Exam 5 Study Guide: Q Flashcards
an individual with a history of antisocial personality disorder was arrest for driving under the influence of alcohol and cause a serious car accident.
which comment on this behavior would be expected?
o “its not my fault”
o “im too ashamed to talk about it”
o “i just dont remember doing it”
o im really sorry about all the people”
“its not my fault”
A client diagnosed with borderline personality disorder is admitted to a psychiatric unit. Which behavior pattern would the nurse expect to observe?
o Social isolation
o Suspiciousness of others
o Bizarre speech patterns
o Generates conflict among the staff
generates conflict among the staff
In assessing a client diagnosed with borderline personality disorder, which characteristic would the nurse expect to observe?
Predictability
Controlled anger
Little tolerance for being alone
Stable and satisfactory relationships
little tolerance for being alone
When assessing a client diagnosed with narcissistic personality disorder, the nurse expects to identify which characteristic behavior?
Odd beliefs and magical thinking
Grandiose sense of self-importance
Pattern of intense and chaotic relationships
Submissive and clinging behaviors
grandiose sense of self-importance
will you introduce food right away to severely malnourished clients?
No
because of refeeding syndrome
Which assessment finding would the nurse expect to find in clients diagnosed with bulimia?
They are below normal weight.
They binge when they experience hunger.
They will be highly motivated to seek help.
They are within their normal weight range.
they are within their normal weight range
A client is 5′8″ tall and weighs 105 pounds. The client has been taking laxatives daily and self-induces vomiting after eating. Which is the priority nursing diagnosis for this client?
Ineffective denial
Disturbed body image
Low self-esteem
Imbalanced nutrition, less than body requirements
imbalanced nutrition, less than body requirements
An adolescent diagnosed with ADHD is having difficulty maintaining concentration in the in-client milieu. Which nursing intervention would help improve the client’s task performance?
o Mandate that the client remain in their room until all homework is complete.
o Remove privileges if homework is not completed within a 2-hour period.
o Encourage dividing tasks into smaller, attainable steps and reward successful completion.
o Seek a physician’s order to discontinue the stimulant methylphenidate (Ritalin)
encourage dividing tasks into smaller, attainable steps and reward successful completion
Conduct disorder may be a precursor to the diagnosis of which personality disorder?
o Narcissistic personality disorder
o Antisocial personality disorder
o Histrionic personality disorder
o Passive-aggressive personality disorder
antisocial personality disorder
A nurse is educating staff on personality disorders. Which statement by the staff indicates understanding?
o Antisocial personality disorder can start as conduct disorder
o It is very easy to categorize the clients based on their disorder
o All clients with personality disorders were the victims of abuse
o All clients with personality disorders take advantage of others
antisocial personality disorder can start as conduct disorder
The nurse working in an acute care psychiatric facility is working with clients that have personality disorders. The nurse knows that cluster A personality disorders (odd, eccentric) tend to exhibit what behaviors?
o Dramatic
o Dependency
o Indifference to social situations
o Splitting between healthcare providers
indifference to social situations
Consider this comment to three different nurses by a patient diagnosed with antisocial personality disorder, “Another nurse said you don’t do your job right.” Collectively, these interactions can be assessed as:
o Insightful
o Guilt-producing
o Manipulative
o Detached
manipulative
A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client?
o A seclusion room until the client’s activity level becomes more subdued
o A semi-private room with a roommate who has a similar diagnosis
o A private room away from the nursing station
o A private room in a quiet location that can easily be monitored
a private room in a quiet location that can easily be monitored
The client states “I just can’t fall asleep”. The nurse responds, “You are having difficulty falling asleep?” Why is the nurse using the restating technique?
o The nurse wants the client to know they understand
o The nurse is allowing the client to elaborate or clear up misunderstanding
o The nurse is keeping the conversation going
o The nurse wants to focus on one idea
the nurse is allowing the client to elaborate or clear up misunderstanding
A client is experiencing command hallucinations and appears to be frightened. Which of the following actions are appropriate nursing interventions?
o Keep the client physically safe
o Ignore the client’s feelings in response to altered perceptions
o Assure the client that they are not experiencing something real
o Inform the client that their hallucinations are just bad dreams
keep the client physically safe
A nurse is performing an admission assessment for an adolescent client with a diagnosis of schizophrenia. Which of the following findings should the nurse identify as a positive symptom?
o Somatic Delusions
o Anhedonia
o Waxy Posture (immobile posturing)
o Anergia
somatic delusions
(positive symptoms, negative schizophrenia)
A 28-year-old client with body dysmorphic disorder (BDD) tells the nurse that they plan to have a surgical procedure that will affect their appearance. The nurse understands that this plan is an effort to
o Suppress intrusive thoughts
o Deal with multiple physical complaints
o Treat associated depression
o Cure the imagined defect
cure the imagined defect
An unlicensed assistive personnel (UAP) is working with clients that have diagnosis of obsessive compulsive disorder. The UAP understands the reason not to stop the carrying out of compulsions is:
o If this is not done therapeutically the client will have an escalation in anxiety
o The RNs don’t trust the UAPs
o Stopping compulsions is not part of the treatment plan
o The obsessions are the client’s problems not the compulsions
if this is not done therapeutically the client will have an escalation in anxiety
A client is pacing the hall near the nurse’s station, swearing loudly. An appropriate initial intervention for the nurse would be to address the client by name and say:
o “Please quiet down.”
o “You seem upset. Would you like to tell me about it?”
o “Hey, why are you so upset?”
o “You need to go to your room to get control of yourself.”
“you seem upset. would you like to tell me about it?”
A nurse is reviewing the medical histories of four clients. Which of the following clients will be most likely to develop extrapyramidal symptoms from medication therapy?
o A client with depression taking selective serotonin reuptake inhibitors
o A client with schizoaffective disorder taking an atypical antipsychotic
o A client with schizophrenia taking a first-generation antipsychotic
o A client with anxiety disorder taking an anxiolytic medication
a client with schizophrenia taking a first-generation antipsychotic
first generation = typical antipsychotics = more potent = have more side effects
A client with anorexia nervosa is at increased risk for which of the following?
o Osteopenia
o Increased testosterone
o Hyperglycemia
o Hypertension
Osteopenia
A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens (Severe alcohol withdrawal symptoms such as shaking, confusion, and hallucinations). Which of the following actions should the nurse take first?
o Administer clonidine
o Lower the bed and raise the side rails
o Obtain a medical history
o Complete CIWA scale
lower the bed and raise the side rails
A patient has anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and has lost 25% of body weight. The serum potassium is 2.7 mg/dL. This patient is at risk of what complication?
o Cardiac Arrhythmia
o Increased Bone Density
o Increased Heart Rate
o Possible decrease in cortisol
cardiac arrhythmia
A nurse is caring for a client who has a new prescription for risperidone. Which of the following rating scales should the nurse complete prior to administering the first dose of risperidone?
o Beck’s Depression Inventory
o Abnormal Involuntary Movement Scale
o Hamilton Depression Scale
o The Body Attitude Test
abnormal involuntary movement scale (AIMS)
A nurse is caring for a client who has schizophrenia. The client states, “The weather channel lady loves me and she is going to quit her show to be with me!” The nurse should document that the client is experiencing which of the following types of delusions?
o Erotomanic
o Persecution
o Control
o Somatic
Erotomanic
A nurse is planning care for a client who has a diagnosed anxiety disorder. Which of the following intervention should the nurse implement to promote occupational functioning?
o Help the client to identify prior accomplishments
o Assist the client in identifying triggers
o Identify the client’s spirituality
o Encourage the client to identify positive self attributes
assist the client in identifying triggers
A patient tells the nurse, “I don’t like you, you look like my grandmother.” This is an example of what concept?
o Staff splitting
o Transference
o Manipulation
o Delusion
transference
Which of the following defense mechanisms describes the underlying cause of somatic symptom disorder?
o Denial of depression
o Suppression of grief
o Repression of anxiety
o Displacement of anger
repression of anxiety
Personality traits most likely to be documented regarding a patient demonstrating characteristics of an obsessive-compulsive personality disorder are:
o Affable, generous
o Perfectionist, inflexible
o Dramatic speech, impulsive
o Suspicious, holds grudges
perfectionist, inflexible
A nurse is assessing a client who has a history of alcohol use disorder. Which of the following questions should the nurse include to determine how the use of alcohol affects the client’s psychosocial behaviors?
o “Has alcohol use affected your performance at work?”
o “Do you take any over the counter medications?”
o “Do you receive treatment for any mental health disorders?”
o “What type of alcohol do you drink?”
“has alcohol use affected your performance at work?”
A nurse is teaching a male client who has a depressive disorder about escitalopram. Which of the following information should the nurse include in the teaching?
o This medication may cause muscle rigidity temporarily
o You will notice an improvement in mood within 2-3 days
o A fever is a common side effect of this medication
o This medication may cause an inability to orgasm
this medication may cause an inability to orgasm
A nurse is admitting an older adult client who has a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment?
o Mental status examination (MSE)
o Scale for Assessment of Negative Symptoms (SANS)
o Abnormal Involuntary Movements Scale (AIMS)
o Brief Patient Health Questionnaire (Brief PHQ)
Mental Status Examination (MSE)
A nurse is assessing a child and suspects child abuse. Which assessment finding support the nurse’s assumption?
o A circular burn on the child’s arm
o A bump on the child’s forehead
o Redness on the child’s legs
o The child does not want to listen to instructions
a circular burn on the child’s arm
A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?
o Provide a structured schedule for the client
o Identify stressors that precipitate rituals
o Instruct the client on meditation
o Discuss alternative coping strategies with the client
Identify stressors that precipitate rituals
A client taking phenelzine has a blood pressure of 210/119, a HR of 104 bpm, and diaphoresis. The nurse discovers the client has recently taken over the counter medication for allergies and a cold. The nurse recognizes this client is experiencing:
o Hypertension
o Neuroleptic Malignant Syndrome
o Hypertensive crisis
o Serotonin Syndrome
hypertensive crisis
