an attempt to cause serious self-harm or death.

A nurse is assessing a client with major depression. Which clinical manifestation reflects a disturbance in affect related to depression?

Hopelessness Rationale: Feelings of hopelessness are symptomatic of depression; the individual feels unable to find any solution to problems and therefore feels overwhelmed. Echolalia, the pathological meaningless repetition of another's words or phrases, is associated with schizophrenia, not with depression. Delusions are associated with psychotic disorders such as schizophrenia, not depression. Confusion is not common because these individuals are in contact with reality.

A client with a personality disorder is playing cards with another person in the lounge. When the other person cheats at cards, the client responds by aggressively scattering the cards around the room. What does the nurse conclude about the client's personality?

Inadequate impulse control Rationale: The client is angry and reacts impulsively; the action is unplanned and is not under the client's control. No data are provided to suggest that the client is out of contact with reality; the client is reacting to a real situation with anger. There is no identifiable cluster of behaviors to suggest that the client has a violent personality. There is no pattern of behavior to suggest an antisocial personality, which may or may not involve impulse control.

Within a few hours of alcohol withdrawal the nurse should assess the client for the presence of what symptoms?

Irritability and tremors Rationale: Alcohol is a central nervous system depressant; irritability and tremors are the body's neurological adaptation to the withdrawal of alcohol. Tachycardia, irritability, and tremors are the early signs of withdrawal and will appear 24 to 48 hours after the last ingestion of alcohol. Yawning occurs with heroin withdrawal. Convulsions (delirium tremens, or DTs) are a later sign of severe withdrawal that occurs with alcohol withdrawal delirium. Delirium (paranoia and disorientation) is not an early sign of alcohol withdrawal and occurs 48 to 72 hours after abstinence. Fever and diaphoresis may occur during prolonged periods of delirium and are a result of autonomic overactivity.

When answering questions from the family of a client with Alzheimer disease, how does the nurse describe the disease?

Is a slow, relentless deterioration of the mind Rationale: Alzheimer disease[1][2][3] is a slow and relentless deterioration of the mind; clients become progressively worse over time. The disease usually appears in people 60 years of age and older. Alzheimer disease is an organic, not a functional, disorder. At this time there are no diagnostic tools other than autopsy that can provide a definite confirmation of Alzheimer disease.

What does a nurse expect to determine about a child with a diagnosis of reactive attachment disorder?

Is able to develop just superficial relationships with others Rationale: Children who have experienced attachment difficulties with primary caregivers are not able to trust others and therefore relate superficially. Physical abuse is a possibility but not a necessity for this diagnosis. The child probably will not cling or react when separated from the mother. Attachment will not occur with either parent.

A nurse is caring for a client with an obsessive-compulsive personality disorder that involves rituals. What should the nurse conclude about the ritual?

It seems illogical but is needed by the person Rationale: The client's exact adherence to the compulsive ritual relieves anxiety, at least temporarily. Furthermore, it meets a need and is necessary to the client. The compulsive act is purposeless repetition and useful only in that it temporarily eases the client's anxiety. Urging has no effect getting the the client to start or stop the ritualistic behavior. The person cannot stop the activity; it is not under his voluntary control.

For which clinical indication should a nurse observe a child in whom autism is suspected?

Lack of eye contact Rationale: Children with autism usually have a pervasive impairment of reciprocal social interaction. Lack of eye contact is a typical behavior associated with autism. Crying for attention, rigidity, and parallel play are not indicative of autism.

A client who has been admitted with a diagnosis of schizophrenia says to the nurse, "Yes, it's March. March is Little Women. That's literal, you know." What do these statements illustrate?

Loosening of associations Rationale: Loose associations are thoughts that are presented without the logical connections that are usually necessary for the listener to interpret the message. Echolalia is the purposeless repetition of words spoken by others or repetition of overheard sounds. Neologisms are new meaningless words coined by the client or new, unique meanings given to old words. Flight of ideas is the rapid skipping from one thought to another; these thoughts usually have only superficial or chance relationships.

A client who has been admitted with a diagnosis of schizophrenia says to the nurse, "Yes, it's March. March is Little Women. That's literal, you know." What do these statements illustrate?

Loosening of associations Rationale: Loose associations are thoughts that are presented without the logical connections that are usually necessary for the listener to interpret the message. Echolalia is the purposeless repetition of words spoken by others or repetition of overheard sounds. Neologisms are new meaningless words coined by the client or new, unique meanings given to old words. Flight of ideas is the rapid skipping from one thought to another; these thoughts usually have only superficial or chance relationships.

A nurse determines that a client is pretending to be ill. What does this behavior usually indicate?

Malingering Rationale: When an individual consciously pretends to have an illness with no physical basis, it is called malingering. People who are psychotic experience delusions, hallucinations, and disorganized thoughts, speech, or behavior. The use of conversion defenses is not a conscious act. A person out of contact with reality is unable to pretend to be ill.

A client with a history of chronic alcoholism is admitted to the mental health unit. What does the nurse identify as the cause of a client's use of confabulation?

Marked loss of memory Rationale: Alcoholic clients have loss of memory and adapt to this by unconsciously filling in with false information areas that cannot be remembered. Ideas of grandeur do not occur in this disease. A need to get attention is unrelated to confabulation. These individuals are not purposely lying but instead are trying to cover memory losses.

A 65-year-old man is admitted to a mental health facility with a diagnosis of substance-induced persisting dementia resulting from chronic alcoholism. When conducting the admitting interview, the nurse determines that the client is using confabulation. What does the nurse recall precipitates the client's use of confabulation?

Marked memory loss Rationale: A client with this disorder has a loss of memory and adapts by filling in areas that cannot be remembered with made-up information. Ideas of grandeur do not occur with this type of dementia. The use of confabulation is not attention-seeking behavior; the individual is attempting to mask memory loss. This person is not coping with the diagnosis; when confabulating, the individual is attempting to mask memory loss.

While caring for an older adult client, what symptom requires an immediate reassessment of the client's needs and plan of care?

Memory loss or confusion Rationale: All are common signs of depression due to the aging process, however, memory loss or confusion may require immediate intervention. The development of confusion indicates that the client's ability to maintain equilibrium has not been achieved and that further disequilibrium is occurring, setting the client up for safety issues. Confusion may also be related to more serious physical conditions that can occur which require medical intervention.

A client with schizophrenia is speaking made-up words that have no meaning to other people. What term should the nurse use to document these verbalizations?

Neologisms Rationale: Neologisms are unique words with personal meanings only to the client. Avolition is the lack of motivation associated with a reduced emotional expression (flat affect). Echolalia is parrotlike echoing of spoken words or sounds. Anhedonia is the loss of enjoyment of things that were formerly enjoyed.

A nurse is counseling clients who are attending an alcohol rehabilitation program. Which substance poses the greatest risk of addiction for these clients?

Nicotine Rationale: Although polysubstance abuse is common, clients undergoing rehabilitation from alcohol dependence are more likely to use or develop a dependence on nicotine, another legal substance, than on an illegal substance such as heroin, cocaine, or marijuana.

A nurse is caring for a male client who was admitted to the mental health unit with the diagnosis of schizophrenia. The client is hostile and experiencing auditory hallucinations and states that the voices are saying that they are going to poison him because he is bad. What type of schizophrenic behavior does the nurse identify?

Paranoid Rationale: Clients with paranoid schizophrenia tend to experience persecutory or grandiose delusions and auditory hallucinations and exhibit behavioral changes such as anger, hostility, or violence. Residual schizophrenia is characterized by the negative symptoms of schizophrenia, but the client does not experience delusions, hallucinations, disorganized speech, or disorganized or catatonic behavior. Catatonia is a state in which the client displays extreme psychomotor retardation to the point of not talking or moving. There may be brief intermittent hyperactive episodes with catatonia. Disorganized schizophrenia is characterized by a disintegration of the personality and withdrawn behavior.

A mother brings her 7-year-old son into an outpatient clinic for a follow-up appointment. The mother appears angry and agitated with the boy. Looking at the boy's medical chart, the nurse notes that the boy has a diagnosis of encopresis. What is the primary symptom of encopresis?

Passing feces either voluntarily or involuntarily into inappropriate places Rationale: Encopresis is the passage of feces into inappropriate places such as clothing, closets, floors, or toy boxes, either voluntarily or involuntarily. It may severely limit a child's social development and results in parental disapproval and rejection. Encopresis does not involve self-induced vomiting or self-mutilation. The passage of urine into inappropriate places is called enuresis.

When assessing the characteristics of an adolescent with anorexia nervosa, how does the nurse expect to describe the adolescent?

Perfectionist Rationale: Perfectionistic standards and extremes of self-discipline are an attempt to maintain control and meet the client's own and others' expectations. People with anorexia nervosa are often anxious and depressed, not manic. People with anorexia nervosa are frequently compliant in an attempt to meet the expectations of others. People with anorexia nervosa usually use excessive exercise routines as a means of losing weight. Also, many are trying to become the thin, fit ideal woman depicted in the media.

A psychotic male client is admitted to the hospital for evaluation. While obtaining the history, the nurse asks why he was brought to the hospital by his parents. The client states, "They lied about me. They said I murdered my mother. You killed her. She died before I was born." What does the nurse recognize that the client is experiencing?

Persecutory delusions Rationale: The client's verbalization reflects feelings that others are blaming the client for negative actions. There are no data to demonstrate the client is having feelings of greatness or power. There are no data to demonstrate the client is experiencing confusing misinterpretations of stimuli. There are no data to demonstrate the client is hearing voices at this time.

An older adult client is talking to the nurse about his Vietnam experiences and shares that he still has flashbacks. While assessing him the nurse notes that he is jumpy and exhibits startle reactions and poor concentration. With which mental health disorder does the nurse associate these symptoms?

Posttraumatic stress disorder (PTSD) Rationale: PTSD is a syndrome characterized by the development of symptoms after an extremely traumatic event. Symptoms include helplessness, flashbacks, intrusive thoughts, memories, images, emotional numbing, loss of interest, avoidance of any place that reminds the affected person of the traumatic event, poor concentration, irritability, startle reactions, jumpiness, and hypervigilance. Delusions are beliefs that guide one's interpretation of events and help make sense of disorder. Common delusions among older adults involve being poisoned, having their assets taken by their children, being held prisoner, and being deceived by a spouse or lover. Hallucinations are visual or auditory perceptions of nonexistent objects and sounds. Older adults with hearing and vision deficits may hear voices or see people who are not actually present. OCD is characterized by recurrent and persistent thoughts, impulses, and urges of ritualistic behaviors that improve the affected person's comfort level.

A client with the diagnosis of alcoholism explains to the nurse that alcohol has a calming effect and states, "I function better when I'm drinking than when I'm sober." What defense mechanism does the nurse identify?

Rationalization Rationale: The attempt to justify a behavior by giving it acceptable motives is an example of rationalization. Sublimation is the substitution of a maladaptive behavior for a more socially acceptable behavior. Suppression is the intentional exclusion of things, people, feelings, or events from consciousness. Compensation is the attempt to emphasize a characteristic viewed as an asset to make up for a real or imagined deficiency.

A nurse is caring for a client with a somatoform disorder. What should the nurse anticipate that this client will do?

Redirect the conversation with the nurse to physical symptoms. Rationale: Clients with somatoform disorders are preoccupied with the symptoms that are being experienced and usually do not want to talk about their emotions or relate them to their current situation. Clients with somatoform disorders do not seek opportunities to discuss their feelings. Memory problems are not associated with somatoform disorders. These clients want and seek treatment, not palliative care.

What defense mechanism should the nurse anticipate that a client with the diagnosis of schizophrenia, undifferentiated type, will most often exhibit?

Regression Rationale: Regression is the defense mechanism that is commonly used by clients with schizophrenia, undifferentiated type, to reduce anxiety by returning to earlier behavior. Projection is an organized defense used by clients with schizophrenia, paranoid type, in which the delusional system is well systematized. Repression, or unconscious forgetting, is not a major defense used by clients with schizophrenia; if it were, they would not need to break with reality. Rationalization, in which the individual blames others for problems and attempts to justify actions, is seldom used by clients with schizophrenia.

What characteristic of anxiety is associated with a diagnosis of conversion disorder?

Relieved by the symptom Rationale: The client's anxiety results from being unable to choose psychologically between two conflicting actions. The conversion to a physical disability removes the choice and therefore eases the anxiety. The anxiety is not free floating or diffuse but rather localized and converted to a physical disability. The conversion of the anxiety to a physical disability occurs on an unconscious level; the original anxiety no longer exists, and the client generally is not anxious about the physical disability. The anxiety is internalized into a physical symptom, not projected onto the environment.

A 3-year-old child is found to have a pervasive developmental disorder not otherwise specified. What should the nurse consider most unusual for the child to demonstrate?

Responsiveness to the parents Rationale: One of the symptoms that an autistic child displays is lack of responsiveness to others; there is little or no extension to the external environment. Music is nonthreatening, comforting, and soothing. Repetitive behavior provides comfort. Repetitive visual stimuli, such as a spinning top, are nonthreatening and soothing.

A client with paralysis of the legs is found to have somatoform disorder, conversion type. What must the nurse consider when formulating a plan of care for this client?

The illness is very real to the client and requires appropriate nursing care. Rationale: Individuals who have somatoform disorders are really ill; they need care in a nonthreatening environment. The client requires physiological and emotional care for treatment of motor or sensory functional deficits.

An individual whose employment has been terminated because his company has been acquired by another company is brought by a family member to the mental health clinic because of extreme depression. While talking with the nurse the client says, "I'm a useless, worthless person. No wonder I lost my job." What type of delusion does the nurse identify?

Self-deprecation Rationale: The client's statement is self-derogatory and reflects a low self-appraisal. There is no evidence that the client feels that he is the object of attention from others in the environment, that the client feels harassed, or that the client feels that others are controlling or manipulative.

A nurse, understanding the possible cause of alcohol-induced amnestic disorder, should take into consideration that the client is probably experiencing which imbalance?

Thiamine deficiency Rationale: The deficiency of thiamine (vitamin B 1) is thought to be a primary cause of alcohol-induced amnestic disorder. Reduced iron intake, increased serotonin, and riboflavin malabsorption are all unrelated to alcohol-induced amnestic disorder.

A nurse is caring for a hyperactive, manic client who exhibits flight of ideas and is not eating. What may be the reason why the client is not eating?

Too busy to take the time to eat Rationale: Hyperactive clients frequently will not take the time to eat because they are overinvolved with everything in their environment. Feeling undeserving of the food is characteristic of a depressive episode. The client is unable to sit long enough with the other clients to eat a meal; this is not conscious avoidance. The client probably gives no thought to food because of overinvolvement with the activities in the environment.

A nurse is caring for a client with an obsessive-compulsive disorder. What is the basis for the obsessions and compulsions?

Unconscious control of unacceptable feelings Rationale: In carrying out the compulsive ritual the client unconsciously tries to control anxiety by avoiding acting on unacceptable feelings and impulses. The client does not consciously use this method to punish herself. Hallucinations are not part of this disorder. People with obsessive-compulsive disorder feel no need to punish others.

What characteristic uniquely associated with psychophysiologic disorders differentiates them from somatoform disorders?

Underlying pathophysiology Rationale: The psychophysiologic response (e.g., hyperfunction or hypofunction) produces actual tissue change. Somatoform disorders are unrelated to organic changes. There is an emotional component in both instances. There is a feeling of illness in both instances. There may be a restriction of activities in both instances.

A client with a history of drug abuse begins group therapy. After attending the first meeting the client says to the nurse, "It helps to know that I'm not the only one with this type of problem." What concept does this statement reflect?

Universality Rationale: Universality is the sense that one is not alone in any situation; one purpose of group therapy is to share feelings and gain support from others with similar thoughts and feelings. Altruism in group therapy is giving support, insight, and reassurance to others, which eventually promotes self-knowledge and growth. Catharsis involves group members relating to one another through the verbal expression of negative and positive feelings. Transference occurs when a client unconsciously assigns to the therapist feelings and attitudes originally associated with another important person in the client's life.

What behavior by a client with a long history of alcohol abuse is an indication that the client may be ready for treatment?

Verbalizing an honest desire for help Rationale: When clients with alcohol problems voice a desire for help, it usually signifies that they are ready for treatment, because they are admitting they have a problem. Adherence to an alcohol treatment program requires abstinence. A week is too short a time to signal readiness for treatment. Hospitalization alone is not an indication that the client is really ready for treatment, because many factors can influence admission.

A nurse is caring for a newly admitted client with obsessive-compulsive disorder. When should the nurse anticipate that the client's anxiety level will increase?

When limits are set on the performance of a ritual Rationale: Setting limits on the performance of a ritual will increase the client's anxiety. The ritual is a defense that the client needs at this time to control anxiety. The client needs time to develop other defenses before the ritual can be limited. The precipitation of anxiety in a client with obsessive-compulsive disorder is usually unrelated to the time of day. Visits from family members may or may not precipitate anxiety. Researchers have implicated trauma to the basal ganglia or cortical connections or a genetic predisposition as the origin of obsessive-compulsive disorder. A physical assessment by the nurse may or may not precipitate anxiety. The presentation of a nonjudgmental, supportive attitude by the nurse should decrease, not increase, anxiety.

A client in the psychiatric hospital is attempting to communicate by stating, "Sky, flower, angry, green, opposite, blanket." The nurse recognizes what term as describing this type of communication?

Word salad Rationale: Word salad is an incoherent mixture of words. Echolalia is a pathologic repetition of another's words or phrases. Confabulation is the unconscious filling in of memory gaps with imagined or untrue experiences. Flight of ideas is a speech pattern of rapid transition from topic to topic. The client's statement is too limited to be considered flight of ideas.