Practice Test IV- Psychiatric Nursing

Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm and medicating as needed.

Delusion of grandeur is a false belief that one is highly famous and important.

In an emergency, lives saving facts are obtained first. The name and the amount of medication ingested are of outmost important in treating this potentially life threatening situation.

The nurse needs to set limits in the client’s manipulative behavior to help the client control dysfunctional behavior. A consistent approach by the staff is necessary to decrease manipulation.

The Nurse has a responsibility to observe continuously the acutely suicidal client. The Nurse should watch for clues, such as communicating suicidal thoughts, and messages; hoarding medications and talking about death.

When hallucination is present, the nurse should reinforce reality with the client.

These are the major signs of anorexia nervosa. Weight loss is excessive (15% of expected weight)

Establishing a consistent eating plan and monitoring client’s weight are important to this disorder.

The expression of these feeling may indicate that this client is unable to continue the struggle of life.

Bulimia disorder generally is a maladaptive coping response to stress and underlying issues. The client should identify anxiety causing situation that stimulate the bulimic behavior and then learn new ways of coping with the anxiety.

Clients who are withdrawn may be immobile and mute, and require consistent, repeated interventions. Communication with withdrawn clients requires much patience from the nurse. The nurse facilitates communication with the client by sitting in silence, asking open-ended question and pausing to provide opportunities for the client to respond.

Electroconvulsive therapy is an effective treatment for depression that has not responded to medication

Environmental (MILIEU) therapy aims at having everything in the client’s surrounding area toward helping the client.

Hallucinations are visual, auditory, gustatory, tactile or olfactory perceptions that have no basis in reality.

Regular coffee contains caffeine which acts as psychomotor stimulants and leads to feelings of anxiety and agitation. Serving coffee top the client may add to tremors or wakefulness.

Experiencing the actual trauma in dreams or flashback is the major symptom that distinguishes post traumatic stress disorder from other anxiety disorder.

The rituals used by a client with obsessive compulsive disorder help control the anxiety level by maintaining a set pattern of action.

Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid specific stimulus.

Limiting unnecessary interaction will decrease stimulation and agitation.

Discussion of the feared object triggers an emotional response to the object.

The nurse presence may provide the client with support & feeling of control.

Neuromuscular Blocker, such as SUCCINYLCHOLINE (Anectine) produces respiratory depression because it inhibits contractions of respiratory muscles.

Confabulation or the filling in of memory gaps with imaginary facts is a defense mechanism used by people experiencing memory deficits.

Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts

Any suicidal statement must be assessed by the nurse. The nurse should discuss the client’s statement with her to determine its meaning in terms of suicide.

Children have difficulty verbally expressing their feelings, acting out behavior, such as temper tantrums, may indicate underlying depression.

Dental enamel erosion occurs from repeated self-induced vomiting.

When the staff member ask the client if he wonders why others find him repulsive, the client is likely to feel defensive because the question is belittling. The natural tendency is to counterattack the threat to self image.

Structure tends to decrease agitation and anxiety and to increase the client’s feeling of security.

Total abstinence is the only effective treatment for alcoholism

These clients have severely depleted levels of sodium and potassium because of their starvation diet and energy expenditure, these electrolytes are necessary for cardiac functioning.

Ritualistic behavior seen in this disorder is aimed at controlling guilt and inadequacy by maintaining an absolute set pattern of behavior.

Personal characteristics of abuser include low self-esteem, immaturity, dependence, insecurity and jealousy.

The nurse would most likely administer benzodiazepine, such as lorazepan (ativan) to the client who is experiencing symptom: The client’s experiences symptoms of withdrawal because of the rebound phenomenon when the sedation of the CNS from alcohol begins to decrease.

A short acting skeletal muscle relaxant such as succinylcholine (Anectine) is administered during this procedure to prevent injuries during seizure.

The autistic child repeat sounds or words spoken by others.

Depression usually is both emotional & physical. A simple daily routine is the best, least stressful and least anxiety producing.

Loose associations are thoughts that are presented without the logical connections usually necessary for the listening to interpret the message.

The client statement is an example of the use of denial, a defense that blocks problem by unconscious refusing to admit they exist

With depression, there is little or no emotional involvement therefore little alteration in affect.

Open ended questions and silence are strategies used to encourage clients to discuss their problem in descriptive manner.

The nurse would specifically use supportive confrontation with the client to point out discrepancies between what the client states and what actually exists to increase responsibility for self.

Moving to a client’s personal space increases the feeling of threat, which increases anxiety.

Developing insight into his behavior is crucial because it allows the client to understand the root causes of his paranoia and unfounded accusations. By gaining insight, the client can:

Recognize the irrational nature of his thoughts and feelings.

Understand the impact of his behavior on his relationship with his wife and others.

Learn to differentiate between justified concerns and paranoid thoughts.

Identify and work through underlying issues contributing to his distrust, such as low self-esteem, past trauma, or other psychological factors.

Individual with dependent personality disorder typically shows indecisiveness submissiveness and clinging behavior so that others will make decisions with them.

Children who have experienced attachment difficulties with primary caregiver are not able to trust others and therefore relate superficially

These clients often hide food or force vomiting; therefore they must be carefully monitored.

A person with this disorder would not have adequate self-boundaries

Vomiting and diarrhea are usually the late signs of heroin withdrawal, along with muscle spasm, fever, nausea, repetitive, abdominal cramps and backache.

An adult age 31 to 45 generates new level of awareness.