Psychiatric Nursing | NCLEX Quiz 190 | Attempts: 7444

2.

Which information is the most essential in the initial teaching session for the family of a young adult recently diagnosed with schizophrenia?

Symptoms of this disease imbalance in the brain.
Genetic history is an important factor related to the development of schizophrenia.
Schizophrenia is a serious disease affecting every aspect of a person’s functioning.
The distressing symptoms of this disorder can respond to treatment with medications.

Correct Answer

A. The distressing symptoms of this disorder can respond to treatment with medications.

Explanation

This statement provides accurate information and an element of hope for the family of a schizophrenic client.Options A. B. and C: Although the remaining statements are true. they do not provide the empathic response the family needs after just learning about the diagnosis. These facts can become part of the ongoing teaching.

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3.

A nurse is working with a client who has schizophrenia. paranoid type. Which of the following outcomes related to the client’s delusional perceptions would the nurse establish?

The client will demonstrate realistic interpretation of daily events in the unit.
The client will perform daily hygiene and grooming without assistance.
The client will take prescribed medications without difficulty.
The client will participate in unit activities.

Correct Answer

A. The client will demonstrate realistic interpretation of daily events in the unit.

Explanation

A client with schizophrenia. paranoid type. has distorted perceptions and views people. institutions. and aspects of the environment as plotting against him. The desired outcome for someone with delusional perceptions would be to have a realistic interpretation of daily events.Option B: The client with a distorted perception of the environment would not necessarily have impairments affecting hygiene and grooming skills.Options C and D: Although taking medications and participating in unit activities may be appropriate outcomes for nursing intervention; these responses are not related to client perceptions.

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4.

A client with bipolar disorder. manic type. exhibits extreme excitement. delusional thinking. and command hallucinations. Which of the following is the priority nursing diagnosis?

Anxiety
Impaired social interaction
Disturbed sensory-perceptual alteration (auditory)
Risk for other-directed violence

Correct Answer

A. Risk for other-directed violence

Explanation

A client with these symptoms would have poor impulse control and would therefore be prone to acting-out behavior that may be harmful to either himself or others. All of the remaining nursing diagnoses may apply to the client with mania; however. the priority diagnosis would be risk for violence.Options A. B. and C: All of the remaining nursing diagnoses may apply to the client with mania; however. the priority diagnosis would be risk for violence.

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5.

A client who abuses alcohol and cocaine tells a nurse that he only uses substances because of his stressful marriage and difficult job. Which defense mechanisms is this client using?

Displacement
Projection
Rationalization
Sublimation

Correct Answer

A. Rationalization

Explanation

Rationalization is the defense mechanism that involves offering excuses for maladaptive behavior. The client is defending his substance abuse by providing reasons related to life stressors. This is a common defense mechanism used by clients with substance abuse problems.Options A. B. and D: None of the remaining defense mechanisms involves making excuses for behaviors.

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4

6.

An 11-year-old child diagnosed with conduct disorder is admitted to the psychiatric unit for treatment. Which of the following behaviors would the nurse assess?

Restlessness. short attention span. hyperactivity
Physical aggressiveness. low-stress tolerance disregard for the rights of others
Deterioration in social functioning. excessive anxiety. and worry. bizarre behavior
Sadness. poor appetite and sleeplessness. loss of interest in activities

Correct Answer

A. Physical aggressiveness. low-stress tolerance disregard for the rights of others

Explanation

Physical aggressiveness. low-stress tolerance. and a disregard for the rights of others are common behaviors in clients with conduct disorders.Option A: Restlessness. short attention span. and hyperactivity are typical behaviors in a client with attention deficit hyperactivity disorder.Option C: Deterioration in social functioning. excessive anxiety and worry and bizarre behaviors are typical in schizophrenic disorders.Option D: Sadness. poor appetite. sleeplessness. and loss of interest in activities are behaviors commonly seen in depressive disorders.

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7.

The nurse understands that if a client continues to be dependent on heroin throughout her pregnancy. her baby will be at high risk for:

Mental retardation.
Heroin dependence.
Addiction in adulthood.
Psychological disturbances.

Correct Answer

A. Heroin dependence.

Explanation

Babies born to heroin-dependent women are also heroin-dependent and need to go through withdrawal. There is no evidence to support any of the remaining answer choices.

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8.

The emergency department nurse is assigned to provide care for a victim of a sexual assault. When following legal and agency guidelines. which intervention is most important?

Determine the assailant’s identity.
Preserve the client’s privacy.
Identify the extent of an injury.
Ensure an unbroken chain of evidence.

Correct Answer

A. Ensure an unbroken chain of evidence.

Explanation

Establishing an unbroken chain of evidence is essential in order to ensure that the prosecution of the perpetrator can occur.Options A and D: The nurse will also need to preserve the client’s privacy and identify the extent of an injury. However. it is essential that the nurse follows legal and agency guidelines for preserving evidence.Option C: Identifying the assailant is the job of law enforcement. not the nurse.

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5

9.

Which factor is least important in the decision regarding whether a victim of family violence can safely remain in the home?

The availability of appropriate community shelters
The non-abusing caretaker’s ability to intervene on the client’s behalf
The client’s possible response to relocation
The family’s socioeconomic status

Correct Answer

A. The family’s socioeconomic status

Explanation

Socioeconomic status is not a reliable predictor of abuse in the home so that it would be the least important consideration in deciding issues of safety for the victim of family violence.Options A and B: The availability of appropriate community shelters and the ability of the non-abusing caretaker to intervene on the client’s behalf are important factors when making safety decisions.Option C: The client’s response to possible relocation (if the client is a competent adult) would be the most important factor to consider; feelings of empowerment and being treated as a competent person can help a client feel less like a victim.

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10.

The nurse would expect a client with early Alzheimer’s disease to have problems with:

Balancing a checkbook.
Self-care measures.
Relating to family members.
Remembering his own name

Correct Answer

A. Balancing a checkbook.

Explanation

In the early stage of Alzheimer’s disease. complex tasks (such as balancing a checkbook) would be the first cognitive deficit to occur.Options B. C. and D: The loss of self-care ability. problems with relating to family members. and difficulty remembering one’s own name are all areas of cognitive decline that occur later in the disease process.

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Psychiatric Nursing | NCLEX Quiz 190

A client tells a nurse. “Everyone would be better off if I wasn’t alive.” Which nursing diagnosis would be made based on this statement?

Which information is the most essential in the initial teaching session for the family of a young adult recently diagnosed with schizophrenia?

A nurse is working with a client who has schizophrenia. paranoid type. Which of the following outcomes related to the client’s delusional perceptions would the nurse establish?

A client with bipolar disorder. manic type. exhibits extreme excitement. delusional thinking. and command hallucinations. Which of the following is the priority nursing diagnosis?

A client who abuses alcohol and cocaine tells a nurse that he only uses substances because of his stressful marriage and difficult job. Which defense mechanisms is this client using?

An 11-year-old child diagnosed with conduct disorder is admitted to the psychiatric unit for treatment. Which of the following behaviors would the nurse assess?

The nurse understands that if a client continues to be dependent on heroin throughout her pregnancy. her baby will be at high risk for:

The emergency department nurse is assigned to provide care for a victim of a sexual assault. When following legal and agency guidelines. which intervention is most important?

Which factor is least important in the decision regarding whether a victim of family violence can safely remain in the home?

The nurse would expect a client with early Alzheimer’s disease to have problems with: