Psychiatric Nursing | NCLEX Quiz 191

1.

Which nursing intervention is most appropriate for a client with Alzheimer’s disease who has frequent episodes emotional lability?

A.

Attempt humor to alter the client mood.
B.

Explore reasons for the client’s altered mood.
C.

Reduce environmental stimuli to redirect the client’s attention.
D.

Use logic to point out reality aspects.

Correct Answer
C. Reduce environmental stimuli to redirect the client’s attention.

Explanation
The client with Alzheimer’s disease can have frequent episode of labile mood. which can best be handled by decreasing a stimulating environment and redirecting the client’s attention.Option A: The client with Alzheimer’s disease loses the cognitive ability to respond to either humor or logic.Option B: An over stimulating environment may cause the labile mood. which will be difficult for the client to understand.Option D: The client lacks any insight into his or her own behavior and therefore will be unaware of any causative factors.

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2.

Which neurotransmitter has been implicated in the development of Alzheimer’s disease?

A.

Acetylcholine
B.

Dopamine
C.

Epinephrine
D.

Serotonin

Correct Answer
A. Acetylcholine

Explanation
A relative deficiency of acetylcholine is associated with this disorder. The drugs used in the early stages of Alzheimer’s disease will act to increase available acetylcholine in the brain. The remaining neurotransmitters have not been implicated in Alzheimer’s disease.

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3.

Which factors are the most essential for the nurse to assess when providing crisis intervention foer a client?

A.

The client’s communication and coping skills
B.

The client’s anxiety level and ability to express feelings
C.

The client’s perception of the triggering event and availability of situational supports
D.

The client’s use of reality testing and level of depression

Correct Answer
C. The client’s perception of the triggering event and availability of situational supports

Explanation
The most important factors to determine in this situations are the client’s perception of the crisis event and the availability of support (including family and friends) to provide basic needs.Options A. B. and D: Although the nurse should assess the other factors. they are not as essential as determining why the client considers this a crisis and whether he can meet his present needs.

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4.

The nurse considers a client’s response to crisis intervention successful if the client:

A.

Changes coping skills and behavioral patterns.
B.

Develops insight into reasons why the crisis occurred.
C.

Learns to relate better to others.
D.

Returns to his previous level of functioning.

Correct Answer
D. Returns to his previous level of functioning.

Explanation
Crisis intervention is based on the idea that a crisis is a disturbance in homeostasis (steady state). The goal is to help the client return to a previous level of equilibrium in functioning.Options A. B. and C: The remaining answer choices are not considered the primary outcome of crisis intervention. although they may occur as a side benefit.

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5.

Two nurses are co-leading group therapy for seven clients in the psychiatric unit. The leaders observe that the group members are anxious and look to the leaders for answers. Which phase of development is this group in?

A.

Conflict resolution phase
B.

Initiation phase
C.

Working phase
D.

Termination phase

Correct Answer
B. Initiation phase

Explanation
Increased anxiety and uncertainty characterize the initiation phase in group therapy. Group members are more self-reliant during the working and termination phases.

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6.

Group members have worked very hard. and the nurse reminds them that termination is approaching. Termination is considered successful if group members:

A.

Decide to continue.
B.

Elevate group progress
C.

Focus on positive experience
D.

Stop attending prior to termination.

Correct Answer
A. Decide to continue.

Explanation
As the group progresses into the working phase. group members assume more responsibility for the group. The leader becomes more of a facilitator. Comments about behavior in a group are indicators that the group is active and involved.Options B. C. and D: The remaining answer choices would indicate the group progress has not advanced to the working phase.

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7.

The nurse is teaching a group of clients about the mood-stabilizing medications lithium carbonate. Which medications should she instruct the clients to avoid because of the increased risk of lithium toxicity?

A.

Antacids
B.

Antibiotics
C.

Diuretics
D.

Hypoglycemic agents

Correct Answer
C. Diuretics

Explanation
The use of diuretics would cause sodium and water excretion. which would increase the risk of lithium toxicity. Clients taking lithium carbonate should be taught to increase their fluid intake and to maintain normal intake of sodium.Options A. B. and D: Concurrent use of any of the remaining medications will not increase the risk of lithium toxicity.

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8.

The nurse is working with a client with a somatoform disorder. Which client outcome goal would the nurse most likely establish in this situation?

A.

The client will recognize signs and symptoms of physical illness.
B.

The client will cope with physical illness.
C.

The client will take prescribed medications.
D.

The client will express anxiety verbally rather than through physical symptoms.

Correct Answer
D. The client will express anxiety verbally rather than through physical symptoms.

Explanation
In a functional family. parents typically do not agree on all issues and problems. Open discussion of thoughts and feeling is healthy. and parental disagreement should not cause system stress.Options A. B. and C: The remaining answer choices are life transitions that are expected to increase family stress.

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9.

A client taking the monoamine oxidase inhibitor (MAOI) antidepressant isocarboxazid (Marplan) is instructed by the nurse to avoid which foods and beverages?

A.

Aged cheese and red wine
B.

Milk and green. leafy vegetables
C.

Carbonated beverages and tomato products
D.

Lean red meats and fruit juices

Correct Answer
A. Aged cheese and red wine

Explanation
Aged cheese and red wines contain the substance tyramine which. when taken with an MAOI. can precipitate a hypertensive crisis.Options B. C. and D: The other foods and beverages do not contain significant amounts of tyramine and. therefore. are not restricted.

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10.

Prior to administering chlorpromazine (Thorazine) to an agitated client. the nurse should:

A.

Assess skin color and sclera
B.

Assess the radial pulse
C.

Take the client’s blood pressure
D.

Ask the client to void

Correct Answer
C. Take the client’s blood pressure

Explanation
Because chlorpromazine (Thorazine) can cause a significant hypotensive effect (and possible client injury). the nurse must assess the client’s blood pressure (lying. sitting. and standing) before administering this drug.Option A: If the client had taken the drug previously. the nurse would also need to assess the skin color and sclera for signs of jaundice. a possible drug side affect; however. based on the information given here. there is no evidence that the client has received chlorpromazine before.Option D: Although the drug can cause urine retention. asking the client to avoid will not alter this anticholinergic effect.

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