Exam 2 Flashcards
The nurse notes the client has a documented HX of sexual masochism. From which of the following would the client derive sexual pleasure
By being humiliated by their sexual partners
Which statement made by a client indicates a concern over their ability to perform sexually
Im scared I will climax before she orgasms
Which of the following statements best describes gender dysphoria
When biological sex differs from gender identity
Which is the tx priority for a client who weighs less than 75% of their ideal body weight
Provide immediate medical stabilization
During an interview which client statement should alert the nurse to a potential dx of schizotypal personality disorder
I’m getting a message from the beyond that we have been involved with each other in previous life
Which is considered the first line of tx for a client with paranoid personality disorder
psychotherapy
During a therapy session a male client shares the he enjoys secretly seeing other people in intimate situations. The nurse recognizes this behavior as
Voyeuristic disorder
A pt dx with schizophrenia has taken a first gen antipsychotic med for a year. hallucinations are less intrusive but the patient continues to have apathy and social isolation. The nurse expects a change to which med?
Chlorpromazine (Thorazine)
Which testing usually involves one or two nights of sleep in a lab with electrodes and monitor places on the head chest and legs
polysomnography
Which nursing dx is established when providing care to a client dx with an avoidant personality disorder
Impaired social interaction
The nurse cares for a client with akathisia. What symptoms would the nurse expect to see in this client
Repetitive movement
Inability to remain still
Pacing
A client dx with major depressive disorder is taking a tricyclic antidepressant. The client says “I don’t think I can keep taking these pills they make me so dizzy especially when I stand up” The nurse should implement what intervention
Withhold the drug, force oral fluids and notify the HCP to examine the client
A nurse works with a pt dx with schizophrenia regarding the importance of medication management. The pt repeatedly says “I don’t like taking pills” The HCP orders the use of long acting antipsychotic injections. The downside of this medication administration is
Pt feels like they have less control
Which medication will the nurse be ready to administer to a client dx with binge eating disorder
Lisdexamfetamine (Vyvanse)
The nurse is completing a client sexual history. The client states they are asexual. Which statement can be applied to the clients comment
Interested in cuddling but not sex
Physical assessment of a pt dx with bulimia nervosa often reveals
Prominent parotid glands
The nurse is admitting a client who dresses in the clothes of the opposite gender but states they are satisfied with their gender. The nurse recognizes this as being which of the following
Transvestism
For which prescription will the nurse plan to provide education for a client dx with erectile dysfunction
Tadalafil (Cialis)
Hypoalbuminemia in a pt with an eating disorder would produce which assessment finding
peripheral edema
When a hyperactive pt experiencing acute mania is hospitalized what initial nursing intervention is priority
Setting limits on the client’s behavior as necessary
Which medications are commonly given for a client experiencing severe agitation
Risperidone (Risperdal)
Which of the following behavioral characteristics would the nurse identify as being due to OCD
Limited emotional expression
Preoccupation with orderliness
Strong desire for control
Perfectionist
Which of the following should the nurse include in the plan of care for a client dx with anorexia nervosa
The client is able to attain a safe weight
The nurse observes a client group therapy expressing themselves in an overly dramatic and theatrical manner. The clients emotions change rapidly from one extreme to the next. This behavior is a characteristic of which personality disorder
Histrionic personality disorder
When a patient dx with schizophrenia was discharged 6 months ago, haloperidol was prescribed. The pt now says “I stopped taking those pills they make me feel like a robot. What likely side effect did the pt experience
Sedation and muscle stiffness
Which information will the nurse include when teaching a client about sleep hygiene
Maintain a regular sleep wake cycle
Avoid heavy meals before bed
Reserve the bedroom for sleep and intimacy
Avoid daytime napping
A 15yo client dx with schizophrenia spectrum disorder states he is feeling bugs crawling on him. The nurse recognizes that the pt is experiencing which of the following
Tactile Hallucinations
Cortisol is released in prolonged to a pts prolonged stress. Which initial effect would the nurse expect in results from the increased cortisol level
Focused and alert mental staus
Which is a priority nursing intervention when caring for a client displaying manipulative behavior
Discuss concerns about behavior
Which extrapyramidal side effects will the nurse monitor for a client receiving a first generation antipsychotic
akathisia
tardive dyskinesia
Pseudoparkinsonism
Acute dystonia
During a group therapy a client sharing about the loss of their child was interrupted by another client. the client that interrupted the session monopolized the therapy session without any regard to others. When confronted the client was calloused and unbothered. Which disorder is this behavior associated with
Antisocial personality disorder
An acutely violent pt dx with schizophrenia receives several doses of haldol. Two hours later the nurse notices the pts head rotated to one side in a stiffly fixed position, the lower jaw is thrust forward and the pt is drooling. Which intervention by the nurse is indicated
Admin benadryl 50mg IM
The nurse is admitting a client with pedophilic disorder. Which of the following assessments is a priority for this client
Assess for potential self harm and suicide
the nurse is discussing discharge planning with a client dx with pedophilic disorder. The client has not acted on these urges but feels shame. Which finding best indicates that this adult is making progress in tx
States he has less sexual fantasies regarding children
A client dx with schizophrenia spectrum disorder lies in bed all day expressing feelings of rejection and loneliness. Which is a priority nursing dx to include in the client’s plan of care
Risk for violence directed towards self
A pt has taken haldol orally for 2yrs the pt grimaces and constantly smacks both lips. Which problem would the nurse expect
Tardive dyskinesia
Which lab value is a priority for the nurse to assess in a pt who is restless disoriented and experiencing delirium
Sodium level
A desired outcome for a 12yo dx with oppositional defiant disorder is to improve relationships with other children. Which tx modality should the nurse suggest for the plan of care
Social skills groups
Which of the following clients most struggles with feelings of inadequacy and is extremely sensitive to rejection
A client dx with avoidant personality disorder
Which is considered standard tx for a client with paraphilic disorder
Cognitive behavioral therapy
Which behavior would the nurse expect to observe in a client dx with borderline personality disorder
Sensitive to personal rejection
A female client states having a lack of interest in sex although she engages in sex with her husband. The client states “I just do it for him” the client tells the nurse she has not had an orgasm in 2 years. Which of the following conditions is this related to
Female orgasmic disorder
A pt dx with borderline personality disorder has self inflicted wrist lacerations. The healthcare provider prescribes daily dressing changes. The nurse performing this care should
Provide care in a kind matter of fact manner
Showing genuineness from a schizophrenic pt
Using congruent communication
Anorexic pt gained 10 pounds SATA
Assess heart and lung sounds
Assess for peripheral edema
