NCLEX-RN

The client has begun to wash the hands every hour due to the fear of germs becoming embedded in the client's skin leading the client to develop cancer. The nurse interprets this behavior as indicating which condition? An obsession A panic attack A compulsion Acute stress disorder

Compulsions are ritualistic behaviors that people feel compelled to perform either in accord with a specific set of rules or in a routine manner. A repeated action performed as the result of a persistent thought is termed a compulsion. Obsessions refer to recurrent, intrusive, and persistent ideas, thoughts, images, or impulses. Compulsions are the behaviors people with obsessive-compulsive disorder will carry out in order to neutralize the anxiety caused by the obsessions. Panic attacks typically are characterized by a discrete period of intense apprehension or terror without any real accompanying danger, accompanied by at least four of 13 somatic or cognitive symptoms. Acute stress disorder occurs within the first month of exposure to extreme trauma: combat, rape, physical assault, near-death experience, or witnessing a murder.

Which would be an expected reaction from a 5 year old when his 3-month-old infant sibling dies from Sudden Infant Death Syndrome (SIDS)? Acceptance of infant's death Understanding infant is dead Lack of concern where infant is Guilt he may have caused the death

Erikson's theory for preschoolers is initiative vs guilt. Preschoolers do not understand the concept of death, therefore, the most appropriate answer is; guilt that he may have caused the death of his sibling.

When reviewing a client's chart, the nurse notes that the client is in the disorganization stage of grief. Which assessment finding would support this diagnosis? "A lot of the time I'm terrified that I'm going to die the same way." "I haven't let my children out of my sight. I am afraid something will happen to them." "I had a good time at my class reunion. It was nice to be out with other people again." "I feel like I have absolutely no idea what to do next

In the disorganization stage of grief, the client may exhibit difficulty making decisions, aimlessness, decreased resistance to illness, and loss of interest in people, work, and usual activities. In the protest stage of grief, the client may exhibit preoccupation with thoughts of the deceased, searching for the deceased, dreams/nightmares, hallucinations, and concerns about others' health and safety. In the shock stage, the client may exhibit slowed and disorganized thinking, blocking of thoughts, neglect of appearance, and wish to join the deceased. In the reorganization stage of grief, the client may exhibit a realistic memory of the deceased, be comfortable when remembering the deceased, and return to previous level of ability.

A dehydrated infant is receiving IV therapy. The parent tells the nurse about wanting to hold the infant but being afraid this might cause the IV line to become dislodged. How should the nurse respond? Encourage the parent to interact with the infant while lying in the bed. Provide a comfortable chair for the parent to hold the infant while connected to the IV. Temporarily disconnect the IV line so the parent can hold the child comfortably. Place a restraint on the arm with the IV site so it cannot move or become dislodged.

Infant bonding is very important, and the need increases when the child is ill. The parent should be provided with a comfortable chair with support to help hold the infant. The IV pump needs to be close to the chair with enough tubing to allow for movement. Placing a restraint over the IV site requires a prescription from the health care provider and is not necessary. The IV site can be protected with blankets or clothing. The nurse should encourage the parent to participate in the child's care whenever possible, not just during IV therapy. The IV should not be disconnected for bonding time. IV fluids should remain continuously at a rate prescribed by the health care provider.

Which occurs when an individual intentionally produces illness symptoms to avoid work? Malingering Alexithymia Conversion disorder Illness anxiety disorder

Malingering occurs when an individual intentionally produces illness symptoms, motivated by another specific self-serving goal, such as being classified as disabled or avoiding work. Individuals with alexithymia have difficulty identifying and expressing their emotions. They have a preoccupation with external events and are described as concrete, externally oriented thinkers. Conversion disorder is a psychiatric condition in which severe emotional distress or unconscious conflict is expressed through physical symptoms. Illness anxiety disorder occurs when an individual is fearful of developing a serious illness based on a misinterpretation of body sensations.

Which statement best captures the current understanding of the etiology of mental illness? The role of "nurture," experiences, and relationships has been largely disproven. Mental illness can be attributed to organic brain changes and pathophysiologic processes. Mental illness exists from the interplay of biologic factors and psychosocial influences. Current understanding of mental illness has shown that both biologic psychiatry and psychosocial psychiatry are incorrect.

Mental illness is currently thought to be the outcome of anatomical/physiologic influences and psychosocial factors. Neither factor can attribute for 100% of the diagnoses and manifestations of mental illness. Both biologic and psychosocial psychiatry have their merits and demerits; neither is wholly incorrect.

As the nurse is conducting an interview with a client with a diagnosis of schizophrenia, the client states, "Bunnies are cute as a button, buttons are on my shirt, shirts can be bought in a store." Which is a term used to describe this thought process? Magical thinking Neologisms Loose associations Ideas of reference

In some cases a client presents several thoughts that don't make sense in conjunction with one another. This is often seen in clients with acute exacerbations of schizophrenia and is described as loose association.

A client is on a stress management program. She states that she is open to trying a guided meditation class. When helping her get started, a nurse tells her that which of the following is not important? a quiet environment an open attitude soft music a focus of attention

Music may be helpful for some but is not essential for meditation.

A client with paranoid personality disorder is admitted to a psychiatric facility. Which remark by the nurse would best establish rapport and encourage the client to confide in the nurse? "I get upset once in a while, too." "I know just how you feel. I'd feel the same way in your situation." "I worry, too, when I think people are talking about me." "At times, it's normal not to trust anyone."

Sharing a benign, nonthreatening, personal fact or feeling helps the nurse establish rapport with the client and encourages the client to confide in the nurse. The nurse can't know how the client feels. Telling the client otherwise would justify the suspicions of a paranoid client; furthermore, the client relies on the nurse to interpret reality. The nurse stating that she worries when people talk about her is incorrect because the statement focuses on the nurse's feelings, not the client's. Saying it's normal not to trust anyone wouldn't help establish rapport or encourage the client to confide in the nurse.

Children of parents who abused alcohol and substances are able to develop self-esteem and self-efficacy by developing which characteristics? Resilience Hardiness Social skills Tolerance

Resilience is having healthy responses to stressful situations or risky environments. Hardiness is the ability to resist illness when under stress. Social skills are a type of coping strategy. Tolerance is the ability to deal with increasing levels of stress in an adaptive way.

The nurse is working with two children who have been apprehended from a neglectful and abusive home. Initial assessments reveal that one child is much more traumatized than the other, despite similarities in their circumstances. The nurse should consider what possible explanation for their differing responses? The children have differing levels of resilience The child who is less traumatized is developmentally delayed The child who is more traumatized is developmentally delayed The children's differing responses are genetically determined

Resilience is the capacity to withstand stress and is a protective factor against trauma. Resilience is determined by the interplay of multiple variables, not just genetics. Developmental delays are less likely to be the root cause of the children's differing responses to trauma.

A client reports overwhelming stress and several physical ailments. What client responses related to poor adaptation will the nurse address in the client's plan of care? Select all that apply. deficient knowledge ineffective coping feelings of powerlessness hopelessness anxiety

Stress is everywhere and anywhere. Feelings of anxiety, frustration, anger, helplessness, and inadequacy are often associated with stress. The most common examples include defensive or ineffective coping, feelings of powerlessness, hopelessness, anxiety, social isolation, spiritual distress, and denial. Deficient knowledge is not necessarily linked with stress.

The nurse is teaching a prenatal class about preparing for their expanding families. What is helpful advice from the nurse? "Expect your other children to react positively to their new brother/sister." "Your old coping methods will adequately get you through this period of adjustment." "The hormones of pregnancy may cause anxiety or depression postpartum." "Caring for your new infant is instinctual and will come naturally to you."

The "raging hormones" of pregnancy can keep the woman slightly out of touch with her usual methods of coping. Although she may normally interact and communicate in quite mature ways, during a pregnancy she may become depressed, anxious, withdrawn, or angry as she accomplishes her own developmental tasks. Siblings often react to a pregnancy by regression in behavior and attitude because they fear they will be replaced or unloved. In addition to anticipatory guidance concerning the alterations in family structure and functioning, prenatal preparation for first-time parents involves learning the basics of infant care and preparing for infant feeding, particularly for women who plan to breastfeed.

A nurse is developing a plan of care for a client to meet the client's self-actualization needs. The nurse would focus on which area as most important? Emphasizing the client's strengths Addressing the client's problems Reducing fear Promoting socialization

To help meet a client's self-actualization needs, the nurse focuses on the person's strengths and possibilities rather than on problems. Reducing fear would assist in meeting the client's safety and security needs. Promoting socialization would aid in meeting the client's love and belonging needs.

A woman is 10 weeks' pregnant and tells the nurse that this pregnancy was unplanned and she has no real family support. The nurse's most therapeutic response would be to: encourage her to identify someone that she can talk to and share the pregnancy experience. tell her to move home so her family will be nearby to help her. remind her that she is still early in the pregnancy and she will feel better about it as the pregnancy progresses. offer to meet with the client on a regular basis to provide her someone to talk to about her concerns.

A pregnant woman without social support needs to identify someone with whom she can share the experience of pregnancy because social support is a crucial part of adapting to parenthood. Telling her to move home and telling her that she will feel better as the pregnancy progresses do not address the issue of isolation. Also, moving home may not be a possibility for this woman. The nurse should maintain a professional relationship and not commit to a long-term relationship with a client.

During a home visit on the 5th postpartum day, the client begins to cry and says that she is worried about her ability to care for her baby adequately. She tells the nurse, "I wish I could just get organized—I need 8 hours of sleep!" The nurse determines that she is experiencing which condition? Taking-in phase of childbearing; she is exhibiting typical signs of adaptation. Postpartum blues phase of childbearing; she needs psychological counseling. Letting-go phase of childbearing; she needs help to assume the maternal role. Taking-hold phase of childbearing; she is feeling inadequate about neonatal care.

A primipara often has concerns about her ability to care for her infant properly during the taking-hold phase. She is working toward independence and autonomy and wants to be able to perform well in her new role as mother. She needs emotional support, advice on how to manage, reassurance, and reinforcement of appropriate behavior.The taking-in phase occurs from birth up to about the second to third postpartum day. During this phase, the client is focused on herself and not the neonate.Postpartum blues are evidenced by extreme sadness. However, this client is exhibiting usual behavior associated with the taking-hold phase. Psychological counseling is not warranted.In the letting-go phase, the woman redefines her new role. This phase is extended and continues into the child's growing years. This process requires some grief work and readjustment.

For a person to be clinically depressed, signs of a depressed mood or depressed interest in pleasurable activities must occur for at least 3 days. 1 week. 10 days. 2 weeks.

Clinically depressed people usually have had signs of a depressed mood or a decreased interest in pleasurable activities for at least a 2-week period. An obvious impairment in social, occupational, and overall daily functioning occurs in some people. All other time frames are not appropriate.

One of the primary reforms accomplished by Dorothea Lynde Dix was the ... establishment of "commitment" laws in state legislatures. establishment or enlargement of state hospitals. use of music to treat mentally ill clients. use of exercise therapy to treat mentally ill clients.

One of the primary reforms accomplished by Dorothea Lynde Dix was the establishment or enlargement of state hospitals to treat the mentally ill. She also was instrumental in the establishment of mental hospitals in England, Canada, and Europe in the 19th century.

Morbidity rates among children are most highly associated with which cause? Firearms at home School violence Environmental factors Suicide and homicide

The factors most commonly associated with child morbidity are environmental and socioeconomic problems. The more difficult the societal issues and the more marked the environmental poverty, the higher the illness rates and childhood morbidity. Firearms, violence in schools, homicide, and suicide are all factors in morbidity, but they are not strictly related to children.

A nurse is caring for an adolescent with posttraumatic stress syndrome. The client reports having difficulty concentrating and has an increased startle reflex. The nurse's documentation includes the presence of: Hyperarousal Intrusion Shell shock Resistance

The nurse should document the presence of hyperarousal, defined as the presence of increased irritability, difficulty concentrating, exaggerated startle reflex, increased vigilance, and/or concern over safety in a client with posttraumatic stress syndrome.

A nurse is providing care to a couple who have experienced intrauterine fetal demise. Which action would be least effective in assisting a couple at this time? Avoid any discussion of the situation with the couple. Allow the couple to spend as much time as they want with their stillborn infant. Give the parents a lock of the infant's hair. Assist the family in making arrangements for their stillborn infant.

The nurse should encourage discussion of the loss and allow the couple to vent their feelings of grief and guilt. The nurse should allow the parents to spend unlimited time with their stillborn infant so that they can validate the death. Providing the parents and family with mementos of the infant helps validate the reality of the death. Assisting the family with arrangements is helpful to reduce the stress of coping with the situation and making decisions at this difficult time.