Mental Health Exam 2 1023

Which clinical presentation is associated with the most commonly diagnosed adjustment disorder (AD)? 1. Anxiety, feelings of hopelessness, and worry 2. Truancy, vandalism, and fighting 3. Nervousness, worry, and jitteriness 4. Depressed mood, tearfulness, and hopelessness

Answer : 4 AD with depressed mood is the most commonly diagnosed adjustment disorder. The clinical presentation is one of predominant mood disturbance, although less pronounced than that of major depression. The symptoms—such as depressed mood, tearfulness, and feelings of hopelessness—exceed what is an expected or normative response to an identified stressor.

Which information will help the nurse differentiate the diagnosis of posttraumatic stress disorder (PTSD) from the diagnosis of adjustment disorder (AD)? 1. PTSD results from exposure to an extreme traumatic event, whereas AD results from exposure to "normal" daily events. 2. AD is more common in women, whereas PTSD is more common in men. 3. AD can occur from severe motor vehicle accidents, while PTSD can occur from the birth of a stillborn. 4. PTSD occurs more often when compared to AD.

Answer: 1 PTSD results from exposure to an extreme traumatic event, whereas AD results from exposure to "normal" daily events or "less extreme" events, such as being a victim of bullying or being incarcerated.

Which of the following is the most commonly used treatment for clients with adjustment disorder (AD) and its appropriate rationale? 1. Psychotherapy; to examine the stressor and confront unresolved issues 2. Selective serotonin reuptake inhibitors; to stabilize mood and resolve symptoms 3. Eye movement desensitization therapy; to reprocess traumatic events 4. Antianxiety agents; a first-line treatment to address symptoms of anxiety

Answer: 1 Psychotherapy is the most common treatment used for AD. Individual psychotherapy allows the client to examine the stressor that is causing the problem, possibly assign personal meaning to the stressor, and confront unresolved issues that may be exacerbating this crisis.

Which approach should the nurse use to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder (BPD)? 1. Being firm, consistent, and empathic while addressing specific client behaviors 2. Promoting client self-expression by implementing laissez-faire leadership 3. Using authoritative leadership to help clients learn to conform to society norms 4. Overlooking inappropriate behaviors to avoid providing secondary gains

Answer: 1 The best nursing approach when working with a client diagnosed with borderline personality disorder is to be firm, consistent, and empathetic while addressing specific client behaviors. Individuals with borderline personality disorder always seem to be in a state of crisis and can often have negative patterns of interaction, such as manipulation and splitting

The client diagnosed with posttraumatic stress disorder (PTSD) has a nursing diagnosis of posttrauma syndrome R/T surviving a workplace shooting. Which nursing intervention would the nurse add to this client's plan of care? 1. Monitor for substance use 2.Alternate staff members 3. Use a firm approach 4. Offer social skill training

Answer: 1 The nurse must monitor for substance use, as this can be a maladaptive form of coping clients with PTSD employ.

Family members of a client ask the nurse to explain the difference between schizoid and avoidant personality disorders. Which nursing response is appropriate? 1. Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone. 2. Clients diagnosed with schizoid personality disorder exhibit delusions and hallucinations, while clients diagnosed with avoidant personality disorder do not. 3. Clients diagnosed with avoidant personality disorder are eccentric, and clients diagnosed with schizoid personality disorder are dull and vacant. 4. Clients diagnosed with schizoid personality disorder have a history of psychosis, while clients diagnosed with avoidant personality disorder remain based in reality.

Answer: 1 The nurse should educate the family that clients diagnosed with avoidant personality disorder desire intimacy but fear it, while clients diagnosed with schizoid personality disorder prefer to be alone.

1. A kindergarten student is frequently violent toward other children. A school nurse notices bruises and burns on the child's face and arms. Which other symptom would indicate to the nurse that the child may have been physically abused? 1. The child shrinks at the approach of adults. 2. The child begs or steals food or money. 3. The child is frequently absent from school. 4. The child is delayed in physical and emotional development.

Answer: 1 The nurse would determine that a child who shrinks at the approach of adults in addition to having bruises and burns may be a victim of abuse. Maltreatment is considered, whether or not the adult intended to harm the child.

Which information would be included in a lesson about domestic violence? 1. Power and control are central to the dynamic of domestic violence. 2. Poor communication and social isolation are central to the dynamic of domestic violence. 3. Erratic relationships and vulnerability are central to the dynamic of domestic violence. 4. Emotional injury and learned helplessness are central to the dynamic of domestic violence

Answer: 1 The nursing instructor would include the concept that power and control are central to the dynamic of domestic violence. Battering is defined as a pattern of coercive control founded on physical and/or sexual violence or threat of violence. The typical abuser is very possessive and perceives the victim as a possession.

Which nursing diagnosis is the priority when providing nursing care to a client diagnosed with paranoid personality disorder? 1. Risk for violence: directed toward others R/T suspicious thinking 2. Risk for suicide R/T altered thought 3. Altered sensory perception R/T increased levels of anxiety 4. Social isolation R/T inability to relate to others

Answer: 1 The priority nursing diagnosis for a client diagnosed with paranoid personality disorder should be risk for violence: directed toward others R/T suspicious thinking. Clients diagnosed with paranoid personality disorder are often tense and irritable, which increases the likelihood of violent behavior. The desire for reprisal and vindication is so intense that a possible loss of control can result in aggression and violence.

12. Which statement indicates a nurse has a correct understanding about how eye movement desensitization and reprocessing (EMDR) achieves its therapeutic effect? 1. "The exact biological mechanism is unknown." 2. "It causes an increase in imagery vividness." 3. "This therapy decreases memory access." 4. "EMDR disrupts the fear associated with trauma."

Answer: 1 This statement indicates the nurse has a correct understanding. The exact biological mechanisms by which EMDR achieves it therapeutic effects are unknown. However, some studies have indicated that eye movements cause a decrease in imagery vividness and distress, as well as an increase in memory CO access.

Which statements represent positive outcomes for clients diagnosed with narcissistic personality disorder? (Select all that apply.) 1. The client will relate one empathetic statement to another client in group by day four. 2. The client will identify one personal limitation by day two. 3. The client will acknowledge one strength that another client possesses by day three. 4. The client will list four personal strengths by day three. 5. The client will discuss two lifetime achievements by discharge.

Answer: 1, 2, 3 1. The nurse should determine that appropriate outcomes for a client diagnosed with narcissistic personality disorder include relating empathetic statements to other clients. This indicates the client is improving because he or she is reducing self-centeredness. 2. The nurse should determine that appropriate outcomes for a client diagnosed with narcissistic personality disorder include identifying one personal limitation. This indicates improvement because the client is realizing humility, something that he or she lacks. 3. The nurse should determine that appropriate outcomes for a client diagnosed with narcissistic personality disorder include acknowledging one strength in another client. This indicates the client is improving because he or she views self as "superior" to others.

The client diagnosed with an adjustment disorder says, "Tell me about medications that will cure this problem." Which responses by the nurse are appropriate? (Select all that apply.) 1. "Medications can interfere with your ability to find a more permanent solution." 2. "Medications may mask the real problem at the root of this diagnosis." 3. "Adjustment disorders are not commonly treated with medications." 4. "Psychoactive drugs carry the potential for physiological and psychological dependence." 5. "Psychoactive drugs will be prescribed only if your problems persist for more than three months."

Answer: 1, 2, 3, 4 1. Adjustment disorders are not commonly treated with medications because of interfering with finding a permanent solution. 2. Adjustment disorders are not commonly treated with medications because of masking the real problem. 3. Adjustment disorder is not commonly treated with medication. 4. Adjustment disorders are not commonly treated with medications because of the potential for physiological and psychological addiction.

The nurse is admitting a client who has been diagnosed with posttraumatic stress disorder (PTSD). Which symptoms might the nurse observe upon assessment? (Select all that apply.) 1. Feelings of guilt that precipitate social isolation 2. Aggressive behavior that affects job performance 3. Relationship problems 4. High levels of anxiety 5. Escalating symptoms lasting less than one month

Answer: 1, 2, 3, 4 1. Characteristic symptoms of PTSD include guilt feelings, especially survivor guilt, that can lead to social isolation. 2. Characteristic symptoms of PTSD include aggressive behaviors and impaired occupational functioning. 3. Characteristic symptoms of PTSD include relationship problems with feelings of detachment or estrangement from others. 4. Characteristic symptoms of PTSD include high levels of anxiety with hypervigilance and exaggerated startle response.

The nurse is assessing a client for antisocial personality disorder. According to the DSM-5, which symptoms must the client meet in order to be assigned this diagnosis? (Select all that apply.) 1. Age of at least 18 years old 2. Deceitful for personal gain 3. Frequent feelings of being down, remorseful, or hopeless 4. Disregard for and failure to honor financial obligations 5. Avoidance of social events and interaction with others

Answer: 1, 2, 4 1. According to the DSM-5, the client must be at least 18 years, and tI here must be evidence of conduct disorder with onset before age 15. 2. According to the DSM-5, the client is deceitful, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. 4. According to the DSM-5, the client displays consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.

Based upon the research with Vietnam veterans, which factors are the best predictors of posttraumatic stress disorder (PTSD)? (Select all that apply.) 1. The severity of the stressor 2. The degree of ego strength 3. The degree of psychosocial isolation in the recovery environment 4. The attitudes of society regarding the experience 5. The presence of preexisting psychopathology

Answer: 1, 3 1. In research with Vietnam veterans, it was shown that one of the best predictors of PTSD was the severity of the stressor. 3. In research with Vietnam veterans, it was shown that one of the best predictors of PTSD was the degree of psychosocial isolation in the recovery environment.

The nurse is caring for a client diagnosed with antisocial personality disorder. Which factors should the nurse consider when planning this client's care? (Select all that apply.) 1. This client has personality traits that are deeply ingrained and difficult to modify. 2. This client needs medication to treat the underlying physiological pathology. 3. This client uses manipulation, making the implementation of treatment problematic. 4. This client wants instant gratification, which hinders compliance with a plan of care. 5. This client is likely to have secondary diagnoses of substance abuse and depression.

Answer: 1, 3, 4, 5 1. The nurse should consider that individuals diagnosed with antisocial personality disorders have deeply ingrained personality traits, making changes difficult. 3. The nurse should consider that individuals diagnosed with antisocial personality disorders use manipulation frequently to obtain their way. 4. The nurse should consider that individuals diagnosed with antisocial personality disorders use manipulation frequently to obtain their way. 5. The nurse should consider that individuals diagnosed with antisocial personality disorders use manipulation frequently to obtain their way.

. The nurse is admitting a client with a diagnosis of schizotypal personality disorder. Which client findings would make the nurse question this diagnosis? (Select all that apply.) 1. Is the center of attention 2. Has unusual perceptual experiences 3. Has a bipolar disorder 4. Is odd and eccentric but not delusional 5. Has autism spectrum disorder

Answer: 1, 3, 5 1. The nurse would question the diagnosis of a schizotypal personality disorder if the client is the center of attention. These clients have an acute discomfort with and reduced capacity for close relationships. They do not want to be the center of attention. Clients with histrionic personality disorder want to be the center of attention 3. The nurse would question the diagnosis of a schizotypal personality disorder in a client with a bipolar disorder. The DSM-5 criteria states that it does not occur exclusively during the course of a bipolar disorder. 5. The nurse would question the diagnosis of a schizotypal personality disorder in a client with autism spectrum disorder. The DSM-5 criteria states that it does not occur exclusively during the course of autism spectrum disorder.

Place the spectrum of schizophrenic and other psychotic disorder as described by the DSm-5 on a gradient of psychopathology from least to most severe (1-4) 1. Delusional disorder 2. Schizophrenia 3. Schizophreniform disorder 4. Substance-induced psychotic disorder

Answer: 1, 4, 3, 2 Rationale: Schizophrenia and other psychotic disorders has been identified in the DSM-5. These include (on a gradient of psychopathology form least to most severe): schizotypal personality disorder, delusional disorder, brief psychotic disorder, substance-induced psychotic disorder, psychotic disorder associated with another medical condition, catatonic disorder associated with another medical condition, schiopheniform disorder, schizoaffective disorder, and schizophrenia. For the disorders listed the organization is as follows: 1. Delusional disorder 2. Substance-induced psychotic disorder 3. Schizophreniform disorder 4. Schizophrenia

The client has been extremely anxious ever since relocating to another state because of a job transfer. When assessing for the diagnosis of adjustment disorder (AD), within what time frame should the nurse expect the client to exhibit symptoms? 1. Within 1 year of the move 2. Within 3 months of the move 3. Within 6 months of the move 4. Within 9 months of the move

Answer: 2 According to the DSM-5 diagnostic criteria for adjustment disorders, the development of emotional or behavioral symptoms in response to an identifiable stressor occurs within 3 months of the onset of the stressor.

The client has a nursing diagnosis of complicated grieving related to the death of multiple family members from a tornado. Which action should the nurse take first? 1. Encourage the journaling of feelings. 2. Assess for the stage of grief in which the client is fixed. 3. Provide community resources to address the client's concerns. 4. Suggest attending a grief therapy group.

Answer: 2 Prior to implementing all other nursing interventions presented, the nurse must assess the stage of grief in which the client is fixed. Appropriate nursing interventions are always based on accurate assessments.

Which nursing intervention is appropriate when caring for a client diagnosed with borderline personality disorder? 1. Seclude the client when inappropriate behaviors are exhibited. 2. Rotate staff members who work with the client. 3. Teach about antianxiety medications to improve medication compliance. 4. Offer sympathy when client engages in self-mutilation.

Answer: 2 Rotate staff members who work with the client in order to avoid client's developing dependence on particular individuals. These interventions are intended to help the individual understand that staff splitting will not be tolerated, and to work toward diminishing clinging and distancing behaviors.

1. The client diagnosed with antisocial personality disorder spits, curses, and refuses to answer questions during the assessment interview. Which response would the nurse make? 1. "You are very disrespectful. You need to learn to control yourself." 2. "I understand that you are angry, but this behavior will not be tolerated." 3. "What behaviors could you modify to improve this situation?" 4. "Which antipersonality disorder medications have helped you in the past?"

Answer: 2 The appropriate nursing response is to reflect the client's feeling while setting firm limits on behavior. Clients diagnosed with antisocial personality disorder have a low tolerance for frustration, see themselves as victims, and use projection as a primary ego defense mechanism.

The client expresses low self-worth, has much difficulty making decisions, avoids positions of responsibility, and has a behavioral pattern of "suffering" in silence. Which information best explains the childhood nurturance of this client's personality disorder? 1. Was provided from many sources, and independent behaviors were encouraged 2. Was provided exclusively from one source, and independent behaviors were discouraged 3. Was provided exclusively from one source, and independent behaviors were encouraged 4. Was provided from many sources, and independent behaviors were discouraged

Answer: 2 The behaviors presented in the question represent symptoms of dependent personality disorder. Nurturance provided from one source and discouragement of independent behaviors can contribute to the development of this personality disorder. Dependent behaviors may be rewarded by a parent who is overprotective and discourages autonomy.

Which nursing action is appropriate for a client brought to the emergency department after being raped? 1. Discourage the client from discussing the rape, because this may lead to further emotional trauma. 2. Remain nonjudgmental while actively listening to the client's description of the rape event. 3. Meet the client's self-care needs by assisting with showering and perineal care. 4. Probe for further, detailed description of the rape event.

Answer: 2 The most appropriate nursing action is to remain nonjudgmental and actively listen to the client's description of the event. It is important to also communicate to the victim that he/she is safe and that it is not his/her fault. Nonjudgmental listening provides an avenue for catharsis, which contributes to the healing process.

The client presents at an outpatient clinic appointment and states, "My dead husband returned to me during a séance." Which personality disorder should the nurse associate with this behavior? 1. Obsessive-compulsive 2. Schizotypal 3. Narcissistic 4. Borderline

Answer: 2 The nurse should associate schizotypal personality disorder with this behavior. Magical thinking, ideas of reference, illusions, and depersonalization are part of their everyday world. Examples include superstitiousness; belief in clairvoyance, telepathy, or "sixth sense"; and beliefs that "others can feel my feelings."

The nurse is teaching staff about clients diagnosed with histrionic personality disorder and the quality of their relationships. Which statement made by a staff member indicates learning has occurred? 1. "Their dramatic style tends to make their interpersonal relationships interesting and fulfilling." 2. "Their interpersonal relationships tend to be shallow and fleeting, serving their dependency needs." 3. "They tend to develop few relationships because they are strongly independent but generally maintain deep affection." 4. "They pay particular attention to details, which can interfere with the development of relationships."

Answer: 2 The nurse should evaluate that learning has occurred when the staff member describes clients diagnosed with histrionic personality disorder as having relationships that are shallow and fleeting. These types of relationships tend to serve their dependency needs.

When planning care for a client diagnosed with borderline personality disorder, which self-harm behavior should a nurse expect the client to exhibit? 1. Highly lethal methods to commit suicide 2. Suicidal gestures to elicit a rescue response from others 3. Isolation and starvation as suicidal methods 4. Self-mutilation from decreased endorphins in the body

Answer: 2 The nurse should expect that a client diagnosed with borderline personality disorder may use suicidal gestures to elicit a rescue response from others. Repetitive, self-mutilating behaviors are common in borderline personality disorders that result from feelings of abandonment following separation from significant others.

Which client is most likely to be admitted to an inpatient facility for self-destructive behaviors? 1. One with antisocial personality disorder 2. One with borderline personality disorder 3. One with schizoid personality disorder 4. One with paranoid personality disorder

Answer: 2 The nurse should expect that a client diagnosed with borderline personality disorder would most likely be admitted to an inpatient facility for self-destructive behaviors. The behavior of clients with borderline personality disorder is unstable, and hospitalization is often required as a result of attempts at self-injury, persistent suicide risk, substance abuse and dependence, or a combination of these behaviors.

The client diagnosed with borderline personality disorder brings up a conflict with the staff in a community meeting and develops a following of clients who unreasonably demand modification of unit rules. How can the nursing staff best handle this situation? 1. Allow the clients to apply the autocratic process when developing unit rules. 2. Maintain consistency of care and open communication to avoid staff manipulation. 3. Allow the client spokesman to verbalize concerns during a unit staff meeting. 4. Maintain unit order by the application of punitive leadership.

Answer: 2 The nursing staff can best handle this situation by maintaining consistency of care by open communication to avoid staff manipulation. Clients with borderline personality disorder can exhibit negative patterns of interaction, such as clinging and distancing, splitting, manipulation, and self-destructive behaviors.

After a teaching session about grief, a client says to the nurse, "I seem to be stuck in the bargaining stage of grieving over the loss of my daughter." In which phase of the nursing process would this occur, and how would the nurse interpret this statement? 1. Assessment phase; nursing actions have been successful in achieving accurate data. 2. Evaluation phase; nursing actions have been successful in achieving the objectives of care. 3. Implementation phase; nursing actions have been successful in achieving the objectives of care. 4. Diagnosis phase; nursing actions have been successful in achieving accurate data.

Answer: 2 The statement occurs in the evaluation phase. In the evaluation phase of the nursing process, reassessment is conducted to determine if the nursing actions have been successful in achieving the objectives of care. The implementation of client teaching has enabled the client to verbalize an understanding of the grief process and his or her position in the process. Therefore, the nurse's actions can be evaluated as successful. Without the evaluation phase, it would be difficult for the nurse to determine if actions have been successful.

The nursing instructor is explaining the etiology of trauma-related disorders from a learning theory perspective. Which student statement indicates teaching has been effective? 1. "How clients perceive events and view the world affects their response to trauma." 2. "Psychic numbing in PTSD is a result of negative reinforcement." 3. "The individual becomes addicted to the trauma owing to an endogenous opioid response." 4. "Believing that the world is meaningful and controllable can protect an individual from PTSD."

Answer: 2 This statement indicates effective teaching. Learning theorists view negative reinforcement as behavior that leads to a reduction in an aversive experience, thereby reinforcing and resulting in repetition of the behavior. Psychic numbing decreases or protects an individual from emotional pain and, therefore, the learned response is the repetition of this behavior.

The client receiving eye movement desensitization and reprocessing (EMDR) therapy says, "After only three sessions, I am feeling great. Now I can stop and get on with my life." Which response by the nurse is most appropriate? 1. "I am thrilled that you have responded so rapidly to EMDR." 2. "To achieve lasting results, all eight phases of EMDR must be completed." 3. "If I were you, I would complete the EMDR and comply with the health-care provider's orders." 4. "How do you feel about continuing the therapy?"

Answer: 2 This statement is most appropriate. Clients often feel relief quite rapidly with EMDR. However, to achieve lasting results, it is important that each of the eight phases be completed. The nurse's most appropriate response should be to give information to correct the client's misconceptions about the therapy.

Parents ask the nurse why their daughter was diagnosed with posttraumatic stress disorder (PTSD) and others survivors of the terrorist attack were not. Which information should the nurse offer? (Select all that apply.) 1. An individual's stated religious affiliation can affect response to trauma. 2. Responses are affected by how an individual handled previous trauma. 3. Protectiveness of family and friends can help an individual deal with trauma. 4. Control over the possibility of recurrence can affect the response to trauma. 5. The duration of how long the trauma lasted can affect the individual's response.

Answer: 2, 3, 4, 5 2. Variables that affect whether an individual exposed to massive trauma develops trauma-related disorders are grouped into characteristics of the individual, such as outcomes of previous experiences with stress or trauma. 3. Variables that affect whether an individual exposed to massive trauma develops trauma-related disorders are grouped into characteristics of the recovery environment, like the cohesiveness and protectiveness of family and friends. 4. Variables that affect whether an individual exposed to massive trauma develops trauma-related disorders are grouped into characteristics of the traumatic experience, such as amount of control over recurrence. 5. Variables that affect whether an individual exposed to massive trauma develops trauma-related disorders are grouped into characteristics of the traumatic experience, like duration and severity of the stressor.

The client diagnosed with posttraumatic stress disorder (PTSD) asks, "Why did my health-care provider prescribe an antidepressant rather than an antianxiety drug for me?" Which explanations should the nurse make? (Select all that apply.) 1. "I'm not sure, because antianxiety drugs have been approved by the FDA for PTSD." 2. "Antidepressants are now considered first-line treatment choice for PTSD." 3. "Many people experience side effects to antianxiety drugs." 4. "Because of their addictive properties, antianxiety drugs are less desirable." 5. "That is strange because antipsychotics have provided the best results for treatment of PTSD."

Answer: 2, 4, 5 2. Antidepressants, specifically certain selective serotonin reuptake inhibitors, are now considered the first-line treatment of choice for PTSD. 4. Addictive properties of antianxiety agents make them less desirable than other medications used in the treatment of PTSD. 5. There is little positive evidence concerning the use of antipsychotics in the treatment of PTSD. These drugs are only used for short-term control of severe aggression and agitation.

Which factor differentiates a client diagnosed with schizotypal personality disorder from a client diagnosed with schizoid personality disorder? 1. Clients diagnosed with schizotypal personality disorder are treated with cognitive behavioral therapy, whereas clients diagnosed with schizoid personality disorder need medications. 2. Clients diagnosed with schizoid personality disorder experience anxiety only in social settings, whereas clients diagnosed with schizotypal personality disorder experience generalized anxiety. 3. Clients diagnosed with schizotypal personality disorder experience social anxiety from paranoid fears, whereas clients diagnosed with schizoid personality disorder would isolate themselves on a continual basis. 4. Clients diagnosed with schizoid personality disorder have magical thinking and depersonalization, whereas clients diagnosed with schizotypal personality disorder do not.

Answer: 3 A client diagnosed with schizoid personality disorder prefers being alone to being with others. However, clients with schizotypal personality disorder have excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.

Which physically healthy adult client should a nurse identify as exhibiting the characteristics of a dependent personality disorder? 1. Meets social needs by contact with 15 cats 2. Has a history of depending on intense relationships to meet basic needs 3. Lives with parents and relies totally on public transportation 4. Is serious, inflexible, and lacks spontaneity

Answer: 3 An adult client who lives with parents and totally relies upon public transportation exhibits signs of dependent personality disorder. Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive behaviors.

The nurse is describing the Transactional Model of Stress and Adaptation. When using this model, which factor would the nurse categorize as intrapersonal? 1. Occupational opportunities 2. Economic conditions 3. Degree of flexibility 4. Availability of social supports

Answer: 3 Degree of flexibility is an intrapersonal factor in this model. Intrapersonal factors that might influence an individual's ability to adjust to a painful life change include social skills, coping strategies, the presence of psychiatric illness, degree of flexibility, and level of intelligence.

Which action would the nurse take to provide trauma-informed care to a homeless client who is combative? 1. Place the client in seclusion 2. Apply soft wrist restraints 3. Allow the client some control 4. Encourage dependent behavior

Answer: 3 Empowering the trauma survivor to guide and direct his or her recovery plan by providing input is reflective of trauma-informed care.

The nurse is caring for a client diagnosed with posttraumatic stress disorder (PTSD). Which realistic goal should be included in this client's plan of care? 1. The client will have no flashbacks. 2. The client will be able to feel a full range of emotions by discharge. 3. The client will not require medication to obtain adequate sleep by discharge. 4. The client will refrain from discussing the traumatic event.

Answer: 3 Obtaining adequate sleep without medication by discharge is a goal that should be included in the client's plan of care.

As the sole survivor of a roadside bombing, a veteran is experiencing extreme guilt. Which nursing diagnosis would address this client's symptom? 1. Anxiety 2. Altered thought processes 3. Complicated grieving Altered sensory perception

Answer: 3 The client's survivor guilt is disrupting the normal process of grieving, indicating complicated grieving as the nursing diagnosis.

When planning care for clients diagnosed with personality disorders, which treatment goal is appropriate? 1. To stabilize the client's pathology by using the correct combination of psychotropic medications 2. To change the characteristics of the dysfunctional personality 3. To reduce personality trait inflexibility that interferes with functioning and relationships 4. To decrease the prevalence of neurotransmitters at receptor sites

Answer: 3 The goal of treatment for clients diagnosed with personality disorders should be to reduce inflexibility of personality traits that interfere with functioning and relationships.

3. The client diagnosed with paranoid personality disorder becomes aggressive on the unit. Which nursing intervention is most appropriate? 1. Provide objective evidence that reasons for violence are unwarranted. 2. Initially restrain the client to maintain safety. 3. Use clear, calm statements with a confident physical stance. 4. Empathize with the client's paranoid perceptions.

Answer: 3 The most appropriate nursing intervention is to use clear, calm statements with a confident physical stance. A calm attitude provides the client with a feeling of safety and security.

2. At 11:30 p.m. the client diagnosed with antisocial personality disorder demands to phone a lawyer to file for a divorce. Unit rules state that no phone calls are permitted after 10 p.m. Which nursing response is most appropriate? 1. "Go ahead and use the phone. I know this pending divorce is stressful." 2. "You know better than to break the rules. I'm surprised at you." 3. "It is after the 10 p.m. phone curfew. You will be able to call tomorrow." 4. "A divorce shouldn't be considered until you have had a good night's sleep."

Answer: 3 The most appropriate response by the staff is to restate the unit rules in a calm, assertive manner. The nurse can encourage the client to verbalize frustration while maintaining an accepting attitude. The nurse may also help the client to identify the true source of frustration.

Which reaction to a compliment from a staff member should the nurse identify as a typical response from a client diagnosed with avoidant personality disorder? 1. Interpreting the compliment as a secret code used to increase personal power 2. Feeling the compliment was well deserved 3. Being grateful for the compliment but fearing later rejection and humiliation 4. Wondering what deep meaning and purpose is attached to the compliment

Answer: 3 The nurse should identify that a client diagnosed with avoidant personality disorder would be grateful for the compliment but would fear later rejection and humiliation. Individuals diagnosed with avoidant personality disorder are extremely sensitive to rejection and are often awkward and uncomfortable in social situations.

Which symptom should the nurse observe in a client diagnosed with obsessive-compulsive personality disorder? 1. Intrusive and persistent thoughts 2. Unwanted, repetitive ritualistic behavior 3. Lack of spontaneity when dealing with others 4. Feelings of "sixth sense" that are externally imposed

Answer: 3 The nurse should suspect a diagnosis of obsessive-compulsive personality disorder when a client experiences lack of spontaneity. Individuals with this disorder are very serious, formal, and have difficulty expressing emotions. They are perfectionistic and preoccupied with rules.

Place the following stages of the codependency recovery process according to Cermak beginning with the first stage (1-4) 1. The Core Issues Stage 2. The Reintegration Stage 3. The Survival Stage 4. The Reidentification Stage

Answer: 3, 4, 1, 2 Rationale: Cermak in 1986 identified four stages in the recovery process for individuals with codependent personality. During the survival stage, the codependent must begin to let go of denial. During the reidentificaiton stage, the individual begins to glimpse their true selves. During the core issues stage, the individual must face the fact that relationships cannot be managed by force or will. During the reintegration stage, control is achieved through self-discipline and self-confidence. The sequence is as follows: Stage 1: The survival Stage Stage 2: The Reidentification Stage Stage 3: The Core Issues Stage Stage 4: The Reintegration Stage

7. Which nursing diagnosis should a nurse identify as appropriate when working with a client diagnosed with schizoid personality disorder? 1. Altered thought processes R/T increased stress 2. Risk for suicide R/T loneliness 3. Risk for violence: directed toward others R/T paranoid thinking 4. Social isolation R/T inability to relate to others

Answer: 4 An appropriate nursing diagnosis when working with a client diagnosed with schizoid personality disorder is social isolation R/T inability to relate to others. These clients avoid close or romantic relationships, interpersonal attachments, and intimate sexual relationships.

The client is receiving eye movement desensitization and reprocessing (EMDR) treatments. The nurse is most likely caring for which client? 1. One with schizophrenia 2. One with borderline personality disorder 3. One with manic episodes 4. One with posttraumatic stress disorder

Answer: 4 EMDR is used for posttraumatic stress disorder (PTSD). It has been used for depression, adjustment disorder, phobias, addictions, generalized anxiety disorder, and panic disorder, but it has only been empirically validated for PTSD.

A 22-year-old client and a 62-year-old client were involved in motor vehicle accidents and are both experiencing extreme anxiety. From a psychosocial theory perspective, which client would be predisposed to the diagnosis of adjustment disorder? 1. The 62-year-old, because of memory deficits 2. The 62-year-old, because of uncomplicated bereavement 3. The 22-year-old, because of decreased cognitive processing 4. The 22-year-old, because of lack of developmental maturity

Answer: 4 The 22-year-old would be predisposed to the diagnosis of adjustment disorder because of limited developmental maturity. By comparison in psychosocial theory, the 22-year-old does not have the developmental maturity, life experiences, and coping strategies that the 62-year-old might possess.

Which client response would reflect the impulsive self-destructive behavior that is commonly associated with borderline personality disorder when the day-shift nurse leaves the unit? 1. The client suddenly leans on the nurse's arm and whispers, "The night nurse is evil. You have to stay." 2. The client suddenly hugs the nurse's arm and states, "I will be up all night if you don't stay with me." 3. The client suddenly grabs the nurse's arm, yelling, "Please don't go! I can't sleep without you being here." 4. The client suddenly shows the nurse a bloody arm and states, "I cut myself because you are leaving me."

Answer: 4 The client who states, "I cut myself because you are leaving me," reflects impulsive self-destructive behavior that is commonly associated with borderline personality disorder. Repetitive, self-mutilating behaviors are common in clients diagnosed with borderline personality disorders that result from feelings of abandonment following separation from significant others.

The nurse is caring for a client with a diagnosis of adjustment disorder unspecified from a divorce after over 30 years of marriage. Which signs and symptoms would the nurse observe? 1. Re-experiences spouse asking for a divorce, is hyperalert, and has nightmares 2. Has anxiety, begins to shoplift, and exhibits reckless driving 3. Is belligerent, violates others' rights, and defaults on legal responsibilities 4. Reports many physical ailments, refuses to socialize, and has unproductive work performance

Answer: 4 The diagnosis of adjustment disorder unspecified is assigned when the maladaptive reaction is not consistent with any of the other categories. Manifestations may include physical complaints, withdrawal from relationships, or impaired work or academic performance, without significant disturbance in emotions or conduct.

During an interview, which client statement should alert the nurse to a potential diagnosis of schizotypal personality disorder? 1. "I don't have a problem. My family is inflexible, and my relatives are out to get me." 2. "I am so excited about working with you. Have you noticed my new nail polish, 'Ruby Red Roses'?" 3. "I spend all my time tending my bees. I know a whole lot of information about bees." 4. "I am getting a message from the beyond that we have been involved with each other in a previous life."

Answer: 4 The nurse should assess that a client who states that he or she is getting a message from beyond indicates a potential diagnosis of schizotypal personality disorder. The person experiences magical thinking, ideas of reference, illusions, and depersonalization as part of daily life. Examples include superstitiousness; belief in clairvoyance; telepathy, or "sixth sense"; and beliefs that "others can feel my feelings."

A woman presents with a history of physical and emotional abuse in her intimate relationships. Which would this information lead a nurse to suspect? 1. The woman may be exhibiting a controlled response pattern. 2. The woman may have a history of childhood neglect. 3. The woman may be exhibiting codependent characteristics. 4. The woman may be a victim of incest.

Answer: 4 The nurse would suspect that this client may be a victim of incest. Many women who are battered have low self-esteem and have feelings of guilt, anger, fear, and shame. Women in abusive relationships often grew up in an abusive home.

Which nursing diagnosis is priority when providing nursing care to a client diagnosed with avoidant personality disorder? 1. Risk for violence: directed toward others R/T suspicious thinking 2. Risk for suicide R/T altered thought 3. Altered sensory perception R/T increased levels of anxiety 4. Social isolation R/T fear of rejection

Answer: 4 The priority nursing diagnosis for a client diagnosed with avoidant personality disorder should be social isolation R/T fear of rejection. These individuals are extremely sensitive to rejection and consequently may lead a very socially withdrawn life.

The nurse tells a client diagnosed with obsessive-compulsive personality disorder that the nursing staff will start alternating weekend shifts. Which response should the nurse expect from this client? 1. "You really don't have to go by that schedule. I'd just stay home sick." 2. "There has got to be a hidden agenda behind this schedule change." 3. "Who do you think you are? I expect to interact with the same nurse every Saturday." 4. "You can't make these kinds of changes! Isn't there a rule that governs this decision?"

Answer: 4 The statement, "You can't make these kinds of changes! Isn't there a rule that governs this decision?" is typical of a client with obsessive-compulsive disorder. The nurse should identify that a client with obsessive-compulsive personality disorder would have a difficult time accepting changes. This disorder is characterized by inflexibility and lack of spontaneity. Individuals with this disorder are very serious, formal, over-disciplined, perfectionistic, and preoccupied with rules.

The nurse is teaching about trauma- and stressor-related disorders. Which statement by one of the staff members indicates that follow-up instruction is needed? 1. "The trauma that women experience is more likely to be sexual assault and child sexual abuse." 2. "The trauma that men experience is more likely to be accidents, physical assaults, combat, or viewing death or injury." 3. "After exposure to a traumatic event, less than 10 percent of victims develop posttraumatic stress disorder (PTSD)." 4. "Research shows that PTSD is more common in men than in women."

Answer: 4 This statement indicates a need for further instruction. Research shows that PTSD is more common in women than in men.

The nurse is teaching a client about the eight-phase process of eye movement desensitization and reprocessing (EMDR). In which order should the nurse list the phases, starting with the early phases and ending with the last (1-4)? (Enter the number of the phases in the proper sequence, using comma and space format, such as 1, 2, 3, 4) 1. Installation 2. Body scan 3. Reevaluation 4. Desensitization

Answer: 4, 1, 2, 3 EMDR is an integrative psychotherapy approach with a theoretical model that emphasizes the brain's information processing system and memories of disturbing experiences as the basis of pathology. EMDR has been shown to be an effective therapy for PTSD and other trauma-related disorders. The phases are described as Phase 1: History and treatment planning - a thorough history is taken and treatment plan is developed. Phase 2: Preparation - client learns certain self-care techniques, like relaxation techniques Phase 3: Assessment - client specifies a scene or picture from the target event; negative self-belief and positive self-statement developed; client uses 2 scales: Validity of Cognition (VOC) and Subjective Units of Disturbance (SUD) Phase 4: Desensitization - client gives attention to the negative beliefs and disturbing emotions while focusing on the back-and-forth motion of the therapist's finger; SUD scale is used Phase 5: Installation - client gives attention to the positive belief to replace the negative belief; VOC scale is used Phase 6: Body scan - The client must be able to focus on the traumatic event without experiencing bodily tension Phase 7: Closure - client leaves feeling better than he or she felt at the beginning Phase 8: Reevaluation - The therapist determines whether positive changes have been maintained and identifies any new target areas at the beginning of each new therapy session The sequence for the question is as follows: 1. Desensitization 2. Installation 3. Body scan 4. Reevaluation

The diagnosis of catatonic disordered due to another medical condition is made when the client's medical history, physical examination, or laboratory findings provide evidence that symptoms are directly attributed to which conditions? (Select all that apply) A. Epilepsy B. Hypothryiodism C. Hyperadrenalism D. Encephalitis E. Hyperaphia

Answer: A, B, C, D Rationale: A, B, & C. Types of medical conditions that have been associated with catatonic disorder include neurological conditions such as epilepsy. The diagnosis of catatonic disorder due to another medical condition is made when the symptomatology is evidenced from medical history, physical exam, or lab findings to be directly attributable to the physiological consequences of a general medication. D. Encephalitis is a neurological condition that can lead to catatonic disorder due to another medical condition. The diagnosis of a catatonic disorder due to another medical condition is made when the symptomatology is evidenced from medical history, physical exam, or lab findings to be directly attributable to the physiological consequences of a general medical condition

A clinic nurse is about to meet with a client diagnosed with a gambling disorder. The nurse would assess which symptoms and behaviors? (Select all that apply) A. Stressful situation precipitate gambling behaviors B. Anticipation and restlessness can only be relieved by placing a bet C. Winning brings about feelings of sexual satisfaction D. Gambling is used as a coping strategy E. Compulsive gambling began in early adolescence

Answer: A, B, D Rationale: A. In gambling disorder, the preoccupation with the impulse to gamble intensifies when the individual is under stress B. Many impulsive gamblers describe a physical sensation of restlessness and anticipation that can only be relieved by placing a bet. D. Compulsive gambling behaviors really occur before young adulthood; however, gambling behaviors usually begins in adolescences

Which nursing statements exemplify the process that must be completed by nurse in the pre-introductory phase prior to care for clients diagnosis with a substance-related disorders (Select all that apply). A. "I am easily manipulated and need to work on this prior to caring for these clients" B. "Because of my father's alcoholism, I need to examine my attitude toward these clients" C. "I need to review the side effects of the medications used in the withdrawal process" D. ''Ill need to set boundaries to maintain a therapeutic relationship" E. "I need to take charge when dealing with clients diagnosed with substance disorders"

Answer: A, B, D Rationale: A. This statement indicates the nurse has completed the process of reviewing attitudes and beliefs prior to caring for clients diagnosed with substance-related disorders. B. This statement indicates the nurse completed the pre-introductory process of reviewing attitudes and beliefs. It is important for nurses to identify potential areas of need within their own attitudes and beliefs that may affect their relationships with clients diagnoses with this problem. D. Determining the need to set boundaries is an example of a pre-introductory process of reviewing attitudes and beliefs that must be completed by a nurse to a client care.

Which modalities should a nurse recognize as integral parts of a treatment program when planning care for clients diagnosed with schizophrenia spectrum disorder? (Select all that apply) A. Group therapy B. Medication management C. Deterrent therapy D. Supportive family therapy E. Social skills training

Answer: A, B, D, E Rationale: A. The nurse should recognize that group therapy plays an integral part of treatment programs for clients diagnosed with schizophrenia B. The nurse should recognize that medication management plays an integral part of treatment programs for clients diagnosed with schizophrenia D. The nurse should recognize that supportive family therapy plays an integral part of treatment programs for clients diagnosed with schizophrenia E. The nurse should recognize that social skills training plays an integral part of treatment programs for clients diagnosed with schizophrenia

A nursing supervisor is offering an impaired staff member information regarding a peer assistance program. Which facts should the supervisor include? (Select all that apply) A. A hot-line number will be available in order to call for help B. A verbal contract detailing the method of treatment will be initiated prior to the program C. Peer support is provided through regular contact with the impaired nurse D. Contact to provide peer support will last for one year E. One of the program goals is to intervene early in order to reduce hazards to clients

Answer: A, C, E Rationale: A. Most states provides either a hot-line number that the impaired nurse may call or phone numbers of peer assistance committee members, which are made available for the same purpose C. Peer support is provided through regular contact with he impaired nurse E. One of the goals of treatment is to intervene early to reduce hazards to clients. The peer assistance programs strive to intervene early, reduce hazards to clients, and increase prospects for the nurse's recovery.

A nurse is about to meet with a client suffering from codependency. Which date would the nurse expect to find during the assessment of this client? (Select all that apply) A. Has a long history of focusing thoughts and behaviors on other people B. As a child, experienced overindulgent and overprotective parents C. Is a people pleaser and does almost anything to gain approval D. Exhibits helpless behaviors but actually feels very competent E. Can achieve a sense of control through fulfilling the needs of others

Answer: A, C, E Rationale: A. The codependent person has a long history of focusing thoughts and behavior on other people. C. Codependent clients are "people pleasers" and will do almost anything to get the approval of others. E. Codependent clients achieve a sense of control when they are fulfilling the needs of others.

An adolescent diagnosed with schizophrenia spectrum disorder experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which response should the nurse take? A. "Your child has a chemical imbalance of the brain, which leads to altered perceptions" B. "Your child's hallucinations are caused by medication interactions" C. "Your child has too little serotonin in the Bain, causing delusions and hallucinations" D. "Your child's abnormal hormonal changes have precipitated auditory hallucination"

Answer: A. "Your child has a chemical imbalance of the brain, which leads to altered perceptions" Rationale: The nurse should explain that a chemical imbalance of the brain leads to altered perceptions. The current position on the dopamine hypotheses is that positive symptoms (like command hallucinations) may be related to increased numbers of dopamine receptors in the brain causing an imbalance

A nurse is assessing a pathological gambler. What would differentiate this client's behaviors form the behaviors of a non pathological gambler? A. Pathological gamblers have abnormal levels of neurotransmitters, whereas non-pathological gamblers do not B. Pathological gambling occurs more commonly among women, whereas non pathological gambling occurs more commonly among men C. Pathological gambling generally runs an acute course, whereas non pathological gambling runs a chronic course D. Pathological gambling is not related to stress relief, whereas non pathological gambling is related to stress relief

Answer: A. Pathological gamblers have abnormal levels of neurotransmitters, whereas non-pathological gamblers do not Rationale: There is a correlation between pathological gambling and abnormalities in the neurotransmitter, dopamine. This is not the case with non pathological gambling

A lonely, depressed divorcée has been self-medicating with small amounts of cocaine for the past year. Which term should a nurse use to best describe this individual's situation? A. Psychological addiction B. Codependence C. Substance induced disorder D. Intoxication

Answer: A. Psychological addiction Rationale: The nurse should use therm psychological addiction to best describe the client's situation. A client is considered to be psychologically addicted to a substance when there is an overwhelming desire to use a drug in order to produce pleasure (feel better) or avoid discomfort.

Which nursing diagnosis is the priority for a client experiencing alcohol withdrawal? A. Risk for injury r/t central nervous system stimulation B. Disturbed thought processes r/t tactile hallucinations C. Ineffective coping r/t powerlessness over alcohol use D. Ineffective denial r/t continued alcohol use despite negative consequences

Answer: A. Risk for injury r/t central nervous system stimulation. Rationale: the priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury r/t central nervous system stimulation. Alcohol withdrawal may include the following symptoms: curse tremors of hands, tongue, or eyelids; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia

A client diagnosed with major depression and substance use disorder has an altered sleep pattern and demands a psychiatrist prescribe a sedative. Which rationale explains why the nurse should encourage the client to first try non pharmacological interventions? A. Sedative-hypnotics are potentially addictive, and their effectiveness will be compromised owing tolerance B. Sedative-hypnotics decrease the production of needed liver enzymes. C. Sedative-hypnotics lengthen necessary REM (rapid eye movement) sleep D. Sedative-hypnotics are known not to be as effective in promoting sleep as antidepressant medications

Answer: A. Sedative-hypnotics are potentially addictive, and their effectiveness will be compromised owing tolerance Rationale: The nurse should recommend non pharmacological interventions to this client because sedative-hypnotics are potentially addictive, and their effectiveness will be compromised owing to tolerance and cross-tolerance. The effects of central nervous system depressants are additive with one another, capable of producing physiological and psychological addiction.

The client diagnosed with schizophrenia spectrum disorder is prescribed an antipsychotic. Which client symptoms, related to the side effects of this medication, should prompt a nurse to intervene immediately? A. Sore throat and malaise B. Light-colored urine and bradycardia C. Anosognosia and avolition D. Dry mouth and urinary retention

Answer: A. Sore throat and malaise Rationale: The nurse should intervene immediately if the client experiences signs of an infectious process - such as a sore throat, fever, and malaise - when taking antipsychotic drugs.

A client diagnosed with chronic alcohol dependency is being discharged from an inpatient treatment facility after detoxification. Which client outcome related to Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss with the client during discharge teaching? A. To immediately attend AA meetings at least weekly B. To rely on an AA sponsor to help control alcohol cravings C. To incorporate family in AA attendance D. To seek appropriate deterrent medications through AA

Answer: A. To immediately attend AA meetings at least weekly Rationale: The most appropriate client outcome for the nurse to discuss during discharge teaching is attending AA meetings at least weekly. AA is a major self-help organization for the treatment of alcohol addiction. It accepts alcohol addiction as an illness and promotes total abstinence as the only cure.

A nursing supervisor is about to meet with a staff nurse suspected of diverting clients' pain medications. Which assessment date would lead the supervisor that the staff nurse is impaired? (Select all that apply) A. Is frequently absent form work B. Experiences mood swings C. Make elaborate excuses for behavior D. Frequently uses the restroom E. Has a flushed face

Answer: B, C, D, E Rationale: B. Mood swings can be a sign of substance abuse. C. The impaired nurse may make elaborate excuses for behavior D. The impaired nurse will frequently use the restroom E. A flushed face is a sign of drug use.

A nursing instructor is teaching nursing students about cirrhosis of the liver. Which statements by nursing students about hepatic encephalopathy indicate successful teaching? (Select all that apply) A. "A diet rich in protein will promote hepatic healing" B. "This condition results from a rise in serum ammonia, leading to impaired mental functioning" C. "in this condition, an excessive amount of serous fluid accumulates in the abdominal cavity" D. Neomycin and lactulose are used in the treatment of this condition" E. "This condition is caused by the inability of the liver to convert ammonia to urea"

Answer: B, D, E Rationale: B. This statement indicates that teaching has been effective because this condition results from a rise in serum ammonia, leading to impaired mental functioning. D. The instructor should interpret this as successful teaching because neomycin and lactulose are medications used for this disorder. E. The instructor should interpret this as successful teaching because hepatic encephalopathy in the inability of the diseased liver to convert ammonia to aria

A nurse is reviewing the stat laboratory date of a client in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur? A. 50 mg/dL B. 100 mg/dL C. 250 mg/dL D. 300 mg/dL

Answer: B. 100 mg/dL Rationale: The nurse should expect that 100 mg/dL is the minimum blood alcohol level at which intoxication occurs. Intoxication usually occurs between 100 and 200 mg/dL.

Which action would the nurse take to establish a trusting relationship with a client diagnosed with schizophrenia spectrum disorder? A. Establish persona contact with family members B. Be reliable, honest, and consistent during interactions C. Share limited personal information D. Sit close to the client to establish rapport

Answer: B. Be reliable, honest, and consistent during interactions Rationale: The nurse can enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia by being reliable, honest, and consistent during interactions. The nurse should also convey acceptance of the client's needs and maintain a calm attitude.

A client with a history of alcohol use disorder is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 48 hours. When the nurse reports to the ED physician, which client sign or symptom should be the nurse's first priority A. Hearing and visual impairment B. Blood pressure of 180/100 mm Hg C. Mood rating of 2/10 on numeric scale D. Dehydration

Answer: B. Blood pressure of 180/100 mm Hg Rationale: The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal syndrome and should promptly report this finding to the physician. Complications associated with alcohol withdrawal syndrome may progress to alcohol withdrawal delirium in about the second or third day following cessation of prolonged alcohol use.

The nurse evaluates the client's patient-controlled analgesia (PCA) pump and notices 50 attempts within a 15 minute period. Which is the best rationale for assess this client for substance addiction? A. Narcotic pain medication is contraindicated for all clients with active substance use disorders B. Clients who are addicted to alcohol or benzodiazepines may develop cross-tolerance to analgesics and require increased doses to achieve effective pain control C. There is no need to assess the client for substance addiction. There is an obvious PCA malfunction, because these clients have a higher pain tolerance D. The client is experiencing alcohol withdrawal symptoms and needs accurate assessment

Answer: B. Clients who are addicted to alcohol or benzodiazepines may develop cross-tolerance to analgesics and require increased doses to achieve effective pain control Rationale: The nurse should assess the client for substance addiction, because clients who are addicted to alcohol or bentos may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. Cross-tolerance is exhibited when one drug results in a lessened response to another drug.

Which client assessment finding would alert the nurse to question a diagnosis of brief psychotic disorder? A. Has impaired reality testing for a 24 hour period B. Has auditory hallucinations for the past 3 hours C. Has bizarre behavior for 1 day D. Has confusion for 3 weeks

Answer: B. Has auditory hallucinations for the past 3 hours Rationale: This disorder is identified by the sudden onset of psychotic symptoms that may or may not be preceded by a severe psychosocial stressor. These symptoms last at least 1 day but less than 1 month and there is an eventual full return to the premorbid level of functioning

A client with schizophrenia spectrum disorder presents with bizarre behaviors and delusions. Which nursing action should be prioritized to maintain this client's safety? A. Monitor for medication non-adherence B. Note escalating behaviors immediately C. Interpret attempts at communication D. Assess triggers for bizarre, inappropriate behaviors

Answer: B. Note escalating behaviors immediately Rationale: The nurse should note escalating behaviors immediately, to maintain this client's safety. Early intervention may prevent an aggressive response and keep the client and others safe.

The nurse is caring for a client with schizophrenia spectrum disorder who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia? A. Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia B. Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia C. Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia D. Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia

Answer: B. Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia Rationale: The nurse should recognize that positive symptoms of schizophrenia include, but are not limited to, paranoid delusions, neologisms, and echolalia

Parents ask a nurse how they should reply when their son, diagnosed with schizophrenia spectrum disorder, tells them that voices command him to harm others. Which nursing response is appropriate? A. "Tell him to stop discussing the voices" B. "Ignore what he is saying, while attempting to discover the underlying cause" C. "Focus on the feelings generated by the hallucinations and present reality" D. "Present objective evidence that the voices are not real"

Answer: C. "Focus on the feelings generated by the hallucinations and present reality" Rationale: The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should accept that their child is experiencing the hallucination but should not reinforce this unreal sensory perception.

The aging client takes an antipsychotic for schizophrenia spectrum disorder and a beta-adrenergic blocking agent for hypertension. Based on an understanding of the combined side effects of these drugs, which statement by a nurse is most appropriate? A. "Make sure you concentrate on taking slow, deep, cleansing breaths" B. "Watch your diet and try to engage in some regular physical activity" C. "Rise slowly when you change position from lying to sitting or sitting to standing" D. "Wear sunscreen and try to avoid midday sun exposure"

Answer: C. "Rise slowly when you change position from lying to sitting or sitting to standing" Rationale: The most appropriate statement by the nurse is to instruct the client to rise slowly when changing positions. Antipsychotic medications and beta blockers cause a decrease in blood pressure. When given in combination, the additive effect of these drugs places the client at risk for developing orthostatic hypotension

A nurse is preparing a staff education session about the impaired nurse and the consequences of this impairment. Which statement by the staff member indicates successful teaching? A. "The state roads of nursing must be notified with subjective documentation of impairment" B. All state boards of nursing have passed laws that, under any circumstances, do not allow impaired nurses to practice" C. "Some state boards of nursing administer the treatment programs themselves, while other reference the nurse to tother resources" D. "After a return to practice, a recovering nurse may be closely monitored for several days"

Answer: C. "Some state boards of nursing administer the treatment programs themselves, while other reference the nurse to tother resources" Rationale: Some of these state boards administer the treatment programs themselves, and others refer the nurse to community resources or state nurses' association assistance programs. This may require successful completion of inpatient, outpatient, group, or individual counseling treatment programs; evidence of regular attendance at nurse support groups or 12-step program; random negative drug screens; and employment or volunteer activities during the suspension period.

A client diagnosed with schizophrenia spectrum disorder states, "Cant you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing response? A. "Did you take your medicine this morning?" B. "You are not going to hell. You are a good person." C. "The voices must sound scary, but I do not hear any voices." D. "The devil only talks to people who are receptive to his influences"

Answer: C. "The voices must sound scary, but I do not hear any voices." Rationale: The most appropriate nursing response is to reassure the client while not reinforcing the hallucination. Reminding the client that "the voices" are not real will prevent validation of the hallucinations. It is also important for the nurse to connect with the client's fears and inner feelings

A clients wife has been making excuses for her alcoholic husband's work absences. In family therapy, she states, "His problems at work are my fault." Which response by the nurse is therapeutic? A. "Why do you assume responsibility for his behaviors B. "I think you should start to confront his behavior" C. "Your husband needs to deal with the consequences of his drinking" D. "Do you understand what the term enabler means?"

Answer: C. "Your husband needs to deal with the consequences of his drinking" Rationale: The appropriate nursing response is to use confrontation with caring. The nurse should understand that the client's wife may be in denial and enabling the husbands behavior. Codependency is a typical behavior of spouses of alcoholics. The nurse must help the wife through the stages of recovery beginning with Stage 1: The survival stage in which the partner begins to let go of the denial that problems exists.

On the first day of a client's alcohol detoxification, which nursing intervention should take priority? A. Strongly encourage the client to attend 90 AA meetings in 90 days. B. Educate the client about the biopsychosocial consequences of alcohol abuse. C. Administer orders chlordiazepoxide (Librium) in dosage according to protocol. D. Provide thiamin supplements to prevent Wenicke-Korsakoff syndrome.

Answer: C. Administer orders chlordiazepoxide (Librium) in dosage according to protocol. Rationale: Priority nursing intervention for this client should be to administer ordered chlordiazepoxide in a dosage according to protocol. Chlordiazepoxide is a benzodiazepine and is often used for medication-assisted therapy in alcohol withdrawal to reduce life-threatening complications.

The client diagnosed with schizophrenia spectrum disorder tells the nurse, "I'm sad that the voice is telling me to stop being my psychiatrist" Which symptom is the client exhibiting? A. Magical thinking B. Persecutory delusions C. Command hallucinations D. Altered thought processes

Answer: C. Command hallucinations Rationale: The nurse should determine that the client is exhibit common hallucinations. Clients with command hallucinations could potentially by physically, emotionally, and/or sexually harmful to other or to self

Which data in the history would the nurse expect to find in a client diagnosed with substance-induced psychotic disorder? A. Had delirium B. Had less severe withdrawal symptoms C. Has an opioid use disorder D. Has a fluid and electrolyte imbalance

Answer: C. Has an opioid use disorder Rationale: The prominent hallucinations and delusions associated with substance-9induced or medication-induced disorder are found to be directly attributable to substance intoxication or withdrawal, like opioid use disorder

A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be included in the nurse's teaching? A. The side effects of medication B. Deep breathing techniques to decrease stress C. How to make eye contact when communicating D. Behaviors needed to be a leader

Answer: C. How to make eye contact when communicating Rationale: The nurse should plan to teach the client how to make eye contact when communicating. Social skills, such as making eye contact, can assist clients to communicate needs and to establish relationships.

The client presents with symptoms of alcohol withdrawal and states, "I haven't eaten in three days." The nurse's assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97 F with dry mucous membranes and poor skin turgor. What should be the priority nursing diagnosis? A. Denial B. Fluid volume excess C. Imbalance nutrition: less than body requirements D. Ineffective individual coping

Answer: C. Imbalance nutrition: less than body requirements Rationale: The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements based upon the client's statement regarding lack of nutritional intake for three days. The client is exhibiting signs and symptoms of malnutrition, as well as alcohol withdrawal. The nurse should provide small, frequent feedings of nonirritating foods.

A client diagnosed with a gambling disorder asks the nurse about medications that may be ordered by the physician to treat this disorder. The nurse would give the client information on which medications? A. Escitalopram (Lexapro) and clozapine (Clozaril) B. Citalopram (Celexa) and olanzapine (Zyprexa) C. Lithium carbonate (Lithobid) and naltrexone (ReVia) D. Haloperidol (Haldol) and ziprasidone (Geodon)

Answer: C. Lithium carbonate (Lithobid) and naltrexone (ReVia) Rationale: Lithium carbonate (Lithobid) and naltrexone (ReVia) have demonstrated some effectiveness for gambling disorder

The psychiatrist prescribes haloperidol (Haldol) 50 mg bid, benzotropine (Cogentin) 1 mg pan, and zolpidem (Ambient) 10 mg at bedtime for a client with schizophrenia spectrum disorder. Which client behaviors would warrant the nurse to administer benzotropine? A. Tactile hallucinations B. Tardive dyskinesia C. Muscle rigidity D. Reports of hearing disturbing voices

Answer: C. Muscle rigidity Rationale: An anticholinergic medication such as benzotropine would be used to treat the extrapyramidal symptom of muscle rigidity

Which client statement demonstrates positive progress toward recovery from substance abuse? A. "I have completed detox and therefore am in control of my drug use." B. "When I can't control my cravings, I will faithfully attend Narcotic Anonymous." C. "As a church deacon, my focus will now be on spiritual renewal." D. "Taking those pills got out of control. It cost me my job, marriage, and children."

Answer: D. "Taking those pills got out of control. It cost me my job, marriage, and children." Rationale: A client who takes responsibility for the consequences of substance use disorder or substance addiction is making positive progress toward recovery. This would indicate completion of the first step of the a 12 step program (AA)

The nurse holds the hand of a client who is experiencing alcohol withdrawal. The nurse is assessing for which condition? A. Emotional strength B. Wernicke-Korsakoff syndrome C. Tachycardia D. Coarse tremors

Answer: D. Coarse tremors Rationale: The nurse is most likely assessing the client for coarse tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, and coarse tremors

Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during alcohol withdrawal? A. Antagonist therapy B. Deterrent therapy C. Codependency therapy D. Medication-assisted treatment

Answer: D. Medication-assisted treatment Rationale: Various medications have been used to decrease the intensity of symptoms in an individual who is withdrawing from, or who is experiencing the effects of excessive use of, alcohol and other drugs. This is called medication-assisted treatment.

Which medications would the nurse most likely administer to a client who has a history of opiate withdrawal? A. Haloperidol (Haldol) and acamprosate (Campare) B. Naloxone (Narcan) and naltrexone (ReVia) C. Disulfiram (Antabuse) and lorazepam (Ativan) D. Methadone (Dolophine) and clonidine (Catapres)

Answer: D. Methadone (Dolophine) and clonidine (Catapres) Rationale: The nurse would administer methadone and clonidine for a client who has a history of opiate withdrawal. As the dose of methadone diminishes, renewed abstinence symptoms may be ameliorated by the addiction of clonidine.

Which nursing intervention would be most appropriate when caring for an agitated, suspicious client diagnosed with schizophrenia spectrum disorder? A. Supply neon lights and soft music B. Maintain continual eye contact throughout the interview C. Use therapeutic touch to increase trust and rapport D. Provide personal space to respect the client's boundaries

Answer: D. Provide personal space to respect the client's boundaries Rationale: The most appropriate nursing intervention is to provide personal space to respect the client's boundaries. Providing personal space may serve to reduce anxiety and thus reduce the clients risk for violence. The nurse should observe the client while carrying out routine tasks

The nurse ask the client with schizophrenia spectrum disorder, "Do you receive special messages from certain sources, such as the TV or radio?" The nurse is assessing which potential symptom of this disorder? A. Loose associations B. Paranoid delusions C. Magical thinking D. Delusions of reference

Answer: D. Delusions of reference Rationale: The nurse is assessing for the potential symptom of delusions of reference. A client who believes he or she receives messages through the radio or TV is experiencing delusions of reference. These delusions involve the client interpreting events within the environment as being directed toward himself or herself. Clients with delusions of reference believe that others are trying to send them messages in various ways, or they must break a code to receive message

Which client statement indicated a knowledge deficit related to a substance use disorder? A. "Although it's legal, alcohol is one of the most widely abused drugs in our society" B. "Tolerance to heroin develops quickly" C. "Flashbacks form lysergic acid diethyl amide (LSD) use may reoccur spontaneously." D. Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless''

Answer: D. Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless'' Rationale: The nurse should determine that the client has a knowledge deficit related to substance use disorder when the client compares marijuana to smoking cigarettes and claims it to be harmless. The evidence of research indicates that smoked marijuana is harmful.

Looking at a slightly bleeding paper cut, the client screams, "Somebody help me quick! I'm bleeding. Call 911!" The nurse should identify this behavior as characteristic of which personality disorder? 1. Schizoid 2. Obsessive-compulsive 3. Histrionic 4. Paranoid

Answer: 3 The nurse should identify this behavior as characteristic of histrionic personality disorder. Individuals with this disorder tend to be self-dramatizing, attention seeking, over-gregarious, and seductive.

The client diagnosed with schizophrenia spectrum disorder tells a nurse about voices commanding him to kill his ex-spouse. Which nursing diagnosis is priority for this client? A. Disturbed sensory perception B. Altered thought processes C. Risk of violence: directed toward others D. Risk for injury

Answer: C. Risk of violence: directed toward others Rationale: The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices commanding him to kill someone is at risk for other-directed violence. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions.