EX3: psych NCLEX Has some alcohol and substance abuse questions

A nursing student is asked to identify the characteristics of bulimia nervosa. Which response by the student indicates a need to further research the disorder? 1. Dental erosion 2. Electrolyte imbalances 3. Enlarged parotid glands 4. Body weight well below ideal range*

1. Dental erosion 2. Electrolyte imbalances 3. Enlarged parotid glands *4. Body weight well below ideal range* *rationale* Clients with bulimia nervosa may not initially appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, the client demonstrates enlargement of the parotid glands with dental erosion and caries if he or she has been inducing vomiting. Electrolyte imbalances are present.

A nurse is assigned to care for a client at risk for alcohol withdrawal. The nurse monitors the client, knowing that the early signs of withdrawal will usually develop within how much time after cessation or reduction of alcohol intake? 1. In 7 days 2. In 14 days 3. In 21 days 4. Within a few hours *I think ours gave hours, 24-48 being correct. What do you think?

1. In 7 days 2. In 14 days 3. In 21 days *4. Within a few hours* *rationale* Early signs of alcohol withdrawal develop within a few hours after cessation or reduction of alcohol and peak after 24 to 48 hours.

Which data indicates to the nurse that a client may be experiencing ineffective coping? 1. Constantly neglects personal grooming* 2. Visits her husband's grave once a month 3. Visits the senior citizens' center once a month 4. Frequently looks at snapshots of her husband and family

*1. Constantly neglects personal grooming* *rationale* Coping mechanisms are behaviors that are used to decreased stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some instances may be harmful to the individual, physically, psychologically, or both. Option 1 is indicative of a behavior that identifies an ineffective coping behavior as part of the grieving process. The remaining options identify effective coping behaviors.

A nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client states: 1. "My medications won't make me anxious." 2. "I'll go to a support group and talk so that I won't hurt anyone." 3. "I won't get anxious or hear things if I get enough sleep and eat well." 4. "I can call my therapist when I'm hallucinating so that I can talk about my feelings and plans and not hurt anyone."*

1. "My medications won't make me anxious." 2. "I'll go to a support group and talk so that I won't hurt anyone." 3. "I won't get anxious or hear things if I get enough sleep and eat well." *4. "I can call my therapist when I'm hallucinating so that I can talk about my feelings and plans and not hurt anyone."* *rationale* There may be an increased risk for impulsive and/or aggressive behavior if a client is receiving command hallucinations to harm self or others. Talking about the auditory hallucinations can interfere with the subvocal muscular activity associated with a hallucination. Option 4 is a specific agreement to seek help and evidences self-responsible commitment and control over his or her own behavior.

A nurse is providing care to a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" The appropriate nursing response is which of the following? 1. "No, I won't tell anyone." 2. "I cannot promise to keep a secret."* 3. "If you tell me the secret, I will tell it to your doctor." 4. "If you tell me the secret, I will need to document it in your record."

1. "No, I won't tell anyone." *2. "I cannot promise to keep a secret."* 3. "If you tell me the secret, I will tell it to your doctor." 4. "If you tell me the secret, I will need to document it in your record." *rationale* The nurse should never promise to keep a secret. Secrets are appropriate in a social relationship, but not in a therapeutic one. The nurse needs to be honest with the client and tell the client that a promise cannot be made to keep the secret.

A nurse is preparing a client for the termination phase of the nurse-client relationship. Which nursing task would the nurse appropriately plan for this phase?

1. Plan short-term goals. 2. Identify expected outcomes. *3. Assist in making appropriate referrals.* 4. Assist in developing realistic solutions. *rationale* Tasks of the termination phase include evaluating client performance, evaluating achievement of expected outcomes, evaluating future needs, making appropriate referrals, and dealing with the common behaviors associated with termination. Options 1, 2, and 4 identify the tasks of the working phase of the relationship.

A client is unwilling to go out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The nurse determines that the client has: 1. Agoraphobia* 2. Hematophobia 3. Claustrophobia 4. Hypochondriasis

*1. Agoraphobia* 2. Hematophobia 3. Claustrophobia 4. Hypochondriasis *rationale* Agoraphobia is a fear of being alone in open or public places where escape might be difficult. Agoraphobia includes experiencing fear or a sense of helplessness or embarrassment if a phobic attack occurs. Avoidance of such situations usually results in the reduction of social and professional interactions. Hematophobia is the fear of blood. Claustrophobia is a fear of closed-in places. Clients with hypochondriacal symptoms focus their anxiety on physical complaints and are preoccupied with their health.

Which of the following are appropriate interventions for caring for the client in alcohol withdrawal. *Select all that apply.* Select All 1. Monitor vital signs. 2. Maintain an NPO status. 3. Provide a safe environment. 4. Address hallucinations therapeutically. 5. Provide stimulation in the environment. 6. Provide reality orientation as appropriate.

*1. Monitor vital signs.* 2. Maintain an NPO status. *3. Provide a safe environment.* *4. Address hallucinations therapeutically.* 5. Provide stimulation in the environment. *6. Provide reality orientation as appropriate.* *rationale* When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming himself or herself or others. The nurse would provide a low stimulating environment to maintain the client in as calm a state as possible. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would frequently reorient the client to reality and would address hallucinations therapeutically. Adequate nutritional and fluid intake needs to be maintained.

A nurse is assigned to care for a client who is experiencing disturbed thought processes. The nurse is told that the client believes that the food is being poisoned. Which communication technique does the nurse plan to use to encourage the client to eat? 1. Open-ended questions and silence* 2. Focusing on self-disclosure regarding food preferences 3. Stating the reasons that the client may not want to eat 4. Offering opinions about the necessity of adequate nutrition

*1. Open-ended questions and silence* *rationale* Open-ended questions and silence are strategies used to encourage clients to discuss their problem. Options 3 and 4 do not encourage the client to express feelings. The nurse should not offer opinions and should not state the reasons, but should encourage the client to identify the reasons for the behavior. Option 2 is not a client-centered intervention.

A nurse is assisting with the data collection on a client admitted to the psychiatric unit. The nurse reviews the data obtained and identifies which of the following as a priority concern? 1. The client's report of suicidal thoughts* 2. The client's report of not eating or sleeping 3. The presence of bruises on the client's body 4. The family member is disapproving of the treatment

*1. The client's report of suicidal thoughts* *rationale* The client's thoughts are extremely important when verbalized. Suicidal thoughts are the highest priority. Options 2, 3, and 4 will all affect the treatment of the client but are not of greatest importance at this time.

During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client? 1. "Have you talked to your family about this?" 2. "Everyone feels this way when they are depressed." 3. "You will feel better once your medication begins to work." 4. "You sound very upset. Are you thinking of hurting yourself?"

1. "Have you talked to your family about this?" 2. "Everyone feels this way when they are depressed." 3. "You will feel better once your medication begins to work." *4. "You sound very upset. Are you thinking of hurting yourself?"* *rationale* Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The client should be directly asked if a plan for self-harm exists. Options 1, 2, and 3 are not therapeutic responses.

A nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time? 1. "I know you feel 'they are out to get you,' but it's not true." 2. "I can hear the voice and she wants you to come to dinner." 3. "Sometimes people hear things or voices others can't hear."* 4. "I talked to the voices you're hearing and they won't hurt you now."

1. "I know you feel 'they are out to get you,' but it's not true." 2. "I can hear the voice and she wants you to come to dinner." *3. "Sometimes people hear things or voices others can't hear."* 4. "I talked to the voices you're hearing and they won't hurt you now." *rationale* It is important for the nurse to reinforce reality with the client. Options 1, 2, and 4 do not reinforce reality but reinforce the hallucination that the voices are real.

A nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which clinical manifestations are specifically associated with withdrawal from opioids? 1. Dilated pupils, tachycardia, and diaphoresis 2. Yawning, irritability, diaphoresis, cramps, and diarrhea* 3. Tachycardia, hypertension, sweating, and marked tremors 4. Depressed feelings, high drug craving, fatigue, and agitation

1. Dilated pupils, tachycardia, and diaphoresis *2. Yawning, irritability, diaphoresis, cramps, and diarrhea* 3. Tachycardia, hypertension, sweating, and marked tremors 4. Depressed feelings, high drug craving, fatigue, and agitation *rationale* Opioids are central nervous system (CNS) depressants. Withdrawal effects include yawning, insomnia, irritability, rhinorrhea, diaphoresis, cramps, nausea and vomiting, muscle aches, chills, fever, lacrimation, and diarrhea. Withdrawal is treated by methadone tapering or medication detoxification. Option 2 identifies the clinical manifestations associated with withdrawal from opioids. Option 3 describes withdrawal from alcohol. Option 1 describes intoxication from hallucinogens. Option 4 describes withdrawal from cocaine.

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. The appropriate nursing action is to:

*1. Call the nursing supervisor.* 2. Call security to block all exit areas. 3. Restrain the client until the health care provider (HCP) can be reached. 4. Tell the client that she cannot return to this hospital again if she leaves now. *rationale* A nurse can be charged with false imprisonment if a client is made to wrongfully believe that he or she cannot leave the hospital. Most health care facilities have documents that the client is asked to sign, which relate to the client's responsibilities when he or she leaves against medical advice (AMA). The client should be asked to sign this document before leaving. The nurse should request that the client wait to speak to the HCP before leaving, but, if the client refuses to do so, the nurse cannot hold the client against his or her will. Restraining the client and calling security to block exits constitutes false imprisonment. Any client has a right to health care (option 4) and cannot be told otherwise.

A nurse is assisting in planning care for a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention will the nurse include in the plan of care? 1. One-to-one suicide precautions 2. Suicide precautions, with 30-minute checks 3. Checking the whereabouts of the client every 15 minutes 4. Asking that the client report suicidal thoughts immediately *Our one on one was the person disrobing in the hall 3x so far*

*1. One-to-one suicide precautions* 2. Suicide precautions, with 30-minute checks 3. Checking the whereabouts of the client every 15 minutes 4. Asking that the client report suicidal thoughts immediately *rationale* One-to-one suicide precautions are required for the client who has attempted suicide. Options 2 and 3 are not appropriate, considering the situation. Option 4 may be an appropriate nursing intervention, but the priority is stated in option 1. The best option is constant supervision so that the nurse may intervene as needed if the client attempts to cause harm to him or herself.

A nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic? 1. "Right! Why not just 'pack it in'?" 2. "That seems rather unlikely to me." 3. "I don't believe that, and neither do you." 4. "You must be feeling all alone at this point."

1. "Right! Why not just 'pack it in'?" 2. "That seems rather unlikely to me." 3. "I don't believe that, and neither do you." *4. "You must be feeling all alone at this point."* *rationale* The client is experiencing loss and is feeling hopeless. The therapeutic response by the nurse is the one that attempts to translate words into feelings. In option 2, the nurse is voicing doubt, which is often used when a client verbalizes delusional ideas. In option 3, the nurse is disagreeing with the client, which implies that the nurse has passed judgment on the client's ideas or opinions. In option 1, the nurse uses sarcasm, which gives advice and is nontherapeutic as a nursing response.

A nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by: 1. Engaging in immoral acts 2. Always reinforcing self-approval 3. Observing rigid rules and regulations* 4. Having the need to always make the right decision

1. Engaging in immoral acts 2. Always reinforcing self-approval *3. Observing rigid rules and regulations* 4. Having the need to always make the right decision *rationale* Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help the clients manage their anxiety. Options 1, 2, and 4 are incorrect.

A nursing student is developing a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which incorrect intervention in the plan? 1. Monitor intake and output. 2. Monitor electrolyte levels. 3. Observe for excessive exercise.* 4. Monitor for the use of laxatives and diuretics.

1. Monitor intake and output. 2. Monitor electrolyte levels. *3. Observe for excessive exercise.* 4. Monitor for the use of laxatives and diuretics. *rationale* Excessive exercise is a characteristic of anorexia nervosa, not bulimia nervosa. Frequent vomiting, in addition to laxative and diuretic abuse, may lead to dehydration and electrolyte imbalance. Monitoring for dehydration and electrolyte imbalance are important nursing actions. Option 3 is the only option that is not associated with care of the client with bulimia.

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is to: 1. Move the client next to the nurse's station. 2. Use a night light and turn off the television.* 3. Keep the television and a soft light on during the night. 4. Play soft music during the night and maintain a well-lit room.

1. Move the client next to the nurse's station. *2. Use a night light and turn off the television.* 3. Keep the television and a soft light on during the night. 4. Play soft music during the night and maintain a well-lit room. *rationale* It is important to provide a consistent daily routine and a low-stimulation environment when the client is agitated and confused. Noise levels including a radio and television may add to the confusion and disorientation. Moving the client next to the nurses' station is not the initial intervention.

A client was admitted to a medical unit with acute blindness. Many tests are performed and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash, in which a family of three was killed. The nurse suspects that the client may be experiencing a: 1. Psychosis 2. Repression 3. Conversion disorder* 4. Dissociative disorder

1. Psychosis 2. Repression *3. Conversion disorder* 4. Dissociative disorder *rationale* A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. It is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, thus interfering with the person's capacity to deal with life's demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness.

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. The nurse's most important aspect of care is to maintain client safety and plans to: 1. Request that a peer remain with the client at all times. 2. Remove the client's clothing and place the client in a hospital gown. 3. Assign a staff member to the client who will remain with him or her at all times. 4. Admit the client to a seclusion room where all potentially dangerous articles are removed.

1. Request that a peer remain with the client at all times. 2. Remove the client's clothing and place the client in a hospital gown. *3. Assign a staff member to the client who will remain with him or her at all times.* 4. Admit the client to a seclusion room where all potentially dangerous articles are removed. *rationale* Hanging is a serious suicide attempt. The plan of care must reflect action that will promote the client's safety. Constant observation status (one on one) with a staff member who is never less than an arm's length away is the safest intervention.