Psychiatric Nursing | NCLEX Quiz 182 | Attempts: 3059

2.

A 25 –year old client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority?

The client will commit to a drug-free lifestyle
The client will work with the nurse to remain safe
The client will drink plenty of fluids daily
The client will make a personal inventory of strength

Correct Answer

A. The client will work with the nurse to remain safe

Explanation

The priority goal in alcohol withdrawal is maintaining the client’s safety.Options A. C. and D: Committing to a drug-free lifestyle. drinking plenty of fluids. and identifying personal strengths are important goals. but ensuring the client’s safety is the nurse’s top priority.

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3.

A male client is admitted to a psychiatric facility by court order for evaluation for antisocial personality disorder. This client has a long history of initiating fights and abusing animals and recently was arrested for setting a neighbor’s dog on fire. When evaluating this client for the potential for violence. nurse Perry should assess for which behavioral clues?

A rigid posture. restlessness. and glaring
Depression and physical withdrawal
Silence and noncompliance
Hypervigilance and talk of past violent acts

Correct Answer

A. A rigid posture. restlessness. and glaring

Explanation

Behavioral clues that suggest the potential for violence includes: a rigid posture. restlessness. glaring. a change in usual behavior. clenched hands. overtly aggressive actions. physical withdrawal. noncompliance. overreaction. hostile threats. recent alcohol ingestion or drug use. talk of past violent acts. inability to express feelings. repetitive demands and complaints. argumentativeness. profanity. disorientation. inability to focus attention. hallucinations or delusions. paranoid ideas or suspicions. and somatic complaints.Options B. C. and D: Violent clients rarely exhibit depression. silence. or hypervigilance.

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4.

A male client is brought to the psychiatric clinic by family members. who tell the admitting nurse that the client repeatedly drives while intoxicated despite their pleas to stop. During an interview with the nurse Linda. which statement by the client most strongly supports a diagnosis of psychoactive substance abuse?

“I’m not addicted to alcohol. In fact. I can drink more than I used to without being affected.”
“I only spend half of my paycheck at the bar.”
“I just drink to relax after work.”
“I know I’ve been arrested three times for drinking and driving. but the police are just trying to hassle me.”

Correct Answer

A. “I know I’ve been arrested three times for drinking and driving. but the police are just trying to hassle me.”

Explanation

According to the Diagnostic and Statistical Manual of Mental Disorders. 4th edition. diagnostic criteria for psychoactive substance abuse include a maladaptive pattern of such use. indicated either by continued use despite knowledge of having a persistent or recurrent social. occupational. psychological. or physical problem caused or exacerbated by substance abuse or recurrent use in dangerous situations (for example. while driving).For this client. psychoactive substance dependence must be ruled out; criteria for this disorder include a need for increasing amounts of the substance to achieve intoxication (option A). increased time and money spent on the substance (option B). inability to fulfill role obligations (option C). and typical withdrawal symptoms.

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5.

A female client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client’s wrists are scratched from a recent suicide attempt. Based on this finding. the nurse Lenny should formulate a nursing diagnosis of:

Ineffective individual coping related to feelings of guilt.
Situational low self-esteem related to feelings of loss of control
Risk for violence: Self-directed related to impulsive mutilating acts
Risk for violence: Directed toward others related to verbal threats

Correct Answer

A. Risk for violence: Self-directed related to impulsive mutilating acts

Explanation

The predominant behavioral characteristic of the client with borderline personality disorder is impulsiveness. especially of a physically self-destructive sort. The observation that the client has scratched wrists doesn’t substantiate the other options.

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1

6.

A male client recently admitted to the hospital with sharp. substernal chest pain suddenly complains of palpitations. Nurse Ryan notes a rise in the client’s arterial blood pressure and a heart rate of 144 beats/minute. On further questioning. the client admits to having used cocaine recently after previously denying use of the drug. The nurse concludes that the client is at high risk for which complication of cocaine use?

Coronary artery spasm
Bradyarrhythmias
Neurobehavioral deficits
Panic disorder

Correct Answer

A. Coronary artery spasm

Explanation

Cocaine use may cause such cardiac complications as coronary artery spasm. myocardial infarction. dilated cardiomyopathy. acute heart failure. endocarditis. and sudden death. Cocaine blocks reuptake of norepinephrine. epinephrine. and dopamine. causing an excess of these neurotransmitters at postsynaptic receptor sites.Option B: Consequently. the drug is more likely to cause tachyarrhythmias than bradyarrhythmias.Option C: Although neurobehavioral deficits are common in neonates born to cocaine users. they are rare in adults.Option D: As craving for the drug increases. a person who’s addicted to cocaine typically experiences euphoria followed by depression. not panic disorder

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7.

A male client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview. the nurse asks him when he had his last alcoholic drink. He says that he had his last drink six (6) hours before admission. Based on this response. nurse Lorena should expect early withdrawal symptoms to:

Begin after seven (7) days
Not occur at all because the time period for their occurrence has passed
Begin anytime within the next one (1) to two (2) days
Begin within two (2) to seven (7) days

Correct Answer

A. Begin anytime within the next one (1) to two (2) days

Explanation

Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1 to 2 days later. Delirium tremens may occur 2 to 4 days — even up to 7 days — after the last drink.

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8.

Nurse Helen is assigned to care for a client with anorexia nervosa. Initially. which nursing intervention is most appropriate for this client?

Providing one-on-one supervision during meals and for one (1) hour afterward
Letting the client eat with other clients to create a normal mealtime atmosphere
Trying to persuade the client to eat and thus restore nutritional balance
Giving the client as much time to eat as desired

Correct Answer

A. Providing one-on-one supervision during meals and for one (1) hour afterward

Explanation

Because the client with anorexia nervosa may discard food or induce vomiting in the bathroom. the nurse should provide one-on-one supervision during meals and for 1 hour afterward.Option B wouldn’t be therapeutic because other clients may urge the client to eat and give attention for not eating.Option C would reinforce control issues. which are central to this client’s underlying psychological problem.Instead of giving the client unlimited time to eat. the nurse should set limits and let the client know what is expected.

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9.

A female client begins to experience alcoholic hallucinosis. Nurse Joy is aware that the best nursing intervention at this time?

Keeping the client restrained in bed
Checking the client’s blood pressure every 15 minutes and offering juices
Providing a quiet environment and administering medication as needed and prescribed
Restraining the client and measuring blood pressure every 30 minutes

Correct Answer

A. Providing a quiet environment and administering medication as needed and prescribed

Explanation

Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment for reducing stimulation and administering prescribed central nervous system depressants in dosages that control symptoms without causing oversedation.Option A: Although bed rest is indicated. restraints are unnecessary unless the client poses a danger to himself or others. Also. restraints may increase agitation and make the client feel trapped and helpless when hallucinating.Option B: Offering juice is appropriate. but measuring blood pressure every 15 minutes would interrupt the client’s rest.Option D: To avoid overstimulating the client. the nurse should check blood pressure every 2 hours.

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10.

Nurse Bella is aware that assessment finding is most consistent with early alcohol withdrawal?

Heart rate of 120 to 140 beats/minute
Heart rate of 50 to 60 beats/minute
Blood pressure of 100/70 mmHg
Blood pressure of 140/80 mmHg

Correct Answer

A. Heart rate of 120 to 140 beats/minute

Explanation

Tachycardia. a heart rate of 120 to 140 beats/minute. is a common sign of alcohol withdrawal. Blood pressure may be labile throughout withdrawal. fluctuating at different stages. Hypertension typically occurs in early withdrawal. Hypotension. although rare during the early withdrawal stages. may occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don’t receive treatment. The nurse should monitor the client’s vital signs carefully throughout the entire alcohol withdrawal process.

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Psychiatric Nursing | NCLEX Quiz 182

When monitoring a female client recently admitted for treatment of cocaine addiction. nurse Aaron notes sudden increases in the arterial blood pressure and heart rate. To correct these problems. the nurse expects the physician to prescribe:

Quiz Preview

A 25 –year old client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority?

A female client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client’s wrists are scratched from a recent suicide attempt. Based on this finding. the nurse Lenny should formulate a nursing diagnosis of:

Nurse Helen is assigned to care for a client with anorexia nervosa. Initially. which nursing intervention is most appropriate for this client?

A female client begins to experience alcoholic hallucinosis. Nurse Joy is aware that the best nursing intervention at this time?

Nurse Bella is aware that assessment finding is most consistent with early alcohol withdrawal?