NCLEX Psychosocial Integrity Questions - NCLEX Questions On Psychosocial Integrity
Psychosocial Integrity NCLEX Practice Questions
Question 1.
A client is discussing her problematic marital relationship with the nurse. Which statement by the nurse is an example of the nontherapeutic communication technique of giving reassurance?
(a) "I think you should try marital counseling. I've had to do that myself once and it helped."
(b) "Why don't you see a conflict resolution specialist? I can give you that information."
(c) "I agree with you. He should not argue with you when he has problems at work that are not your fault."
(d) "Everything will be okay if you talk to him about how it makes you feel."
Answer:
(d) "Everything will be okay if you talk to him about how it makes you feel."
Rationale:
Telling the client that everything will be okay or not to worry is an example of giving reassurance. Options (a) and (b) are examples of giving advice instead of asking the client what she thinks she should do. The nurse should never offer solutions that she has tried, as it takes focus off the client. Agreeing or disagreeing with the client implies that the nurse has the right to judge the client's ideas as right or wrong.
Question 2.
The nurse is caring for a client with a history of schizophrenia. The nurse asks the client if he is ready to eat his lunch. The client responds, "Rain, train, down the drain, Jane's brain." The nurse recognizes this type of speech pattern as which type?
(a) echolalia
(b) word salad
(c) neologisms
(d) clang association
Answer:
(d) clang association
Rationale:
Clang association often involves rhyming words. Echolalia speech is characterized by repeating the other person's words or phrases repeatedly. Mimicry is a technique used to try and identify with the speaker. Word salad is a jumble of random, unrelated words that do not express a complete thought. Neologisms are made-up words that have meaning only to the speaker.
Question 3.
The nurse is talking to a group of student nurses about content of thought in clients with schizophrenia. The nurse gives an example of a client stating that her new tooth filling allows her to communicate with the Secret Service and follow their directives. Which response correctly identifies this content of thought?
(a) somatic delusion
(b) delusion of grandeur
(c) delusion of persecution
(d) delusion of control or influence
Answer:
(d) delusion of control or influence
Rationale:
The client with delusion of control or influence believes that her behavior is controlled by certain people or objects. With somatic delusion, the client has false ideas about the functioning of his body. For example, a man may believe he is pregnant and will give birth. Delusions of grandeur involve feelings of superiority of power, knowledge, or importance. A client with delusions of grandeur may believe that he is God. The client suffering delusions of persecution feels that people are out to get her, for example, that a neighbor is plotting to kill her.
Question 4.
A 79-year-old client with moderate dementia and limited mobility is being cared for at home by her son who lives with her. She has been receiving home health for care of a nonhealing diabetic foot ulcer. The home health nurse encourages the son to bring his mother to the ED for more aggressive treatment in an in-patient setting. The son responds that he cannot afford to pay for the medical bills and prefers to care for her at home. The nurse then notices a stage 2 decubitus ulcer on the client's sacrum. The son claims to have his sister come every day and assist with bathing and turning in the bed. Which type of violence is the son guilty of?
(a) physical neglect
(b) physical violence
(c) emotional violence
(d) economic exploitation
Answer:
(a) physical neglect
Rationale:
Nonhealing ulcers and the presence of a stage 2 ulcer indicate a situation that has been going on more than just a few days; the client's limited mobility makes her more vulnerable to decubitus than someone more mobile. No specific findings indicate intentional physical violence. Emotional violence involves inflicting mental anguish or making threats.
Economic exploitation involves illegally using one's assets and other funds for personal gain instead of ensuring that the funds are used to care for the client. The son is worried about treatment cost, and this is not an unreasonable concern for family members who care for elderly family members on limited incomes. He may be unaware of assistive programs available for his mother. The home health nurse should seek social services to assist the client in getting proper medical help and notify the client's health care provider.
Question 5.
The nurse is caring for a client scheduled to receive electroconvulsive therapy (ECT). Which is the priority nursing action while caring for this client during the treatment?
(a) monitor the airway and be prepared to provide suction if needed
(b) continuously observe vital signs and cardiac function on the monitor
(c) provide support and safe positioning to the client's arms and legs during the seizure
(d) record the type, frequency, duration, and amount of movement induced by the seizure
Answer:
(a) monitor the airway and be prepared to provide suction if needed
Rationale:
While all actions are an important part of client care during ECT, airway is always the priority. The nurse should be prepared to suction if needed and assist the anesthesiologist with oxygenation as required.
Question 6.
The nurse is caring for a client for whom English is a second or other language and who is very reluctant to disclose personal information. Which statement reflects an understanding of culturally or socially competent care for this specific client?
(a) Making direct eye contact with the client may be viewed as disrespectful.
(b) Care and activities should be scheduled around designated prayer times whenever possible.
(c) The patient may be undocumented, fearful of disclosing his or her status, and therefore cautious in institutional settings.
(d) The patient may not be well educated.
Answer:
(c) The patient may be undocumented, fearful of disclosing his or her status, and therefore cautious in institutional settings.
Rationale:
Options (a) and (b) reflect the beliefs of people of many backgrounds and should be considered when caring for clients of different cultures and religions. Option (d) may be true of any patient regardless of background; furthermore, level of education has no bearing on the ability to provide basic personal information, and well-educated patients may still have limited English language skills.
However, option (c) reveals sensitivity about the complex life circumstances of a client. Depending on the setting in which the nurse is working, social workers or other liaisons may be available and appropriate for consultation in caring for clients of varying backgrounds.
Question 7.
The nurse is caring for a client diagnosed with bipolar disorder. During the morning assessment, the client tells the nurse that she hears people in the room behind her bed talking about her. Which response by the nurse best reflects therapeutic communication?
(a) "What do you hear them saying?"
(b) "I will see if we can move you to another room."
(c) "I will notify your doctor in case he wants to change your medications."
(d) "I understand that the voices seem real to you, but I don't see or hear anyone else in here."
Answer:
(d) "I understand that the voices seem real to you, but I don't see or hear anyone else in here."
Rationale:
Orienting the client to reality is the best therapeutic communication tool to use with this client. Presenting reality does not belittle the client or disregard her feelings, but provides an alternative line of thought to consider. Asking what the voices are saying encourages the behavior and may further confuse the client. Offering to move the patient to another room implies agreement that the voices are real. Notifying the physician is important with new onset symptoms but is not a therapeutic response for this client as it fails to reorient to reality.
Question 8.
A nurse on the mental health unit is preparing a presentation on suicide for a group of student nurses. Which information would be included in this presentation? Select all that apply.
(a) Chronic pain or serious, disabling illness has little to no effect on suicide risk.
(b) Hispanic Americans attempt suicide at a greater rate than whites or African Americans.
(c) Suicide risk declines sharply once antidepressant medication has been taken for a few weeks.
(d) White males over the age of 80 are at the greatest risk among all age, race, and gender groups.
(e) Threatened suicide and/or gestures should be taken seriously and handled by trained professionals.
Answer:
(d) White males over the age of 80 are at the greatest risk among all age, race, and gender groups.
(e) Threatened suicide and/or gestures should be taken seriously and handled by trained professionals.
Rationale:
White males over 80 are at the greatest risk among age, race, and gender groups, with 84% of elderly suicide victims being male. All threats of suicide should be taken seriously and immediate care should be sought out with the appropriate professionals. Chronic pain and serious illnesses such as cancer increase the risk of suicide. Whites are at the greatest risk of suicide among all ethnic groups. The risk of suicide may increase once antidepressants are effective because they may give the client the energy to formulate and carry out a suicide plan.
Question 9.
The nurse is caring for a client who is taking tricyclic antidepressants. Which statement by the client indicates that the medication is working properly?
(a) "I haven't felt like going to work this week."
(b) "I've joined a bridge club in my neighborhood."
(c) "I sleep 12 hours a night and take a nap during the day."
(d) "I have felt my heart racing since I started the medicine."
Answer:
(b) "I've joined a bridge club in my neighborhood."
(c) "I sleep 12 hours a night and take a nap during the day."
(d) "I have felt my heart racing since I started the medicine."
Rationale:
All evidence must be preserved and collected following a strict chain of custody in order to be admissible in court, should the client pursue legal action. Rape kits are available in the ED that utilize a standard format of what information and items to collect. Some EDs have SANE (sexual assault nurse examiner) nurses who perform forensic nursing functions with specialized training. Photographing injuries provides further evidence for the medical record. Reassuring the client that she did what was needed to survive offers comfort.
Before beginning any assessments or treatments, the client's mental condition should be evaluated. If the client is in extreme distress, it may be necessary to delay certain treatments or provide medication per the health care provider. The nurse should remain with the client at all times, as the pelvic examination may be painful and/or trigger flashbacks.
If possible, ask the client if she would prefer a female physician. Advising the client on clothing choices implies that the client is to blame for the assault and may make the client defensive or less compliant with treatment. The client should receive information on rape crisis groups or other forms of support and counseling once she is able to comprehend and process the information.
Question 10.
The ED nurse is caring for a female client who was just brought in following a sexual assault. Which interventions by the nurse are appropriate for this client? Select all that apply.
(a) help the client bathe and change into fresh clothing before the examination begins
(b) preserve any evidence, including clothing, and take photographs of injuries as appropriate
(c) assure the client that surviving the assault is most important, and she did what was needed to stay alive
(d) take the client to a quiet, private room for assessment to assess stress levels before beginning examination or treatments
(e) tell the client that she should avoid wearing skimpy clothing in questionable areas of the city to avoid another incident
Answer:
(b) preserve any evidence, including clothing, and take photographs of injuries as appropriate
Rationale:
The safest option for the client is one-on-one observation by a staff member trained to work with potentially volatile clients. Distracting the client with a task may be helpful, but it is not the best choice here. Also, access to towels or sheets may allow the client to try and hang himself. Chemical and physical restraints should be used only as a last resort; physical restraints can escalate some clients to more violent behavior.
Keeping the client in the day room is not an option because it is not the responsibility of other clients to watch out for one another and it shifts responsibility away from staff. Placing the client in isolation, even after removing potentially dangerous articles, is not the safest option and should not be used as a priority treatment. Clients have died in seemingly safe conditions in isolation, and this creates issues with risk management. Client safety is always the first priority.
Question 11.
A nurse has admitted a client to the mental health unit following an attempted suicide. The client also attempted suicide four months earlier. Which is the best way to ensure client safety?
(a) give the client a task to do, such as folding towels, to distract him
(b) assign a staff member to remain with the client one-on-one at all times
(c) obtain an order for chemical and physical restraints to be used as needed
(d) keep the client in the day room around other clients who can help watch the client
(e) place the client in isolation after removing potentially unsafe articles, such as shoelaces and belts
Answer:
(b) assign a staff member to remain with the client one-on-one at all times
(c) obtain an order for chemical and physical restraints to be used as needed
(d) keep the client in the day room around other clients who can help watch the client
Rationale:
Risk factors for domestic violence include being under age 30 and growing up in a home where child and spousal abuse occurred. Victims tend to have multiple abusive relationships over their lifetime. Many abusers severely restrict the victim's movement, so social isolation from friends and family is common. If the client is employed, she typically works in a low-paying field or goes through multiple jobs. Economic factors such as low income and lack of education are common in domestic violence, although it can occur in any environment.
Question 12.
The nurse is caring for a client who is a victim of domestic violence. Which of the following would the nurse expect to find in the client's social history? Select all that apply.
(a) The client is under 30 years old.
(b) The client is active in a local charity.
(c) The client has a history of child abuse.
(d) The client has been in past abusive relationships.
(e) The client is employed as a college professor.
Answer:
(a) The client is under 30 years old.
(e) The client is employed as a college professor.
Rationale:
Clients with delirium develop fever and other manifestations of delirium within 48 to 72 hours after the last drink. Disorientation and fluctuating levels of consciousness are common. Other signs in the delirium stage include anorexia and insomnia.
Question 13.
The nurse is caring for a client who presented to the ED with a blood alcohol level of 208 mg/dL. The client states that his last drink was about 8 hours ago. He exhibits coarse tremors of the hands, anxiety, and elevated blood pressure. Which of the following would the nurse expect if his condition progresses to withdrawal delirium? Select all that apply.
(a) fever of 100°F to 103°F
(b) increased appetite, especially for sweets
(c) excessive sleeping of 14 hours or more daily
(d) onset of delirium 12 to 24 hours after the last drink
(e) onset of delirium 48 to 72 hours after the last drink
(f) disorientation and fluctuating levels of consciousness
Answer:
(a) fever of 100°F to 103°F
(e) onset of delirium 48 to 72 hours after the last drink
(f) disorientation and fluctuating levels of consciousness
Rationale:
Clients with delirium develop fever and other manifestations of delirium within 48 to 72 hours after the last drink. Disorientation and fluctuating levels of consciousness are common. Other signs in the delirium stage include anorexia and insomnia.
Question 14.
The nurse in a mental health facility is teaching a group of student nurses about schizophrenia. Which is true regarding the phases of schizophrenia? Select all that apply.
(a) The average length of the prodromal phase in most clients is from 2 to 5 years.
(b) Clients in the premorbid phase tend to do well in school and have more outgoing personalities early in the disorder.
(c) In the active phase of schizophrenia, physiological causes such as drug abuse or a medical condition must be considered as a cause.
(d) During the residual phase, negative symptoms can remain and the client commonly has a flat affect and impaired role functioning.
(e) During the prodromal phase, treatment includes family interventions to improve coping, cognitive therapy, and therapeutic support for identified problems.
Answer:
(a) The average length of the prodromal phase in most clients is from 2 to 5 years.
(d) During the residual phase, negative symptoms can remain and the client commonly has a flat affect and impaired role functioning.
(e) During the prodromal phase, treatment includes family interventions to improve coping, cognitive therapy, and therapeutic support for identified problems.
Rationale:
The prodromal phase may be brief, only a few weeks or months, but the average length according to most studies is 2 to 5 years. The residual phase usually follows the active schizophrenic stage, during which time negative symptoms can remain. Clients usually experience impaired role functioning and a flat affect. Treatment during the prodromal phase is focused on family coping, cognitive therapy, and support for identified problems.
Clients in the premorbid phase tend to do poorly in school, have few or no friends, and avoid social activities. During the active phase, schizophrenia is not caused by drug abuse, medication interactions, or medical conditions.
Question 15.
The nurse is caring for an elderly female client who presents as being alert and oriented.
In the late afternoon, the client becomes extremely agitated and confused. Which of the following responses by the nurse is most appropriate?
(a) call a family member to come and stay with the client
(b) call the health care provider and ask for an order for Xanax
(c) reorient the client and offer distraction and reassurance in a soft voice
(d) tell the client that if she does not cooperate, she will be placed in restraints
Answer:
(c) reorient the client and offer distraction and reassurance in a soft voice
Rationale:
This client is suffering from sundowning syndrome, in which some clients become increasingly confused and irritated late in the afternoon. It is common in clients with dementia or Alzheimer's, but can occur outside those diagnoses. Reorienting and reassuring the client in a soft voice can help calm agitation. Distraction can help the client focus on something else and may calm the client. While asking a family member to stay may help, many clients do not have family that can stay around the clock due to work and other obligations.
Xanax can help decrease anxiety and allow the client to rest, but less invasive measures are always preferable. Dosing a client simply to make her sleep or rest for the nurse's convenience is a form of restraint (chemical). Threatening the client with restraints is more likely to escalate the situation, and the client may become physically violent.
Some clients with sundowning syndrome may suffer hallucinations or mood swings. Being in the hospital interrupts normal patterns of sleep and rest, and certain medications or medical conditions may make the client more likely to have an episode.
Question 16.
The nurse is caring for a teenage client diagnosed with anorexia nervosa. The client's mother asks the nurse about eating disorders in general. Which information would the nurse provide?
Select all that apply.
(a) Anorexia nervosa is more common than bulimia.
(b) Clients with bulimia may have erosion of the tooth enamel.
(c) Binging and purging can occur in both anorexia nervosa and bulimia.
(d) Extreme exercising and calorie restriction is common with anorexia nervosa.
(e) Clients with eating disorders may develop the disorders because of issues of power and control.
(f) Clients with anorexia have a distorted body image and think that they are fat even if they are very thin.
Answer:
(b) Clients with bulimia may have erosion of the tooth enamel.
(c) Binging and purging can occur in both anorexia nervosa and bulimia.
(d) Extreme exercising and calorie restriction is common with anorexia nervosa.
(e) Clients with eating disorders may develop the disorders because of issues of power and control.
Rationale:
Clients with bulimia can develop erosion of the tooth enamel from repeated vomiting due to the acid in the vomitus. Binging and purging can occur with both anorexia nervosa and bulimia. Anorexics tend to eat very low-calorie diets, restrict certain food groups, or exercise compulsively in order to lose weight. Many clients with eating disorders feel that the only thing they can control is their weight, and often feel pressured by family to achieve perfection. Clients with anorexia are obsessed with fear of obesity.
Question 17.
Hie nurse is seeing a client in the clinic with her 18-month-old daughter. The client asks the nurse when her child should start going to the dentist. Which response by the nurse is correct?
(a) "She should go by her first birthday."
(b) "She should start receiving oral exams at 2 years of age."
(c) "She should go to a dentist once a year beginning at age 3."
(d) "You don't need to worry about it until she starts kindergarten."
Answer:
(a) "She should go by her first birthday."
Rationale:
Current recommendations regarding oral health suggest beginning dental care for a child by the first birthday. Age 2 is past the recommended age range for first dental visits. Age 3 is also past the recommended age range for first dental visits. Waiting until the child starts kindergarten increases the risk of cavities and the buildup of tartar.
Question 18.
The nurse is caring for a client in the psychiatric unit who has issues with coping and defense mechanisms. The nurse understands that which is true regarding coping and defense mechanisms? Select all that apply.
(a) Coping mechanisms are destructive ways to avoid dealing with reality.
(b) Physical symptoms, general irritability, and self-destructive behaviors are some of the signs of inadequate coping.
(c) Criticizing ineffective defense mechanisms will guide the client toward better coping techniques.
(d) Ineffective coping mechanisms allow anxiety to increase, triggering the client to utilize defense mechanisms in order to protect himself from the anxiety.
(e) The inability to cope can be caused by a lack of an adequate support system, a serious medical diagnosis, situational crises, or a lack of psychological resources.
Answer:
(b) Physical symptoms, general irritability, and self-destructive behaviors are some of the signs of inadequate coping.
(d) Ineffective coping mechanisms allow anxiety to increase, triggering the client to utilize defense mechanisms in order to protect himself from the anxiety.
(e) The inability to cope can be caused by a lack of an adequate support system, a serious medical diagnosis, situational crises, or a lack of psychological resources.
Rationale:
Inadequate coping can manifest with physical symptoms, general irritability, and destructive behavior toward self or others. The client may or may not be able to verbalize the inability to cope. When coping mechanisms fail, anxiety can trigger defense mechanisms to protect the self. Inadequate coping can be caused by a number of factors. Lack of a family or social support system, serious medical diagnoses, crisis situations, and lack of psychological resources contribute to the inability to cope.
Coping mechanisms are not always destructive; many coping mechanisms are positive and allow the individual to effectively manage stress. The nurse should not criticize the client's defense mechanisms that are not effective. Instead, the nurse should suggest ways to develop better defense mechanisms and work with the client to enhance and reinforce those skills. The nurse must be aware of which coping and defense mechanisms the client uses in order to develop a suitable plan of care.
Question 19.
The nurse is caring for a client whose family brought him to the hospital because they were worried about his personal safety. Which of the following statements by the client during the admission assessment indicates the need for immediate intervention by the nurse?
(a) "Things are so bad that sometimes I don't know what to do make them better."
(b) "My family normally supports my goals and helps me when I have a difficult time."
(c) "I wish that everyone would leave me alone and quit trying to give me advice all the time."
(d) "I keep a gun in my nightstand and sometimes I fall asleep holding it, trying to decide if I should pull the trigger or not."
Answer:
(d) "I keep a gun in my nightstand and sometimes I fall asleep holding it, trying to decide if I should pull the trigger or not."
Rationale:
This client clearly has the means (a gun) with easy access (within reach of the bed) to commit suicide. The client is at high risk and should be placed on suicide precautions, including 24-hour observation. All possible hazards should be removed from the environment. Plastic utensils should be used with all meals, and the client should not wear or have a belt or shoestrings in the room.
The health care provider should be notified of the findings. Options (a) and (c) express despair and frustration, but not necessarily suicidal intentions. Option (b) indicates that the client has an adequate family support system and is a positive response without suicidal ideations.
Question 20.
The nurse is caring for a client with schizophrenia who is having active hallucinations. The nurse implements which actions to manage the client during the episode? Select all that apply.
(a) administers medications as ordered
(b) uses gentle touch to reassure the client
(c) tells the client that others see or hear what he does
(d) distracts the client by placing him in the dayroom with others
(e) asks the client if he hears voices telling him to harm himself or others
(f) goes along with what the client says to decrease the risk of increasing the client's anxiety
Answer:
(c) tells the client that others see or hear what he does
Rationale:
During an active hallucination, safety is the first priority. The nurse should administer medications as ordered to manage the hallucinations. Asking the client if he hears voices telling him to harm himself or others is important for both client and nurse safety, as well as others in the area. A client having hallucinations should not be touched.
The nurse should not tell the client that others are experiencing the same thing as this only reinforces the hallucination and false beliefs. The client should be moved to an area with decreased stimuli, not taken to the dayroom with others. The nurse should gently attempt to reorient the client to reality. Going along with what the client says he is experiencing reinforces false beliefs and interferes with reorienting the client to reality.
Question 21.
A client suffering from visual hallucinations calls the nurse to her room and says, "You need to hurry up and kill all these bugs on the wall before they get on me." Which response by the nurse is most appropriate?
(a) "Why don't you lay down and take a nap?"
(b) "I don't see them. Can you show me where they are?"
(c) "I will call maintenance and have them come take care of this right away."
(d) "I know the bugs seem real to you, but I don't see anything on the walls."
Answer:
(d) "I know the bugs seem real to you, but I don't see anything on the walls."
Rationale:
The nurse is presenting reality while acknowledging that the client's perception is real to her. This response shows respect for the client's feelings. Suggesting that the client take a nap diverts attention away from the topic and does not present a solution to the problem. This response may lead to agitation in the client. Options (b) and (c) acknowledge that the client's misperception is real, and do not help reorient the client to reality. The nurse should never "play along" when clients are experiencing visual or auditory hallucinations.
Question 22.
The nurse is in the dayroom of the psychiatric unit observing the clients. Which client behavior would the nurse interpret as exhibiting inadequate coping?
(a) A client is sitting in a chair coloring in a coloring book.
(b) A client is arguing about a TV program with another client.
(c) A client is playing a new card game with a group for the first time.
(d) A client is in the corner alone, rocking and pulling out her eyelashes.
Answer:
(d) A client is in the corner alone, rocking and pulling out her eyelashes.
Rationale:
Pulling out hair or eyelashes, picking compulsively at the skin, and rocking back and forth are signs of unaddressed anxiety or stress. The nurse should intervene and ask the client what is bothering her. Open-ended questions allow the client to verbalize her feelings without a simple yes-or-no answer. Options (a) and (c) show clients engaging in healthy outlets.
Two clients arguing over the TV does not necessarily indicate inadequate coping. In a group environment, clients will have different tastes in entertainment. As long as a compromise is reached without physical or verbal violence, this situation does not reflect anxious behavior like self-harm does. While pulling out one's hair or other "picking" behavior does not constitute suicidal behavior, it is still considered self-harm.
Question 23.
The nurse is working in a mental health facility that uses group therapy with the clients. The nurse understands which to be correct regarding group therapy?
(a) The termination stage begins with the initial group meeting.
(b) Members' feelings about their accomplishments are explored in the working stage.
(c) During the working stage, members may be unclear about the purpose of the group.
(d) Group roles and responsibilities are established in the working stage of group therapy.
Answer:
(a) The termination stage begins with the initial group meeting.
Rationale:
The termination stage begins with the initial group meeting. Members' feeling about their accomplishments are explored during the termination stage. Members may be unclear about the group's purpose during the initial stage. Group roles and responsibilities are established in the initial stage of group therapy.
Question 24.
The nurse is admitting a client with schizophrenia. The client is extremely socially withdrawn, is unable to perform activities of daily living, has an inappropriate affect, and has grimacing mannerisms. The nurse understands that this client is experiencing which type of schizophrenia?
(a) residual schizophrenia
(b) paranoid schizophrenia
(c) catatonic schizophrenia
(d) disorganized schizophrenia
(e) undifferentiated schizophrenia
Answer:
(d) disorganized schizophrenia
Rationale:
Characteristics of disorganized schizophrenia include extreme social withdrawal, inability to perform activities of daily living, inappropriate affect, and grimacing mannerisms. Residual schizophrenia is characterized by being diagnosed with schizophrenia in the past, extreme social isolation, and impaired role functioning. Several years may pass between episodes. Paranoid schizophrenia includes hostility, delusions, violence, persecutory themes, and suspiciousness.
Clients with catatonic schizophrenia experience waxy flexibility, psychomotor disturbances, stupor, and excessive purposeless motor activity. They may also be automatically obedient to directions and exhibit stereotypical or repetitive behaviors. Undifferentiated schizophrenia does not meet the definition of paranoid, disorganized, or catatonic schizophrenia. It is characterized by disorganized speech, delusions and hallucinations, flat affect, social withdrawal, and catatonic or disorganized behavior.
Question 25.
A client is having a panic attack. Which nursing intervention has priority for this client?
(a) have the client recount a positive childhood memory
(b) provide the client with a glass of water
(c) tell the client to take deep breaths
(d) ask the client to identify the source of his anxiety
Answer:
(c) tell the client to take deep breaths
Rationale:
The nurse can change the client's physiologic response by directing him to take deep breaths. This directive will shift the client's focus to the present. During a panic attack the client will be unable to move his focus to a long-term memory. Providing the client with a glass of water could prove harmful as he may be unable to physically perform the acting of drinking. The client most likely will not be able to identify the source of his anxiety.
Question 26.
The nurse is precepting a new nurse in the psychiatric unit. The nurse is discussing interventions for schizophrenia. Which statement by the student nurse indicates an understanding of ' management of schizophrenia? Select all that apply.
(a) "I should be warm and friendly to put the client at ease."
(b) "I can reassure the client that he is in a safe environment."
(c) "Puzzles or word games are good activities to engage in."
(d) "I can help the client use art or writing to express his feelings."
(e) "I won't tell the client when I'm leaving him so he won't get upset."
Answer:
(b) "I can reassure the client that he is in a safe environment."
(c) "Puzzles or word games are good activities to engage in."
(d) "I can help the client use art or writing to express his feelings."
Rationale:
Interventions for schizophrenia include reassuring the client that the environment is safe and engaging in simple, concrete activities such as puzzles or word games. Art, writing, and music can help the client safely express his feelings. A neutral approach is less threatening than an overly warm and friendly approach. The nurse should inform the client when she is leaving to orient the client to reality and reassure him.
Question 27.
The mental health nurse is caring for a client with Cluster B personality disorder. The nurse I would expect the client to exhibit which behaviors? Select all that apply.
(a) suspicious of others, magical thinking, eccentric behavior, paranoia, relationship deficits
(b) preoccupation with rules and details, hoarding, ritualistic behavior, extremely devoted I to work
(c) easily bored, poor and shallow interpersonal relationships, enjoys being the center of attention
(d) impulsivity, unpredictable behavior, extreme mood shifts, easily angered, playing people against each other
(e) suspicious and untrusting of others, argumentative, controlling of others, thoughts of grandiosity
Answer:
(c) easily bored, poor and shallow interpersonal relationships, enjoys being the center of attention
(d) impulsivity, unpredictable behavior, extreme mood shifts, easily angered, playing people against each other
Rationale:
Clients who are easily bored, have poor and shallow interpersonal relationships, and enjoy being the center of attention have histrionic personality disorder, which is one of the four types of Cluster B personality disorders. Clients who are impulsive, exhibit unpredictable behavior, experience extreme mood shifts, are easily angered, and play people against each other exhibit borderline personality disorder, which is a Cluster B personality disorder.
Other Cluster B personality disorders include narcissistic and antisocial personality disorders. Preoccupation with rules and details, hoarding, ritualistic behavior, and extreme devotion to work are characteristics of obsessive compulsive personality disorder, which is one of the Cluster C personality disorders. Other Cluster C personality disorders include dependent and avoidant personality disorders.
Clients who are suspicious of others and engage in magical thinking, eccentric behavior, paranoia, and relationship deficits exhibit schizoid personality disorder, which is a Cluster A personality disorder. Clients who are suspicious and untrusting of others, are argumentative, are controlling of others, and have thoughts of grandiosity have paranoid personality , disorder, which is a Cluster A disorder. The other Cluster A disorder is schizotypal personality disorder.
Question 28.
The nurse suspects a client is experiencing alcohol withdrawal syndrome. Which action is most appropriate?
(a) record suspicions in the medical record
(b) question the family about his drinking
(c) notify the physician
(d) ask the client about his drinking
Answer:
(d) ask the client about his drinking
Rationale:
In applying the nursing process, the most appropriate action is to assess the situation by interviewing the client. Recording suspicions in the medical record without further assessment would be premature. Obtaining information from the client, rather than his family, is most appropriate. Notifying the physician should occur after assessment.
Question 29.
A client is suspected of having posttraumatic stress disorder. Which problem is the most important for the nurse to assess?
(a) panic attacks
(b) anorexia
(c) suicide
(d) short-term memory loss
Answer:
(c) suicide
Rationale:
Suicide and other violent behaviors are high risk for clients who experience posttraumatic stress disorder and pose the most significant of the problems listed. While panic attacks and short-term memory loss may occur with posttraumatic stress disorder, suicide is the most important problem. Anorexia is not seen in clients with posttraumatic stress disorder, though anorexia nervosa may present as a co-occurring disorder.
Question 30.
The nurse is caring for a client whose cultural background is different from her own. Which nursing action is appropriate?
(a) understand that fear of death is universal
(b) know that dietary habits are equally important to all cultures
(c) respect the client's cultural beliefs
(d) explain the nurse's cultural beliefs to the client
Answer:
(c) respect the client's cultural beliefs
Rationale:
Response (c) is consistent with being culturally sensitive to the client's needs. Death is 1 understood differently based on one's culture. Dietary habits vary in importance between cultures. Explaining the nurse's cultural beliefs to the client is unnecessary as the client's needs are what is I important.
Question 31.
The nurse discovers a hospice client has expired. The family members are assembled in the facility's waiting room. Which of the following statements by the nurse would be the most appropriate?
(a) "My condolences on the passing of your family member. You may visit him if you wish."
(b) "I will give you some time to spend with your loved one. Let me know if you need anything."
(c) "You should view your loved one as a way of saying farewell."
(d) "It would be best if you not view your loved one just yet."
Answer:
(a) "My condolences on the passing of your family member. You may visit him if you wish."
Rationale:
In response (a), the nurse expresses sympathy, acknowledges the family's loss, and leaves the decision to view their loved one with the family. The second and third responses assume the family wants to view their loved one. In the last response, the nurse makes the decision about the family viewing the body.
Question 32.
A 17-year-old female with a self-admitted opioid addiction is seen by the nurse in a mental health clinic. Which intervention would the nurse not consider in establishing a therapeutic relationship?
(a) discuss the impact of substance use
(b) require the client to attend all therapy sessions
(c) explore alternative approaches to managing stress
(d) assess the presence of other psychiatric disorders
Answer:
(b) require the client to attend all therapy sessions
Rationale:
Attendance at all therapy sessions should be an expectation established within the confines of the therapeutic relationship. Requirement of attendance places the client in a position where failure to attend all sessions, rather than being a point for learning, becomes a mechanism for punishment. Using this approach will not assist the client in achieving the desired outcome of abstinence from drugs.
Establishing a therapeutic relationship with a client who is addicted to drugs requires open, supportive communication consistent with options (a) and (c). Determining the presence of a concurrent psychiatric disorder is necessary to provide a comprehensive therapeutic approach.
Question 33.
A nurse is caring for a client with agoraphobia. Which signs and symptoms would the nurse anticipate? Select all that apply.
(a) panic attacks
(b) impaired short-term memory
(c) auditory hallucinations
(d) inability to leave home
Answer:
(a) panic attacks
(d) inability to leave home
Rationale:
Agoraphobia is the fear of being in open spaces. Panic attacks and the fear of leaving home are symptoms associated with the disorder. Neither short-term memory nor auditory hallucinations are associated with agoraphobia.
Question 34.
The nurse is caring for a client who has been diagnosed with terminal pancreatic cancer. The family is asking what to expect when the end draws near. Which response by the nurse is most appropriate?
(a) "I will have the doctor talk to you about that."
(b) "The hospice nurse is the best person to answer your questions. I can put in a consult for you."
(c) "Don't worry about that right now. You don't know if there is another treatment option that will work."
(d) "I can tell you what to look for when the time comes. In the meantime, what are your wishes and goals for care?"
Answer:
(d) "I can tell you what to look for when the time comes. In the meantime, what are your wishes and goals for care?"
Rationale:
The nurse can explain to the client and the family the signs that indicate death is near. The nurse should allow the client and family to discuss goals for care, such as pain relief. The client may wish to have heroic measures taken, or he may prefer to be kept comfortable without heroic interventions. The nurse should respect the client's wishes, even if they differ from what she thinks is right.
Telling the family that she will have the doctor come talk to them passes off responsibility, and may make the family more anxious if they have to wait to talk to the doctor. The nurse knows the information to share, and should take the opportunity to establish rapport with the family and reassure them that their wishes will be respected. Telling the family not to worry and that other treatments may be effective belittles their feelings and offers false hope.
Question 35.
The nurse is educating a group of student nurses about perceived loss. The nurse knows that the students understand when one of them verbalizes which example?
(a) a single mother loses her job
(b) a student fails his college chemistry class
(c) a husband is grieving the loss of his wife of 40 years
(d) a first-time mother is disappointed that she had a boy instead of a girl
Answer:
(d) a first-time mother is disappointed that she had a boy instead of a girl
Rationale:
A perceived loss is one that is not obvious to those around the person experiencing the loss. Disappointment over the birth of a child of the "wrong" sex would not be obvious to those around her unless she verbalized it. Losing a job, failing a class, and losing a spouse are events that would obviously be perceived as a loss.
Question 36.
The nurse is teaching a group of women at a community center about risk factors for spousal abuse. Which would the nurse identify as risk factors? Select all that apply.
(a) alcohol or drug use
(b) low income or poverty
(c) being over the age of 40
(d) a higher level of education
(e) having a large circle of friends
(f) pregnancy, especially if it is unplanned
Answer:
(a) alcohol or drug use
(b) low income or poverty
(f) pregnancy, especially if it is unplanned
Rationale:
Risk factors for spousal abuse include alcohol or drug use by either partner and low income or living at the poverty level. An unplanned pregnancy may trigger violence in the spouse, especially if the couple has any of the other risk factors. The more risk factors a couple has, the greater the potential for abuse. The risk is greater for those under the age of 30. A higher level of education lessens the risk of abuse, but does not guarantee it will not occur.
Having a large circle of friends is less risky than being socially isolated from friends or family. Many abusers control their spouses by keeping them from family and friends and limiting their freedom. The nurse must understand that simply living at a low income level or having less education does not automatically mean that the relationship is abusive, because abuse can occur in any environment for any number of reasons.
Question 37.
During the nurse's shift in the emergency department, a nurse assesses a client who is suspected of being under the influence of opioids. Which symptom is indicative of opioid use?
(a) hypotension
(b) diaphoresis
(c) shallow respirations
(d) outbursts of anger
Answer:
(d) outbursts of angered
Rationale:
Physical signs and symptoms of opioid addiction can be physical, psychological, and behavioral. Physical signs and symptoms include runny nose, bloodshot eyes, sleep disturbance, slurred speech, impaired coordination, and change in appetite. Psychological signs and symptoms include irritability, paranoia, unusual breathing, anxiety/irritability, mood swings, outbursts of anger, and unusual fear. Behavioral signs and symptoms include lack of personal hygiene, neglect of responsibilities, secretive spending, and foregoing social connections. Hypotension, diaphoresis, and shallow respirations are not characteristic of opioid abuse.
Question 38.
A client is prescribed diazepam (Valium) as needed to control the symptom of alcohol withdrawal. Which symptom may indicate the need for the nurse to administer phenytoin 1 (Dilantin) to supplement the effect of Valium?
(a) disturbed heart rate
(b) hallucinations
(c) drowsiness
(d) seizures
Answer:
(d) seizures
Rationale:
Phenytoin (Dilantin) may be given to a person experiencing seizures while undergoing withdrawal from alcohol. For a disturbed heart rate, lidocaine (Xylocaine) may be given. For hallucinations, Haldol (haloperidol) may be given. For drowsiness, the nurse would lessen the dosage of diazepam.
Question 39.
The nurse is assessing a client who is a polysubstance abuser, with fentanyl being one of the drugs most frequently used. Which physiological symptoms are suggestive of fentanyl intoxication? Select all that apply.
(a) diarrhea
(b) nausea
(c) urge to urinate
(d) anxiety
Answer:
(b) nausea
Rationale:
A common physiological symptom of fentanyl intoxication is nausea. Constipation, rather than diarrhea, is a common symptom of fentanyl intoxication. Urinary function is not affected by fentanyl. Drowsiness, rather than anxiety, is a common symptom of fentanyl intoxication.
Question 40.
A client is telling the nurse about his perception of his thought patterns. Which of the following statements by the client would validate the diagnosis of bipolar disorder?
(a) "Sometimes I'm ready to take on the world, but other times I'm too tired to get out of bed."
(b) "I need to check and then recheck all the kitchen appliances several times to make sure they are off before I feel comfortable leaving my home."
(c) "My neighbors hold sacrificial rites in their backyard."
(d) "I keep on patrol all night so the enemy won't invade my home and hurt me or my family."
Answer:
(a) "Sometimes I'm ready to take on the world, but other times I'm too tired to get out of bed."
Rationale:
Bipolar disorder results in dramatic changes in a person's mood and energy. In the mania phase, people feel energized, even euphoric. When in the depressed stage, people have low energy and resist engaging with the world. The need to repeat a given behavior is consistent with obsessive- compulsive disorder. Hallucination /seeing/smelling/hearing things that do not exist is associated with schizophrenia. Intense feelings about the need to protect oneself is associated with post- traumatic stress disorder.
Question 41.
The nurse is caring for a client with end-stage kidney disease and multiple organ failure. Which action by the nurse indicates an understanding of end-of-life care? Select all that apply.
(a) The nurse explains signs and symptoms that indicate death is near.
(b) The nurse explains to the client and family what to expect during the final phase of the illness.
(c) Cultural beliefs are acknowledged, but priority is placed on life-lengthening treatment options.
(d) The nurse avoids talking to the client about impending death to avoid upsetting him and the family.
(e) The nurse asks the client and family what their goals and wishes are regarding care, pain management, and emergency resuscitation.
Answer:
(a) The nurse explains signs and symptoms that indicate death is near.
(b) The nurse explains to the client and family what to expect during the final phase of the illness.
(e) The nurse asks the client and family what their goals and wishes are regarding care, pain management, and emergency resuscitation.
Rationale:
In providing end-of-life care, the nurse explains to the client and family the signs and symptoms that death is approaching. Explaining what to expect during the final phase of the illness may help alleviate fear and anxiety as the family observes their loved one transitioning through the stages of death.
Addressing client and family wishes regarding care, pain management, and emergency resuscitation respects their wishes and ensures that their choices are carried out as much as possible. Cultural beliefs are acknowledged, and life-lengthening treatment options may give way to maintaining comfort. The nurse should not avoid the difficult topic about end-of-life care, but ensure that open discussion is a central part of the client's care.
Question 42.
The nurse is talking in the lounge with other nurses about grief and loss. The nurse understands which to be true regarding grief and loss? Select all that apply.
(a) The process of grief is detrimental to physical and emotional health.
(b) Age, gender, and culture are a few factors that influence the grieving process.
(c) The nurse must explore his own feelings about death before he may effectively help others.
(d) The nurse should discourage expression of grief and loss because it may upset other clients nearby.
(e) The nurse can help the family develop ways to relieve loneliness and depression following the death of a loved one.
Answer:
(b) Age, gender, and culture are a few factors that influence the grieving process.
(c) The nurse must explore his own feelings about death before he may effectively help others.
(e) The nurse can help the family develop ways to relieve loneliness and depression following the death of a loved one.
Rationale:
Age, gender, and culture are a few factors that influence the grieving process. The nurse must explore his own feelings about death before he may effectively help others. Nurses can help families find ways to cope with the loneliness and depression that follow the death of a loved one. The process of grief is normal following a loss, and expression of grief is essential for physical and emotional well-being. The expression of grief should never be discouraged; family members should have a quiet room in which they may express their feelings in private.
Question 43.
The nurse has assessed the assigned group of clients. Which client would the nurse identify as being at the greatest risk for alterations in sensory perception?
(a) a client in a halo vest following an automobile accident
(b) a child with severe autism who is having a tonsillectomy
(c) a teenager who broke her leg during cheerleader practice
(d) a schoolteacher who was hospitalized for shortness of breath
Answer:
(b) a child with severe autism who is having a tonsillectomy
Rationale:
A child with severe autism who is having a tonsillectomy is at greatest risk for alterations in sensory perception. Clients with severe autism experience altered thought processes. Adding an unfamiliar environment (the hospital) with pain from a surgical procedure compounds the risk of altered 1 sensory perception. The client in the halo vest may have pain and restricted mobility, but he does not have as great a risk for altered perception as the child with severe autism.
A teenager who broke her leg during cheerleader practice is more likely to have a large social group and be less isolated. A schoolteacher is more likely to work in a stimulating environment and have many social contacts. Risk factors for altered perception include emotional disorders, a non-stimulating environment, acute illness, limited mobility, pain, decreased cognitive ability, and impaired hearing or vision.
Question 44.
The nurse is working in a mental health facility that uses group therapy with the clients. The nurse understands which to be correct regarding group therapy?
(a) The termination stage begins with the initial group meeting.
(b) Members' feelings about their accomplishments are explored in the working stage.
(c) During the working stage, members may be unclear about the purpose of the group.
(d) Group roles and responsibilities are established in the working stage of group therapy.
Answer:
(a) The termination stage begins with the initial group meeting.
Rationale:
The termination stage begins with the initial group meeting. Members' feeling about their accomplishments are explored during the termination stage. Members may be unclear about the group's 1 purpose during the initial stage. Group roles and responsibilities are established in the initial stage of group therapy
Question 45.
The nurse is caring for a client who is having surgery the next morning. The client says, "I'm really scared about surgery. I've never been put to sleep before and I'm afraid I might not wake up." Which response by the nurse is the most therapeutic?
(a) "Why are you worried about such a minor procedure?"
(b) "We can call the doctor and cancel the surgery if you would prefer."
(c) "It's normal to be afraid of something new like surgery. Tell me how you feel."
(d) "Don't worry, you have a really good doctor and he will see to it that nothing goes wrong."
Answer:
(c) "It's normal to be afraid of something new like surgery. Tell me how you feel."
Rationale:
Telling the client that it is normal to be afraid and asking how he feels is the most therapeutic option. Asking the client why he is worried about such a minor procedure puts the client on the defensive and trivializes the procedure. What the nurse may see as a minor procedure may feel like major surgery to the client. Offering to call the doctor and cancel the surgery may not be an option, depending on the procedure the client is having.
It also does not allow for exploration of the client's feelings and may increase the client's fear if the nurse is quick to offer canceling the procedure. Telling the client not to worry and that the doctor will be sure that nothing goes wrong offers false reassurance and dismisses the client's feelings.
Question 46.
The nurse is caring for a client who has just been diagnosed with ovarian cancer. The nurse is using silence as an effective therapeutic response. How is silence an effective therapeutic response?
(a) It is not therapeutic; it implies that the nurse is not listening.
(b) It encourages the client to keep her feelings to herself.
(c) It allows the client time to think and reflect and lead the conversation.
(d) It allows the nurse to think about other tasks she needs to tackle to provide efficient care to all of her clients.
Answer:
(c) It allows the client time to think and reflect and lead the conversation.
Rationale:
Silence allows the client time to think and reflect and lead the conversation in the desired direction. Silence does not imply that the nurse is not listening, nor does it encourage the client to keep her feelings to herself. Silence is part of listening; the nurse should be focused on the client and not thinking ahead to what else she needs to do.
Question 47.
The nurse is caring for a client with schizophrenia who is having active hallucinations. The nurse implements which actions to manage the client during the episode? Select all that apply.
(a) administers medications as ordered
(b) uses gentle touch to reassure the client
(c) tells the client that others see or hear what he does
(d) distracts the client by placing him in the dayroom with others
(e) asks the client if he hears voices telling him to harm himself or others
(f) goes along with what the client says to decrease the risk of increasing the client's anxiety
Answer:
(a) administers medications as ordered
(e) asks the client if he hears voices telling him to harm himself or others
Rationale:
During an active hallucination, safety is the first priority. The nurse should administer medications as ordered to manage the hallucinations. Asking the client if he hears voices telling him to harm himself or others is important for both client and nurse safety, as well as others in the area. A client having hallucinations should not be touched.
The nurse should not tell the client that others are experiencing the same thing as this only reinforces the hallucination and false beliefs. The client should be moved to an area with decreased stimuli, not taken to the dayroom with others. The nurse should gently attempt to reorient the client to reality. Going along with what the client says he is experiencing reinforces false beliefs and interferes with reorienting the client to reality.
Question 48.
The nurse is admitting a client with schizophrenia. The client is extremely socially withdrawn, is unable to perform activities of daily living, has an inappropriate affect, and has grimacing mannerisms. The nurse understands that this client is experiencing which type of schizophrenia?
(a) residual schizophrenia
(b) paranoid schizophrenia
(c) catatonic schizophrenia
(d) disorganized schizophrenia
(e) undifferentiated schizophrenia
Answer:
(d) disorganized schizophrenia
Rationale:
Characteristics of disorganized schizophrenia include extreme social withdrawal, inability to perform activities of daily living, inappropriate affect, and grimacing mannerisms. Residual schizophrenia is characterized by being diagnosed with schizophrenia in the past, extreme social isolation, and impaired role functioning. Several years may pass between episodes. Paranoid schizophrenia includes hostility, delusions, violence, persecutory themes, and suspiciousness.
Clients with catatonic schizophrenia experience waxy flexibility, psychomotor disturbances, stupor, and excessive purposeless motor activity. They may also be automatically obedient to directions and exhibit stereotypical or repetitive behaviors. Undifferentiated schizophrenia does not meet the definition of paranoid, disorganized, or catatonic schizophrenia. It is characterized by disorganized speech, delusions and hallucinations, flat affect, social withdrawal, and catatonic or disorganized behavior.
Question 49.
The nurse is precepting a new nurse in the psychiatric unit. The nurse is discussing interventions
for schizophrenia. Which statement by the student nurse indicates an understanding of
management of schizophrenia? Select all that apply.
(a) "I should be warm and friendly to put the client at ease."
(b) "I can reassure the client that he is in a safe environment."
(c) "Puzzles or word games are good activities to engage in."
(d) "I can help the client use art or writing to express his feelings."
(e) "I won't tell the client when I'm leaving him so he won't get upset."
Answer:
(b) "I can reassure the client that he is in a safe environment."
(c) "Puzzles or word games are good activities to engage in."
(d) "I can help the client use art or writing to express his feelings."
Rationale:
Interventions for schizophrenia include reassuring the client that the environment is safe and engaging in simple, concrete activities such as puzzles or word games. Art, writing, and music can help the client safely express his feelings. A neutral approach is less threatening than an overly warm and friendly approach. The nurse should inform the client when she is leaving to orient the client to reality and reassure him.
Question 50.
The mental health nurse is caring for a client with Cluster B personality disorder. The nurse would expect the client to exhibit which behaviors? Select all that apply.
(a) suspicious of others, magical thinking, eccentric behavior, paranoia, relationship deficits
(b) preoccupation with rules and details, hoarding, ritualistic behavior, extremely devoted to work
(c) easily bored, poor and shallow interpersonal relationships, enjoys being the center of attention
(d) impulsivity, unpredictable behavior, extreme mood shifts, easily angered, playing people against each other
(e) suspicious and untrusting of others, argumentative, controlling of others, thoughts of grandiosity
Answer:
(c) easily bored, poor and shallow interpersonal relationships, enjoys being the center of attention
(d) impulsivity, unpredictable behavior, extreme mood shifts, easily angered, playing people against each other
Rationale:
Clients who are easily bored, have poor and shallow interpersonal relationships, and enjoy being the center of attention have histrionic personality disorder, which is one of the four types of Cluster B personality disorders. Clients who are impulsive, exhibit unpredictable behavior, experience extreme mood shifts, are easily angered, and play people against each other exhibit borderline personality disorder, which is a Cluster B personality disorder.
Other Cluster B personality disorders include narcissistic and antisocial personality disorders. Preoccupation with rules and details, hoarding, ritualistic behavior, and extreme devotion to work are characteristics of obsessive-compulsive personality disorder, which is one of the Cluster C personality disorders. Other Cluster C personality disorders include dependent and avoidant personality disorders.
Clients who are suspicious of others and engage in magical thinking, eccentric behavior, paranoia, and relationship deficits exhibit schizoid personality disorder, which is a Cluster A personality disorder. Clients who are suspicious and untrusting of others, are argumentative, are controlling of others, and have thoughts of grandiosity have paranoid personality disorder, which is a Cluster A disorder. The other Cluster A disorder is schizotypal personality disorder.