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NCLEX Psychiatric Nursing questions & answers part 4
301. What
is the rationale for a nurse to perform a full physical health assessment on a
client admitted with a diagnosis of major depressive episode?
1. The attention during the assessment is beneficial
in decreasing social isolation.
2. Depression can generate somatic symptoms that can
mask actual physical disorders.
3. Physical health complications are likely to arise
from antidepressant therapy.
4. Depressed clients avoid addressing physical health
and ignore medical problems.
ANS: 2
Rationale: The nurse should determine that a client
with a diagnosis of major depressive episode needs a full physical health assessment,
because depression can generate somatic symptoms that can mask actual physical
disorders.
302. A nurse is planning care for a 13 -year-old who
is experiencing depression. Which medication is approved by the Food and Drug
Administration (FDA) for the treatment of depression in adolescents?
1. Paroxetine (Paxil)
2. Sertraline (Zoloft)
3. Citalopram (Celexa)
4. Escitalopram (Lexipro)
ANS: 4
Rationale: Fluoxetine (Prozac) has been approved by
the FDA to treat depression in children and adolescents, and escitalopram was
approved in 2009 for treatment of depression in adolescents aged 12 to 17
years. All antidepressants carry an FDA warning for increased risk of suicide
in children and adolescents.
303. A nurse admits an older client with memory loss, confused
thinking, and apathy. A psychiatrist suspects a depressive disorder. What is
the rationale for performing a mini-mental status exam?
1. To rule out bipolar disorder
2. To rule out schizophrenia
3. To rule out neurocognitive disorder
4. To rule out personality disorder
ANS: 3
Rationale: A mini-mental status exam should be
performed to rule out neurocognitive disorder. The client may be experiencing
reversible dementia, which can occur as a result of depression.
304. A nurse recently admitted a client to an
inpatient unit after a suicide attempt. A health-care provider orders
amitriptyline (Elavil) for the client. Which intervention, related to this
medication, should be initiated to maintain this client’s safety upon
discharge?
1. Provide a 6-month supply of Elavil to ensure
long-term compliance.
2. Provide a 1-week supply of Elavil, with refills
contingent on follow-up appointments.
3. Provide pill dispenser as a memory aid.
4. Provide education regarding the avoidance of foods
containing tyramine.
ANS: 2
Rationale: The health-care provider should provide no
more than a 1-week supply of amitriptyline, with refills contingent on
follow-up appointments, as an appropriate intervention to maintain the client’s
safety. Antidepressants, which are central nervous system depressants, can be
used to commit suicide. Also these medications can precipitate suicidal
thoughts during the initial use period. Limiting the amount of medication and
monitoring the client weekly would be appropriate interventions to address the
client’s risk for suicide.
305. An older client has recently been prescribed
sertraline (Zoloft). The client’s spouse is taking paroxetine (Paxil). A nurse
assesses that the client is experiencing restlessness, tachycardia,
diaphoresis, and tremors. Which complication should a nurse suspect, and why?
1. Neuroleptic malignant syndrome; caused by ingestion
of two different seratonin reuptake inhibitors (SSRIs)
2. Neuroleptic malignant syndrome; caused by ingestion
of an SSRI and a monoamine oxidase inhibitor (MAOI)
3. Serotonin syndrome; possibly caused by ingestion of
an SSRI and an MAOI
4. Serotonin syndrome; possibly caused by ingestion of
two different SSRIs
ANS: 4
Rationale: The nurse should suspect that the client is
suffering from serotonin syndrome; possibly caused by ingesting two different
SSRI’s (sertraline and paroxetine). Symptoms of serotonin syndrome include
confusion, agitation, tachycardia, hypertension, nausea, abdominal pain,
myoclonus, muscle rigidity, fever, sweating, and tremor.
306. A client who has been taking fluvoxamine (Luvox)
without significant improvement asks a nurse, “I heard about something called a
monoamine oxidase inhibitor (MAOI). Can’t my doctor add that to my
medications?” Which is an appropriate nursing response?
1. “This combination of drugs can lead to delirium
tremens.”
2. “A combination of an MAOI and Luvox can lead to a
life-threatening hypertensive crisis.”
3. “That’s a good idea. There have been good results
with the combination of these two drugs.”
4. “The only disadvantage would be the exorbitant cost
of the MAOI.”
ANS: 2
Rationale: The nurse should explain to the client that
combining an MAOI and fluvoxamine, an SSRI, can lead to a life-threatening
hypertensive crisis. Symptoms of hypertensive crisis include severe occipital
and/or temporal pounding headaches, with occasional photophobia, sensations of
choking, palpitations, and a feeling of “dread.”
307. A number of assessment rating scales are
available for measuring severity of depressive symptoms. Which scale would a
nurse practitioner use to assess a depressed client?
1. Zung Depression Scale
2. Hamilton Depression Rating Scale
3. Beck Depression Inventory
4. AIMS Depression Rating Scale
ANS: 2
Rationale: A number of assessment rating scales are available
for measuring severity of depressive symptoms. Some are meant to be clinician
administered, whereas others may be self-administered. Examples of self-rating
scales include the Zung Self-Rating Depression Scale and the Beck Depression
Inventory. One of the most widely used clinician-administered scales is the
Hamilton Depression Rating Scale. The Abnormal Involuntary Movement Scale
(AIMS) is a rating scale that measures involuntary movements associated with
tardive dyskinesia.
308. The severity of depressive symptoms in the
postpartum period varies from a feeling of the “blues,” to moderate depression,
to psychotic depression or melancholia. Which disorder is correctly matched
with its presenting symptoms?
1. Maternity blues (lack of concentration, agitation,
guilt, and an abnormal attitude toward bodily functions)
2. Postpartum depression (irritability, loss of
libido, sleep disturbances, expresses concern about inability to care for baby)
3. Postpartum melancholia (overprotection of infant,
expresses concern about inability to care for baby, mysophobia)
4. Postpartum depressive psychosis (transient
depressed mood, agitation, abnormal fear of child abduction, suicidal
ideations)
ANS: 2
Rationale: The symptoms of the maternity blues include
tearfulness, despondency, anxiety, and subjectively impaired concentration
appearing in the early puerperium. Symptoms of postpartum depression are
associated with fatigue, irritability, loss of appetite, sleep disturbances,
loss of libido, and expressions of great concern about her inability to care
for her baby. Both postpartum melancholia and postpartum depressive psychosis
are characterized by a lack of interest in, or rejection of, the baby, or a
morbid fear that the baby may be harmed. Other symptoms include depressed mood,
agitation, indecision, lack of concentration, guilt, and an abnormal attitude
toward bodily functions.
309. A staff nurse is counseling a depressed client.
The nurse determines that the client is using the cognitive distortion of
“automatic thoughts.” Which client statement is evidence of the “automatic
thought” of discounting positives?
1. “It’s all my fault for trusting him.”
2. “I don’t play games. I never win.”
3. “She never visits because she thinks I don’t care.”
4. “I don’t have a green thumb. Any old fool can grow
a rose.”
ANS: 4
Rationale: Examples of automatic thoughts in
depression include: Personalizing: “I’m the only one who failed.” All or
nothing: “I’m a complete failure.” Mind reading: “He thinks I’m foolish.”
Discounting positives: “The other questions were so easy. Any dummy could have
gotten them right.”
310. A client, who is taking transdermal selegiline
(Emsam) for depressive symptoms, states, “My physician told me there was no
need to worry about dietary restrictions.” Which would be the most appropriate
nursing response?
1. “Because your dose of Emsam is 6 mg in 24 hours,
dietary restrictions are not recommended.”
2. “You must have misunderstood. An MAOI like Emsam
always has dietary restrictions.”
3. “Only oral MAOIs require dietary restrictions.”
4. “All transdermal MAOIs do not require dietary
modifications.”
ANS: 1
Rationale: Selegiline is a Monoamine Oxidase Inhibitor
(MAOI). Hypertensive crisis, caused by the ingestion of foods high in tyramine,
has not shown to be a problem with selegiline transdermal system at the 6 mg/24
hr dosage, and dietary restrictions at this dose are not recommended. Dietary
modifications are recommended, however, at the 9 mg/24 hr and 12 mg/24 hr
dosages.
311. After 6 months of taking imipramine (Tofranil)
for depressive symptoms, a client complains that the medication doesn’t seem as
effective as before. Which question should the nurse ask to determine the cause
of this problem?
1. “Are you consuming foods high in tyramine?”
2. “How many packs of cigarettes do you smoke daily?”
3. “Do you drink any alcohol?”
4. “Are you taking St. John’s wort?”
ANS: 2
Rationale: Imipramine is a tricyclic antidepressant.
Smoking should be avoided while receiving tricyclic therapy. Smoking increases
the metabolism of tricyclics, requiring an adjustment in dosage to achieve the
therapeutic effect. Alcohol potentiates the effects of antidepressants.
Tyramine is only an issue when MAOI medications are prescribed. Concomitant use
of St. John’s wort and SSRIs, not tricyclics, increases, not decreases the
effects of the drug.
312. A nursing home resident has a diagnosis of
dysthymic disorder. When planning care for this client, which of the following
symptoms should a nurse expect the client to exhibit? (Select all that apply.)
1. Sad mood on most days
2. Mood rating of 2 out of 10 for the past 6 months
3. Labile mood
4. Sad mood for the past 3 years after spouse’s death
5. Pressured speech when communicating
ANS: 1, 4
Rationale: The nurse should anticipate that a client
with a diagnosis of dysthymic disorder would experience a sad mood on most days
for more than two years. The essential feature of dysthymia is a chronically
depressed mood, which can have an early or late onset.
313. An individual experiences sadness and melancholia
in September continuing through November. Which of the following factors should
a nurse identify as most likely to contribute to the etiology of these
symptoms? (Select all that apply.)
1. Gender differences in social opportunities that
occur with age
2. Drastic temperature and barometric pressure changes
3. A seasonal increase in social interactions
4. Variations in serotonergic functioning
5. Inaccessibility of resources for dealing with life
stressors
ANS: 2, 3, 4
Rationale: The nurse should identify drastic
temperature and barometric pressure changes, a seasonal increase in social
interactions, and/or variations in serotonergic functioning as contributing to
the etiology of the client’s symptoms. A number of studies have examined seasonal
patterns associated with mood disorders and have revealed two prevalent periods
of seasonal involvement: spring (March, April, May) and fall (September,
October, November).
314. A client is prescribed phenelzine (Nardil). Which
of the following statements by the client should indicate to a nurse that
discharge teaching about this medication has been successful? (Select all that
apply.)
1. “I’ll have to let my surgeon know about this
medication before I have my cholecystectomy.”
2. “I guess I will have to give up my glass of red
wine with dinner.”
3. “I’ll have to be very careful about reading food
and medication labels.”
4. “I’m going to miss my caffeinated coffee in the
morning.”
5. “I’ll be sure not to stop this medication
abruptly.”
ANS: 1, 2, 3, 5
Rationale: The nurse should evaluate that teaching has
been successful when the client states that phenelzine should not be taken in
conjunction with the use of alcohol or foods high in tyramine and should not be
stopped abruptly. Phenelzine is an MAOI that can have negative interaction with
other medications. The client needs to tell other physicians about taking
MAOIs, because of the risk of drug interactions.
315. A nursing instructor is teaching about the new
DSM-5 diagnostic category of disruptive mood dysregulation disorder (DMDD).
Which of the following information should the instructor include? (Select all
that apply.)
1. Symptoms include verbal rages or physical
aggression toward people or property.
2. Temper outbursts must be present in at least two
settings (at home, at school, or with peers).
3. DMDD is characterized by severe recurrent temper
outbursts.
4. The temper outbursts are manifested only
behaviorally.
5. Symptoms of DMDD must be present for 18 or more
months to meet diagnostic criteria.
ANS: 1, 2, 3
Rationale: The APA has included a new diagnostic
category in the Depressive Disorders chapter of the DSM-5. This childhood
disorder is called disruptive mood dysregulation disorder. Criteria for the
diagnosis include, but are not limited to, the following. Verbal rages or
physical aggression toward people or property; temper outbursts must be present
in at least two settings (at home, at school, or with peers). DMDD is
characterized by severe recurrent temper outbursts. The temper outbursts are
manifested both behaviorally and/or verbally. Symptoms of DMDD must be present
for 12, not 18 or more months to meet diagnostic criteria.
316. A highly agitated client paces the unit and
states, “I could buy and sell this place.” The client’s mood fluctuates from
fits of laughter to outbursts of anger. Which is the most accurate
documentation of this client’s behavior?
1. “Rates mood 8/10. Exhibiting looseness of
association. Euphoric.”
2. “Mood euthymic. Exhibiting magical thinking.
Restless.”
3. “Mood labile. Exhibiting delusions of reference.
Hyperactive.”
4. “Agitated and pacing. Exhibiting grandiosity. Mood
labile.”
ANS: 4
Rationale: The nurse should document that this
client’s behavior is “Agitated and pacing. Exhibiting grandiosity. Mood labile.”
The client is exhibiting mood swings from euphoria to irritability. Grandiosity
refers to the attitude that one’s abilities are better than everyone else’s.
317. A client diagnosed with bipolar disorder is
distraught over insomnia experienced over the last 3 nights and a 12-pound
weight loss over the past 2 weeks. Which should be this client’s priority
nursing diagnosis?
1. Knowledge deficit R/T bipolar disorder AEB concern
about symptoms
2. Altered nutrition: less than body requirements R/T
hyperactivity AEB weight loss
3. Risk for suicide R/T powerlessness AEB insomnia and
anorexia
4. Altered sleep patterns R/T mania AEB insomnia for
the past 3 nights
ANS: 2
Rationale: The nurse should identify that the priority
nursing diagnosis for this client is altered nutrition: less than body
requirements R/T hyperactivity AEB weight loss. Because of the client’s rapid
weight loss, the nurse should prioritize interventions to ensure proper
nutrition and physical health.
318. A nurse is planning care for a client diagnosed
with bipolar disorder: manic episode. In which order should the nurse
prioritize the client outcomes in the exhibit?
Client Outcomes:
1. Maintains nutritional status
2. Interacts appropriately with peers
3. Remains free from injury
4. Sleeps 6 to 8 hours a night
1. 2, 1, 3, 4
2. 4, 1, 2, 3
3. 3, 1, 4, 2
4. 1, 4, 2, 3
ANS: 3
Rationale: The nurse should order client outcomes
based on priority in the following order: Remains free of injury, maintains
nutritional status, sleeps 6 to 8 hours a night, and interacts appropriately
with peers. The nurse should prioritize the client’s safety and physical health
as most important.
319. A client diagnosed with bipolar disorder:
depressive episode intentionally overdoses on sertraline (Zoloft). Family members
report that the client has experienced anorexia, insomnia, and recent job loss.
Which nursing diagnosis should a nurse prioritize?
1. Risk for suicide R/T hopelessness
2. Anxiety: severe R/T hyperactivity
3. Imbalanced nutrition: less than body requirements
R/T refusal to eat
4. Dysfunctional grieving R/T loss of employment
ANS: 1
Rationale: The priority nursing diagnosis for this
client should be risk for suicide R/T hopelessness. The nurse should always
prioritize client safety. This client is at risk for suicide because of his or
her recent suicide attempt.
320. A client diagnosed with bipolar I disorder: manic
episode refuses to take lithium carbonate (Lithobid) because of excessive
weight gain. In order to increase adherence, which medication should a nurse
anticipate that a physician may prescribe?
1. Sertraline (Zoloft)
2. Valproic acid (Depakote)
3. Trazodone (Desyrel)
4. Paroxetine (Paxil)
ANS: 2
Rationale: The nurse should anticipate that the
physician may prescribe valproic acid in order to increase this client’s
medication adherence. Valproic acid is an anticonvulsant medication that can be
used to treat bipolar disorder. One of the side effects of this medication is
weight loss.
321. A client diagnosed with bipolar I disorder is
exhibiting severe manic behaviors. A physician prescribes lithium carbonate
(Eskalith) and olanzapine (Zyprexa). The client’s spouse questions the Zyprexa
order. Which is the appropriate nursing response?
1. “Zyprexa in combination with Eskalith cures manic
symptoms.”
2. “Zyprexa prevents extrapyramidal side effects.”
3. “Zyprexa increases the effectiveness of the immune
system.”
4. “Zyprexa calms hyperactivity until the Eskalith
takes effect.”
ANS: 4
Rationale: The nurse should explain to the client’s
spouse that olanzapine can calm hyperactivity until the lithium carbonate takes
effect. Lithium carbonate may take 1 to 3 weeks to begin to decrease
hyperactivity. Monotherapy with the traditional mood stabilizers like lithium
carbonate, or atypical antipsychotics like olanzapine, has been determined to
be the first-line treatment for bipolar I disorder.
322. A client began taking lithium carbonate
(Lithobid) for the treatment of bipolar disorder approximately 1 month ago. The
client asks if it is normal to have gained 12 pounds in this time frame. Which
is the appropriate nursing response?
1. “That’s strange. Weight loss is the typical
pattern.”
2. “What have you been eating? Weight gain is not
usually associated with lithium.”
3. “Weight gain is a common, but troubling, side
effect.”
4. “Weight gain only occurs during the first month of
treatment with this drug.”
ANS: 3
Rationale: The nurse should explain to the client that
weight gain is a common side effect of lithium carbonate. The nurse should
educate the client on the importance of medication adherence and discuss
concerns with the prescribing physician if the client does not wish to continue
taking the medication.
323. A client diagnosed with bipolar disorder has been
taking lithium carbonate (Lithobid) for one year. The client presents in an
emergency department with a temperature of 101°F (38°C), severe diarrhea,
blurred vision, and tinnitus. How should the nurse interpret these symptoms?
1. Symptoms indicate consumption of foods high in
tyramine.
2. Symptoms indicate lithium carbonate discontinuation
syndrome.
3. Symptoms indicate the development of lithium
carbonate tolerance.
4. Symptoms indicate lithium carbonate toxicity.
ANS: 4
Rationale: The nurse should interpret that the
client’s symptoms indicate lithium carbonate toxicity. The initial signs of
toxicity include ataxia, blurred vision, severe diarrhea, nausea and vomiting,
and tinnitus. Lithium levels should be monitored monthly with maintenance
therapy to ensure proper dosage.
324. What tool should a nurse use to differentiate
occasional spontaneous behaviors of children from behaviors associated with
bipolar disorder?
1. “Risky Activity” tool
2. “FIND” tool
3. “Consensus Committee” tool
4. “Monotherapy” tool
ANS: 2
Rationale: The nurse should use the “FIND” tool to
differentiate occasional spontaneous behaviors of children from behaviors
associated with bipolar disorder. FIND is an acronym that stands for frequency,
intensity, number, and duration and is used to assess behaviors in children.
325. A nursing instructor is discussing various
challenges in the treatment of clients diagnosed with bipolar disorder. Which
student statement demonstrates an understanding of the most critical challenge
in the care of these clients?
1. “Treatment is compromised when clients can’t
sleep.”
2. “Treatment is compromised when irritability
interferes with social interactions.”
3. “Treatment is compromised when clients have no
insight into their problems.”
4. “Treatment is compromised when clients choose not
to take their medications.”
ANS: 4
Rationale: The nursing student is accurate when
stating that the most critical challenge in the care of clients diagnosed with
bipolar disorder is that treatment is often compromised when clients choose not
to take their medications. Clients diagnosed with bipolar disorder feel most
productive and creative during manic episodes. This may lead to purposeful
medication nonadherence. Symptoms of bipolar disorder will reemerge if
medication is stopped.
326. A client is diagnosed with bipolar disorder:
manic episode. Which nursing intervention would be implemented to achieve the
outcome of “Client will gain 2 lb by the end of the week?”
1. Provide client with high-calorie finger foods
throughout the day.
2. Accompany client to cafeteria to encourage adequate
dietary consumption.
3. Initiate total parenteral nutrition to meet dietary
needs.
4. Teach the importance of a varied diet to meet
nutritional needs.
ANS: 1
Rationale: The nurse should provide the client with
high-calorie finger foods throughout the day to help the client achieve the
outcome of gaining 2 lb by the end of the week. Because of the hyperactive
state, the client will have difficulty sitting still to consume large meals.
327. A nursing instructor is teaching about bipolar
disorders. Which statement differentiates the DSM-5 diagnostic criteria of a
manic episode from a hypomanic episode?
1. During a manic episode, clients may experience an
inflated self-esteem or grandiosity, and these symptoms are absent in
hypomania.
2. During a manic episode, clients may experience a
decreased need for sleep, and this symptom is absent in hypomania.
3. During a manic episode, clients may experience
psychosis, and this symptom is absent in hypomania.
4. During a manic episode, clients may experience
flight of ideas and racing thoughts, and these symptoms are absent in
hypomania.
ANS: 3
Rationale: Three or more of the following symptoms may
be experienced in both hypomanic and manic episodes: Inflated self-esteem or
grandiosity, decreased need for sleep (e.g., feels rested after only 3 hours of
sleep), more talkative than usual or pressure to keep talking, flight of ideas
and racing thoughts, distractibility, increase in goal-directed activity
(either socially, at work or school, or sexually) or psychomotor agitation,
excessive involvement in pleasurable activities that have a high potential for
painful consequences (e.g., the person engages in unrestrained buying sprees,
sexual indiscretions, or foolish business investments). If there are psychotic
features, the episode is, by definition, manic.
328. A client has been diagnosed with major depressive
episode. After treatment with fluoxetine (Prozac), the client exhibits
pressured speech and flight of ideas. Based on this symptom change, which
physician action would the nurse anticipate?
1. Increase the dosage of fluoxetine.
2. Discontinue the fluoxetine and rethink the client’s
diagnosis.
3. Order benztropine (Cogentin) to address
extrapyramidal symptoms.
4. Order olanzapine (Zyprexa) to address altered
thoughts.
ANS: 2
Rationale: A full manic episode emerging during
antidepressant treatment (medication, electroconvulsive therapy, etc.), but
persisting beyond the physiological effect of that treatment is sufficient
evidence for a manic episode and, therefore, a Bipolar I diagnosis.
329. Which is the basic premise of a recovery model
used to treat clients diagnosed with bipolar disorder?
1. Medication adherence
2. Empowerment of the consumer
3. Total absence of symptoms
4. Improved psychosocial relationships
ANS: 2
Rationale: The basic premise of a recovery model is
empowerment of the consumer. The recovery model is designed to allow consumers
primary control over decisions about their own care and to enable a person with
a mental health problem to live a meaningful life in a community of his or her
choice while striving to achieve his or her full potential.
330. Which of the following instructions regarding
lithium therapy should be included in a nurse’s discharge teaching? (Select all
that apply.)
1. Avoid excessive use of beverages containing
caffeine.
2. Maintain a consistent sodium intake.
3. Consume at least 2,500 to 3,000 mL of fluid per
day.
4. Restrict sodium content.
5. Restrict fluids to 1,500 mL per day.
ANS: 1, 2, 3
Rationale: The nurse should instruct the client taking
lithium to avoid excessive use of caffeine, maintain a consistent sodium
intake, and consume at least 2,500 to 3,000 mL of fluid per day. The risk of
developing lithium toxicity is high because of the narrow margin between
therapeutic doses and toxic levels. Fluid or sodium restriction can impact
lithium levels.
331. A nurse is assessing an adolescent client
diagnosed with cyclothymic disorder. Which of the following DSM-5 diagnostic
criteria would the nurse expect this client to meet? (Select all that apply.)
1. Symptoms lasting for a minimum of two years
2. Numerous periods with manic symptoms
3. Possible comorbid diagnosis of a delusional
disorder
4. Symptoms cause clinically significant impairment in
important areas of functioning
5. Depressive symptoms that do not meet the criteria
for major depressive episode
ANS: 4, 5
Rationale: The following are selected criteria for the
diagnosis of cyclothymic disorder. For at least one year in children and
adolescents there have been numerous periods with hypomanic, not manic symptoms
that do not meet criteria for hypomanic episode and numerous periods with
depressive symptoms that do not meet the criteria for a major depressive
episode. The symptoms are not better accounted for by schizoaffective disorder
and are not superimposed on schizophrenia, schizophreniform disorder,
delusional disorder, or psychotic disorder not elsewhere classified. The
symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
332. Which of the following rationales by a nurse
explain to parents why is it difficult to diagnose a child or adolescent
exhibiting symptoms of bipolar disorder? (Select all that apply.)
1. Bipolar symptoms mimic attention
deficit-hyperactivity disorder symptoms.
2. Children are naturally active, energetic, and
spontaneous.
3. Neurotransmitter levels vary considerably in
accordance with age.
4. The diagnosis of bipolar disorder cannot be
assigned prior to the age of 18.
5. Genetic predisposition is not a reliable diagnostic
determinant.
ANS: 1, 2
Rationale: It is difficult to diagnose a child or
adolescent with bipolar disorder, because bipolar symptoms mimic attention
deficit-hyperactivity disorder symptoms and because children are naturally
active, energetic, and spontaneous. Symptoms may also be comorbid with other
childhood disorders, such as conduct disorder
333. Family dynamics are thought to be a major
influence in the development of anorexia nervosa. Which statement regarding a
client’s home environment should a nurse associate with the development of
anorexia nervosa?
1. The home environment maintains loose personal
boundaries.
2. The home environment places an overemphasis on
food.
3. The home environment is overprotective and demands
perfection.
4. The home environment condones corporal punishment.
ANS: 3
Rationale: The nurse should assess that a home
environment that is overprotective and demands perfection may be a major
influence in the development of anorexia nervosa. In adolescence, distorted
eating patterns may represent a rebellion against the parents viewed by the
child as a means of gaining and remaining in control.
334. A client’s altered body image is evidenced by
claims of “feeling fat,” even though the client is emaciated. Which is the
appropriate outcome criterion for this client’s problem?
1. The client will consume adequate calories to
sustain normal weight.
2. The client will cease strenuous exercise programs.
3. The client will perceive personal ideal body weight
and shape as normal.
4. The client will not express a preoccupation with
food.
ANS: 3
Rationale: The nurse should identify that the
appropriate outcome for this client is to perceive personal ideal body weight
and shape as normal. Additional goals include accepting self based on
self-attributes instead of appearance and to realize that perfection is
unrealistic.
335. A nurse is counseling a client diagnosed with
bulimia nervosa about the symptom of tooth enamel deterioration. Which
explanation for this complication of bulimia nervosa, should the nurse provide?
1. The emesis produced during purging is acidic and
corrodes the tooth enamel.
2. Purging causes the depletion of dietary calcium.
3. Food is rapidly ingested without proper
mastication.
4. Poor dental and oral hygiene leads to dental
caries.
ANS: 1
Rationale: The nurse should explain to the client
diagnosed with bulimia nervosa that his or her teeth will eventually
deteriorate, because the emesis produced during purging is acidic and corrodes
the tooth enamel. Excessive vomiting may also lead to dehydration and
electrolyte imbalance.
336. A nurse is teaching a client diagnosed with an
eating disorder about behavior-modification programs. Why is this intervention
the treatment of choice?
1. It helps the client correct a distorted body image.
2. It addresses the underlying client anger.
3. It manages the client’s uncontrollable behaviors.
4. It allows clients to maintain control.
ANS: 4
Rationale: Behavior-modification programs are the
treatment of choice for clients diagnosed with eating disorders, because these
programs allow clients to maintain control. Issues of control are central to
the etiology of these disorders. Behavior modification techniques function to restore
healthy weight.
337. A potential Olympic figure skater collapses
during practice and is hospitalized for severe malnutrition. Anorexia nervosa
is diagnosed. Which client statement best reflects insight related to this
disorder?
1. “Skaters need to be thin to improve their daily
performance.”
2. “All the skaters on the team are following an
approved 1200-calorie diet.”
3. “The exercise of skating reduces my appetite but
improves my energy level.”
4. “I am angry at my mother. I can only get her
approval when I win competitions.”
ANS: 4
Rationale: The client reflects insight when referring
to feelings toward family dynamics that may have influenced the development of
the disease. Families who are overprotective and perfectionistic can contribute
to the development of anorexia nervosa.
338. The family of a client diagnosed with anorexia
nervosa becomes defensive when the treatment team calls for a family meeting.
Which is the appropriate nursing response?
1. “Tell me why this family meeting is causing you to
be defensive. All clients are required to participate in two family sessions.”
2. “Eating disorders have been correlated to certain
familial patterns; without addressing these, your child’s condition will not
improve.”
3. “Family dynamics are not linked to eating
disorders. The meeting is to provide your child with family support.”
4. “Clients diagnosed with anorexia nervosa are part
of the family system, and any alteration in family processes needs to be
addressed.”
ANS: 2
Rationale: The nurse should educate the family on the
correlation between certain familial patterns and anorexia nervosa. Families
engaging in conflict avoidance and struggling with issues of power and control
may contribute to the development of anorexia nervosa.
339. A client diagnosed with bulimia nervosa has been
attending a mental health clinic for several months. Which factor should a
nurse identify as an appropriate indicator of a positive client behavioral
change?
1. The client gained two pounds in one week.
2. The client focused conversations on nutritious
food.
3. The client demonstrated healthy coping mechanisms
that decreased anxiety.
4. The client verbalized an understanding of the
etiology of the disorder.
ANS: 3
Rationale: The nurse should identify that a client who
demonstrates healthy coping mechanisms to decrease anxiety indicates a positive
behavioral change. Stress and anxiety can increase bingeing, which is followed
by inappropriate compensatory behavior.
340. A morbidly obese client is prescribed an
anorexiant medication. The nurse should expect to teach the client about which
medication?
1. Phentermine (Mirapront)
2. Dexfenfluramine (Redux)
3. Sibutramine (Meridia)
4. Pemoline (Cylert)
ANS: 1
Rationale: The nurse should teach the client that
phentermine is an anorexiant medication prescribed for morbidly obese clients.
Phentermine works on the hypothalamus to stimulate the adrenal glands to
release norepinephrine, a neurotransmitter that signals a fight-or-flight
response, reducing hunger. Dexfenfluramine has been removed from the market
because of its association with serious heart and lung disease. Several deaths
have been associated with the use of sibutramine by high-risk clients. Based on
pressure from the FDA, the manufacturer issued a recall of the drug in October
2010. Withdrawal from anorexiants can result in rebound weight gain, lethargy,
and depression.
341. A nurse is attempting to differentiate between
the symptoms of anorexia nervosa and the symptoms of bulimia. Which statement
delineates the difference between these two disorders?
1. Clients diagnosed with anorexia nervosa experience
extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do
not.
2. Clients diagnosed with bulimia nervosa experience
amenorrhea, whereas clients diagnosed with anorexia nervosa do not.
3. Clients diagnosed with bulimia nervosa experience
hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa
do not.
4. Clients diagnosed with anorexia nervosa have eroded
tooth enamel, whereas clients diagnosed with bulimia nervosa do not.
ANS: 1
Rationale: The nurse should understand that clients
diagnosed with anorexia nervosa experience nutritional deficits, whereas
clients diagnosed with bulimia do not. Anorexia is characterized by a morbid
fear of obesity and often results in low caloric and nutritional intake.
Bulimia is characterized by episodic, rapid consumption of large quantities of
food followed by purging.
342. A client diagnosed with a history of anorexia
nervosa comes to an outpatient clinic after being medically cleared. The client
states, “My parents watch me like a hawk and never let me out of their sight.”
Which nursing diagnosis would take priority at this time?
1. Altered nutrition less than body requirements
2. Altered social interaction
3. Impaired verbal communication
4. Altered family processes
ANS: 4
Rationale: The nurse should determine that once the
client has been medically cleared, the diagnosis of altered family process
should take priority. Clients diagnosed with anorexia nervosa have a need to
control and feel in charge of their own treatment choices.
Behavioral-modification therapy allows the client to maintain control of
eating.
343. A nurse should identify topiramate (Topamax) as
the drug of choice for which of the following conditions? (Select all that
apply.)
1. Binge eating with a diagnosis of obesity
2. Bingeing and purging with a diagnosis of bulimia
nervosa
3. Weight loss with a diagnosis of anorexia nervosa
4. Amenorrhea with a diagnosis of anorexia nervosa
5. Emaciation with a diagnosis of bulimia nervosa
ANS: 1, 2
Rationale: The nurse should identify that topiramate
is the drug of choice when treating binge eating with a diagnosis of obesity or
bingeing and purging with a diagnosis of bulimia nervosa. Topiramate is an
anticonvulsant that produces a significant decline in binge frequency and
reduction in body weight.
344. A nursing instructor is teaching about the DSM-5
criteria for the diagnosis of binge-eating disorder. Which of the following
student statements indicates that further instruction is needed? (Select all
that apply.)
1. “In this disorder, binge eating occurs exclusively
during the course of bulimia nervosa.”
2. “In this disorder, binge eating occurs, on average,
at least once a week for three months.”
3. “In this disorder, binge eating occurs, on average,
at least two days a week for six months.”
4. “In this disorder, distress regarding binge eating
is present.”
5. “In this disorder, distress regarding binge eating
is absent.”
ANS: 1, 3, 5
Rationale: According to the DSM-5 criteria for the
diagnosis of binge-eating disorder, binge eating should not occur exclusively
during the course of anorexia nervosa or bulimia nervosa. The new time frame
criteria in the DSM-5 states that binge eating must occur, on average, at least
once a week for three months not two days a week for six months. The DSM-5
criteria states that distress regarding binge eating would be present.
345. Which of the following would contribute to a
client’s excessive weight gain? (Select all that apply.)
1. A hypothalamus lesion
2. Hyperthyroidism
3. Diabetes mellitus
4. Cushing’s disease
5. Low levels of serotonin
ANS: 1, 3, 4
Rationale: Lesions in the appetite and satiety centers
in the hypothalamus may contribute to overeating and lead to obesity.
Hypothyroidism, not hyperthyroidism, is a problem that interferes with basal
metabolism and may lead to weight gain. Weight gain can also occur in response
to the decreased insulin production of diabetes mellitus and the increased
cortisone production of Cushing’s disease. New evidence also exists to indicate
that low levels of the neurotransmitter serotonin may play a role in compulsive
eating.
346. Which developmental characteristic should a nurse
identify as typical of a client diagnosed with severe intellectual
developmental disorder (IDD)?
1. The client can perform some self-care activities
independently.
2. The client has more advanced speech development.
3. Other than possible coordination problems, the
client’s psychomotor skills are not affected.
4. The client communicates wants and needs by “acting
out” behaviors.
ANS: 4
Rationale: The nurse should identify that a client
diagnosed with severe IDD may communicate wants and needs by “acting out”
behaviors. Severe IDD indicates an IQ between 20 and 34. Individuals diagnosed
with severe IDD require complete supervision and have minimal verbal skills and
poor psychomotor development.
347. Which nursing intervention related to self-care
would be most appropriate for a teenager diagnosed with moderate IDD?
1. Meeting all of the client’s self-care needs to
avoid injury to the client
2. Providing simple directions and praising client’s
independent self-care efforts
3. Avoid interfering with the client’s self-care
efforts in order to promote autonomy
4. Encouraging family to meet the client’s self-care
needs to promote bonding
ANS: 2
Rationale: Providing simple directions and praise is
an appropriate intervention for a teenager diagnosed with moderate IDD.
Individuals with moderate mental retardation can perform some activities
independently and may be capable of academic skill to a second-grade level.
348. A child has been diagnosed with autistic spectrum
disorder. The distraught mother cries out, “I’m such a terrible mother. What
did I do to cause this?” Which nursing response is most appropriate?
1. “Researchers really don’t know what causes autistic
spectrum disorder, but the relationship between autistic disorder and fetal
alcohol syndrome is being explored.”
2. “Poor parenting doesn’t cause autistic spectrum
disorder. Research has shown that abnormalities in brain structure or function
are to blame. This is beyond your control.”
3. “Research has shown that the mother appears to play
a greater role in the development of autistic spectrum disorder than the
father.”
4. “Lack of early infant bonding with the mother has
shown to be a cause of autistic spectrum disorder. Did you breastfeed or
bottle-feed?”
ANS: 2
Rationale: The most appropriate response by the nurse
is to explain to the parent that autistic spectrum disorder is believed to be
caused by abnormalities in brain structure or function, not poor parenting.
Autism occurs in approximately 11.3 per 1,000 children and is about 4.5 times
more likely to occur in boys than girls.
349. In planning care for a child diagnosed with
autistic spectrum disorder, which would be a realistic client outcome?
1. The client will communicate all needs verbally by
discharge.
2. The client will participate with peers in a team
sport by day four.
3. The client will establish trust with at least one
caregiver by day five.
4. The client will perform most self-care tasks
independently.
ANS: 3
Rationale: The most realistic client outcome for a
child diagnosed with autistic spectrum disorder is for the client to establish
trust with at least one caregiver. Trust should be evidenced by facial
responsiveness and eye contact. This outcome relates to the nursing diagnosis
impaired social interaction.
350. After an adolescent diagnosed with attention
deficit-hyperactivity disorder (ADHD) begins methylphenidate (Ritalin) therapy,
a nurse notes that the adolescent loses 10 pounds in a 2-month period. What is
the best explanation for this weight loss?
1. The pharmacological action of Ritalin causes a
decrease in appetite.
2. Hyperactivity seen in ADHD causes increased caloric
expenditure.
3. Side effects of Ritalin cause nausea, and,
therefore, caloric intake is decreased.
4. Increased ability to concentrate allows the client
to focus on activities rather than food.
ANS: 1
Rationale: The pharmacological action of Ritalin
causes a decrease in appetite, which often leads to weight loss.
Methylphenidate is a central nervous symptom stimulant that serves to increase
attention span, control hyperactive behaviors, and improve learning ability.
351. A nurse assesses an adolescent client diagnosed
with conduct disorder who, at the age of 8, was sentenced to juvenile
detention. How should the nurse interpret this assessment data?
1. Childhood-onset conduct disorder is more severe
than the adolescent-onset type, and these individuals likely develop antisocial
personality disorder in adulthood.
2. Childhood-onset conduct disorder is caused by a
difficult temperament, and the child is likely to outgrow these behaviors by adulthood.
3. Childhood-onset conduct disorder is diagnosed only
when behaviors emerge before the age of 5, and, therefore, improvement is
likely.
4. Childhood-onset conduct disorder has no treatment
or cure, and children diagnosed with this disorder are likely to develop
progressive oppositional defiant disorder.
ANS: 1
Rationale: The nurse should determine that
childhood-onset conduct disorder is more severe than adolescent-onset type.
These individuals are likely to develop antisocial personality disorder in
adulthood. Individuals with this subtype are usually boys and frequently
display physical aggression and have disturbed peer relationships.
352. Which finding should a nurse expect when
assessing a child diagnosed with separation anxiety disorder?
1. The child has a history of antisocial behaviors.
2. The child’s mother is diagnosed with an anxiety
disorder.
3. The child previously had an extroverted
temperament.
4. The child’s mother and father have an inconsistent
parenting style.
ANS: 2
Rationale: The nurse should expect to find a mother
diagnosed with an anxiety disorder when assessing a child with separation
anxiety. Some parents instill anxiety in their children by being overprotective
or by exaggerating dangers. Research studies speculate that there is a
hereditary influence in the development of separation anxiety disorder.
353. A child has been recently diagnosed with mild
IDD. What information about this diagnosis should the nurse include when
teaching the child’s mother?
1. Children with mild IDD need constant supervision.
2. Children with mild IDD develop academic skills up
to a sixth-grade level.
3. Children with mild IDD appear different from their
peers.
4. Children with mild IDD have significant
sensory-motor impairment.
ANS: 2
Rationale: The nurse should inform the child’s mother
that children with mild IDD develop academic skills up to a sixth-grade level.
Individuals with mild IDD are capable of independent living, capable of
developing social skills, and have normal psychomotor skills.
354. A nursing instructor is teaching about the
developmental characteristics of clients diagnosed with moderate intellectual
developmental disorder (IDD). Which student statement indicates that further
instruction is needed?
1. “These clients can work in a sheltered workshop
setting.”
2. “These clients can perform some personal care
activities.”
3. “These clients may have difficulties relating to
peers.”
4. “These clients can successfully complete elementary
school.”
ANS: 4
Rationale: The nursing student needs further
instruction about moderate IDD, because individuals diagnosed with moderate IDD
are capable of academic skill up to a second-grade level. Moderate IDD reflects
an IQ range of 35 to 49.
355. A preschool child is admitted to a psychiatric unit
with the diagnosis autistic spectrum disorder. To help the child feel more
secure on the unit, which intervention should a nurse include in this client’s
plan of care?
1. Encourage and reward peer contact.
2. Provide consistent caregivers.
3. Provide a variety of safe daily activities.
4. Maintain close physical contact throughout the day.
ANS: 2
Rationale: The nurse should provide consistent
caregivers as part of the plan of care for a child diagnosed with autistic
spectrum disorder. Children diagnosed with autistic spectrum disorder have an
inability to trust. Providing consistent caregivers allows the client to
develop trust and a sense of security.
356. A preschool child diagnosed with autistic
spectrum disorder has been engaging in constant head-banging behavior. Which
nursing intervention is appropriate?
1. Place client in restraints until the aggression
subsides.
2. Sedate the client with neuroleptic medications.
3. Hold client’s head steady and apply a helmet.
4. Distract the client with a variety of games and
puzzles.
ANS: 3
Rationale: The most appropriate intervention for head
banging is to hold the client’s head steady and apply a helmet. The helmet is
the least restrictive intervention and will serve to protect the client’s head
from injury.
357. When planning care for a client, which medication
classification should a nurse recognize as effective in the treatment of
Tourette’s syndrome?
1. Neuroleptic medications
2. Anti-manic medications
3. Tricyclic antidepressant medications
4. Monoamine oxidase inhibitor medications
ANS: 1
Rationale: The nurse should recognize that neuroleptic
(antipsychotic) medications are effective in the treatment of Tourette’s
syndrome. These medications are used to reduce the severity of tics and are
most effective when combined with psychosocial therapy.
358. Which behavioral approach should a nurse use when
caring for children diagnosed with disruptive behavior disorders?
1. Involving parents in designing and implementing the
treatment process
2. Reinforcing positive actions to encourage
repetition of desirable behaviors
3. Providing opportunities to learn appropriate peer
interactions
4. Administering psychotropic medications to improve
quality of life
ANS: 2
Rationale: The nurse should reinforce positive actions
to encourage repetition of desirable behaviors when caring for children
diagnosed with disruptive behavior disorder. Behavior therapy is based on the
concepts of classical conditioning and operant conditioning.
359. A child diagnosed with severe autistic spectrum
disorder has the nursing diagnosis disturbed personal identity. Which outcome
would best address this client diagnosis?
1. The client will name own body parts as separate
from others by day five.
2. The client will establish a means of communicating
personal needs by discharge.
3. The client will initiate social interactions with
caregivers by day four.
4. The client will not harm self or others by
discharge.
ANS: 1
Rationale: An appropriate outcome for this client is
to name own body parts as separate from others. The nurse should assist the
client in the recognition of separateness during self-care activities, such as
dressing and feeding. The long-term goal for disturbed personal identity is for
the client to develop an ego identity.
360. A nursing instructor presents a case study in
which a three-year-old child is in constant motion and is unable to sit still
during story time. She asks a student to evaluate this child’s behavior. Which
student response indicates an appropriate evaluation of the situation?
1. “This child’s behavior must be evaluated according
to developmental norms.”
2. “This child has symptoms of attention
deficit-hyperactivity disorder.”
3. “This child has symptoms of the early stages of
autistic disorder.”
4. “This child’s behavior indicates possible symptoms
of oppositional defiant disorder.”
ANS: 1
Rationale: The student’s evaluation of the situation
is appropriate when indicating a need for the client to be evaluated according
to developmental norms. The DSM-5 indicates that emotional problems exist if
the behavioral manifestations are not age-appropriate, deviate from cultural
norms, or create deficits or impairments in adaptive functioning.
361. A client has an IQ of 47. Which nursing diagnosis
best addresses a client problem associated with this degree of IDD?
1. Risk for injury R/T self-mutilation
2. Altered social interaction R/T non-adherence to
social convention
3. Altered verbal communication R/T delusional
thinking
4. Social isolation R/T severely decreased gross motor
skills
ANS: 2
Rationale: The appropriate nursing diagnosis
associated with this degree of IDD is altered social interaction R/T
non-adherence to social convention. A client with an IQ of 47 would be
diagnosed with moderate intellectual developmental disorder and may also
experience some limitations in speech communications.
362. A physician orders methylphenidate (Ritalin) for
a child diagnosed with ADHD. Which information about this medication should the
nurse provide to the parents?
1. If one dose of Ritalin is missed, double the next
dose.
2. Administer Ritalin to the child after breakfast.
3. Administer Ritalin to the child just prior to
bedtime.
4. A side effect of Ritalin is decreased ability to
learn.
ANS: 2
Rationale: The nurse should instruct the parents to
administer Ritalin to the child after breakfast. Ritalin is a central nervous
system stimulant and can cause decreased appetite. Central nervous system
stimulants can also temporarily interrupt growth and development.
363. Which should be the priority nursing intervention
when caring for a child diagnosed with conduct disorder?
1. Modify environment to decrease stimulation and
provide opportunities for quiet reflection.
2. Convey unconditional acceptance and positive
regard.
3. Recognize escalating aggressive behavior and
intervene before violence occurs.
4. Provide immediate positive feedback for appropriate
behaviors.
ANS: 3
Rationale: The priority nursing intervention when
caring for a child diagnosed with conduct disorder should be to recognize
escalating aggressive behavior and to intervene before violence occurs. This
intervention serves to keep the client as well as others safe, which is the
priority nursing concern.
364. A mother questions the decreased effectiveness of
methylphenidate (Ritalin), prescribed for her child’s ADHD. Which nursing
response best addresses the mother’s concern?
1. “The physician will probably switch from Ritalin to
a central nervous system stimulant.”
2. “The physician may prescribe an antihistamine with
the Ritalin to improve effectiveness.”
3. “Your child has probably developed a tolerance to
Ritalin and may need a higher dosage.”
4. “Your child has developed sensitivity to Ritalin
and may be exhibiting an allergy.”
ANS: 3
Rationale: The nurse should explain to the mother that
the child has probably developed a tolerance to Ritalin and may need a higher
dosage. Methylphenidate is a central nervous system stimulant, and tolerance
can develop rapidly. Physical and psychological dependence can also occur.
365. After studying the DSM-5 criteria for
oppositional defiant disorder (ODD), which listed symptom would a student nurse
recognize?
1. Arguing and annoying older sibling over the past
year
2. Angry and resentful behavior over a three-month
period
3. Initiating physical fights for more than 18 months
4. Arguing with authority figures for more than six
months
ANS: 4
Rationale: The DSM-5 rules out the diagnosis of ODD
when only siblings are involved in argumentative interactions. Angry and
resentful behavior over more than six months, not three months, would be
considered a symptom of ODD. Initiating physical fights is a symptom of conduct
disorder, not ODD. Arguing with authority figures for more than six months is
listed by the DSM-5 as a symptom for the diagnosis of ODD.
366. Which of the following risk factors, if noted
during a family history assessment, should a nurse associate with the
development of IDD? (Select all that apply.)
1. A family history of Tay-Sachs disease
2. Childhood meningococcal infection
3. Deprivation of nurturance and social contact
4. History of maternal multiple motor and verbal tics
5. A diagnosis of maternal major depressive disorder
ANS: 1, 2, 3
Rationale: The nurse should recognize a family history
of Tay-Sachs disease, childhood meningococcal infections, and deprivation of
nurturance and social contact as risk factors that would predispose a child to
IDD. There are five major predisposing factors of IDD: hereditary factors,
early alterations in embryonic development, pregnancy and perinatal factors,
medical conditions acquired in infancy or childhood, and environmental
influences and other mental disorders.
367. Which of the following findings should a nurse
identify that would contribute to a client’s development of ADHD? (Select all
that apply.)
1. The client’s father was a smoker.
2. The client was born 7 weeks premature.
3. The client is lactose intolerant.
4. The client has a sibling diagnosed with ADHD.
5. The client has been diagnosed with dyslexia.
ANS: 2, 4
Rationale: The nurse should identify that premature
birth and having a sibling diagnosed with ADHD would predispose a client to the
development of ADHD. Research indicates evidence of genetic influences in the
etiology of ADHD. Studies also indicate that environmental influences, such as
lead exposure and diet, can be linked with the development of ADHD.
368. A geriatric nurse is teaching the client’s family
about the possible cause of delirium. Which statement by the nurse is most
accurate?
1. “Taking multiple medications may lead to adverse
interactions or toxicity.”
2. “Age-related cognitive changes may lead to
alterations in mental status.”
3. “Lack of rigorous exercise may lead to decreased
cerebral blood flow.”
4. “Decreased social interaction may lead to profound
isolation and psychosis.”
ANS: 1
Rationale: The nurse should identify that taking
multiple medications that may lead to adverse reactions or toxicity is a risk
factor for the development of delirium in older adults. Symptoms of delirium
include difficulty sustaining and shifting attention. The client with delirium
is disoriented to time and place and may also have impaired memory.
369. A husband has agreed to admit his spouse,
diagnosed with Alzheimer’s disease (AD), to a long-term care facility. He is
expressing feelings of guilt and symptoms of depression. Which appropriate
nursing diagnosis and subsequent intervention would the nurse document?
1. Dysfunctional grieving; AD support group
2. Altered thought process; AD support group
3. Major depressive episode; psychiatric referral
4. Caregiver role strain; psychiatric referral
ANS: 1
Rationale: The most appropriate nursing diagnosis and
intervention for the husband is dysfunctional grieving; AD support group.
Clients with AD are often at risk for trauma and have significant self-care
deficits that require more care than a spouse may be able to provide.
370. A client diagnosed with vascular neurocognitive
disorder (NCD) is discharged to home under the care of his wife. Which
information should cause the nurse to question the client’s safety?
1. His wife works from home in telecommunication.
2. The client has worked the nightshift his entire
career.
3. His wife has minimal family support.
4. The client smokes one pack of cigarettes per day.
ANS: 4
Rationale: The nurse should question the client’s
safety at home if the client smokes cigarettes. Vascular NCD is a clinical
syndrome of NCD due to significant cerebrovascular disease. The cause of
vascular NCD is related to an interruption of blood flow to the brain.
Hypertension is a significant factor in the etiology.
371. A client diagnosed with AD can no longer
ambulate, does not recognize family members, and communicates with agitated
behaviors and incoherent verbalizations. The nurse recognizes these symptoms as
indicative of which stage of the illness?
1. Stage 4: Mild-to-Moderate Cognitive Decline
2. Stage 5. Moderate Cognitive Decline
3. Stage 6. Moderate-to-Severe Cognitive Decline
4. Stage 7. Severe Cognitive Decline
ANS: 4
Rationale: The nurse should recognize that a client
exhibiting these symptoms is in the severe cognitive decline, seventh stage, of
AD.
372. A client is diagnosed in stage seven of AD. To
address the client’s symptoms, which nursing intervention should take priority?
1. Improve cognitive status by encouraging involvement
in social activities.
2. Decrease social isolation by providing group
therapies.
3. Promote dignity by providing comfort, safety, and
self-care measures.
4. Facilitate communication by providing assistive devices.
ANS: 3
Rationale: The most appropriate intervention in the
seventh stage of AD is to promote the client’s dignity by providing comfort,
safety, and self-care measures. Stage is characterized by severe cognitive
decline in which the client is unable to recognize family members and is most
commonly bedfast and aphasic.
373. Which is the reason for the proliferation of the
diagnosis of NCDs?
1. Increased numbers of neurotransmitters has been
implicated in the proliferation of NCD.
2. Similar symptoms of NCD and depression lead to
misdiagnoses, increasing numbers of NCD.
3. Societal stress contributes to the increase in this
diagnosis.
4. More people now survive into the high-risk period
for neurocognitive disorders.
ANS: 4
Rationale: The proliferation of NCD has occurred
because more people now survive into the high-risk period for neurocognitive
disorder, which is middle age and beyond..
374. A client diagnosed recently with AD is prescribed
donepezil (Aricept). The client’s spouse inquires, “How does this work? Will
this cure him?” Which is the appropriate nursing response?
1. “This medication delays the destruction of
acetylcholine, a chemical in the brain necessary for memory processes. Although
most effective in the early stages, it serves to delay, but not stop, the
progression of the disease.”
2. “This medication encourages production of
acetylcholine, a chemical in the brain necessary for memory processes. It
delays the progression of the disease.”
3. “This medication delays the destruction of
dopamine, a chemical in the brain necessary for memory processes. Although most
effective in the early stages, it serves to delay, but not stop, the
progression of the disease.”
4. “This medication encourages production of dopamine,
a chemical in the brain necessary for memory processes. It delays the
progression of the disease.”
ANS: 1
Rationale: The most appropriate response by the nurse
is to explain that donepezil delays the destruction of acetylcholine, a
chemical in the brain necessary for memory processes. Although most effective
in the early stages, it serves to delay, but not stop, the progression of the
AD. Some side effects include dizziness, headache, gastrointestinal upset, and
elevated transaminase.
375. Which symptom should a nurse identify that
differentiates clients diagnosed with NCDs from clients diagnosed with mood
disorders?
1. Altered sleep
2. Altered concentration
3. Impaired memory
4. Impaired psychomotor activity
ANS: 3
Rationale: The nurse should identify that impaired
memory is a symptom that occurs in NCD and not in mood disorders.
Neurocognitive disorder is classified in the DSM-5 as either mild or major,
with the distinction primarily being one of severity of symptomatology.
376. A client diagnosed with AD exhibits progressive
memory loss, diminished cognitive functioning, and verbal aggression upon
experiencing frustration. Which nursing intervention is most appropriate?
1. Organize a group activity to present reality.
2. Minimize environmental lighting.
3. Schedule structured daily routines.
4. Explain the consequences for aggressive behaviors.
ANS: 3
Rationale: The most appropriate nursing intervention
for this client is to schedule structured daily routines. A structured routine
will reduce frustration and thereby reduce verbal aggression.
377. After one week of continuous mental confusion, an
older African American client is admitted with a preliminary diagnosis of AD.
What should cause the nurse to question this diagnosis?
1. AD does not typically occur in African American
clients.
2. The symptoms presented are more indicative of
Parkinsonism.
3. AD does not develop suddenly.
4. There has been no T3- or T4-level evaluation
ordered.
ANS: 3
Rationale: The nurse should recognize that AD does not
develop suddenly and should question this diagnosis. The onset of AD symptoms
is slow and insidious. The disease is generally progressive and deteriorating.
378. A client diagnosed with AD has impairments of
memory and judgment and is incapable of performing activities of daily living.
Which nursing intervention should take priority?
1. Present evidence of objective reality to improve
cognition.
2. Design a bulletin board to represent the current
season.
3. Label the client’s room with name and number.
4. Assist with bathing and toileting.
ANS: 4
Rationale: The priority nursing intervention for this
client is to assist with bathing and toileting. A client who is incapable of
performing activities of daily living requires assistance in these areas to
ensure health and safety.
379. A client diagnosed with major NCD is exhibiting
behavioral problems on a daily basis. At change of shift, the client’s behavior
escalates from pacing to screaming and flailing. Which action should be a
nursing priority?
1. Consult the psychologist regarding
behavior-modification techniques.
2. Medicate the client with prn antianxiety
medications.
3. Assess environmental triggers and potential unmet
needs.
4. Anticipate the behavior and restrain when pacing
begins.
ANS: 2
Rationale: The priority nursing action is to first
medicate the client to avoid injury to self or others. It is important to
assess environmental triggers and potential unmet needs in order to address
these problems in the future, but interventions to ensure safety must take
priority. Because of the cognitive decline experienced in clients diagnosed
with this disorder, communication skills and orientation may limit assessment
and teaching interventions.
380. A client with a history of cerebrovascular
accident (CVA) is brought to an emergency department experiencing memory
problems, confusion, and disorientation. Based on this client’s assessment
data, which diagnosis would the nurse expect the physician to assign?
1. Delirium due to adverse effects of cardiac
medications
2. Vascular neurocognitive disorder
3. Altered thought processes
4. Alzheimer’s disease
ANS: 2
Rationale: The nurse should expect that the client
will be diagnosed with vascular NCD, which is caused by significant cerebrovascular
disease. Vascular NCD often has an abrupt onset. Progression of this disease
often occurs in a fluctuating pattern.
381. An older client has recently moved to a nursing
home. The client has trouble concentrating and socially isolates. A physician
believes the client would benefit from medication therapy. Which medication
should the nurse expect the physician to prescribe?
1. Haloperidol (Haldol)
2. Donepezil (Aricept)
3. Diazepam (Valium)
4. Sertraline (Zoloft)
ANS: 4
Rationale: The nurse should expect the physician to
prescribe sertraline to improve the client’s social functioning and
concentration levels. Sertraline is an selective serotonin reuptake inhibitor
(SSRI) antidepressant. Depression is the most common mental illness in older
adults and is often misdiagnosed as a neurocognitive disorder.
382. A client diagnosed with NCD is disoriented and
ataxic and wanders. Which is the priority nursing diagnosis?
1. Disturbed thought processes
2. Self-care deficit
3. Risk for injury
4. Altered health-care maintenance
ANS: 3
Rationale: The priority nursing diagnosis for this
client is risk for injury. The client who is ataxic suffers from motor
coordination deficits and is at an increased risk for falls. Clients that
wander are at a higher risk for injury.
383. Which statement accurately differentiates mild
NCD from major NCD?
1. Major NCD involves disorientation that develops
suddenly, whereas mild NCD develops more slowly.
2. Major NCD involves impairment of abstract thinking
and judgment, whereas mild NCD does not.
3. Major NCD criteria requires substantial cognitive
decline from a previous level of performance, and mild NCD requires modest
decline.
4. Major NCD criteria requires decline from a previous
level of performance in three of the listed domains, and mild NCD requires only
one.
ANS: 3
Rationale: The progression of the disorder is not a
criterion for determining the severity of an NCD. Abstract thinking and
judgment can be affected in both mild NCD and major NCD. Major NCD criteria
requires substantial cognitive decline, and mild NCD requires modest decline.
Both major and mild NCD classifications require decline from a previous level
of performance in only one of the listed domains.
385. Which statement accurately differentiates NCD from
pseudodementia (depression)?
1. NCD has a rapid onset, whereas pseudodementia does
not.
2. NCD symptoms include disorientation to time and
place, and pseudodementia does not.
3. NCD symptoms improve as the day progresses, but
symptoms of pseudodementia worsen.
4. NCD causes decreased appetite, whereas
pseudodementia does not.
ANS: 2
Rationale: NCD has a slow progression of symptoms,
whereas pseudodementia has a rapid progression of symptoms. NCD symptoms
include disorientation to time and place, and pseudodementia does not. NCD
symptoms’ severity worsens as the day progresses, whereas in pseudodementia,
symptoms improve as the day progresses. In NCD the appetite remains unchanged.
whereas in pseudodementia, the appetite diminishes.
386. Which of the following conditions have been known
to precipitate delirium in some individuals? (Select all that apply.)
1. Febrile illness
2. Seizures
3. Migraine headaches
4. Herniated brain stem
5. Temporomandibular joint syndrome
ANS: 1, 2, 3
Rationale: Delirium most commonly occurs in
individuals with serious medical, surgical, or neurological conditions. Some
examples of conditions that have been known to precipitate delirium in some
individuals include the following: systemic infections; febrile illness;
metabolic disorders, such as hypoxia, hypercarbia, or hypoglycemia; hepatic
encephalopathy; head trauma; seizures; migraine headaches; brain abscess;
stroke; postoperative states; and electrolyte imbalance. A herniated brain stem
would most likely result in death, not delirium. Temporomandibular joint
syndrome is marked by limited movement of the joint during chewing, not
delirium.
387. Which of the following medications that have been
known to precipitate delirium? (Select all that apply.)
1. Antineoplastic agents
2. H2-receptor antagonists
3. Antihypertensives
4. Corticosteroids
5. Lipid-lowering agents
ANS: 1, 2, 3, 4
Rationale: Medications that have been known to
precipitate delirium include anticholinergics, antihypertensives,
corticosteroids, anticonvulsants, cardiac glycosides, analgesics, anesthetics,
antineoplastic agents, antiparkinson drugs, H2-receptor antagonists (e.g.,
cimetidine), and others. There have been no reports of delirium ascribed to the
use of lipid-lowering agents.
388. A nursing instructor is teaching about trauma and
stressor-related disorders. Which student statement indicates that further
instruction is needed?
1. “The trauma that women experience is more likely to
be sexual assault and child sexual abuse.”
2. “The trauma that men experience is more likely to
be accidents, physical assaults, combat, or viewing death or injury.”
3. “After exposure to a traumatic event, only 10
percent of victims develop post-traumatic stress disorder (PTSD).”
4. “Research shows that PTSD is more common in men
than in women.”
ANS: 4
Rationale: Research shows that PTSD is more common in
women than in men. This student statement indicates a need for further
instruction.
389. Which factors differentiate the diagnosis of PTSD
from the diagnosis of adjustment disorder (AD)?
1. PTSD results from exposure to an extreme traumatic
event, whereas AD results from exposure to “normal” daily events.
2. AD results from exposure to an extreme traumatic
event, whereas PTSD results from exposure to “normal” daily events.
3. Depressive symptoms occur in PTSD and not in AD.
4. Depressive symptoms occur in AD and not in PTSD.
ANS: 1
Rationale: PTSD results from exposure to an extreme
traumatic event, whereas AD results from exposure to “normal” daily events,
such as divorce, failure, or rejection. Depressive symptoms can occur in both
PTSD and AD.
390. Which client would a nurse recognize as being at
highest risk for the development of an AD?
1. A young married woman
2. An elderly unmarried man
3. A young unmarried woman
4. A young unmarried man
ANS: 3
Rationale: Adjustment disorders are more common in
women, unmarried persons, and younger people. Although more common in the
young, it can occur at any age.
391. A nursing instructor is explaining the etiology
of trauma-related disorders from a learning theory perspective. Which student
statement indicates that learning has occurred?
1. “How clients perceive events and view the world
affect their response to trauma.”
2. “The psychic numbing in PTSD is a result of
negative reinforcement.”
3. “The individual becomes addicted to the trauma
owing to an endogenous opioid response.”
4. “Believing that the world is meaningful and
controllable can protect an individual from PTSD.”
ANS: 2
Rationale: Learning theorists view negative reinforcement
as behavior that leads to a reduction in an aversive experience, thereby
reinforcing and resulting in repetition of the behavior. Psychic numbing
decreases or protects an individual from emotional pain and, therefore, the
learned response is the repetition of this behavior.
392. As the sole survivor of a roadside bombing, a
veteran is experiencing extreme guilt. Which nursing diagnosis would address
this client’s symptom?
1. Anxiety
2. Altered thought processes
3. Complicated grieving
4. Altered sensory perception
ANS: 3
Rationale: The client’s survivor guilt is disrupting
the normal process of grieving. Although the client may also experience
anxiety, the symptom presented in the question is extreme guilt. There is no
evidence presented in the question to indicate altered thought or altered
sensory perception.
394. A client has been assigned a nursing diagnosis of
complicated grieving related to the death of multiple family members in a motor
vehicle accident. Which intervention should the nurse initially employ?
1. Encourage the journaling of feelings.
2. Assess for the stage of grief in which the client
is fixed.
3. Provide community resources to address the client’s
concerns.
4. Encourage attending a grief therapy group.
ANS: 2
Rationale: Prior to implementing all other nursing
interventions presented, the nurse must assess the stage of grief in which the
client is fixed. Appropriate nursing interventions are always based on accurate
assessments.
395. Which clinical presentation is associated with
the most commonly diagnosed adjustment disorder (AD)?
1. Anxiety, feelings of hopelessness, and worry
2. Truancy, vandalism, and fighting
3. Nervousness, worry, and jitteriness
4. Depressed mood, tearfulness, and hopelessness
ANS: 4
Rationale: AD with depressed mood is the most commonly
diagnosed adjustment disorder. The clinical presentation is one of predominant
mood disturbance, although less pronounced than that of major depression. The
symptoms, such as depressed mood, tearfulness, and feelings of hopelessness,
exceed what is an expected or normative response to an identified stressor.
396. Both situational and intrapersonal factors most
likely contribute to an individual’s stress response. Which factor would a
nurse categorize as intrapersonal?
1. Occupational opportunities
2. Economic conditions
3. Degree of flexibility
4. Availability of social supports
ANS: 3
Rationale: Intrapersonal factors that might influence
an individual’s ability to adjust to a painful life change include social
skills, coping strategies, the presence of psychiatric illness, degree of
flexibility, and level of intelligence.
397. A client diagnosed with AD has been assigned the
nursing diagnosis of anxiety R/T divorce. Which correctly written outcome
addresses this client’s problem?
1. Rates anxiety as 4 out of 10 by discharge.
2. States anxiety level has decreased by day one.
3. Accomplishes activities of daily living
independently.
4. Demonstrates ability for adequate social
functioning by day three.
ANS: 1
Rationale: An outcome statement must be
client-centered, specific, measurable, and contain a time frame, so that it can
be evaluated effectively. A “decrease” in anxiety is vague rather than
specific, and expecting an anxiety decrease by day one may also be unrealistic.
Accomplishing activities of daily living independently and demonstrating the
ability for adequate social functioning do not address the anxiety nursing
diagnosis.
398. Eye movement desensitization and reprocessing
(EMDR) has been empirically validated for which disorder?
1. Adjustment disorder
2. Generalized anxiety disorder
3. Panic disorder
4. Post-traumatic stress disorder
ANS: 4
Rationale: EMDR has been used for depression,
adjustment disorder, phobias, addictions, generalized anxiety disorder, and panic
disorder. However, at present, EMDR has only been empirically validated for
trauma-related disorders such as PTSD and acute stress disorder.
399. After a teaching session about grief, a client
says to the nurse, “I seem to be stuck in the anger stage of grieving over the
loss of my son.” How would the nurse assess this statement, and in what phase
of the nursing process would this occur?
1. Assessment phase; nursing actions have been
successful in achieving the objectives of care.
2. Evaluation phase; nursing actions have been
successful in achieving the objectives of care.
3. Implementation phase; nursing actions have been
successful in achieving the objectives of care.
4. Diagnosis phase; nursing actions have been
successful in achieving the objectives of care.
ANS: 2
Rationale: In the evaluation phase of the nursing
process, reassessment is conducted to determine if the nursing actions have
been successful in achieving the objectives of care. The implementation of
client teaching has enabled the client to verbalize an understanding of the
grief process and his or her position in the process. Therefore, the nurse’s
actions can be evaluated as successful.
400. By which biological mechanism does EMDR achieve
its therapeutic effect?
1. EMDR achieves its therapeutic effect, but the exact
biological mechanism is unknown.
2. EMDR achieves its therapeutic effect by causing a
decrease in imagery vividness.
3. EMDR achieves its therapeutic effect by causing an
increase in memory access.
4. EMDR achieves its therapeutic effect by decreasing
trauma associated anxiety.
ANS: 1
Rationale: Some studies have indicated that eye
movements cause a decrease in imagery vividness and distress, as well as an
increase in memory access. EMDR is thought to relieve anxiety associated with
the traumatic event. However, the exact biological mechanisms by which EMDR
achieves its therapeutic effects are unknown.
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