EAQ: Mental Health Disorders and Addictions
A client is admitted to the psychiatric hospital after many self-inflicted nonlethal injuries over the preceding month. Of which level of suicidal behavior is the client's behavior reflective? 1 Threats 2 Ideation 3 Gestures 4 Attempts
Gestures A suicidal gesture involves superficial, nonlethal injuries; the client has no intent to die as a result of the injuries. A suicidal threat is a person's verbal statement of intent to commit suicide; there is no action. Suicidal ideation is a person's thoughts regarding suicide; there is no definitive intent or action expressed. A suicide attempt is an actual implementation of a severe self-injurious act; there is an attempt to cause serious self-harm or death.
A client with schizophrenia sees a group of visitors sitting together talking. The client tells the nurse, "I know they're talking about me." Which altered thought process should the nurse identify? 1 Flight of ideas 2 Ideas of reference 3 Grandiose delusion 4 Thought broadcasting
Ideas of reference Ideas of reference, seen with psychotic thinking, is a delusional belief that others are talking about the client. Flight of ideas is the rapid thinking seen in clients in a manic state. Grandiose delusions are irrational beliefs that overestimate one's ability or worth. Thought broadcasting is the delusional belief that others can read one's thoughts.
A client with schizophrenia is speaking made-up words that have no meaning to other people. What term should the nurse use to document these verbalizations? 1 Avolition 2 Echolalia 3 Anhedonia 4 Neologisms
Neologisms Neologisms are unique words with personal meanings only to the client. Avolition is the lack of motivation associated with a reduced emotional expression (flat affect). Echolalia is parrotlike echoing of spoken words or sounds. Anhedonia is the loss of enjoyment of things that were formerly enjoyed.
A mental health nurse is admitting a client with anorexia nervosa. When obtaining the history and physical assessment, the nurse expects the client's condition to reveal which symptom? 1 Edema 2 Diarrhea 3 Amenorrhea 4 Hypertension
Amenorrhea
A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful? 1 Trust 2 Growth 3 Belonging 4 Independence
Belonging Self-help groups are successful because they support a basic human need for acceptance. A feeling of comfort and safety and a sense of belonging may be achieved in a nonjudgmental, supportive, sharing experience with others. AA meets dependency needs rather than focusing on trust, growth, and independence.
A nurse is caring for a client with the diagnosis of somatoform disorder, conversion type. What type of affect does the nurse expect this client to exhibit? Select all that apply. 1 Calm 2 Cheerful 3 Depressed 4 Frightened 5 Matter-of-fact
Calm, Matter-of-fact The symptoms prevent the individual from being forced to act in relation to a conflict or stressor; the client's symptoms thus reduce anxiety and remove the conflict. The individual demonstrates a lack of concern about the symptoms (la belle indifférence). The individual will not be happy and cheerful, sad and depressed, or frightened.
While a client is attending an Alcoholics Anonymous (AA) meeting, a nurse talks with the client's spouse about the purpose of AA. What is the priority goal of this self-help group? 1 Changing destructive behavior 2 Developing functional relationships 3 Identifying how people present themselves to others 4 Understanding patterns of interacting within the group
Changing destructive behavior The purpose of a self-help group is for individuals to develop their strengths and new, constructive patterns of coping. Developing functional relationships, identifying how people present themselves to others, and understanding patterns of interaction within the group are purposes of group therapy.
A client is brought to the emergency department by friends because of increasingly bizarre behavior. Which signs does the nurse identify that indicate that the client was using cocaine? Select all that apply. 1 Euphoria 2 Agitation 3 Panic attacks 4 Slurred speech 5 Hypervigilance 6 Impaired judgment
Euphoria, Agitation, Hypervigilance, Impaired judgment Cocaine is an alkaloid stimulant; euphoria or affective blunting, agitation or anger, hypervigilance, and impairment of judgment and social function are all associated with cocaine intoxication. Panic attacks are associated with hallucinogens. Slurred speech is associated with opioids.
A psychotic male client is admitted to the hospital for evaluation. While obtaining the history, the nurse asks why he was brought to the hospital by his parents. The client states, "They lied about me. They said I murdered my mother. You killed her. She died before I was born." What does the nurse recognize that the client is experiencing? 1 Ideas of grandeur 2 Confusing illusions 3 Persecutory delusions 4 Auditory hallucinations
Persecutory delusions The client's verbalization reflects feelings that others are blaming the client for negative actions. There are no data to demonstrate the client is having feelings of greatness or power. There are no data to demonstrate the client is experiencing confusing misinterpretations of stimuli. There are no data to demonstrate the client is hearing voices at this time.
What childhood problem has legal as well as emotional aspects and cannot be ignored? 1 School phobia 2 Fear of animals 3 Fear of monsters 4 Sleep disturbances
School phobia School phobia is a disorder that cannot legally be ignored for long because children must attend school. It requires intervention to alleviate the separation anxiety and promote the child's increasing independence. Fear of animals and monsters and sleep disturbances all require parents to comfort the child, to reorient the child to reality, and to help the child regain self-control. Legally there are no requirements mandating treatment for these common childhood problems.
What manifestations does the nurse expect to identify when taking a health history from a client with moderate dementia? Select all that apply. 1 Sundowning 2 Hypervigilance 3 Increased inhibition 4 Exaggeration of premorbid traits 5 Inability to recognize family members
Sundowning, Exaggeration of premorbid traits Confusion and agitation with an inability to remain asleep that get worse or only occur at night (sundowning) are characteristics of moderate (stage 2) dementia. Moderate dementia is characterized by increasing dependence on environmental and social structures and by increasing psychological rigidity that accentuates previous traits and behaviors. In addition, a lower-functioning frontal lobe may impair judgment that in the past moderated negative traits and behaviors. Although paranoid attitudes may be exhibited, a decrease in cognitive function, disorientation, and loss of memory usually do not lead to hypervigilance. With the decrease in impulse control that is associated with dementia, decreased, not increased, inhibition is usually present. An inability to recognize family members reflects a decline in cognitive function associated with advanced (stage 3) dementia.
A 40-year-old male client begins to display signs of anger and aggression during a group therapy session. To prevent or minimize this behavior, it is important for the nurse to understand that anger and aggression are often preceded by what emotion? 1 Elation 2 Isolation 3 Depression 4 Vulnerability
Vulnerability Anger and aggression are often preceded by feelings of vulnerability, especially when someone is in new and unfamiliar surroundings, such as an inpatient unit. Feelings of elation do not typically result in displays of anger or aggressive behavior. Some individuals may feel isolation or depression, but these are not the primary factors leading to anger and aggression.
A client in the psychiatric hospital is attempting to communicate by stating, "Sky, flower, angry, green, opposite, blanket." The nurse recognizes what term as describing this type of communication? 1 Echolalia 2 Word salad 3 Confabulation 4 Flight of ideas
Word Salad
A hospitalized client hurriedly approaches the nurse, saying that it sounds like there is a roaring fire in the bathroom. In reality, the client's roommate has just turned the shower on full force. What term best describes this experience? 1 Illusion 2 Delusion 3 Dissociation 4 Hallucination
Illusion An illusion is a misperception of an actual stimulus. A delusion is a fixed false belief that is unrelated to an external stimulus. Dissociation is a disturbance in the integrative functions of the client. A hallucination is a false perception with no actual external stimulus.
A nurse working on a detoxification unit has clients who are in active withdrawal from alcohol, opiates, benzodiazepines, cocaine, and marijuana. Place these clients in order, from the one with the highest risk for life-threatening physiologic withdrawal to the one with the lowest risk: 1. An adolescent who is withdrawing from cocaine 2. An older adult who is withdrawing from alcohol 3. A middle-aged adult who is withdrawing from marijuana 4. A young adult who is withdrawing from a long-acting benzodiazepine
1. An older adult who is withdrawing from alcohol Correct 2. A young adult who is withdrawing from a long-acting benzodiazepine Correct 3. An adolescent who is withdrawing from cocaine Correct 4. A middle-aged adult who is withdrawing from marijuana Older adults possess fewer physiological reserves and are at the highest risk for life-threatening withdrawal, especially from a drug, such as alcohol, that has a short half-life. Long-acting benzodiazepines, although potentially lethal in withdrawal, will be less of a problem in a young adult because young adults have greater physiologic reserves than do older adults. Cocaine is not lethal during withdrawal unless clients intentionally hurt themselves. Marijuana has minimal physiologic withdrawal symptoms because of its long half-life.
A nurse, planning care for a client who is an alcoholic, knows that the most serious life-threatening effects of alcohol withdrawal usually begin after a specific time interval. How many hours after the last drink do they occur? 1 8 to 12 2 12 to 24 3 24 to 72 4 72 to 96
24 to 72 Alcohol withdrawal delirium, a life-threatening central nervous system response to alcohol withdrawal, occurs in 1 to 3 days, when the blood alcohol level drops as alcohol is detoxified and excreted. Jitteriness, nervousness, and insomnia may occur 8 to 12 hours after withdrawal; these are not life-threatening issues. Nervousness, insomnia, nausea, vomiting, and increased blood pressure and pulse may occur after 12 to 24 hours; these are not life-threatening problems. Withdrawal symptoms will have begun to subside after 72 to 96 hours, and the risk for complications is diminished.
A nurse should reassess an older adult client's needs and current plan of care when the client's behavior indicates the development of what symptom? 1 Confusion 2 Hypochondriasis 3 Additional complaints 4 Increased socialization
Confusion The development of confusion indicates that the client's ability to maintain equilibrium has not been achieved and that further disequilibrium is occurring. Hypochondriasis and additional complaints do not indicate that the plan needs to be changed unless the client's history demonstrates no prior use of these defenses. Increased socialization is a positive response to the plan of care that does not require reassessment.
A 30-year-old woman reports to the mental health clinic on the recommendation of her primary health care provider. She has been unable to carry out everyday activities due to increased pain in her lower back and legs. Neurologic and orthopedic workups indicate that symptoms seem excessive when compared with physical problem on physical examination and repeated MRIs and x-rays. Client states it has been difficult to care for her 32-year-old husband, who has an inoperable brain tumor and is undergoing chemotherapy. Considering history and symptoms, what disorder should the nurse suspect? 1 Conversion 2 Malingering 3 Referred pain 4 Body dysmorphic
Conversion Clients with conversion disorder have physical symptoms caused by unconscious psychological conflicts and stressors. It is the most common of the somatoform disorders and is initiated or exacerbated by significant psychological stressors. Malingering is a type of manipulation in which false or exaggerated symptoms are used to obtain a specific result, such as avoiding work or jail. Referred pain originates in one area of the body and is experienced (referred) in another part of the body that is not receiving the noxious stimulus directly. Body dysmorphic disorder is when a person believes that his or her body is deformed in some manner that is not readily observed by others.
What does a nurse expect to determine about a child with a diagnosis of reactive attachment disorder? 1 Has been physically abused 2 Tries to cling to the mother on separation 3 Is able to develop just superficial relationships with others 4 Has a more positive relationship with the father than with the mother
Is able to develop just superficial relationships with others Children who have experienced attachment difficulties with primary caregivers are not able to trust others and therefore relate superficially. Physical abuse is a possibility but not a necessity for this diagnosis. The child probably will not cling or react when separated from the mother. Attachment will not occur with either parent.
A nurse spends time in individual sessions helping a depressed, suicidal client verbalize feelings. For what themes should the nurse particularly listen? Select all that apply. 1 Anger 2 Control 3 Isolation 4 Dominance 5 Hopelessness 6 Indecisiveness
Isolation, Hopelessness Feelings of isolation compound feelings of hopelessness and helplessness and may provide the client with the impetus to act on suicide ideation. The main factor leading to acting on suicidal impulses is the feeling of hopelessness, that there is nothing to live for. Anger may be associated with depression; however, a depressed person usually does not have the energy to act out suicidal ideation. The struggle for control or dominance is not an important risk factor for suicide. Indecisiveness may be associated with depression, but an indecisive individual is usually unable to make the decision to commit suicide.
A couple arrives at the mental health clinic for counseling because the husband consistently believes that his wife is having multiple affairs. After several sessions a delusional disorder is diagnosed. What specific subtype of the delusion does the nurse identify? 1 Jealousy 2 Somatic 3 Grandiose 4 Persecutory
Jealousy A client who is convinced that a mate is unfaithful exhibits delusional jealousy. Somatic delusions concern preoccupation with the body, including complaints of disfigurement, nonfunctioning body parts, insect infestation, and presence of a serious illness. In a grandiose delusion, the client seeks a position of power by expressing an exaggerated belief in his or her importance or identity. Clients with persecutory delusions believe that they are being conspired against, spied on, drugged, or poisoned.
A nurse is caring for a male client who was admitted to the mental health unit with the diagnosis of schizophrenia. The client is hostile and experiencing auditory hallucinations and states that the voices are saying that they are going to poison him because he is bad. What type of schizophrenic behavior does the nurse identify? 1 Residual 2 Paranoid 3 Catatonic 4 Disorganized
Paranoid Clients with paranoid schizophrenia tend to experience persecutory or grandiose delusions and auditory hallucinations and exhibit behavioral changes such as anger, hostility, or violence. Residual schizophrenia is characterized by the negative symptoms of schizophrenia, but the client does not experience delusions, hallucinations, disorganized speech, or disorganized or catatonic behavior. Catatonia is a state in which the client displays extreme psychomotor retardation to the point of not talking or moving. There may be brief intermittent hyperactive episodes with catatonia. Disorganized schizophrenia is characterized by a disintegration of the personality and withdrawn behavior.
A nurse is caring for a client with a somatoform disorder. What should the nurse anticipate that this client will do? 1 Write down conversations to facilitate the recall of information. 2 Monopolize conversations about the anxiety being experienced. 3 Redirect the conversation with the nurse to physical symptoms. 4 Start a conversation asking the nurse to recommend palliative care.
Redirect the conversation with the nurse to physical symptoms. Clients with somatoform disorders are preoccupied with the symptoms that are being experienced and usually do not want to talk about their emotions or relate them to their current situation. Clients with somatoform disorders do not seek opportunities to discuss their feelings. Memory problems are not associated with somatoform disorders. These clients want and seek treatment, not palliative care.
A 3-year-old child is found to have a pervasive developmental disorder not otherwise specified. What should the nurse consider most unusual for the child to demonstrate? 1 Interest in music 2 Ritualistic behavior 3 Attachment to odd objects 4 Responsiveness to the parents
Responsiveness to the parents One of the symptoms that an autistic child displays is lack of responsiveness to others; there is little or no extension to the external environment. Music is nonthreatening, comforting, and soothing. Repetitive behavior provides comfort. Repetitive visual stimuli, such as a spinning top, are nonthreatening and soothing.
An individual whose employment has been terminated because his company has been acquired by another company is brought by a family member to the mental health clinic because of extreme depression. While talking with the nurse the client says, "I'm a useless, worthless person. No wonder I lost my job." What type of delusion does the nurse identify? 1 Reference 2 Persecution 3 Alien control 4 Self-deprecation
Self-deprecation The client's statement is self-derogatory and reflects a low self-appraisal. There is no evidence that the client feels that he is the object of attention from others in the environment, that the client feels harassed, or that the client feels that others are controlling or manipulative.
A client has been instructed to stop smoking. The nurse discovers a pack of cigarettes in the client's bathrobe. What is the nurse's initial action? 1 Notify the healthcare provider. 2 Report this to the nurse manager. 3 Tell the client that the cigarettes were found. 4 Discard the cigarettes without commenting to the client
Tell the client that the cigarettes were found. Honest nurse-client relationships should be maintained so that trust can develop. Although other healthcare team members may need to be informed eventually, the initial action should involve only the nurse and client. Discarding the cigarettes without commenting to the client does not promote trust or communication between the client and nurse.
When planning activities for a child with autism, what does the nurse remember that autistic children respond best to? 1 Loud, cheerful music 2 Large-group activities 3 Individuals in small groups 4 Their own self-stimulating acts
Their own self-stimulation acts Autistic behavior turns inward. Autistic children do not respond to the environment; instead, they attempt to maintain emotional equilibrium by rubbing and manipulating themselves, and they display a compulsive need for behavioral repetition. Autistic children do seem to respond to music, but not necessarily loud, cheerful music. Large-group (or small-group) activities have little effect on the autistic child's response. Part of the autistic pattern is the inability to interact with others in the environment, regardless of the size of the group.
A nurse is providing information about Alcoholics Anonymous (AA) meetings to a client with a history of alcohol abuse. What will be required when the client attends AA meetings? 1 Speaking aloud at weekly meetings 2 Maintaining controlled drinking after 6 months 3 Promising to attend at least 12 meetings yearly 4 Acknowledging an inability to control the alcoholism
Acknowledging an inability to control the alcoholism A major premise of AA is that to be successful in achieving sobriety, clients with an alcohol abuse problem must acknowledge their inability to control the use of alcohol. There are no rules of attendance or speaking at meetings, although both actions are strongly encouraged. Maintaining controlled drinking after 6 months is not part of the AA program; this group strongly supports total abstinence for life.
When working with a client who is in an alcohol detoxification program, what nursing action is most important? 1 Address the client's holistic needs. 2 Support the client's need for nurture. 3 Discuss with the client the negative effects of alcohol. 4 Promote the client's compliance with the program through gentle prodding.
Address the client's holistic needs. Clients who abuse alcohol characteristically have multiple nursing care needs, among them physiological, psychological, social, and occupational. Although nurture is important, this client must learn self-reliance. Discussing with the client the negative effects of alcohol is probably an old story to this client and will have a minimal positive effect. Promoting the client's compliance with the program through gentle prodding will not provide an atmosphere that can help the client withstand the stress of the detoxification program.
A nurse is assessing a client with dementia. Which clinical manifestations are expected? Select all that apply. 1 Agitation 2 Pessimism 3 Short attention span 4 Disordered reasoning 5 Impaired motor activities
Agitation, Short attention span, Disordered reasoning, Impaired motor activities The behavior of clients with dementia tends to be inappropriate, restless, and agitated. Cognitive abilities are impaired, as evidenced by a short attention span, limited ability to focus, and limited judgment and insight. Reasoning is disordered, speech may be incoherent, and memory, particularly short-term memory, is impaired. Impaired motor activity (apraxia) and impaired coordination (ataxia) are associated with dementia. Pessimism is more characteristic of depression, not dementia.
A nurse is working in a clinic that provides services to clients who abuse drugs. What effect of cocaine should the nurse consider as the reason that it easily causes dependence? 1 Eases pain 2 Blurs reality 3 Clears the sensorium 4 Decreases motor activity
Blurs reality The addict tries to avoid stress and reality. The drug produces a blurring of these feelings to the point that the addict becomes dependent on it. The psychological effect is usually more important than the ability to ease pain. Large doses of opioids, not cocaine, can cause a dreamlike state. Cocaine can increase, not decrease, motor activity.
What is the primary reason that the nurse encourages the family of an alcoholic to become involved in the treatment program? 1 Alcoholism involves the entire family. 2 Alcoholics try to hide their drinking from their families. 3 Family members provide insights into the dynamics behind the drinking. 4 Family members have been most successful in providing necessary support
Alcoholism involves the entire family. Research indicates that alcoholism is a family disease, with its roots in the family of origin. Although alcoholics may try to hide their drinking from their families, this is not the reason for including the family in the treatment program. Family members often have no understanding of the dynamics behind the drinking and often need assistance with coping and counseling. Family members often do not understand the dynamics behind the drinking and often are enablers; they also need assistance with coping and counseling.
A female client with obsessive-compulsive disorder has become immobilized by her elaborate handwashing and walking rituals. Which feelings does the nurse recall are often the basis of obsessive-compulsive disorder? 1 Anxiety and guilt 2 Anger and hostility 3 Embarrassment and shame 4 Hopelessness and powerlessness
Anxiety and guilt Ritualistic behavior seen in this disorder is aimed at controlling feelings of anxiety and guilt by maintaining an absolute set pattern of action. Although the person with an obsessive-compulsive disorder may be angry and hostile, the feelings of anger and hostility do not precipitate the rituals. Although the person with an obsessive-compulsive disorder may be embarrassed and ashamed by the ritual or feel hopeless and powerless to the ritual, the basic feelings precipitating the rituals are usually anxiety and guilt.
A 37-year-old man has been remanded by the court to the drug rehabilitation unit of a psychiatric facility for treatment of cocaine addiction. When taking his health history, what characteristics should the nurse expect the client to report? Select all that apply. 1 Anxiety 2 Palpitations 3 Weight loss 4 Sedentary habits 5 Difficulties with speech
Anxiety, Palpitations, Weight loss Cocaine, an alkaloid stimulant, can precipitate anxiety, hypervigilance, euphoria, agitation, and anger. The loss of appetite and increased metabolic rate associated with cocaine addiction both promote weight loss. Cocaine is a stimulant that has cardiac effects such as tachycardia and dysrhythmias. Sedentary habits are associated with barbiturate addiction. Difficulties with speech are associated with other addictions such as alcohol and methadone.
When planning for a client's care during the detoxification phase of acute alcohol withdrawal, what need should the nurse anticipate? 1 Checking on the client frequently 2 Keeping the client's room lights dim 3 Addressing the client in a loud, clear voice 4 Restraining the client during periods of agitation
Checking on the client frequently During detoxification frequent checks help ensure safety and prevent suicide, which is a real threat. Bright light is preferable to dim light because it minimizes shadows that may contribute to misinterpretation of environmental stimuli (illusions). The client who is going through the detoxification phase of acute alcohol withdrawal usually does not lose his sense of hearing, so there is no need to shout. Restraints may upset the client further; they should be used only if the client is a danger to himself or others.
A client with the diagnosis of bulimia nervosa, purging type, is admitted to the mental health unit after an acute episode of bingeing. Which clinical manifestation is most important for the nurse to assess? 1 Weight gain 2 Dehydration 3 Hyperactivity 4 Hyperglycemia
Dehydration The nurse should be alert for dehydration caused by fluid loss through vomiting in the binge-purge cycle. Weight gain is not expected because purging frequently follows a binge. Hyperactivity is not expected because many individuals with bulimia withdraw and vomit after a binge. Hyperglycemia is not expected because of the vomiting that follows a binge.
During a one-to-one interaction with a client with schizophrenia, paranoid type, the client says to the nurse, "I figured out how foreign agents have infiltrated the news media. They want to shut me up before I spill the beans." How should the nurse describe this statement? 1 Nihilistic delusion 2 Delusion of grandeur 3 Auditory hallucination 4 Overvaluation of the self
Delusion of grandeur Thoughts of being pursued by some powerful agent or agents because of one's special attributes or powers are fixed false beliefs and referred to as delusions of grandeur. There is no evidence to indicate that a delusion of total or partial nonexistence is being used. There is no evidence to indicate that a sensory-perceptual disturbance is present. Delusions of grandeur are usually used to deny unconscious feelings of low self-esteem.
A male client in a mental health facility turns his head to the side during a unit meeting as if he hears something. When the nurse comments about it, the client replies, "You know, it's that microcomputer those foreign agents implanted in my ear." In light of this statement, what does the nurse determine that the client is experiencing? 1 Illusions 2 Delusional thoughts 3 Neologistic thinking 4 Disorganized cognition
Delusional thoughts The client's statement reveals the cognitive disturbance called a delusion, which is a fixed set of false beliefs that cannot be corrected by reason. An illusion is a misperception of an actual environmental stimulus. Disorganized thought would include the inability to organize thought process. Neologisms are made-up words understood only by the speaker.
A client is using ritualistic behaviors. Why should a nurse give the client ample time in which to perform the ritual? 1 Denial of this activity may precipitate a panic level of anxiety. 2 Anger turned inward on the self should be allowed to be expressed. 3 Successful performance of independent activities enhances self-esteem. 4 Ample time provides an opportunity to point out the inappropriate behavior.
Denial of this activity may precipitate a panic level of anxiety. The repeated act protects the client against severe anxiety; interruption of the ritual will result in increased anxiety. The performance of a ritual is not anger turned inward on the self; the ritual reduces anxiety. Rituals are not activities that enhance self-esteem; they control anxiety. Pointing out that the behavior is inappropriate will further increase anxiety. The client does not want to perform the ritual but feels compelled to do so to keep anxiety at a controllable level.
When caring for a client with bulimia nervosa, the nurse remembers that bulimia nervosa follows a cyclical pattern. What does the nurse identify as the first pattern in this cycle? 1 Hunger resulting from food deprivation and stress 2 Dieting in an attempt to maintain control of one's life 3 Binge eating to numb physical and emotional discomforts 4 Purging in another attempt to regain control and alleviate guilt
Dieting in an attempt to maintain control of one's life Dieting may be one area of control the person has in her life, and she elects to exercise control over it. The body does experience hunger, and binge eating serves as emotional comfort when the person ingests large amounts of calories. Purging is the final phase in this cycle; individuals are unaware often that purging rids fewer than 50% of the calories ingested.
A nurse is caring for a client with the diagnosis of schizophrenia. During assessment the nurse identifies both positive (type I) and negative (type II) signs and symptoms. Which clinical findings should the nurse document as positive? Select all that apply. 1 Anergy 2 Flat affect 3 Social withdrawal 4 Disorganized thoughts 5 Auditory hallucinations
Disorganized thoughts, Auditory hallucinations Disorganized thoughts (e.g., derailment, tangentiality, illogicality, incoherence, and circumstantiality) are a positive sign of schizophrenia. Positive signs and symptoms, referred to as "florid psychotic symptoms," are related to alterations in thinking, speech, perception, and behavior. They usually respond to antipsychotic medications. Positive symptoms reflect an excess or distortion of function and include delusions, hallucinations, increased speech production with associations, and bizarre behavior. A lack of energy (anergy) is a negative symptom associated with schizophrenia. Negative symptoms reflect a lessening or loss of normal function. A lack of emotional expression (flat affect) is a negative sign associated with schizophrenia. Inadequate social skills leading to withdrawal and isolation are negative symptoms associated with schizophrenia.
A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive disorder (OCD). Before providing care for this client, what should the nurse remember about clients with OCD? 1 Are unaware that the ritual serves no purpose 2 Can alter the ritual depending on the situation 3 Should be prevented from performing the ritual 4 Do not want to repeat the ritual but feel compelled to do so
Do not want to repeat the ritual but feel compelled to do so The repeated thought or act defends the client against even higher, more severe levels of anxiety. Clients usually do recognize that the ritual serves little or no purpose. Rituals are usually followed rigidly; setting limits on or altering a ritual increases anxiety. Preventing the client from performing the ritual may precipitate a panic level of anxiety.
When answering questions from the family of a client with Alzheimer disease, how does the nurse describe the disease? 1 Emerges in the fourth decade of life 2 Is a slow, relentless deterioration of the mind 3 Is functional in origin and occurs in the later years 4 Is diagnosed through laboratory and psychological tests
Is a slow, relentless deterioration of the mind Alzheimer disease is a slow and relentless deterioration of the mind; clients become progressively worse over time. The disease usually appears in people 60 years of age and older. Alzheimer disease is an organic, not a functional, disorder. At this time there are no diagnostic tools other than autopsy that can provide a definite confirmation of Alzheimer disease.
A client with vascular dementia (formerly known as multiinfarct dementia) has signs and symptoms that are different from dementia of the Alzheimer type. What characteristics unique to vascular dementia should the nurse expect when assessing a client with this diagnosis? Select all that apply. 1 Memory impairment 2 Failure to identify objects 3 Exaggerated deep tendon reflexes 4 Episodic progression of symptoms 5 Inability to use words to communicate
Exaggerated deep tendon reflexes, Episodic progression of symptoms The diagnosis of vascular dementia is made when there is evidence of focal neurological signs and symptoms such as exaggerated deep tendon reflexes, extensor plantar response, gait abnormalities, and muscle weakness and when computed tomography reveals multiple infarcts involving the cortex and underlying white matter. Usually the signs and symptoms associated with vascular dementia have a steplike progression because of further intermittent occlusion of small arteries or arterioles in the cortex of the brain. Dementia of the Alzheimer type is associated with a gradual, progressive loss of memory and cognitive abilities. Both vascular dementia and dementia of the Alzheimer type are associated with deficits in memory and cognition. Failure to identify objects despite intact sensory function (agnosia) is a cognitive disturbance associated with both vascular dementia and dementia of the Alzheimer type. Both vascular dementia and dementia of the Alzheimer type are associated with language disturbances such as inability to use or understand words (aphasia).
The nurse suggests counseling for a 13-year-old whose close friend has just committed suicide. The nurse's intervention is based on the understanding that an adolescent is at risk for copycat suicide mainly because members of this age group exhibit which characteristic? 1 Generally have poor impulse control 2 Have had few experiences with mortality 3 Often forge very close peer relationships 4 Typically mimic the behavior of their peers
Generally have poor impulse control Adolescents are at especially high risk because of the immaturity of the prefrontal cortex. This is the portion of the brain that is responsible for judgment and impulse control. Although lack of life experience, the closeness of peer relationships, and behavioral mimicking are all characteristics of this age group, they are not as influential in a behavior such as copycat suicide.
A nurse is assessing a client with major depression. Which clinical manifestation reflects a disturbance in affect related to depression? 1 Echolalia 2 Delusions 3 Confusion 4 Hopelessness
Hopelessness Feelings of hopelessness are symptomatic of depression; the individual feels unable to find any solution to problems and therefore feels overwhelmed. Echolalia, the pathological meaningless repetition of another's words or phrases, is associated with schizophrenia, not with depression. Delusions are associated with psychotic disorders such as schizophrenia, not depression. Confusion is not common because these individuals are in contact with reality.
A client with a personality disorder is playing cards with another person in the lounge. When the other person cheats at cards, the client responds by aggressively scattering the cards around the room. What does the nurse conclude about the client's personality? 1 Poor reality testing 2 A violent personality 3 An antisocial personality 4 Inadequate impulse control
Inadequate impulse control The client is angry and reacts impulsively; the action is unplanned and is not under the client's control. No data are provided to suggest that the client is out of contact with reality; the client is reacting to a real situation with anger. There is no identifiable cluster of behaviors to suggest that the client has a violent personality. There is no pattern of behavior to suggest an antisocial personality, which may or may not involve impulse control.
A client admitted for substance abuse detoxification is displaying severe anger toward his spouse. In light of this information, how effectively does the nurse manager determine that the situation was handled? 1 Appropriately, because the client expressed his feelings and is now calm 2 Inappropriately, because the client was allowed to monopolize the nurse's attention for 30 minutes 3 Appropriately, because the nurse used therapeutic communication techniques to deescalate the client's behavior 4 Inappropriately, because the nurse failed to effectively address the client's threat of physical harm to his wife
Inappropriately, because the nurse failed to effectively address the client's threat of physical harm to his wife Threatening physical harm requires notification of the appropriate individuals about any viable threat. This documentation fails to address such an intervention by the nurse. Deescalation is a desirable outcome, and therapeutic communication is a vital tool in addressing the client's anger, but the major safety issue cannot be left unaddressed. Communicating with the nurse for an extended period for the purpose of deescalating anger is not inappropriate
An older nursing home resident with the diagnosis of early-onset dementia likes to talk about the old days and at times has a tendency to confabulate. What does the nurse determine is the purpose of the client's confabulation? 1 Prevent regression 2 Increase self-esteem 3 Attract the attention of others 4 Help him reminisce about achievements
Increase self-esteem Confabulation is used as a defense mechanism against embarrassment caused by a lapse of memory; the client fills in the blanks in memory by making up details, thus maintaining self-esteem. Regression is a defense mechanism in which the individual moves back to earlier developmental defenses; the client is not regressing at this time. Although older adults fear being forgotten or losing others' affection, this is not the reason for confabulation. Confabulation is not used to reminisce about past achievement.
For what clinical manifestations should the nurse assess a client during the first few hours of the alcohol withdrawal? Select all that apply. 1 Irritability 2 Tachycardia 3 Hallucinations 4 Increasing anxiety 5 Profuse diaphoresis
Irritability, Tachycardia, Increasing anxiety Alcohol is a central nervous system depressant; irritability and increasing anxiety reflect the body's neurologic adaptation to the withdrawal of alcohol. Tachycardia is one of the early sign of withdrawal; it results from autonomic overactivity. Hallucinations are not early signs of alcohol withdrawal; they usually do not occur before 48 to 72 hours of abstinence. Fever and diaphoresis are later signs of withdrawal that may be seen during alcohol withdrawal delirium; they result from autonomic overactivity.
For which clinical indication should a nurse observe a child in whom autism is suspected? 1 Lack of eye contact 2 Crying for attention 3 Catatonia-like rigidity 4 Engaging in parallel play
Lack of eye contact Children with autism usually have a pervasive impairment of reciprocal social interaction. Lack of eye contact is a typical behavior associated with autism. Crying for attention, rigidity, and parallel play are not indicative of autism.
A client's admitting history indicates signs of akathisia. What clinical finding should the nurse expect when assessing for this condition? 1 Facial tics 2 Motor restlessness 3 Maintaining a body position for hours 4 Repeating the movements of another person
Motor restlessness With akathisia the client exhibits a constant state of movement; this is characterized by restlessness and difficulty sitting still, including constant jiggling of the arms or legs. The distortion of voluntary movements, such as tics, spasms, or myoclonus, is known as dyskinesia. Maintaining a body position for hours is a form of catatonia known as waxy flexibility. Repeating the movements of another person is known as echopraxia
A mother brings her 7-year-old son into an outpatient clinic for a follow-up appointment. The mother appears angry and agitated with the boy. Looking at the boy's medical chart, the nurse notes that the boy has a diagnosis of encopresis. What is the primary symptom of encopresis? 1 Practicing self-mutilation 2 Practicing self-induced vomiting 3 Passing feces either voluntarily or involuntarily into inappropriate places 4 Passing urine either voluntarily or involuntarily into inappropriate places
Passing feces either voluntarily or involuntarily into inappropriate places Encopresis is the passage of feces into inappropriate places such as clothing, closets, floors, or toy boxes, either voluntarily or involuntarily. It may severely limit a child's social development and results in parental disapproval and rejection. Encopresis does not involve self-induced vomiting or self-mutilation. The passage of urine into inappropriate places is called enuresis.
When assessing the characteristics of an adolescent with anorexia nervosa, how does the nurse expect to describe the adolescent? 1 Manic 2 Rebellious 3 Hypoactive 4 Perfectionistic
Perfectionistic Perfectionistic standards and extremes of self-discipline are an attempt to maintain control and meet the client's own and others' expectations. People with anorexia nervosa are often anxious and depressed, not manic. People with anorexia nervosa are frequently compliant in an attempt to meet the expectations of others. People with anorexia nervosa usually use excessive exercise routines as a means of losing weight. Also, many are trying to become the thin, fit ideal woman depicted in the media.
What defense mechanism should the nurse anticipate that a client with the diagnosis of schizophrenia, undifferentiated type, will most often exhibit? 1 Projection 2 Regression 3 Repression 4 Rationalization
Regression Regression is the defense mechanism that is commonly used by clients with schizophrenia, undifferentiated type, to reduce anxiety by returning to earlier behavior. Projection is an organized defense used by clients with schizophrenia, paranoid type, in which the delusional system is well systematized. Repression, or unconscious forgetting, is not a major defense used by clients with schizophrenia; if it were, they would not need to break with reality. Rationalization, in which the individual blames others for problems and attempts to justify actions, is seldom used by clients with schizophrenia.
A client with paralysis of the legs is found to have somatoform disorder, conversion type. What must the nurse consider when formulating a plan of care for this client? 1 The illness is very real to the client and requires appropriate nursing care. 2 Although the client believes that there is an illness, there is no cause for concern. 3 There is no physiological basis for the illness; therefore only emotional care is needed. 4 Nursing intervention is needed even though the nurse understands that the client is not ill
The illness is very real to the client and requires appropriate nursing care. Individuals who have somatoform disorders are really ill; they need care in a nonthreatening environment. The client requires physiological and emotional care for treatment of motor or sensory functional deficits.
A nurse is caring for a client with an obsessive-compulsive disorder. What is the basis for the obsessions and compulsions? 1 Unconscious control of unacceptable feelings 2 Conscious use of this method to punish themselves 3 Acceptance of voices that tell her that doorknobs are unclean 4 Fulfillment of a need to punish others by carrying out the procedure
Unconscious control of unacceptable feelings In carrying out the compulsive ritual the client unconsciously tries to control anxiety by avoiding acting on unacceptable feelings and impulses. The client does not consciously use this method to punish herself. Hallucinations are not part of this disorder. People with obsessive-compulsive disorder feel no need to punish others.
What characteristic uniquely associated with psychophysiologic disorders differentiates them from somatoform disorders? 1 Emotional cause 2 Feeling of illness 3 Restriction of activities 4 Underlying pathophysiology
Underlying pathophysiology The psychophysiologic response (e.g., hyperfunction or hypofunction) produces actual tissue change. Somatoform disorders are unrelated to organic changes. There is an emotional component in both instances. There is a feeling of illness in both instances. There may be a restriction of activities in both instances.
A client with a history of drug abuse begins group therapy. After attending the first meeting the client says to the nurse, "It helps to know that I'm not the only one with this type of problem." What concept does this statement reflect? 1 Altruism 2 Catharsis 3 Universality 4 Transference
Universality Universality is the sense that one is not alone in any situation; one purpose of group therapy is to share feelings and gain support from others with similar thoughts and feelings. Altruism in group therapy is giving support, insight, and reassurance to others, which eventually promotes self-knowledge and growth. Catharsis involves group members relating to one another through the verbal expression of negative and positive feelings. Transference occurs when a client unconsciously assigns to the therapist feelings and attitudes originally associated with another important person in the client's life.
A client with a history of heavy drinking is brought to a psychiatric facility in a stupor. On the day after admission the client is confused, disoriented, and delusional. What alcohol-related symptom does the nurse decide the client may be experiencing? 1 Amnesia 2 Hallucinations 3 Withdrawal syndrome 4 Uncomplicated dementia
Withdrawal syndrome The central nervous system is affected by the abrupt withdrawal of alcohol intake, resulting in the classic responses indicated in the situation; they occur 1 to 3 days after the cessation of alcohol intake. The information presented does not indicate the presence of impaired short- or long-term memory or of hallucinations. There are insufficient data with which to identify dementia; impairment of thought processes, judgment, and intellectual abilities must continue for 3 weeks or longer for dementia to be considered as a diagnosis.
