Exam 2

Question 1

The nurse notes the client has a documented HX of sexual masochism. From which of the following would the client derive sexual pleasure

Answer 1

By being humiliated by their sexual partners

Question 2

Which statement made by a client indicates a concern over their ability to perform sexually

Answer 2

Im scared I will climax before she orgasms

Question 3

Which of the following statements best describes gender dysphoria

Answer 3

When biological sex differs from gender identity

Question 4

Which is the tx priority for a client who weighs less than 75% of their ideal body weight

Answer 4

Provide immediate medical stabilization

Question 5

During an interview which client statement should alert the nurse to a potential dx of schizotypal personality disorder

Answer 5

I’m getting a message from the beyond that we have been involved with each other in previous life

Question 6

Which is considered the first line of tx for a client with paranoid personality disorder

Answer 6

psychotherapy

Question 7

During a therapy session a male client shares the he enjoys secretly seeing other people in intimate situations. The nurse recognizes this behavior as

Answer 7

Voyeuristic disorder

Question 8

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?

Answer 8

Chlorpromazine (Thorazine)

Question 9

Which testing usually involves one or two nights of sleep in a lab with electrodes and monitor places on the head chest and legs

Answer 9

polysomnography

Question 10

Which nursing dx is established when providing care to a client dx with an avoidant personality disorder

Answer 10

Impaired social interaction

Question 11

The nurse cares for a client with akathisia. What symptoms would the nurse expect to see in this client

Answer 11

Repetitive movement
Inability to remain still
Pacing

Question 12

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

Answer 12

Withhold the drug, force oral fluids and notify the HCP to examine the client

Question 13

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

Answer 13

Pt feels like they have less control

Question 14

Which medication will the nurse be ready to administer to a client dx with binge eating disorder

Answer 14

Lisdexamfetamine (Vyvanse)

Question 15

The nurse is completing a client sexual history. The client states they are asexual. Which statement can be applied to the clients comment

Answer 15

Interested in cuddling but not sex

Question 16

Physical assessment of a pt dx with bulimia nervosa often reveals

Answer 16

Prominent parotid glands

Question 17

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

Answer 17

Transvestism

Question 18

For which prescription will the nurse plan to provide education for a client dx with erectile dysfunction

Answer 18

Tadalafil (Cialis)

Question 19

Hypoalbuminemia in a pt with an eating disorder would produce which assessment finding

Answer 19

peripheral edema

Question 20

When a hyperactive pt experiencing acute mania is hospitalized what initial nursing intervention is priority

Answer 20

Setting limits on the client’s behavior as necessary

Question 21

Which medications are commonly given for a client experiencing severe agitation

Answer 21

Risperidone (Risperdal)

Question 22

Which of the following behavioral characteristics would the nurse identify as being due to OCD

Answer 22

Limited emotional expression
Preoccupation with orderliness
Strong desire for control
Perfectionist

Question 23

Which of the following should the nurse include in the plan of care for a client dx with anorexia nervosa

Answer 23

The client is able to attain a safe weight

Question 24

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

Answer 24

Histrionic personality disorder

Question 25

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

Answer 25

Sedation and muscle stiffness

Question 26

Which information will the nurse include when teaching a client about sleep hygiene

Answer 26

Maintain a regular sleep wake cycle
Avoid heavy meals before bed
Reserve the bedroom for sleep and intimacy
Avoid daytime napping

Question 27

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

Answer 27

Tactile Hallucinations

Question 28

Cortisol is released in prolonged to a pts prolonged stress. Which initial effect would the nurse expect in results from the increased cortisol level

Answer 28

Focused and alert mental staus

Question 29

Which is a priority nursing intervention when caring for a client displaying manipulative behavior

Answer 29

Discuss concerns about behavior

Question 30

Which extrapyramidal side effects will the nurse monitor for a client receiving a first generation antipsychotic

Answer 30

akathisia
tardive dyskinesia
Pseudoparkinsonism
Acute dystonia

Question 31

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

Answer 31

Antisocial personality disorder

Question 32

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

Answer 32

Admin benadryl 50mg IM

Question 33

The nurse is admitting a client with pedophilic disorder. Which of the following assessments is a priority for this client

Answer 33

Assess for potential self harm and suicide

Question 34

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

Answer 34

States he has less sexual fantasies regarding children

Question 35

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

Answer 35

Risk for violence directed towards self

Question 36

A pt has taken haldol orally for 2yrs the pt grimaces and constantly smacks both lips. Which problem would the nurse expect

Answer 36

Tardive dyskinesia

Question 37

Which lab value is a priority for the nurse to assess in a pt who is restless disoriented and experiencing delirium

Answer 37

Sodium level

Question 38

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

Answer 38

Social skills groups

Question 39

Which of the following clients most struggles with feelings of inadequacy and is extremely sensitive to rejection

Answer 39

A client dx with avoidant personality disorder

Question 40

Which is considered standard tx for a client with paraphilic disorder

Answer 40

Cognitive behavioral therapy

Question 41

Which behavior would the nurse expect to observe in a client dx with borderline personality disorder

Answer 41

Sensitive to personal rejection

Question 42

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

Answer 42

Female orgasmic disorder

Question 43

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

Answer 43

Provide care in a kind matter of fact manner

Question 44

Showing genuineness from a schizophrenic pt

Answer 44

Using congruent communication

Question 45

Anorexic pt gained 10 pounds SATA

Answer 45

Assess heart and lung sounds
Assess for peripheral edema