Psychiatric Nursing | NCLEX Quiz 181

1. A 14-year-old client was admitted to the clinic by her mother. Her mother tells concern about her daughter's weight loss and constant dieting. Nurse Mandy conducts a health history interview. Which comment indicates that the client might be suffering from anorexia nervosa?

“I like the way I look. I just need to keep my weight down because I’m a cheerleader.”

“I don’t like the food my mother cooks. I eat plenty of fast food when I’m out with my friends.”

“I just can’t seem to get down to the weight I want to be. I’m so fat compared to other girls.”

“I do diet around my periods; otherwise. I just get so bloated.”

The comment "I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls." indicates that the client might be suffering from anorexia nervosa because it suggests a distorted body image and an intense fear of gaining weight. The client's focus on comparing herself to other girls and feeling fat despite evidence to the contrary is a common characteristic of individuals with anorexia nervosa.

Explanation

The comment "I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls." indicates that the client might be suffering from anorexia nervosa because it suggests a distorted body image and an intense fear of gaining weight. The client's focus on comparing herself to other girls and feeling fat despite evidence to the contrary is a common characteristic of individuals with anorexia nervosa.

2. A male client is sitting on the floor of the bathroom on the day treatment clinic with moderate lacerations on both wrists. He is surrounded by broken glass. He is staring blankly at his bleeding wrists while staff members look for an ambulance. How should Nurse Julia approach her initially?

Enter the room quietly and move beside him to assess his injuries

Call for staff back-up before entering the room and restraining him

Move as much glass away from him as possible and sit next to him quietly

Approach him slowly while speaking in a calm voice. calling him name. and telling him that the nurse is here to help him

Nurse Julia should approach the client slowly while speaking in a calm voice, calling him by name, and reassuring him that she is there to help. This approach aims to establish trust and provide emotional support to the client during a distressing situation. By speaking calmly and using his name, Nurse Julia can help to create a sense of safety and demonstrate her presence as a caring healthcare professional.

Explanation

Nurse Julia should approach the client slowly while speaking in a calm voice, calling him by name, and reassuring him that she is there to help. This approach aims to establish trust and provide emotional support to the client during a distressing situation. By speaking calmly and using his name, Nurse Julia can help to create a sense of safety and demonstrate her presence as a caring healthcare professional.

3. A male client informs the nurse that he got in a car accident while he was intoxicated. What should be the most therapeutic response from nurse Julia?

“Why didn’t you get someone else to drive you?”

“Tell me how you feel about the accident.”

“You should know better than to drink and drive.”

“I recommend that you attend an Alcoholics Anonymous meeting.”

The most therapeutic response from nurse Julia would be to ask the client about their feelings regarding the accident. This response shows empathy and allows the client to express their emotions, which can be helpful in the therapeutic process. It also avoids judgment or blame, creating a safe space for the client to open up and discuss their experience.

Explanation

The most therapeutic response from nurse Julia would be to ask the client about their feelings regarding the accident. This response shows empathy and allows the client to express their emotions, which can be helpful in the therapeutic process. It also avoids judgment or blame, creating a safe space for the client to open up and discuss their experience.

4. Eighteen hours after an emergency appendectomy, a client with a reported history of social drinking displays these vital signs: temperature. 101.6° F (38.7° C); heart rate. 126 beats/minute; respiratory rate. 24 breaths/minute; and blood pressure. 140/96 mm Hg. The client shows gross hand tremors and is crying for someone to kill the bugs in the bed. Nurse Julia should suspect:

A postoperative infection

Alcohol withdrawal

Acute sepsis.

Pneumonia.

The client's history of social drinking and the symptoms they are experiencing, such as gross hand tremors and hallucinations (crying for someone to kill bugs in the bed), are consistent with alcohol withdrawal. The elevated heart rate, respiratory rate, and blood pressure could be attributed to the physiological response to withdrawal. Additionally, the client's history of social drinking suggests that they may have developed a dependence on alcohol, making them more susceptible to withdrawal symptoms after surgery. Therefore, alcohol withdrawal is the most likely explanation for the client's symptoms.

Explanation

The client's history of social drinking and the symptoms they are experiencing, such as gross hand tremors and hallucinations (crying for someone to kill bugs in the bed), are consistent with alcohol withdrawal. The elevated heart rate, respiratory rate, and blood pressure could be attributed to the physiological response to withdrawal. Additionally, the client's history of social drinking suggests that they may have developed a dependence on alcohol, making them more susceptible to withdrawal symptoms after surgery. Therefore, alcohol withdrawal is the most likely explanation for the client's symptoms.

5. A male adult client admits himself into the substance abuse unit. He says that he drinks one (1) qt or more of vodka every day and uses cocaine occasionally. In the afternoon. he begins to gives signs of alcohol withdrawal. What are the early signs of this condition?

Vomiting. diarrhea. and bradycardia

Dehydration. temperature above 101° F (38.3° C). and pruritus

Hypertension. diaphoresis. and seizures

Diaphoresis. tremors. and nervousness

The early signs of alcohol withdrawal include diaphoresis (excessive sweating), tremors (shaking), and nervousness. These symptoms are commonly seen in individuals who abruptly stop or significantly reduce their alcohol intake after prolonged heavy drinking. Diaphoresis is a result of the body's attempt to regulate its temperature, tremors are caused by the overactivity of the central nervous system, and nervousness is a psychological manifestation of withdrawal. These symptoms can progress to more severe manifestations such as seizures if not properly managed.

Explanation

The early signs of alcohol withdrawal include diaphoresis (excessive sweating), tremors (shaking), and nervousness. These symptoms are commonly seen in individuals who abruptly stop or significantly reduce their alcohol intake after prolonged heavy drinking. Diaphoresis is a result of the body's attempt to regulate its temperature, tremors are caused by the overactivity of the central nervous system, and nervousness is a psychological manifestation of withdrawal. These symptoms can progress to more severe manifestations such as seizures if not properly managed.

6. A female client with anorexia nervosa mentions herself as “a whale.” However. the nurse’s assessment shows that the client is 5? 8? (1.7 m) tall and weighs only 90 lb (40.8 kg). As per the client’s unrealistic body image. which intervention should nurse Julia include in the plan of care?

Asking the client to compare her figure with magazine photographs of women her age

Assigning the client to group therapy in which participants provide realistic feedback about her weight

Confronting the client about her actual appearance during one-on-one sessions. scheduled during each shift

Telling the client of the nurse’s concern for her health and desire to help her make decisions to keep her healthy

The nurse should tell the client of her concern for her health and desire to help her make decisions to keep her healthy because this intervention focuses on building a therapeutic relationship and trust with the client. It acknowledges the client's unrealistic body image but also emphasizes the nurse's genuine care and support. This approach can help the client feel heard and understood, and may be more effective in promoting positive change in her perception of her body and overall health.

Explanation

The nurse should tell the client of her concern for her health and desire to help her make decisions to keep her healthy because this intervention focuses on building a therapeutic relationship and trust with the client. It acknowledges the client's unrealistic body image but also emphasizes the nurse's genuine care and support. This approach can help the client feel heard and understood, and may be more effective in promoting positive change in her perception of her body and overall health.

7. A male client who has a history of cocaine addiction gets admitted to the coronary care unit for evaluation of substernal chest pain. After that, the electrocardiogram (ECG) shows a 1-mm ST-segment elevation the anteroseptal leads and T-wave inversion in leads V3 to V5. looking at the client’s history of drug abuse, nurse Paul expects the physician to prescribe:

Lidocaine (Xylocaine).

Procainamide (Pronestyl).

Nitroglycerin (Nitro-Bid IV).

Epinephrine.

Given the client's history of cocaine addiction and the ECG findings of ST-segment elevation and T-wave inversion, it suggests that the client may be experiencing acute myocardial infarction (heart attack). Nitroglycerin is commonly used in the treatment of myocardial infarction to relieve chest pain and improve blood flow to the heart. Lidocaine and procainamide are antiarrhythmic medications used for different types of arrhythmias, which may not be the primary concern in this case. Epinephrine is not typically used in the treatment of acute myocardial infarction.

Explanation

Given the client's history of cocaine addiction and the ECG findings of ST-segment elevation and T-wave inversion, it suggests that the client may be experiencing acute myocardial infarction (heart attack). Nitroglycerin is commonly used in the treatment of myocardial infarction to relieve chest pain and improve blood flow to the heart. Lidocaine and procainamide are antiarrhythmic medications used for different types of arrhythmias, which may not be the primary concern in this case. Epinephrine is not typically used in the treatment of acute myocardial infarction.

8. The nurse knows that the outcome criteria is going to be appropriate for a child who is diagnosed with oppositional defiant disorder?

Accept responsibility for own behaviors

Be able to verbalize own needs and assert rights.

Set firm and consistent limits with the client

Allow the child to establish his own limits and boundaries

The nurse knows that accepting responsibility for one's own behaviors is an appropriate outcome criteria for a child diagnosed with oppositional defiant disorder because it indicates that the child is taking ownership of their actions and recognizing the consequences of their behavior. This is an important step in the treatment of oppositional defiant disorder as it promotes self-awareness and personal growth. By accepting responsibility, the child is also more likely to engage in positive behaviors and develop healthier coping mechanisms.

Explanation

The nurse knows that accepting responsibility for one's own behaviors is an appropriate outcome criteria for a child diagnosed with oppositional defiant disorder because it indicates that the child is taking ownership of their actions and recognizing the consequences of their behavior. This is an important step in the treatment of oppositional defiant disorder as it promotes self-awareness and personal growth. By accepting responsibility, the child is also more likely to engage in positive behaviors and develop healthier coping mechanisms.

9. Clonidine (Catapres) is useful to treat conditions other than hypertension. Nurse Jenny is aware that in the following conditions might the drug be administered?

Phencyclidine (PCP) intoxication

Alcohol withdrawal

Opiate withdrawal

Cocaine withdrawal

Clonidine (Catapres) is useful in treating opiate withdrawal. Opiate withdrawal refers to the physical and psychological symptoms that occur when someone stops using opioids, such as heroin or prescription painkillers. Clonidine can help alleviate symptoms such as anxiety, agitation, muscle aches, and cravings, making it a valuable medication in the management of opiate withdrawal. It is not typically used for the treatment of PCP intoxication, alcohol withdrawal, or cocaine withdrawal.

Explanation

Clonidine (Catapres) is useful in treating opiate withdrawal. Opiate withdrawal refers to the physical and psychological symptoms that occur when someone stops using opioids, such as heroin or prescription painkillers. Clonidine can help alleviate symptoms such as anxiety, agitation, muscle aches, and cravings, making it a valuable medication in the management of opiate withdrawal. It is not typically used for the treatment of PCP intoxication, alcohol withdrawal, or cocaine withdrawal.

10. For a female client who has anorexia nervosa. Nurse Jenny is aware that which goal shows the highest priority?

The client will establish adequate daily nutritional intake

The client will make a contract with the nurse that sets a target weight

The client will identify self-perceptions about body size as unrealistic

The client will verbalize the possible physiological consequences of self-starvation

While all of these goals are important in the treatment of anorexia nervosa, the highest priority is to address the immediate physical health risks associated with the disorder. Anorexia nervosa can lead to severe malnutrition, which can have life-threatening consequences. Therefore, establishing adequate daily nutritional intake is the most immediate and critical goal. Once the client’s physical health is stabilized, the treatment team can work on the other goals, which address the psychological aspects of the disorder.

Explanation

While all of these goals are important in the treatment of anorexia nervosa, the highest priority is to address the immediate physical health risks associated with the disorder. Anorexia nervosa can lead to severe malnutrition, which can have life-threatening consequences. Therefore, establishing adequate daily nutritional intake is the most immediate and critical goal. Once the client’s physical health is stabilized, the treatment team can work on the other goals, which address the psychological aspects of the disorder.