Psychiatric Nursing | NCLEX Quiz 194 | Attempts: 3635

2.

An elderly man is admitted to the hospital. He was alert and oriented during the admission interview. However. his family states that he becomes disruptive and disoriented around dinnertime. One night he was shouting furiously and didn’t know where he was. He was sedated and the next morning he was fine. At dinnertime. the disruptive behavior returned. The client is diagnosed as having sundown syndrome. The client’s son asks the nurse what causes sundown syndrome. The nurse’s best response is that it is attributed to

An underlying depression.
Inadequate cerebral flow.
Changes in the sensory environment.
Fuctuating levels of oxygen exchange.

Correct Answer

A. Changes in the sensory environment.

Explanation

Because the confusion occurs at sundown. the cause probably changes in the sensory environment. Sundown syndrome is related to environmental and sensory abnormalities that lead to acute confusion.Option A: An underlying depression does not cause sundown syndrome.Option B: There is not sufficient evidence to suggest he has inadequate cerebral blood flow.Option D: Fluctuating levels of oxygen exchange do not cause sundown syndrome.

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3.

A man is admitted to the nursing care unit with a diagnosis of cirrhosis. He has a long history of alcohol dependence. During the late evening following his admission. he becomes increasingly disoriented and agitated. Which of the following would the client be least likely to experience?

Diaphoresis and tremors.
Increased blood pressure and heart rate.
Illusions.
Delusions of grandeur.

Correct Answer

A. Delusions of grandeur.

Explanation

Delusions of grandeur are symptomatic of manic clients. not clients withdrawing from alcohol. The symptoms and history of alcohol abuse suggest this client is in alcohol withdrawal.Option A: Diaphoresis and tremors occur in the first phase of alcohol withdrawal.Option B: The blood pressure and heart rate increase in the first phase of alcohol withdrawal.Option C: Illusions are common in persons withdrawing from alcohol. Illusions occur most often in dim artificial lighting where the environment is not perceived accurately.

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4.

Mr. Peterson. 35. is admitted for bipolar illness. manic phase. after assaulting his landlord in an argument over Mr. Peterson is staying up all night playing loud music. Mr. Peterson is hyperactive. intrusive. and has rapid. pressured speech. He has not slept in three days and appears thin and disheveled. Which of the following is the most essential nursing action at this time?

Providing a meal and beverage for Mr. Peterson to eat in the dining room.
Providing linens and toiletries for Mr. Peterson to attend to his hygiene.
Consulting with the psychiatrist to order a hypnotic to promote sleep.
Providing for client safety by limiting his privileges.

Correct Answer

A. Providing for client safety by limiting his privileges.

Explanation

Mr. Peterson has been assaultive with the landlord. and it is reasonable to expect that he may be with peers and staff. His mental illness produces a hyperactive state and poor judgment and impulse control. External controls such as limiting of unit privileges will assist in feelings of security and safety.Option A: Food and fluids are necessary. However. Mr. Peterson’s hyperactivity does not allow him to sit quietly to eat. Finger foods “on the run” will provide needed nourishment.Option B: When hyperactivity decreases. then approach Mr. Peterson’s. regarding hygiene and grooming needs.Option C: Medications will be ordered. However. a thorough evaluation must be done first.

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5.

The nurse is assessing a 17-year-old female who is admitted to the eating disorders unit with a history of weight fluctuation. abdominal pain. teeth erosion. receding gums. and bad breath. She states that her health has been a problem but there are no other concerns in her life. Which of the following assessments will be the least useful as the nurse develops the care plan?

Information regarding recent mood changes.
Family functioning using a genogram.
Ability to socialize with peers.
Whether she has a sexual relationship with a boyfriend.

Correct Answer

A. Whether she has a sexual relationship with a boyfriend.

Explanation

It is inappropriate to ask about her sexual relationships.Option A: Information about mood changes is important to assess. as bulimia is often associated with affective disorders.Option B: Family functioning is the most essential point to assess. as it reveals if binge eating is triggered by conflict within the family.Option C: Information about the ability to socialize with peers is important to assess. as it is possible the problem initiated with peer relationships.

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6.

A teenage female is admitted with the diagnosis of anorexia nervosa. Upon admission. the nurse finds a bottle of assorted pills in the client’s drawer. The client tells the nurse that they are antacids for stomach pains. The best response by the nurse would be

“These pills aren’t antacids since they are all different.”
“Some teenagers use pills to lose weight.”
“Tell me about your week prior to being admitted.”
“Are you taking pills to change your weight?”

Correct Answer

A. “Tell me about your week prior to being admitted.”

Explanation

This is an open-ended question which is non-judgemental and allows for further discussion. The topic is also nonthreatening yet will give the nurse insight into the client’s view of events leading up to admission. It is the only option that is client centered. The other options focus on the pills.

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7.

The nurse is discussing electroconvulsive therapy (ECT) with a client who asks how long it will be before she feels better. The nurse explains that the beneficial effects of ECT usually occur within

One week.
Three weeks.
Four weeks.
Six weeks.

Correct Answer

A. One week.

Explanation

Beneficial effects of ECT usually are evident after the first several treatments. Since treatments are administered at intervals of 48 hours. these effects are apparent after one week of therapy. Beneficial effects of ECT therapy are usually seen before three weeks. It takes three to four weeks for tricyclic antidepressants to take effect. Beneficial effects of ECT therapy are usually seen before four weeks. It takes three to four weeks for tricyclic antidepressants to take effect. Beneficial effects of ECT therapy are usually seen after the first few treatments.

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8.

A mother with a Roman Catholic belief has given birth in an ambulance on the way to the hospital. The neonate is in very critical condition with little expectation of surviving the trip to the hospital. Which of these requests should the nurse in the ambulance anticipate and be prepared to do?

The refusal of any treatment for self and the neonate until she talks to a reader
The placement of a rosary necklace around the neonate’s neck and not to remove it unless absolutely necessary
Arrange for a church elder to be at the emergency department when the ambulance arrives so a “laying on hands” can be done
Pour fluid over the forehead backward towards the back of the head and say “I baptize you in the name of the father. the son and the holy spirit. Amen.”

Correct Answer

A. Pour fluid over the forehead backward towards the back of the head and say “I baptize you in the name of the father. the son and the holy spirit. Amen.”

Explanation

Infant baptism is mandatory in the Roman Catholic belief especially if a neonate is not expected to live. Anyone may perform this if an infant or child is gravely ill.Option A refers to the Christian Science belief.Option B is a belief of Russian Orthodoxy.Option C: Mormons believe in divine healing with the laying on of hands.

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9.

The nurse is planning care for a client who has a phobic disorder manifested by a fear of elevators. Which goal would need to be accomplished first? The client

Demonstrates the relaxation response when asked.
Verbalizes the underlying cause of the disorder.
Rides the elevator in the company of the nurse.
Role plays the use of an elevator.

Correct Answer

A. Demonstrates the relaxation response when asked.

Explanation

The ability to use relaxation is basic to treatment of phobia.Option B: Clients with phobias are resistant to insight therapy.Option C: Riding the elevator accompanied by the nurse is an appropriate long-term goal.Option D: Role playing may be appropriate after the client has learned relaxation.

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10.

Which of the following would best indicate to the nurse that a depressed client is improving?

Reduced levels of anxiety.
Changes in vegetative signs.
Compliance with medications.
Requests to talk to the nurse.

Correct Answer

A. Changes in vegetative signs.

Explanation

Vegetative signs such as insomnia. anorexia. psychomotor retardation. constipation. diminished libido. and poor concentration are biological responses to depression. Improvement in these signs indicates a lifting of the depression.Option A: Reduced levels of anxiety do not indicate an improvement in depressive symptoms.Option C: Compliance with medications does not indicate improvement in depression.Option D: Requests to talk to the nurse vary. Requests may show trust in the nurse but are not a sign that depression has diminished.

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Psychiatric Nursing | NCLEX Quiz 194

A 34-year-old woman is admitted for treatment of depression. Which of these symptoms would the nurse be least likely to find in the initial assessment?

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A man is admitted to the nursing care unit with a diagnosis of cirrhosis. He has a long history of alcohol dependence. During the late evening following his admission. he becomes increasingly disoriented and agitated. Which of the following would the client be least likely to experience?

A teenage female is admitted with the diagnosis of anorexia nervosa. Upon admission. the nurse finds a bottle of assorted pills in the client’s drawer. The client tells the nurse that they are antacids for stomach pains. The best response by the nurse would be

The nurse is discussing electroconvulsive therapy (ECT) with a client who asks how long it will be before she feels better. The nurse explains that the beneficial effects of ECT usually occur within

A mother with a Roman Catholic belief has given birth in an ambulance on the way to the hospital. The neonate is in very critical condition with little expectation of surviving the trip to the hospital. Which of these requests should the nurse in the ambulance anticipate and be prepared to do?

The nurse is planning care for a client who has a phobic disorder manifested by a fear of elevators. Which goal would need to be accomplished first? The client

Which of the following would best indicate to the nurse that a depressed client is improving?