Final Questions

Question 1

1. Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which statement regarding a client’s home environment should a nurse associate with the development of anorexia nervosa?
2. The home environment maintains loose personal boundaries.
3. The home environment places an overemphasis on food.
4. The home environment is overprotective and demands perfection.
5. The home environment condones corporal punishment.

Answer 1

3

Question 2

2. A client’s altered body image is evidenced by claims of “feeling fat,” even though the client is emaciated. Which is the appropriate outcome criterion for this client’s problem?
3. The client will consume adequate calories to sustain normal weight.
4. The client will cease strenuous exercise programs.
5. The client will perceive personal ideal body weight and shape as normal.
6. The client will not express a preoccupation with food.

Answer 2

3

Question 3

3. A nurse is counseling a client diagnosed with bulimia nervosa about the symptom of tooth enamel deterioration. Which explanation for this complication of bulimia nervosa, should the nurse provide?
4. The emesis produced during purging is acidic and corrodes the tooth enamel.
5. Purging causes the depletion of dietary calcium.
6. Food is rapidly ingested without proper mastication.
7. Poor dental and oral hygiene leads to dental caries.

Answer 3

1

Question 4

4. A nurse is teaching a client diagnosed with an eating disorder about behavior-modification programs. Why is this intervention the treatment of choice?
5. It helps the client correct a distorted body image.
6. It addresses the underlying client anger.
7. It manages the client’s uncontrollable behaviors.
8. It allows clients to maintain control.

Answer 4

4

Question 5

5. A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects insight related to this disorder?
6. “Skaters need to be thin to improve their daily performance.”
7. “All the skaters on the team are following an approved 1200-calorie diet.”
8. “The exercise of skating reduces my appetite but improves my energy level.”
9. “I am angry at my mother. I can only get her approval when I win competitions.”

Answer 5

4

Question 6

6. The family of a client diagnosed with anorexia nervosa becomes defensive when the treatment team calls for a family meeting. Which is the appropriate nursing response?
7. “Tell me why this family meeting is causing you to be defensive. All clients are required to participate in two family sessions.”
8. “Eating disorders have been correlated to certain familial patterns; without addressing these, your child’s condition will not improve.”
9. “Family dynamics are not linked to eating disorders. The meeting is to provide your child with family support.”
10. “Clients diagnosed with anorexia nervosa are part of the family system, and any alteration in family processes needs to be addressed.”

Answer 6

2

Question 7

7. A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change?
8. The client gained two pounds in one week.
9. The client focused conversations on nutritious food.
10. The client demonstrated healthy coping mechanisms that decreased anxiety.
11. The client verbalized an understanding of the etiology of the disorder.

Answer 7

3

Question 8

9. A nurse is attempting to differentiate between the symptoms of anorexia nervosa and the symptoms of bulimia. Which statement delineates the difference between these two disorders?
10. Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not.
11. Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not.
12. Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not.
13. Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not.

Answer 8

1

Question 9

10. A client diagnosed with a history of anorexia nervosa comes to an outpatient clinic after being medically cleared. The client states, “My parents watch me like a hawk and never let me out of their sight.” Which nursing diagnosis would take priority at this time?
11. Altered nutrition less than body requirements
12. Altered social interaction
13. Impaired verbal communication
14. Altered family processes

Answer 9

ANS: 4
Rationale: The nurse should determine that once the client has been medically cleared, the diagnosis of altered family process should take priority. Clients diagnosed with anorexia nervosa have a need to control and feel in charge of their own treatment choices. Behavioral-modification therapy allows the client to maintain control of eating.

Question 10

12. A nursing instructor is teaching about the DSM-5 criteria for the diagnosis of binge-eating disorder. Which of the following student statements indicates that further instruction is needed? (Select all that apply.)
13. “In this disorder, binge eating occurs exclusively during the course of bulimia nervosa.”
14. “In this disorder, binge eating occurs, on average, at least once a week for three months.”
15. “In this disorder, binge eating occurs, on average, at least two days a week for six months.”
16. “In this disorder, distress regarding binge eating is present.”
17. “In this disorder, distress regarding binge eating is absent.”

Answer 10

1, 3, 5

Question 11

4. The diagnosis of __________________ ___________________includes the symptoms of gross distortion of body image, preoccupation with food, and refusal to eat.

Answer 11

Anorexia nervosa

Question 12

15. The episodic, uncontrolled, compulsive, rapid ingestion of large quantities of food over a short period of time is termed ________________________.

Answer 12

Binge eating

Question 13

16. To rid the body of excessive calories, a client diagnosed with bulimia nervosa may engage in ______________________ behaviors, which include self-induced vomiting, or the misuse of laxatives, diuretics, or enemas.

Answer 13

Purging

Question 14

1. A nursing instructor is teaching about specific phobias. Which student statement indicates to the instructor that learning has occurred?
2. “These clients recognize their fear as excessive and frequently seek treatment.”
3. “These clients have a panic level of fear that is overwhelming and unreasonable.”
4. “These clients experience symptoms that mirror a cerebrovascular accident (CVA).”
5. “These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis.”

Answer 14

ANS: 2
Rationale: The nursing instructor should evaluate that learning has occurred when the student knows that clients with phobias have a panic level of fear that is overwhelming and unreasonable. Phobia is fear cued by a specific object or situation in which exposure to the stimuli produces an immediate anxiety response. Even though the disorder is relatively common among the general population, people seldom seek treatment unless the phobia interferes with ability to function.

Question 15

2. Which nursing statement to a client about social anxiety disorder versus schizoid personality disorder (SPD) is most accurate?
3. “Clients diagnosed with social anxiety disorder can manage anxiety without medications, whereas clients diagnosed with SPD can only manage anxiety with medications.”
4. “Clients diagnosed with SPD are distressed by the symptoms experienced in social settings, whereas clients diagnosed with social anxiety disorder are not.”
5. “Clients diagnosed with social anxiety disorder avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life.”
6. “Clients diagnosed with SPD avoid interactions only in social settings, whereas clients diagnosed with social anxiety disorder tend to avoid interactions in all areas of life.”

Answer 15

ANS: 3
Rationale: Clients diagnosed with social anxiety disorder avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. Social anxiety disorder is an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others.

Question 16

3. What symptoms should a nurse recognize that differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)?
4. GAD is acute in nature, and panic disorder is chronic.
5. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders.
6. Hyperventilation is a common symptom in GAD and rare in panic disorder.
7. Depersonalization is commonly seen in panic disorder and absent in GAD.

Answer 16

ANS: 4
Rationale: The nurse should recognize that a client diagnosed with panic disorder experiences depersonalization, whereas a client diagnosed with GAD would not. Depersonalization refers to being detached from oneself when experiencing extreme anxiety.

Question 17

4. Which treatment should a nurse identify as most appropriate for clients diagnosed with generalized anxiety disorder (GAD)?
5. Long-term treatment with diazepam (Valium)
6. Acute symptom control with citalopram (Celexa)
7. Long-term treatment with buspirone (BuSpar)
8. Acute symptom control with ziprasidone (Geodon)

Answer 17

ANS: 3
Rationale: The nurse should identify that an appropriate treatment for clients diagnosed with GAD is long-term treatment with buspirone. Buspirone is an anxiolytic medication that is effective in 60% to 80% of clients diagnosed with GAD. Buspirone takes 10 to 14 days for alleviation of symptoms but does not have the dependency concerns of other anxiolytics.

Question 18

5. Which symptoms should a nurse recognize that differentiate a client diagnosed with obsessive-compulsive disorder (OCD) from a client diagnosed with obsessive-compulsive personality disorder?
6. Clients diagnosed with OCD experience both obsessions and compulsions, and clients diagnosed with obsessive-compulsive personality disorder do not.
7. Clients diagnosed with obsessive-compulsive personality disorder experience both obsessions and compulsions, and clients diagnosed with OCD do not.
8. Clients diagnosed with obsessive-compulsive personality disorder experience only obsessions, and clients diagnosed with OCD experience only compulsions.
9. Clients diagnosed with OCD experience only obsessions, and clients diagnosed with obsessive-compulsive personality disorder experience only compulsions.

Answer 18

1

Question 19

6. A cab driver, stuck in traffic, becomes lightheaded, tremulous, diaphoretic, tachycardic and dyspneic. A workup in an emergency department reveals no pathology. Which medical diagnosis should a nurse suspect, and what nursing diagnosis should be the nurse’s first priority?
7. Generalized anxiety disorder and a nursing diagnosis of fear
8. Altered sensory perception and a nursing diagnosis of panic disorder
9. Pain disorder and a nursing diagnosis of altered role performance
10. Panic disorder and a nursing diagnosis of anxiety

Answer 19

ANS: 4
Rationale: The nurse should suspect that the client has exhibited signs and symptoms of a panic disorder. The priority nursing diagnosis should be anxiety. Panic disorder is characterized by recurrent, sudden-onset panic attacks in which the person feels intense fear, apprehension, or terror.

Question 20

7. A client diagnosed with panic disorder states, “When an attack happens, I feel like I am going to die.” Which is the most appropriate nursing response?
8. “I know it’s frightening, but try to remind yourself that this will only last a short time.”
9. “Death from a panic attack happens so infrequently that there is no need to worry.”
10. “Most people who experience panic attacks have feelings of impending doom.”
11. “Tell me why you think you are going to die every time you have a panic attack.”

Answer 20

ANS: 1
Rationale: The most appropriate nursing response to the client’s concerns is to empathize with the client and provide encouragement that panic attacks only last a short period. Panic attacks usually last minutes but can, rarely, last hours. When the nurse states that “Most people who experience panic attacks…” the nurse depersonalizes and belittles the client’s feeling.

Question 21

8. A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred?
9. “Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder.”
10. “Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder.”
11. “Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks.”
12. “Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks.”

Answer 21

ANS: 1
Rationale: The student indicates learning has occurred when he or she states that clonazepam is a particularly effective treatment for panic disorder. Clonazepam is a type of benzodiazepine in which the major risk is physical dependence and tolerance, which may encourage abuse. It can be used on an as-needed basis to reduce anxiety and the related symptoms.

Question 22

9. A family member is seeking advice about an older parent who seems to worry unnecessarily about everything. The family member states, “Should I seek psychiatric help for my mother?” Which is an appropriate nursing response?
10. “My mother also worries unnecessarily. I think it is part of the aging process.”
11. “Anxiety is considered abnormal when it is out of proportion to the stimulus causing it and when it impairs functioning.”
12. “From what you have told me, you should get her to a psychiatrist as soon as possible.”
13. “Anxiety is a complex phenomenon and is effectively treated only with psychotropic medications.”

Answer 22

2

Question 23

10. A client is experiencing a severe panic attack. Which nursing intervention would meet this client’s physiological need?
11. Teach deep breathing relaxation exercises.
12. Place the client in a Trendelenburg position.
13. Have the client breathe into a paper bag.
14. Administer the ordered prn buspirone (BuSpar).

Answer 23

ANS: 3
Rationale: The nurse can meet this client’s physiological need by having the client breathe into a paper bag. Hyperventilation may occur during periods of extreme anxiety. Hyperventilation causes the amount of carbon dioxide (CO2) in the blood to decrease, possibly resulting in lightheadedness, rapid heart rate, shortness of breath, numbness or tingling in the hands or feet, and syncope. If hyperventilation occurs, assist the client to breathe into a small paper bag held over the mouth and nose. Six to twelve natural breaths should be taken, alternating with short periods of diaphragmatic breathing.

Question 24

11. A college student is unable to take a final exam owing to severe test anxiety. Instead of studying, the student relieves stress by attending a movie. Which priority nursing diagnosis should a campus nurse assign for this client?
    A. Non-adherence R/T test taking
    B. Ineffective role performance R/T helplessness
    C. Altered coping R/T anxiety
    D. Powerlessness R/T fear

Answer 24

C

Question 25

12. A client living in a beachfront community is seeking help with an extreme fear of bridges, which is interfering with daily functioning. A psychiatric nurse practitioner decides to try systematic desensitization. Which explanation of this treatment should the nurse provide?
13. “Using your imagination, we will attempt to achieve a state of relaxation.”
14. “Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a relaxation response for the anxiety response.”
15. “Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety.”
16. “In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate.”

Answer 25

3

Question 26

13. A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization?
14. The client will refrain from ritualistic behaviors during daylight hours.
15. The client will wake early enough to complete rituals prior to breakfast.
16. The client will participate in three unit activities by day three.
17. The client will substitute a productive activity for rituals by day one.

Answer 26

2

Question 27

14. A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions?
15. “I will need scheduled blood work in order to monitor for toxic levels of this drug.”
16. “I won’t stop taking this medication abruptly because there could be serious complications.”
17. “I will not drink alcohol while taking this medication.”
18. “I won’t take extra doses of this drug because I can become addicted.”

Answer 27

1

Question 28

15. A client diagnosed with an obsessive-compulsive disorder spends hours bathing and grooming. During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that the rituals generate. Which defense mechanism should the nurse identify?
16. Sublimation
17. Dissociation
18. Rationalization
19. Intellectualization

Answer 28

4

Question 29

16. A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this client’s problem?
17. Distract the client with other activities whenever ritual behaviors begin.
18. Report the behavior to the psychiatrist to obtain an order for medication dosage increase.
19. Lock the room to discourage ritualistic behavior.
20. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.

Answer 29

4

Question 30

17. A nursing student questions an instructor regarding the order for fluvoxamine (Luvox) 300 mg daily for a client diagnosed with obsessive-compulsive disorder (OCD). Which instructor response is most accurate?
18. High doses of tricyclic medications will be required for effective treatment of OCD.
19. Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for treating depression, may be required for OCD.
20. The dose of Luvox is low because of the side effect of daytime drowsiness.
21. The dose of this selective serotonin reuptake inhibitor (SSRI) is outside the therapeutic range and needs to be questioned.

ANS: 2
Rationale: The most accurate instructor response is that SSRI doses in excess of what is effective for treating depression may be required in the treatment of OCD. SSRIs have been approved by the Food and Drug Administration for the treatment of OCD. Common side effects include headache, sleep disturbances, and restlessness.

Answer 30

2

Question 31

18. A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a nurse to question this order?
A. History of alcohol use disorder
B. History of personality disorder
C. History of schizophrenia
D. History of hypertension

Answer 31

A

Question 32

20. A nursing instructor is teaching about the symptoms of agoraphobia. Which student statement indicates that learning has occurred?
21. Onset of symptoms most commonly occurs in early adolescence and persists until midlife.
22. Onset of symptoms most commonly occurs in the 20s and 30s and persists for many years.
23. Onset of symptoms most commonly occurs in the 40s and 50s and persists until death.
24. Onset of symptoms most commonly occurs after the age of 60 and persists for at least 6 years.

Answer 32

2

Question 33

21. A college student has been diagnosed with generalized anxiety disorder (GAD). Which of the following symptoms should a campus nurse expect this client to exhibit? (Select all that apply.)
22. Fatigue
23. Anorexia
24. Hyperventilation
25. Insomnia
26. Irritability

Answer 33

1, 4, 5

Question 34

22. A nurse is discussing treatment options with a client whose life has been negatively impacted by claustrophobia. Which of the following commonly used behavioral therapies for phobias should the nurse explain to the client? (Select all that apply.)
23. Benzodiazepine therapy
24. Systematic desensitization
25. Imploding (flooding)
26. Assertiveness training
27. Aversion therapy

Answer 34

2, 3

Question 35

23. A nurse has been caring for a client diagnosed with generalized anxiety disorder (GAD). Which of the following nursing interventions would address this client’s symptoms? (Select all that apply.)
24. Encourage the client to recognize the signs of escalating anxiety.
25. Encourage the client to avoid any situation that causes stress.
26. Encourage the client to employ newly learned relaxation techniques.
27. Encourage the client to cognitively reframe thoughts about situations that generate anxiety.
28. Encourage the client to avoid caffeinated products.

Answer 35

1, 3, 4, 5

Question 36

24. An attractive female client presents with high anxiety levels because of her belief that her facial features are large and grotesque. Body dysmorphic disorder (BDD) is suspected. Which of the following additional symptoms would support this diagnosis? (Select all that apply.)
25. Mirror checking
26. Excessive grooming
27. History of an eating disorder
28. History of delusional thinking
29. Skin picking

Answer 36

1, 2, 5

Question 37

1. A nursing instructor is teaching about trauma and stressor-related disorders. Which student statement indicates that further instruction is needed?
2. “The trauma that women experience is more likely to be sexual assault and child sexual abuse.”
3. “The trauma that men experience is more likely to be accidents, physical assaults, combat, or viewing death or injury.”
4. “After exposure to a traumatic event, only 10 percent of victims develop post-traumatic stress disorder (PTSD).”
5. “Research shows that PTSD is more common in men than in women.”

Answer 37

4

Question 38

2. Which factors differentiate the diagnosis of PTSD from the diagnosis of adjustment disorder (AD)?
3. PTSD results from exposure to an extreme traumatic event, whereas AD results from exposure to “normal” daily events.
4. AD results from exposure to an extreme traumatic event, whereas PTSD results from exposure to “normal” daily events.
5. Depressive symptoms occur in PTSD and not in AD.
6. Depressive symptoms occur in AD and not in PTSD.

Answer 38

1

Question 39

5. As the sole survivor of a roadside bombing, a veteran is experiencing extreme guilt. Which nursing diagnosis would address this client’s symptom?
6. Anxiety
7. Altered thought processes
8. Complicated grieving
9. Altered sensory perception

Answer 39

3

Question 40

6. A client has been assigned a nursing diagnosis of complicated grieving related to the death of multiple family members in a motor vehicle accident. Which intervention should the nurse initially employ?
7. Encourage the journaling of feelings.
8. Assess for the stage of grief in which the client is fixed.
9. Provide community resources to address the client’s concerns.
10. Encourage attending a grief therapy group.

Answer 40

2

Question 41

10. Eye movement desensitization and reprocessing (EMDR) has been empirically validated for which disorder?
11. Adjustment disorder
12. Generalized anxiety disorder
13. Panic disorder
14. Post-traumatic stress disorder

Answer 41

4

Question 42

12. By which biological mechanism does EMDR achieve its therapeutic effect?
13. EMDR achieves its therapeutic effect, but the exact biological mechanism is unknown.
14. EMDR achieves its therapeutic effect by causing a decrease in imagery vividness.
15. EMDR achieves its therapeutic effect by causing an increase in memory access.
16. EMDR achieves its therapeutic effect by decreasing trauma associated anxiety.

Answer 42

1

Question 43

15. A nurse has been caring for a client diagnosed with PTSD. Which realistic goal should be included in this client’s plan of care?
16. The client will have no flashbacks.
17. The client will be able to feel a full range of emotions by discharge.
18. The client will not require zolpidem (Ambien) to obtain adequate sleep by discharge.
19. The client will refrain from discussing the traumatic event.

Answer 43

3

Question 44

21. A nurse is admitting a client who has been diagnosed with PTSD. Which of the following symptoms might the nurse expect to assess? (Select all that apply.)
22. Feelings of guilt that precipitate social isolation
23. Aggressive behavior that affects job performance
24. Relationship problems
25. High levels of anxiety
26. Escalating symptoms lasting less than one month

Answer 44

1, 2, 3, 4,
The full-symptom picture must present for more than one month and cause significant interference with social, occupational, and other areas of functioning.

Question 45

22. A family asks the nurse why their son was diagnosed with PTSD and others in the accident were not. Which of the following information should the nurse offer? (Select all that apply.)
23. An individual’s religious affiliation can affect response to trauma.
24. Responses are affected by how an individual handled previous trauma.
25. Protectiveness of family and friends can help an individual deal with trauma.
26. Control over the possibility of recurrence can affect the response to trauma.
27. The time in which the trauma occurred can affect the individual’s response.

Answer 45

2, 3, 4, 5

Question 46

23. A nurse would recognize which of the following as the best predictors of PTSD in Vietnam veterans? (Select all that apply.)
24. The severity of the stressor
25. The degree of ego strength
26. The degree of psychosocial isolation in the recovery environment
27. The attitudes of society regarding the experience
28. The presence of preexisting psychopathology

Answer 46

1, 3

Question 47

24. A client diagnosed with PTSD states, “Why did my doctor prescribe an antidepressant rather than an antianxiety drug for me?” Which of the following are the most appropriate nursing responses? (Select all that apply.)
25. “I’m not sure, because antianxiety drugs have been approved by the FDA for PTSD.”
26. “Antidepressants are now considered first-line treatment choice for PTSD.”
27. “Many people have adverse reactions to antianxiety drugs.”
28. “Because of their addictive properties, antianxiety drugs are less desirable.”
29. “There have been no controlled studies on the effect of antianxiety drugs on PTSD.”

Answer 47

2, 4, 5

Question 48

1. What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal?
2. Risk for injury R/T central nervous system stimulation
3. Disturbed thought processes R/T tactile hallucinations
4. Ineffective coping R/T powerlessness over alcohol use
5. Ineffective denial R/T continued alcohol use despite negative consequences

Answer 48

1. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia

Question 49

2. A nurse evaluates a client’s patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance addiction?
3. Narcotic pain medication is contraindicated for all clients with active substance use disorders.
4. Clients who are addicted to alcohol or benzodiazepines may develop cross-tolerance to analgesics and require increased doses to achieve effective pain control.
5. There is no need to assess the client for substance addiction. There is an obvious PCA malfunction, because these clients have a higher pain tolerance.
6. The client is experiencing alcohol withdrawal symptoms and needs accurate assessment.

Answer 49

2. clients who are addicted to alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. Cross-tolerance is exhibited when one drug results in a lessened response to another drug.

Question 50

3. On the first day of a client’s alcohol detoxification, which nursing intervention should take priority?
4. Strongly encourage the client to attend 90 Alcoholics Anonymous (AA) meetings in 90 days.
5. Educate the client about the biopsychosocial consequences of alcohol abuse.
6. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol.
7. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

ANS: 3
Rationale: The priority nursing intervention for this client should be to administer ordered chlordiazepoxide in a dosage according to protocol. Chlordiazepoxide is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal to reduce life-threatening complications.

Answer 50

3. Chlordiazepoxide is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal to reduce life-threatening complications.

Question 51

4. Which client statement indicates a knowledge deficit related to a substance use disorder?
5. “Although it’s legal, alcohol is one of the most widely abused drugs in our society.”
6. “Tolerance to heroin develops quickly.”
7. “Flashbacks from LSD use may reoccur spontaneously.”
8. “Marijuana is like smoking cigarettes. Everyone does it. It’s essentially harmless.”

Answer 51

4

Question 52

5. A lonely, depressed divorcée has been self-medicating with small amounts of cocaine for the past year. Which term should a nurse use to best describe this individual’s situation?
6. Psychological addiction
7. Physical addiction
8. Substance induced disorder
9. Social induced disorder

Answer 52

1

Question 53

6. Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during the substance induced disorder of alcohol withdrawal?
7. Antagonist therapy
8. Deterrent therapy
9. Codependency therapy
10. Substitution therapy

Answer 53

4

Question 54

7. A client diagnosed with chronic alcohol addiction is being discharged from an inpatient treatment facility after detoxification. Which client outcome, related to AA, would be most appropriate for a nurse to discuss with the client during discharge teaching?
8. After discharge, the client will immediately attend 90 AA meetings in 90 days.
9. After discharge, the client will rely on an AA sponsor to help control alcohol cravings.
10. After discharge, the client will incorporate family in AA attendance.
11. After discharge, the client will seek appropriate deterrent medications through AA.

Answer 54

1

Question 55

8. A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 48 hours. When the nurse reports to the ED physician, which client symptom should be the nurse’s first priority?
9. Hearing and visual impairment
10. Blood pressure of 180/100 mm Hg
11. Mood rating of 2/10 on numeric scale
12. Dehydration

Answer 55

2

Question 56

9. Which client statement demonstrates positive progress toward recovery from a substance use disorder?
10. “I have completed detox and therefore am in control of my drug use.”
11. “I will faithfully attend Narcotic Anonymous (NA) when I can’t control my cravings.”
12. “As a church deacon, my focus will now be on spiritual renewal.”
13. “Taking those pills got out of control. It cost me my job, marriage, and children.”

Answer 56

4

Question 57

10. A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse’s rationale for this intervention?
11. To assess for emotional strength
12. To assess for Wernicke-Korsakoff syndrome
13. To assess for tachycardia
14. To assess for fine tremors

Answer 57

4 - The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, and coarse tremors.

Question 58

11. A client presents with symptoms of alcohol withdrawal and states, “I haven’t eaten in three days.” A nurse’s assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97°F (36°C) with dry mucous membranes and poor skin turgor. What should be the priority nursing diagnosis?
12. Knowledge deficit
13. Fluid volume excess
14. Imbalanced nutrition: less than body requirements
15. Ineffective individual coping

Answer 58

3

Question 59

12. A client’s wife has been making excuses for her alcoholic husband’s work absences. In family therapy, she states, “His problems at work are my fault.” Which is the appropriate nursing response?
13. “Why do you assume responsibility for his behaviors?”
14. “I think you should start to confront his behavior.”
15. “Your husband needs to deal with the consequences of his drinking.”
16. “Do you understand what the term enabler means?”

Answer 59

3

Question 60

13. Which medication orders should a nurse anticipate for a client who has a history of benzodiazepine withdrawal delirium?
14. Haloperidol (Haldol) and fluoxetine (Prozac)
15. Carbamazepine (Tegretol) and donepezil (Aricept)
16. Disulfiram (Antabuse) and lorazepan (Ativan)
17. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

Answer 60

4

Question 61

14. A nurse is interviewing a client in an outpatient addiction clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish?
15. The client will identify one person to turn to for support.
16. The client will give up all old drinking buddies.
17. The client will be able to verbalize the effects of alcohol on the body.
18. The client will correlate life problems with alcohol use.

Answer 61

4

Question 62

15. A nurse is reviewing the stat laboratory data of a client in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur?
16. 50 mg/dL
17. 100 mg/dL
18. 250 mg/dL
19. 300 mg/dL

Answer 62

2

Question 63

16. A client diagnosed with major depressive episode and substance use disorder has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions?
17. Sedative-hypnotics are potentially addictive, and their effectiveness will be compromised owing to tolerance.
18. Sedative-hypnotics are expensive and have numerous side effects.
19. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep.
20. Sedative-hypnotics are known not to be as effective in promoting sleep as antidepressant medications.

Answer 63

1

Question 64

20. Which of the following nursing statements exemplify the cognitive process that must be completed by a nurse prior to caring for clients diagnosed with a substance-related disorder? (Select all that apply.)
21. “I am easily manipulated and need to work on this prior to caring for these clients.”
22. “Because of my father’s alcoholism, I need to examine my attitude toward these clients.”
23. “I need to review the side effects of the medications used in the withdrawal process.”
24. “I’ll need to set boundaries to maintain a therapeutic relationship.”
25. “I need to take charge when dealing with clients diagnosed with substance disorders.”

Answer 64

1, 2, 4

Question 65

21. A nursing instructor is teaching nursing students about cirrhosis of the liver. Which of the following statements about the complications of hepatic encephalopathy should indicate to the nursing instructor that further student teaching is needed? (Select all that apply.)
22. “A diet rich in protein will promote hepatic healing.”
23. “This condition results from a rise in serum ammonia, leading to impaired mental functioning.”
24. “In this condition, an excessive amount of serous fluid accumulates in the abdominal cavity.”
25. “Neomycin and lactulose are used in the treatment of this condition.”
26. “This condition is caused by the inability of the liver to convert ammonia to urea.”

Answer 65

1

Question 66

25. A nursing counselor is about to meet with a client suffering from codependency. Which of the following data would further support the assessment of this dysfunctional behavior? (Select all that apply.)
26. The client has a long history of focusing thoughts and behaviors on other people.
27. The client, as a child, experienced overindulgent and overprotective parents.
28. The client is a people pleaser and does almost anything to gain approval.
29. The client exhibits helpless behaviors but actually feels very competent.
30. The client can achieve a sense of control only through fulfilling the needs of others.

Answer 66

1, 3, 5

Question 67

3. A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate?
4. Provide objective evidence that reasons for violence are unwarranted.
5. Initially restrain the client to maintain safety.
6. Use clear, calm statements and a confident physical stance.
7. Empathize with the client’s paranoid perceptions.

Answer 67

3

Question 68

4. A client diagnosed with borderline personality disorder brings up a conflict with the staff in a community meeting and develops a following of clients who unreasonably demand modification of unit rules. How can the nursing staff best handle this situation?
5. Allow the clients to apply the democratic process when developing unit rules.
6. Maintain consistency of care by open communication to avoid staff manipulation.
7. Allow the client spokesman to verbalize concerns during a unit staff meeting.
8. Maintain unit order by the application of autocratic leadership.

Answer 68

2

Question 69

5. Which nursing approach should be used to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder?
6. Being firm, consistent, and empathic, while addressing specific client behaviors
7. Promoting client self-expression by implementing laissez-faire leadership
8. Using authoritative leadership to help clients learn to conform to society norms
9. Overlooking inappropriate behaviors to avoid providing secondary gains

Answer 69

1

Question 70

6. Which adult client should a nurse identify as exhibiting the characteristics of a dependent personality disorder?
7. A physically healthy client who is dependent on meeting social needs by contact with 15 cat
8. A physically healthy client who has a history of depending on intense relationships to meet basic needs
9. A physically healthy client who lives with parents and depends on public transportation
10. A physically healthy client who is serious, inflexible, perfectionistic, lacks spontaneity, and depends on rules to provide security

Answer 70

3 Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behaviors.

Question 71

7. A client expresses low self-worth, has much difficulty making decisions, avoids positions of responsibility, and has a behavioral pattern of “suffering” in silence. Which statement best explains the etiology of this client’s personality disorder?
8. Childhood nurturance was provided from many sources, and independent behaviors were encouraged.
9. Childhood nurturance was provided exclusively from one source, and independent behaviors were discouraged.
10. Childhood nurturance was provided exclusively from one source, and independent behaviors were encouraged.
11. Childhood nurturance was provided from many sources, and independent behaviors were discouraged.

Answer 71

2

Question 72

8. Family members of a client ask the nurse to explain the difference between schizoid and avoidant personality disorders. Which is the appropriate nursing response?
9. Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone.
10. Clients diagnosed with schizoid personality disorder exhibit delusions and hallucinations, while clients diagnosed with avoidant personality disorder do not.
11. Clients diagnosed with avoidant personality disorder are eccentric, and clients diagnosed with schizoid personality disorder are dull and vacant.
12. Clients diagnosed with schizoid personality disorder have a history of psychosis, while clients diagnosed with avoidant personality disorder remain based in reality.

Answer 72

1

Question 73

9. Which nursing diagnosis should a nurse identify as appropriate when working with a client diagnosed with schizoid personality disorder?
10. Altered thought processes R/T increased stress
11. Risk for suicide R/T loneliness
12. Risk for violence: directed toward others R/T paranoid thinking
13. Social isolation R/T inability to relate to others

Answer 73

4 - Clients diagnosed with schizoid personality disorder appear cold, aloof, and indifferent to others. They prefer to work in isolation and are not sociable.

Question 74

10. Looking at a slightly bleeding paper cut, the client screams, “Somebody help me quick! I’m bleeding. Call 911!” A nurse should identify this behavior as characteristic of which personality disorder?
11. Schizoid personality disorder
12. Obsessive-compulsive personality disorder
13. Histrionic personality disorder
14. Paranoid personality disorder

Answer 74

3

Question 75

11. When planning care for a client diagnosed with borderline personality disorder, which self-harm behavior should a nurse expect the client to exhibit?
12. The use of highly lethal methods to commit suicide
13. The use of suicidal gestures to elicit a rescue response from others
14. The use of isolation and starvation as suicidal methods
15. The use of self-mutilation to decrease endorphins in the body

Answer 75

2

Question 76

12. A nurse tells a client that the nursing staff will start alternating weekend shifts. Which response should a nurse identify as characteristic of clients diagnosed with obsessive-compulsive personality disorder?
13. “You really don’t have to go by that schedule. I’d just stay home sick.”
14. “There has got to be a hidden agenda behind this schedule change.”
15. “Who do you think you are? I expect to interact with the same nurse every Saturday.”
16. “You can’t make these kinds of changes! Isn’t there a rule that governs this decision?”

Answer 76

4 - his disorder is characterized by inflexibility and lack of spontaneity. Individuals with this disorder are very serious, formal, over-disciplined, perfectionistic, and preoccupied with rules.

Question 77

13. Which reaction to a compliment from another client should a nurse identify as a typical response from a client diagnosed with avoidant personality disorder?
14. Interpreting the compliment as a secret code used to increase personal power
15. Feeling the compliment was well deserved
16. Being grateful for the compliment but fearing later rejection and humiliation
17. Wondering what deep meaning and purpose is attached to the compliment

Answer 77

3 - Individuals diagnosed with avoidant personality disorder are extremely sensitive to rejection and are often awkward and uncomfortable in social situations.

Question 78

14. Which factors differentiate a client diagnosed with social phobia from a client diagnosed with schizoid personality disorder?
15. Clients diagnosed with social phobia are treated with cognitive behavioral therapy, whereas clients diagnosed with schizoid personality disorder need medications.
16. Clients diagnosed with schizoid personality disorder experience anxiety only in social settings, whereas clients diagnosed with social phobia experience generalized anxiety.
17. Clients diagnosed with social phobia avoid attending birthday parties, whereas clients diagnosed with schizoid personality disorder would isolate self on a continual basis.
18. Clients diagnosed with schizoid personality disorder avoid attending birthday parties, whereas clients diagnosed with social phobia would isolate self on a continual basis.

Answer 78

3 A client diagnosed with schizoid personality disorder exhibits a profound deficit in the ability to form personal relationships. Clients diagnosed with schizoid personality disorder prefer being alone to being with others and avoid social situations, social contacts, and activities.

Question 79

15. Which client symptoms should lead a nurse to suspect a diagnosis of obsessive-compulsive personality disorder?
16. The client experiences unwanted, intrusive, and persistent thoughts.
17. The client experiences unwanted, repetitive behavior patterns.
18. The client experiences inflexibility and lack of spontaneity when dealing with others.
19. The client experiences obsessive thoughts that are externally imposed.

Answer 79

3

Question 80

16. Which client is a nurse most likely to admit to an inpatient facility for self-destructive behaviors?
17. A client diagnosed with antisocial personality disorder
18. A client diagnosed with borderline personality disorder
19. A client diagnosed with schizoid personality disorder
20. A client diagnosed with paranoid personality disorder

Answer 80

2 - in this disorder, most gestures are designed to elicit a rescue response

Question 81

17. When planning care for clients diagnosed with personality disorders, what should be the goal of treatment?
18. To stabilize the client’s pathology by using the correct combination of psychotropic medications
19. To change the characteristics of the dysfunctional personality
20. To reduce personality trait inflexibility that interferes with functioning and relationships
21. To decrease the prevalence of neurotransmitters at receptor sites

Answer 81

3 - The goal of treatment for clients diagnosed with personality disorders should be to reduce inflexibility of personality traits that interfere with functioning and relationships. Personality disorders are often difficult and, in some cases, seem impossible to treat. There are no psychotropic medications approved specifically for the treatment of personality disorders.

Question 82

18. Which client situation would reflect the impulsive behavior that is commonly associated with borderline personality disorder?
19. As the day-shift nurse leaves the unit, the client suddenly hugs the nurse’s arm and whispers, “The night nurse is evil. You have to stay.”
20. As the day-shift nurse leaves the unit, the client suddenly hugs the nurse’s arm and states, “I will be up all night if you don’t stay with me.”
21. As the day-shift nurse leaves the unit, the client suddenly hugs the nurse’s arm, yelling, “Please don’t go! I can’t sleep without you being here.”
22. As the day-shift nurse leaves the unit, the client suddenly shows the nurse a bloody arm and states, “I cut myself because you are leaving me.”

Answer 82

4 - The client who states, “I cut myself because you are leaving me” reflects impulsive behavior that is commonly associated with borderline personality disorder. Repetitive, self-mutilating behaviors are common in clients diagnosed with borderline personality disorders that result from feelings of abandonment following separation from significant others.

Question 83

19. Which nursing diagnosis should be prioritized when providing nursing care to a client diagnosed with paranoid personality disorder?
20. Risk for violence: directed toward others R/T paranoid thinking
21. Risk for suicide R/T altered thought
22. Altered sensory perception R/T increased levels of anxiety
23. Social isolation R/T inability to relate to others

Answer 83

1 - Clients diagnosed with paranoid personality disorder have a pervasive distrust and suspiciousness of others that result in a constant threat readiness. They are often tense and irritable, which increases the likelihood of violent behavior.

Question 84

20. From a behavioral perspective, which nursing intervention is appropriate when caring for a client diagnosed with borderline personality disorder?
21. Seclude the client when inappropriate behaviors are exhibited.
22. Contract with the client to reinforce positive behaviors with unit privileges.
23. Teach the purpose of anti-anxiety medications to improve medication compliance.
24. Encourage the client to journal feelings to improve awareness of abandonment issues.

Answer 84

2

Question 85

21. A highly emotional client presents at an outpatient clinic appointment and states, “My dead husband returned to me during a séance.” Which personality disorder should a nurse associate with this behavior?
22. Obsessive-compulsive personality disorder
23. Schizotypal personality disorder
24. Narcissistic personality disorder
25. Borderline personality disorder

Answer 85

2

Question 86

22. A nursing instructor is teaching students about clients diagnosed with histrionic personality disorder and the quality of their relationships. Which student statement indicates that learning has occurred?
23. “Their dramatic style tends to make their interpersonal relationships quite interesting and fulfilling.”
24. “Their interpersonal relationships tend to be shallow and fleeting, serving their dependency needs.”
25. “They tend to develop few relationships because they are strongly independent but generally maintain deep affection.”
26. “They pay particular attention to details, which can interfere with the development of relationships.”

Answer 86

2

Question 87

23. During an interview, which client statement should indicate to a nurse a potential diagnosis of schizotypal personality disorder?
24. “I don’t have a problem. My family is inflexible, and relatives are out to get me.”
25. “I am so excited about working with you. Have you noticed my new nail polish, ‘Ruby Red Roses’?”
26. “I spend all my time tending my bees. I know a whole lot of information about bees.”
27. “I am getting a message from the beyond that we have been involved with each other in a previous life.”

Answer 87

4 - Individuals with schizotypal personality disorder are aloof and isolated and behave in a bland and apathetic manner. The person experiences magical thinking, ideas of reference, illusions, and depersonalization as part of daily life.

Question 88

24. Which nursing diagnosis should be prioritized when providing nursing care to a client diagnosed with avoidant personality disorder?
25. Risk for violence: directed toward others R/T paranoid thinking
26. Risk for suicide R/T altered thought
27. Altered sensory perception R/T increased levels of anxiety
28. Social isolation R/T inability to relate to others

Answer 88

4

Question 89

25. A nurse is admitting a client with a new diagnosis of a personality disorder. Which of the following would make the nurse question this diagnosis? (Select all that apply.)
26. The client has been diagnosed with sickle cell anemia.
27. The client has an inflated self-appraisal and feels a sense of entitlement.
28. The client has a history of a substance use disorder.
29. The client is odd and eccentric but not delusional.

Answer 89

1, 3, 5

Question 90

26. Which statements represent positive outcomes for clients diagnosed with narcissistic personality disorder? (Select all that apply.)
27. The client will relate one empathetic statement to another client in group by day two.
28. The client will identify one personal limitation by day one.
29. The client will acknowledge one strength that another client possesses by day two.
30. The client will list four personal strengths by day three.
31. The client will list two lifetime achievements by discharge.

Answer 90

1, 2, 3

Question 91

27. A nurse is caring for a client diagnosed with antisocial personality disorder. Which factors should the nurse consider when planning this client’s care? (Select all that apply.)
28. This client has personality traits that are deeply ingrained and difficult to modify.
29. This client needs medication to treat the underlying physiological pathology.
30. This client uses manipulation, making the implementation of treatment problematic.
31. This client has poor impulse control that hinders compliance with a plan of care.
32. This client is likely to have secondary diagnoses of substance abuse and depression.

Answer 91

1, 3, 4, 5

Question 92

28. A client is being assessed for antisocial personality disorder. According to the DSM-5, which of the following symptoms must the client meet in order to be assigned this diagnosis? (Select all that apply.)
29. Ego-centrism and goal setting based on personal gratification.
30. Incapacity for mutually intimate relationships.
31. Frequent feelings of being down miserable and/or hopeless.
32. Disregard for and failure to honor financial and other obligations.
    5, Intense feelings of nervousness, tenseness, or panic.

Answer 92

1, 2, 4

Question 93

29. _______________________ personality disorder is characterized by a profound defect in the ability to form personal relationships or to respond to others in any meaningful emotional way.

Answer 93

Schizoid

Question 94

30. _____________________ personality disorder is characterized by colorful, dramatic, and extraverted behavior in excitable, emotional people.

Answer 94

Histrionic

Question 95

31. ________________________________ personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation.

Answer 95

Dependent
Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation. These characteristics are evident in the tendency to allow others to make decisions, to feel helpless when alone, to act submissively, to subordinate needs to others, to tolerate mistreatment by others, to demean oneself to gain acceptance, and to fail to function adequately in situations that require assertive or dominant behavior.

Question 96

32. _____________________ personality disorder is a pervasive distrust and suspiciousness of others, such that their motives are interpreted as malevolent.

Answer 96

Paranoid