Answers and Rationale

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1. B

Rationale: Being overly talkative is a common sign of use of amphetamines (Dexedrin). This drug is a stimulant; staring into space and slurring words are side effects typical of depressant type of drugs. Some marijuana users wear sunglasses indoors to disguise their inflamed eyes.

Reference: Timby, B.K., Carmack, A., & Rupert, D.L. Lippincott’s review for NCLEX-PN. 7th_{ed. (2006).} Philadelphia: Lippincott Williams & Wilkins.

2. B

Rationale: The most common side effects of risperidone (Risperdal) include insomnia and agitation. Orthostatic hypotension also occurs with reflex tachycardia. Risperidone (Risperdal) does not increase extrapyramidal symptoms. Anticholinergic symptoms such as urine retention are not commonly reported. Weight gain, not loss may develop.

3. D

Rationale: Displacement is a coping mechanism in which a person transfers his angry feelings for one person onto someone else who is less likely to

retaliate with significant consequences. Introjection involves taking on the characteristics of another. Projection is characterized by accusing someone of one’s own weaknesses. Compensation is demonstrated by overcoming some inadequacy by excelling at another activity.

4. C

Rationale: Clients with bipolar disorder, formerly called manic-depressive disorder, have cycles in which they display a marked change in mood between mania (abnormal highs) and depression (lows). The disorder is called bipolar because of the swings between the opposing poles of mood. Mania often affects thinking, judgment, and social behavior, causing serious problems. Bipolar disorder is a recurring illness that can be treated with long-term medication. The exaggerated mood is followed or preceded by an interval of normal mood. None of the other behaviors is symptomatic of bipolar disorder.

5. A

Rationale: Involuntary facial movements and tongue and eye movements indicate the development of tardive dyskinesia, a negative consequence of

M A D : M a la d a p ti v e D is o rd e rs | B S N 0 0 2

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antipsychotic (neuroleptic) drug therapy. The condition is usually irreversible, even after the drug is discontinued. About 20% of those treated with antipsychotic medications in the long-term develop tardive dyskinesia. None of the other assessment findings is linked to antipsychotic drug withdrawal. Reference: Timby, B.K., Carmack, A., & Rupert, D.L. Lippincott’s review for NCLEX-PN. 7th_{ed. (2006).} Philadelphia: Lippincott Williams & Wilkins.

6. D.

Rationale: The client presents a lethally potential if he/ she appear disorganized and impulsive. Clients at higher risk include those with a history of a dual diagnosis of mental illness and substance abuse; a personal or family history of suicide attempts, depression, alcoholism; or psychotic episodes. Having a plan, particularly if the method is immediate and available, makes the client a very high risk.

Reference: Linda Anne Sivestri. Saunder’s Comprehensive Review for the NCLEX-RN Examination Third Ed. Elsevier Inc. 2005. CD-ROM

7. D.

Rationale: Rigid and inflexible behaviours are characteristics of the client with obsessive-compulsive disorder (OCD). Clients with this disorder are not usually hostile unless they are prevented from engaging in the obsession or compulsion because this behaviour is what decreases the anxiety.

8. B.

Rationale:The initial nursing action would be to assess for any physiological causes of the paralysis. Although a component of the plan of care would be to encourage the client to discuss feelings, this would not be the initial nursing action. To encourage the client to use the arm without ruling out a physiological cause of the paralysis is not appropriate. Although the client may be referred to a psychiatrist, this also is not the initial action.

9. D.

Rationale:A person who is experiencing mania lacks insight and judgment, has poor impulse control, and is highly excitable. The nurse must take control without creating increased stress or anxiety to the client. A quiet, firm approach while distracting the client (walking her room to room and assisting her to get dressed) achieves the goal of having her dressed appropriately and preserving her psychosocial integrity. Ignoring the client is inappropriate. Telling the other clients to go into nursing unit day room immediately is inappropriate and does not address the client’s behaviour.

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10. D.

Rationale: The most therapeutic response by the nurse is the one that makes the client aware of the verbal statement and directs the client to the purpose of the. The nurse should confront the client verbally regarding the client’s statement and refocus the client back to the issue of the session.

11. C

Rationale: A nurse’s initial task when assessing a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. Option c will assist in determining data related to the precipitating event that led to the crisis. Options a and b assess situational support. Option d assesses personal coping mechanism.

Reference: Comprehensive Review for the NCLEX-RN EXAMINATION Ed. 4, 2008, Saunders et al

12. A

Rationale: According to Freud’s psychosexual stages of development, between the ages of 3 and 6, the child is in the phallic stage. At this time, the child devotes much energy in examining his or her genitalia, masturbating and expressing interest in

sexual concerns. Therefore, options b, c and d are incorrect.

Reference: Comprehensive Review for the NCLEX-RN EXAMINATION Ed. 4, 2008, Saunders et al 13. A

Rationale: According to Erickson, the caregiver should not try to anticipate the newborn infant’s needs at all times but must allow the newborn infant to signal needs. If a newborn infant s not allowed to signal a need, the newborn will not learn how to control the environment . Erickson believed that a delayed or prolonged response to a newborn infant’s signal would inhibit the development of trust and would lead to mistrust others.

14. C

Rationale: A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. A conversion disorder is thought to be an expression of psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. A dissociative disorder is a disturbance or alteration in the normally integrative function s of identity, memory or consciousness. Psychosis is a state in which a person’s mental capacity to recognize reality, communicate and relate to others is impaired, thus interfering with the person’s ability to deal with life’s demands. Repression is coping

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mechanism which unacceptable feelings are kept out of awareness.

Reference: Comprehensive Review for the NCLEX-RN EXAMINATION Ed. 4, 2008, Saunders et al 15. B

Rationale: Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with staff and finger painting are the activities that minimize the stimuli and provide a constructive release for tension. Competitive games should be avoided because they can stimulate aggression and increase psychomotor activities.

16. A

RATIONALE: The client with aphasia may need additional time to select the proper words when speaking. It is essential for the nurse to allow the client time to complete the sentence. Showing or naming various objects in the environment and leaving the room are inappropriate responses. Actions such as these often lead to additional client frustration, anxiety, and feelings of low self esteem.

REFERENCE: Lippincott’s review series, Medical-surgical nursing, Fourth edition by Ray A. Hargrove-Huttel, RN, PhD. Page367.

17. B

RATIONALE: Because the client has problems with altered thought and has self-care deficits, the nurse needs to make the decisions. Simple questions and directions are most appropriate. The client is not capable of making decisions at this time. Asking the other 3 options requires the client to make a decision. These types of questions are inappropriate in this situation.

REFERENCE: Lippincott’s review series, Medical-surgical nursing, Fourth edition by Ray A. Hargrove-Huttel, RN, PhD. Page367.

18. B

RATIONALE: the nurse should never promise to keep a secret. Secrets are appropriate in social relationships but not in therapeutic relationships. The nurse needs to be honest with the client and tell the client that a promise cannot be made to keep a secret.

REFERENCE: SAUNDERS comprehensive review NCLEX-RN examination 2008, 4th_{edition. Page} 1139

19. A

RATIONALE: Generally, the client seeks voluntary admission. Voluntary clients have the right to demand and obtain release. If the client is a minor, the release may be contingent on the consent of the

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partent or guardian. The nurse needs to be familiar with the state and facility policies and procedures. The best nursing action is to contact the physician.

20. A

RATIONALE: Denial is refusal to admit painful reality, which is treated as if it does not exist.

21. A

Rationale: In the formal operation stage, the child has the ability to think abstractly and logically. Option 2 identifies concrete operation stage. Option 3 identifies sensorimotor stage. Option 4 identifies the preoperational stage.

22. A

Rationale: Denial is refusal to admit to a painful reality, which is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other persons, objects, or situations. In regression, the client returns to an earlier, more comforting, although less mature way of behaving. Rationalization is justifying illogical or unreasonable

ideas, actions or feelings by developing acceptable explanations that satisfies the teller and the listener.

23. D

Rationale: Short-term goals include the beginning stages of dealing with the rape trauma. Clients will be expected initially to keep appointments, participate in care, begin to explore feelings, and begin to heal any physical wounds that were inflicted at the time of rape.

24. A

Rationale: One-to-one suicide precautions are required for the client who attempted suicide. Options 2 and 3 maybe appropriate, but not at the present time considering the situation. Option 4 also maybe an appropriate nursing intervention, but the priority is identified in option 1. The best intervention is constant supervision so that the nurse may intervene as needed if the client attempts to cause harm to self.

25. C

Rationale: Hanging is a serious suicide attempt. The plan of care must reflect action that will ensure the client’s safety. Constant observation status (one to one) with a staff member who is never less than an arm’s length away is the best selection. Seclusion should not be the initial intervention, and the least restrictive measures should be used. Placing the client in a hospital gown and requesting that a peer remain with the client will not ensure a safe environment. M A D : M a la d a p ti v e D is o rd e rs | B S N 0 0 2

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26. A

Rationale: The manic patient may neglect to eat or sleep, due to excessive energy and flight of ideas.

(Thompson Peterson. NCLEX-PN Certification Exam. Peterson’s Advision of Thompson Learning Corp.2003.p 127)

27. A

Rationale: Structured activities will help keep the depressed patient active, and small groups provide social contact without being overwhelming.

28. A

It is typical for the elderly to feel shamed and humiliated by the abuse they receive.

29. A

The paranoid patient is easily threatened, and the most important point to remember when approaching them is to avoid touching them or getting to close.

30. C

Auditory hallucinations that are “commanding” a patient to hurt someone can make the patient a danger to himself or others. The RN provider needs to know that they are occurring.

31. B.

Rationale: The nurse’s nonverbal behavior, moving away from the window as seethe client’s request, would indicate agreement with the client’s false ideas. The client’s behavior is likely to be reinforced if the nurse takes to agree with the false ideas he holds.

(NCLEX-RN Examination 8th_{Edition by Diane M.} Bilings)

32. B

Rationale: The nursing diagnosis Disturbed Thought Processes related to increase anxiety, as evidenced by delusional thinking, most accurately reflects this client’s problem with paranoid delusions. Disturbed Sensory Perception: Visual would be appropriate if the client were expecting hallucinations. Impaired

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Verbal Communication would be appropriate if the client were demonstrating less coherent speech. Social Isolation would be appropriate if the client were refusing to come out of his room.

33. A

Rationale: The nurse needs to present the reality of the situation. By explaining that the men are groundskeepers and probably talking about work, the nurse is reinforcing reality to encounter the client’s illusion (misinterpretation of reality). Additionally, this response voices doubt in the client’s paranoid interpretation. Telling the client not to pay attention to the men fails to address the client’s misinterpretation and misperceptions. Closing the drapes so that the client doesn’t see the men ignores the client’s misperception and misinterpretation.

34. C

Rationale; Clients may act on command hallucinations and harm themselves or others. Therefore, the staff needs to know when the client is hearing such commands, to ensure safety first. Telling the client the voices are real but nurse doesn’t hear them would be an appropriate response later in the client’s hospitalization when the client’s

safety is no longer an issue because antipsychotics are beginning to take effect. Telling the client that the hallucinations are part of the illness or that the medications will help control the voices would be appropriate once the client has developed some insight into the symptoms of illness.

35. A

Rationale: Hallucination and asocial behaviors are typical symptoms of undifferentiated schizophrenia. Preoccupation with persecutory delusions and hallucinations are associated with paranoid schizophrenia. Grossly disorganized behaviors and speech are associated with disorganized type of schizophrenia. Immobility and waxy flexibility are associated with catatonic type of schizophrenia.

36. C

Rationale: Patients with antisocial personality disorder typically show no remorse and justify their actions as being right for them, despite being socially unacceptable. 1. Such a person would have difficulties with interactions. 2. This person behaves bizarrely and has few interactions with others. 4. This person has intense, angry relationships, is impulsive, and may self-mutilate.

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(Reference: www.evolve.elsevier.com)

37: A

Rationale: Controlling the impulse to self-mutilate or self-destruct would be indicative of improved ability to tolerate distressing thoughts. Ordinarily the patient would impulsively act out the urge. Option 2 is not a desired outcome. Option 3 does not suggest improved management of feelings. Option 4 is not a desired outcome.

38. C

Rationale: This question will give the nurse data about the patient's feelings about entering treatment. Generally, patients who are willing to become involved derive greater benefits. 1. The question will not alter the patient's level of anxiety. 2. The goal of nursing assessment is to gather specific data. 4. This question is not designed to gather this information.

39. A

Rationale: Identity and purpose are often associated with one's job. When one retires, loss of identity and purpose often occur, which requires adaptation. If adaptation does not occur, adjustment disorder may

result. Options 2, 3, and 4 are not the most frequent causes of postretirement adjustment disorder.

40. C

Rationale: Cultural practices dealing with grief and loss differ. Failure to incorporate the significance of cultural practices into the treatment plan may impede resolution of the patient's grieving. 1. Talking about the loss helps the patient come to terms with it. 2. Empathy is a helpful response. 4. Obtaining help from qualified persons to assist with grief resolution is valuable if the patient approves of their involvement.

41. D

Rationale: This response is calm, matter-of-fact and firm. The nurse is not permitting the patient to be manipulative, nor is she setting up a situation in which a power struggle is likely to arise. Option 1 praises the patient for her behavior. Option 2 is manipulative on the part of the nurse. Option 3 suggests the patient will not be weighed according to schedule. (Reference: www.evolve.elsevier.com) 42. A M A D : M a la d a p ti v e D is o rd e rs | B S N 0 0 2

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Rationale: Change comes slowly even when appropriate goals are set with the patient. When goals are unattainable, staff become discouraged or frustrated with lack of progress. Regarding option 2, when a nurse adopts the behaviors used by an antisocial patient, it is not related to lack of progress toward goals. Regarding option 3, the antisocial patient is usually uncaring about the opinions of others. Regarding option 4, antisocial patients act out feelings, instead of turning them inward.

43. B

Rationale: The nurse who is aware of his or her personal feelings and views about sexual issues can assist a patient with a sexual disorder. Lack of clarity about one's feelings and views clouds the nurse's focus. 1. Previous experience may prove to be helpful, but is not the most important qualification. 3. Thinking that all types of sexual dysfunction can be corrected is unrealistic. 4. Thinking that the prognosis for most sexual dysfunction disorders is poor shows lack of information.

44. D

Rationale: This question asks directly about the coping skills used in the past. After this lead-in the nurse can question further to find out how effective the coping skills were. This option is the only question that relates specifically to adequacy of coping skills.

45. Answer: C

Rationale: Reducing stimulation is calming and will allow the patient to focus his or her limited intellectual skills on regaining control. 1. Behavioral responses to the patient should be positive. 2. Touch can easily be misinterpreted as a threat. 4. Patients need increased personal space during catastrophic reactions

(Reference: www.evolve.elsevier.com) 46. C

Rationale: Repetition of words or phrases that are similarly in sound and in no other way (rhyming) is one altered thought and language pattern in schizophrenia. Clang association often take the form of rhyming. Loosened associations occur when individual speaks with frequent changes of subject, and the content is obliquely related. Echolalia is the involuntary parrot like repetition of words spoken by others. Word salad is the use of words with no apparent meaning attached to them or to their relationship to one another.

Reference: Saunders Q & A Review for the NCLEX-RN Examination by Linda Anne Silvestri, 2006, Elsevier Inc

47. B

Rationale: By definition, an ego defense mechanism are operations outside of a person's awareness that the ego calls into play to protect against anxiety. Denial is the defense mechanism that blocks out painful or anxiety inducing events or feelings. In this case, the client cannot deal the upcoming surgery

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for cancer and therefore denies the illness. Psychosis and delusions are not defense mechanism. Displacement is the discharging of pent-up feelings on persons less dangerous than those initially around the feelings.

48. A

Rationale: A client experiencing paranoia is distrustful and suspicious of others. The health care team needs to establish rapport with the client. Laughing or whispering in front of the client would increase the client's paranoia. Options 2,3 and 4 ask the client to trust on multitude levels. These options are too intrusive for a client who is paranoid

49. A

Rationale: Exercising 23 to 4 hours everyday is excessive physical activity and unrealistic fir 16 year old. The nurse needs to further assess this statement immediately to find out why the client feels the need to exercise this much to maintain her figure. Although it's unfortunate that her best friend had this disease this is not considered a major threat to the client's physical well-being. A weight that exceeds 15% below the ideal weight is significant with anorexia nervosa. It is not considered abnormal to check weight every day. Many clients with anorexia nervosa check their weight close to 20 times a day.

50. B

Rationale: The client in manic state often has inadequate food and fluid intake as a result of physical agitation. Foods that the client can eat “on the run” are best because the client is too active to sit at meals and use utensils. Additionally, clients in manic state should not have caffeine containing products.

Reference: Saunders Q & A Review for the NCLEX-RN Examination by Linda Anne Silvestri, 2006, Elsevier Inc.

51. B

Rationale: flight of ideas: flight of ideas is a condition in which patient talks continuously and then switch to unrelated topic. Loose association is somewhat similar to more obvious and completely unrelated. A, C, D are all alteration in perception. A refers to a person thinking that everyone is talking about him. C and D are all sensory alterations. The difference is that, in hallucination, there is no need for a stimulus. In illusion, a stimulus (a phone cord) is mistakenly identified by the client as something else (snake).

52. A

Rationale: I understand and that’s God’s voice are real to you, but I don’t hear anything. I will stay with you: the nurse should first ACKNOWLEDGE that the voices are reality the patient and then PRESENT REALITY by telling the patient that you do not hear anything. The third part of the nursing intervention in hallucination is LESSENING THE SIMULI by either

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staying with the patient or REMOVING the patient from a highly stimulating place. Telling the client that the voices are part of his illness is not therapeutic. People with schizophrenia think that they are ill. Letter C and D disregards the client’s concerns and therefore, not therapeutic.

53. C

Rationale: the depression to be improving and the suicidal ideation to be lessening: too obvious, no need to rationalize.

54. D

Rationale: “I need to call my doctor whenever I notice that I have a fever or sore throat.”: clozapine causes AGRANULOCYTOSIS and bone marrow depression. Early s/s includes fever and sore throat. The medication is to be withheld this time or the patient might develop severe infection leading to death.

55. C.

Rationale: Schizophrenia: when disorders of perception and thoughts came in. the only diagnosis doctor can make is among the choices of schizophrenia. A, B and D can occur in normal individuals without altering their perceptions. Schizophrenia is characterized by disorders of thoughts, hallucinations, delusions, illusion and disorganization.

56. A

Rationale: Because of such factors as suspiciousness, anxiety, and hallucinations, the

client with paranoid schizophrenia is at risk for violence toward himself or others. The other options are also appropriate nursing diagnoses but should be addressed after the safety of the client and those around him is established.

http://www.scribd.com/doc/6389830/109-Questions-and-Rationale-on-Psychotic-Disorders

57. B

Rationale: Option B is the action of Cogentin. Anxiety doesn't cause extrapyramidal effects. Overactivity of acetylcholine and lower levels of dopamine are the causes of extrapyramidal effects. Benztropine doesn't increase norepinephrine in the CNS.

58. C

Rationale: By acknowledging that the client hears voices, the nurse conveys acceptance of the client. By letting the client know that the nurse doesn't hear the voices, the nurse avoids reinforcing the hallucination. The nurse shouldn't touch the client with schizophrenia without advance warning. The hallucinating client may believe that the touch is a threat or act of aggression and respond violently. Being alone in his room encourages the client to withdraw and may promote more hallucinations. The nurse should provide an activity to distract the client. By asking the client what the voices are saying, the

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nurse is reinforcing the hallucination. The nurse should focus on the client's feelings, rather than the content of the hallucination.

59. C

Rationale: Nihilistic delusions are false ideas about the self, others, or the world. Somatic delusions involve a false belief about the functioning of the body. Body dysmorphic disorder is characterized by a belief that the body is deformed or defective in a specific way. Apraxia is the inability to carry out motor activities.

60. C

Rationale: The client's signs and symptoms suggest neuroleptic malignant syndrome, a life-threatening reaction to neuroleptic medication that requires immediate treatment. Tardive dyskinesia causes involuntary movements of the tongue, mouth, facial muscles, and arm and leg muscles. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Akathisia causes restlessness, anxiety, and jitteriness.

61. D

Rationale: The client’s energy level is so high that a complete night’s sleep probably is impossible. The nurse should use any “down” time to promote rest. The client’s sleep pattern, including a bedtime routine, can be repatterned when the client’s come down from the manic phase of the disorder (Option A). During the manic phase, the client’s energy level is so high that enforcing seclusion during the night isn’t likely to promote sleep (Option B). The nurse should encourage the client to sleep or rest at any time to prevent physical exhaustion (Option D)

62. A

Rationale: A depressed client is at great risk for committing suicide and needs continuous observation. This client must not be left alone (Option B and D). The nurse must not relinquish responsibilities to another client (Option C).

63. B

Rationale: The nurse must not reinforce the client’s hallucinations. Telling the client to listen to the voices would reinforce the hallucinations (Option A). The nurse shouldn’t say things that may not be true (Option C). The voices are real to the client, telling him that he doesn’t hear them isn’t therapeutic (Option D).

64. A

Rationale: This response orients the client to reality and provides the structure the client’s needs to solve

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the immediate problem. The client is too anxious and regressed to engage in the problem solving required by options B and C. Option D is insane because the client is unable to provide self care as a result of severe anxiety that interferes with problem solving and prevents awareness of the reality.

65. C

Rationale: Clients with anorexia nervosa commonly communicate on a superficial level and avoid expressing feelings. Identifying feelings and learning to express them are initial steps in decreasing isolation. Clients with anorexia nervosa are usually able to discuss abstract and concrete issues. Confrontation usually isn’t an effective communication strategy as it may cause the client to withdraw and become more depressed.

(Source: Springhouse Review for NCLEX-RN 5th edition; Page 624)

66. A

Rationale: Denial is refusal to admit a painful reality, which is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other persons, objects, or situations. In regression, the client returns to earlier, more comforting, although less mature, way of behaving. Rationalization is justifying illogical or unreasonable ideas, actions or feelings by developing acceptable explanations that the teller and the listener.

67. B

Rationale: Disturbed thought process related to paranoia is the client’s problem, and the plan of care must address this problem. The client is experiencing paranoia and is distrustful and suspicious of others. The members of the health cafe team need to establish a rapport and trust with the client. Therefore laughing or whispering in front of the client would be counterproductive.

68. B

Rationale: Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. Mania is a period when the mood is predominantly elevated, expansive or irritable. All options reflect a client’s possible symptomatology. Option B, however, clearly presents a problem that compromises a physiological integrity and need to be addressed immediately.

69. C

Rationale: The client taking clozapine (Clozaril) may experience agranulocytosis, which is monitored by reviewing the result of the white blood count. Treatment is interrupted if the white blood count drops below 3000/mm3_{. Agranulocytosis can be fatal} if undetected and untreated. The other options are not related specifically to the use of this medication.

70. B

Rationale: Clients with anorexia nervosa frequently are preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide appropriate exercise and place limits on rigorous activities.

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(Reference: Saunders’ Comprehensive Review NCLEX-RN Examination 4TH_{ed by Linda Anne} Silvestri, MSN, RN, Canada 2008.)

71. C

Rationale: The development of physical symptoms without a physical cause is an anxiety-reducing mechanism.

72. B

Rationale: Mediating frustration within the real world is an ego function and requires ego strength.

73. B

Rationale: Slips of the tongue also called Freudian slip are material from the unconscious that slips out in unguarded moments.

74. A

Rationale: Talking in the third person reflect poor ego boundaries and dissociation from the real self. 75. C

Rationale: The superego incorporates all experiences and learning from external environment (society, family etc.) into the external environment.

(Reference: Mosby's Comprehensive Review of Nursing for NCLEX-RNR Examination Book, 2009, by Saxton)

76. A

Rationale: Clients with panic disorder tend to be socially withdrawn. Going to the mall is a sign of working on avoidance behaviors. Hyperventilation is a key symptom of panic disorder. Teaching breathing control is a major intervention for clients with panic disorder. The client taking medications for panic disorder, such as trycyclic antidepressants and benzodiazepines, must be weaned off these drugs. Most clients with panic disorder with agoraphobia don’t have nutritional problems.

77. D

Rationale: The client must be aware of the connection between sources of anxiety and the symptoms of a panic attack. Role-playing a panic attack isn’t useful for the client. Later in treatment, the client can develop an exercise program as part of the overall plan to handle stress. Learning to identify cognitive distortions is a useful strategy to teach the client after he’s begun to work on identifying sources of anxiety.

78. D

Rationale: Stopping antianxiety dugs such as benzodiazepines can cause the client to have withdrawal symptoms. Stopping a benzodiazepine doesn’t tend to cause depression, increase cognitive abilities, or decrease sleeping difficulties.

79. A

Rationale: Use of lithium during pregnancy results in congenital defects, especially cardiac defects. Thyroids problems don’t occur in the first trimester of the pregnancy. In lithium toxicity, a condition called nontoxic goiter ma occur. An adverse effect of lithium is polyuria, not urine retention. The rate of spontaneous abortion is no greater than for non-users. M A D : M a la d a p ti v e D is o rd e rs | B S N 0 0 2

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80. A,B,D

Rationale: A client with an impulse control disorder who displays violent, aggressive, and assaultive behavior generally functions well in other areas of his life. The degree of aggressiveness is typically out of proportion wit the stressor. Such a client commonly has a history of parental alcoholism and a chaotic family life, and often verbalizes sincere remorse and guilt for the aggressive behavior. (Reference: Lippincott Wiliams & Wilkins. NCLEX-RN Question and Answer p. 374)

81. D

Rationale: Although the precise mechanism of inheritance is unknown, developing a social phobia is 11% more likely if a family member has the disorder.

82. C

Rationale: Malingering is characterized by the client’s deliberate attempt to gain attention. The clinical manifestations are not confirmed by lab tests. The client will bring the clinical manifestations to the attention of others for secondary gain. The client does not withdraw but becomes demanding of health care providers and others.

83. A

Rationale: One-to-on supervision and making a suicide contract with a client who has a dissociative disorder are priorities to meet the safety needs of the client under distress. Confidentiality is of the utmost

importance. Never try to force recall of information the client is not prepared to know. Reduction of anxiety helps avoid the emergence of subpersonalities.

84. B

Rationale: Telling the client who complains of seeing UFOs that “I can tell that what you’re seeing frightens you; how can I help to make you more comfortable?” validates the client’s feelings without agreeing with or challenging the client’s irrational beliefs.

85. C

Rationale: A client with a bipolar disorder and a superimposed seasonal affective depression needs to be careful about the time of day that the phototherapy is utilized. Because of circardian rhythms, it has been found that bipolar clients with seasonal depression do best if they utilize the phototherapy treatment in the later afternoon. If the phototherapy is used in the morning, manic manifestations may result. Exploring appetite, energy level, feelings of self-worth, and how much money the client is spending may all be important interventions, but determining the time of the day the client is using phototherapy allows the nurse to obtain the information that may be causing the dramatic change and elevation in mood.

(Reference: Complete Review for NCLEX-RN by Donna Gauwitz, Thomson Asian Edition, NSNA (2007)) 86. A M A D : M a la d a p ti v e D is o rd e rs | B S N 0 0 2

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Rationale: Mild anxiety motivates one to action, such as learning or making changes. Higher levels of anxiety tends to blur the individual's perceptions and interfere with functioning.

87. D

Rationale: The client's early arrival indicates an expected degree of anxiety; the quiet waiting indicates that the client has been told what to expect.

88. D

Rationale: Anxiety is a human response,causing both physical and emotional changes that everyone experiences when faced with stressful situations.

89. C

Rationale: The individual using sublimation attempts to fulfill desires by selecting a socially acceptable activity rather than one that is socially unacceptable.

90. B

Rationale: Toddlers struggle to identify their own needs. Too early and too strict toilet training results in ambivalence because toddler's needs and physical abilities are in conflict with parental demands. Toddlers are faced with giving up these needs or risking parental disapproval.

(Reference: Mosby’s Review of Nursing for NCLEX-RN Examination)

91. C

Rationale: The toddler is learning autonomy, but because of the nature of development, there is still

physical and emotional dependence on the parents. The major task during infancy is the development of trust. School age deals with the task of industry and developing skills for working in and relating to the world. Preschool age deals with developing a sense of initiative.

92. C

Rationale: The child resolves oedipal conflicts by learning to identify with the parent of the same sex and accomplishes this by mimicking the role of his parent. Oral stage is the earliest stage of development and operates solely on the pleasure principle, largely id oriented; this stage is concerned with the development of trust. Genital stage is when the interest shifts from the anal region to the genital region and questions about sexuality arise during this stage. Latency stage is when there is increasing sex-role development; this stage is concerned with peer group identification.

93. B

Rationale: Values and beliefs from parents and society are expressed through the child’s play world. These values become part of the child’s system through the process of internalization (introjection). Projection- if this happens, children will learn to blame others for their own faults. Competition happens in the later stage. Independence is influenced by the environment and others in it rather than play. 94. C M A D : M a la d a p ti v e D is o rd e rs | B S N 0 0 2

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Rationale: the child realizes that the parent of the same sex cannot be bested in a struggle for the affection of the parent of the opposite sex. The role and the behaviour of the same-sex parent are therefore assumed by the child to attract the parent of the opposite sex. Rejects the parent of the same sex – this is a conflict, not a resolution. Introjects behaviours of both parents – doing this gives rise to a greater conflict and leaves a fragmented self. Identifies with the parent of the opposite sex- this is in conflict with heterosexual drives.

95. B

Rationale: Children 2 to 7 years old have difficulty distinguishing reality from fantasy; this presents the greatest challenge to the nurse. Sensorimotor stage- children from birth to 1 year of age focus on “in the moment” thinking; preoperative preparation most likely will not be recalled. Formal operational stage- children 12 to 16 years of age can think in the abstract and have the ability to solve the complex problems; children in this stage usually do not pose difficulties in preoperative teaching. Concrete operational stage- children 7 to 11 years of age have the ability to comprehend and visualize a series of events and can think about the past and present; this stage provides less of a challenge to absorb preoperative teachings.

96. B,E,F

Rationale: Client education should cover the signs and symptoms of drug toxicity as well as the need to

report them to the physician. The client should be instructed to monitor his lithium levels on a regular basis to avoid toxicity. The nurse should explain that 7 to 21 days may pass before the client notes a change in his mood. Lithium doesn’t have addictive properties. Tyramine is a potential concern for clients taking monoamine-oxidase inhibitors.

97. B,C,E

Rationale: Neuroleptic malignant syndrome is a life-threatening adverse effect of antipsychotic medications such as Haldol. It’s associated with a rapid increase in temperature. The most common extrapyramidal adverse effect, akathisia, is a form of psychomotor restlessness that can often be relieved b pacing. Haldol and the anticholinergic medications that are provided to alleviate it extrapyramidal effects can result in a dry mouth. Providing the client with hard candy to suck on can help alleviate this problem. Haldol isn’t given subcutaneously and doesn’t affect blood suga levels. Urticaria is not usually associated with Haldol administration.

98. C

Rationale: The preoccupation in hypochondriasis is related to bodily functions or physical sensations. Repeated physical examinations, diagnostic tests, and reassurance from the physician don’t allay the concerns about bodily disease. There’s a belief that a health care professional has poor insight if he sees the concern about having a serious illness as excessive or unreasonable. The other responses aren’t valid.

99. D

Rationale: Sleep deprivation can lead to hallucinations and delusions. Uninterrupted sleep is an important nursing consideration in planning care.

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All other data are expected and shouldn’t cause sleep deprivation.

100. C

Rationale: The amount of time focused on discussing physical symptoms should be decreased. Lack of positive reinforcement may help her to stop the maladaptive behavior. However, avoiding the statement all together demeans the client and doesn’t address the underlying problem. Asking the client to further explain emphasizes physical symptoms and prevents the client from attending group therapy. All physical complaints need to be evaluated for physiological causes by the physician. (Reference: Lippincott Wiliams & Wilkins. NCLEX-RN Question and Answer p. 307)

101. C

Rationale: By developing skills in one area, the individual compensates or makes up for a real or imagined deficiency, thereby maintaining a positive self-image.

102. D

Rationale: Fears and anxieties about themselves and their possessions are common in older adults because of a decreased self-concept and an altered body image; these changes result in a decreased ability to cope.

103. A

Rationale: Use of denial involves failure to acknowledge the reality of a situation.

104. B

Rationale: Any behavioural therapy or learning of new methods of coping with situations requires modification of approach and attitudes; hence personality is always capable of change.

105. B

Rationale: Attributing unacceptable feelings or attributes to others is the mechanism known as projection, the data demonstrate use of this defense mechanism.

106. A

Rationale: Splitting is the compartmentalization of opposite-affect states and failure to integrate the positive and negative aspects of self or others. 107. C

Rationale: Conscience and a sense of right and wrong are expressed in the superego, which acts to counterbalance the id’s desire for immediate gratification.

108. D

Rationale: The mature personality does not respond to the immediate gratification, demands of the id or

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the oppressive control of the superego because the ego is strong to maintain a balance between them.

109. A

Rationale: Repression is a coping mechanism in which unacceptable feelings are kept out of conscious awareness; later, under stress anxiety, thoughts or feelings surface and come into one’s conscious awareness.

110. D

Rationale: Intellectualization occurs when a painful emotion is avoided by means of a rational explanation that removes the event from any personal significance.

111. C

Rationale: This is the age of Freud’s phallic stage and Erikson’s stage of initiative versus guilt.

112. C

Rationale: Children view their own worth by the response received from their parents. This sense of worth sets the basic ego strengths and is vital to the formation of the personality.

113. D

Rationale: when acting-out against the primary source of anxiety creates even further anxiety or danger, the individual may use displacement to express feelings on a safer person or object.

114. D

Rationale: when the individual experiences a threat to self-esteem, anxiety increases and defense mechanisms are used to protect the self.

115. A

Rationale: this client is using the cognitive distortions of overgeneralization and pessimism. Negative events are magnified and become the focus while the contrary positive experiences are minimized and ignored. By focusing on the negative, the depressive mood is reinforced.

116. B

Rationale: Amphetamines are central nervous system stimulants. They cause sympathetic stimulation including hypertension, tachycardia, vasoconstriction, and hyperthermia. Hot, dry skin is seen with anticholinergic agents such as jimsonweed. Pupils will be dilated not constricted.

117. A

Rationale: anxiety is a normal reaction to the termination of the nurse-client relationship. The nurse should help the client explore his feelings about the end of the therapeutic relationship. While anger about the termination may be a healthy response, banging the table, shouting and other forms of acting out aren’t appropriate behaviour. Withdrawal isn’t a healthy response to the termination of a relationship. By rationalizing the termination, the client avoids expressing his feelings and emotions. M A D : M a la d a p ti v e D is o rd e rs | B S N 0 0 2

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118. A

Rationale: The client’s memory of a traumatic childhood incident and her current signs and symptoms (nightmares, flashbacks, and related fears) suggests that she has PTSD with delayed onset. The client doesn’t occasionally lose track of her movements and actions, as in multiple personality disorder. Her anxiety isn’t primary but results from severe emotional trauma. Although she experiences flashbacks, these aren’t psychotic episodes, as in schizophrenia.

119. B

Rationale: the nurse must question this order immediately. Thioridazine (Mellaril) has and absolute dosage ceiling of 800 mg / day. Any dosage above this level places the client at high risk for toxic pigmentary retinopathy, which can’t be reversed. As written, the order allows for administering more than the maximum 800 mg / day; it should be corrected immediately, before the client’s health is jeopardized.

120. B

Rationale: Diarrhea is the most common physiologic response to stress and anxiety. The other options could also be related to stress and anxiety but they don’t occur as frequently or as commonly as diarrhea

121. B

Rationale: Flight of ideas is the shifting of a topic from one subject to another in a somewhat related way while looseness of association is the shifting of a topic from one subject to another in a completely unrelated way

122. C

Rationale: elevated temperature, elevated blood pressure and diaphoresis are indicative of Neuroleptic malignant syndrome, which is a medical emergency.

123. A

Rationale: Disorganization is the phase of s crisis situation characterized by feelings of great anxiety and inability to perform activities of daily living.

124. C

Rationale: Patients who are narcissistic feels that they are special and they demand special attention from others.

125. C

Rationale: Catatonic schizophrenia is usually manifested by stuporous withdrawal, hallucinations, delusions, waxy flexibilities and catatonic rigidity.

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(Reference: The ABC’s of Psychiatric Nursing: Core Concepts for the Nurse Licensure Exam by Ray A. Gapuz)

126. D

Rationale: Giving broad opening provides an opportunity for a patient to choose the topic of conversation, hence it is appropriate to use when initiating interaction.

127. A

Rationale: Aged cheese, cheddar cheese and Swiss cheese are high in tyramine and are therefore to be avoided. Cottage cheese and cream cheese are allowed.

128. B

Rationale: The therapeutic use of self requires self awareness initially, therefore the nurse has to deal with her feelings first.

129. A

Rationale: The ritual preformed by the obsessive-compulsive patient is their way of expressing fears and tensions.

130. A

Rationale: Depressed patients usually turn their hostile feelings towards themselves. Providing an outlet for theses aggressive feelings will make the patient feel less guilty.

131. C

Rationale: Tardive dyskinesia is usually manifested by lip smacking and tongue twitching. Oculogyric crisis is usually manifested by upward rolling of the eyeballs.

132. C

Rationale: Initial therapeutic effects of antidepressants occur after 2-3 weeks while full therapeutic effects occur after 3-4 weeks.

133. C

Rationale: Projection is attributing to others one’s unconscious wishes/fear. Usually it is seen in paranoid patients.

134. D

Rationale: Interacting with parents with autistic thinking requires thorough analysis of speech patterns, the meanings of their expressions and the relationship of these to their covert needs. This situation usually poses great difficulty on the part of the nurse. 135. A M A D : M a la d a p ti v e D is o rd e rs | B S N 0 0 2

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Rationale: At the height of depression, patients usually have difficulty conceptualizing activities. The patient’s plan to organize child care indicates that his ability to conceptualize is working. This indicates recovery from depression.

136. D

Rationale: The client must first deal with feelings and negative responses before the client can work through the meaning of the crisis.

137. A

Rationale: Denial is refusal to admit to a painful reality and may be a response by a victim of sexual abuse. Projection is transferring one’s internal feelings, thoughts, and unacceptable ideas and traits to someone else. Rationalization is justifying the unacceptable attributes about oneself. Intellectualization is the excessive use of abstract thinking or generalizations to decrease painful thinking.

138. D

Rationale: In the termination phase, the relationship comes to a close. Ending treatment sometimes may be traumatic for clients who have come to value the relationship and the help. Because loss is an issue, any unresolved feelings related to loss may resurface during this phase.

139. D

Rationale: Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating.

140. C

Rationale: Option C uses the therapeutic communication technique of restatement. Although restatement is a technique that has a prompting component to it, it repeats the client’s major theme, which assists the nurse to obtain a more specific perception of the problem from the client.

(Reference: Silvestri, “Comprehensive Review NCLEX-RN Examamination, 4th_{ed”, 2008)}

141. C

Rationale: When the nurse and client agree to work together, a contract should be established, the length of the relationship should be discussed in terms of its ultimate termination.

142. B

Rationale: The nurse should initiate brief, frequent contacts throughout the day to let the client know that he is important to the nurse. This will positively affect the client’s self-esteem.

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143. D

Rationale: The statement “I don’t think about killing myself as much as I used to.” Indicates a lessening of suicidal ideation and improvement in the client’s condition.

144. C

Rationale: The drug of choice for a client experiencing extra pyramidal side effects from haloperidol (Haldol) is benztropine mesylate (cogentin) because of its anti cholinergic properties.

145. D

Rationale: An aloof, detached, withdrawn posture is a means of protecting the self by withdrawing and maintaining a safe, emotional distance.

(Reference: NCLEX Review: Psychiatric Nursing Practice Test Part 2)

146. C

Rationale: This would distract the client by offering alternate activity. Option A should be eliminated never ask “why” question. The client is unable to explain this behavior. Option B is also eliminated because this response is threatening and implies misbehavior by the client. Option D is also eliminated because this does not distract the client from the behavior and leaves her in the room alone to continue washing her hands.

147. C

Rationale: The client preoccupied with delusions of the persecution, grandeur, ideas of reference, and auditory hallucinations is predisposed to suicidal and violent behavior. Option A is not applicable, as this would reinforce the client’s delusions of persecution. Option B and D should be eliminated since this is another area of concern, but safety must be first addressed.

148. C

Rationale: Client with paranoid schizophrenia frequently seclude themselves from others because of their suspiciousness, which results in their reluctance to trust people. Option A should be eliminated because fear of being alone is not the appropriate nursing diagnosis. Option B is also eliminated since this response has to do with suspiciousness and persecutory feelings but it is incorrect because it is an example of circular nursing. Option D is also eliminated as for impaired social skills is not also the appropriate nursing diagnosis.

149. C

Rationale: Clients who are diagnosed with schizophrenic disorders have difficulty handling complex information, so it is best to keep communication simple. Option A should be eliminated because the mood of the staff is not significant. Option B is also eliminated since the client deals best with simple direct sentences. Option D is also eliminated as client in general do not have trouble with violent behaviors.

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150. A

Rationale: Major aspects of the pre-ECT stage are: obtaining lab and diagnostic data, getting an informed consent, and reinforcing client and family education. Option B is not applicable. Option C it should be eliminated because the client is NPO after midnight. Option D is also eliminated since this is important, but not necessarily the nurse’s responsibility.

(Reference: Meyer, J. (2003) “The Princeton Review, cracking the NCLEX-RN”, 7th_{edition, New} York: Random House Inc.)

151. D

Rationale: Option d helps the client focus on the emotion underlying the delusion but does not argue with it. Option 1 places the client in a position that requires a response. Option 2 avoids the client. Option3 is an attempt to convince the client to believe another thought. This response may cause the client to hold the delusion more strongly.

152. D

Rationale: The client must first deal with feelings and negative responses before the client can work through the meaning of the crisis. Option 4 pertains directly to the client’s feelings. Option 1 and 2 do not directly address the client’s feelings. Option 3 is more of an assessment question.

153. C

Rationale: Restating is the therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review what was said. Option 3 uses the therapeutic technique of restating. Option 1, the nurse is attempting to assess the client’s ability to discuss feelings openly with family members. In option 2, the nurse attempts to use focusing, but the attempt to discuss central issues is premature. In option 4, the nurse makes a judgment and is nontherapeutic in the one-to-one relationship.

154. D

Rationale: Clients who are admitted involuntarily do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceeding. The informed consent needs to be obtained from the client.

155. D

Rationale: False imprisonment is an act with the intent to confine a person to a specific area. A nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the hospital if the client has been admitted voluntarily and if no agency or legal policies exist for detaining the client. However, if the client has been admitted involuntarily or had agreed to an evaluation before discharge, the nurse’s actions are reasonable.

(Reference: The ABC’s of Psychiatric Nursing: Core Concepts for the Nurse Licensure Exam by Ray A. Gapuz) M A D : M a la d a p ti v e D is o rd e rs | B S N 0 0 2

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156. C

Rationale: Antiseptic mouthwash often contains alcohol & should be kept in locked area, unless labeling clearly indicates that the product does not contain alcohol.

157. D

Rationale: Monitoring of vital signs provides the best information about the client’s overall physiologic status during alcohol withdrawal & the physiologic response to the medication used.

158. D

Rationale: Barbiturates are CNS depressants; the nurse would be especially alert for the possibility of respiratory failure. Respiratory failure is the most likely cause of death from barbiturate over dose.

159. A

Rationale: The nurse would facilitate progressive review of the accident and its consequence to help the client integrate feelings & memories and to begin the grieving process.

160. A

Rationale: A moderate level of cognitive impairment due to dementia is characterized by increasing dependence on environment & social structure and by increasing psychologic rigidity with accentuated previous traits & behaviors.

(Reference: NCLEX Review: Psychiatric Nursing Practice Test Part 2)

161. B

Rationale: A is a characteristic of a borderline personality disorder. Client with antisocial personality disorder do not experience disordered thoughts. Poor judgment is a result of not paying to the legality of their actions

162. D

Rationale: Avoidant is characterized by a pervasive pattern of social discomfort. Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of. Antisocial is characterized by a pervasive pattern of disregard for and violation of the rights of others. Clients with passive-aggressive personality disorder express resistance through procrastination, FORGETFULNESS, and stubbornness

163. A

Rationale: A is a verbal communication because it consists of words a person uses to speak to one or more listeners. B is an observation which means watching the speaker’s nonverbal customs. Nodding of head is a body language which is also a nonverbal communication. 164. D M A D : M a la d a p ti v e D is o rd e rs | B S N 0 0 2

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Rationale: Introjection is accepting another person’s attributes, beliefs, and values as one’s own. Displacement is ventilation of intense feeling towards persons less threatening. Undoing is exhibiting acceptable behavior to make up for or negate unacceptable behavior. Projection is unconsciously blaming of unacceptable inclinations or thoughts on an external object.

165. A

Rationale: Antisocial personality disorder is characterized by a pervasive pattern of disregard for and violation of the rights of others and with the central characteristics of deceit and MANIPULATION.

(Reference: Videbeck, “Psychiatric Mental Health Nursing”)

166. B

Rationale: Confrontation is the skill of caringly pointing out discrepancies between what a client says and does. In this case, the client displayed developing trust in the nurse, but then seemed to engage in avoidance. The nurse uses a three-part formula, called a perception check, increasing communication without accusing the client or making assumptions about his behaviors. The first option follows the formula for assertive statements, which this scenario does not call for at this time. Telling the client feelings for his wife does not describe, offer possible interpretations of, or ask for feedback about the confusing behavior. With the last statement, the nurse neither describes nor interprets the behavior.

Instead, the nurse makes assumptions that may seem like accusations

167. B

Rationale: Clients older than 18 years old, diagnosed with a conduct disorder before 17 years, possessing a history of fighting, lying and stealing, as well as problems with the criminal justice system, may have antisocial personality disorder. The behaviors are not associated with borderline, narcissistic and histrionic personality disorder.

168. C

Rationale: The first immediate intervention is to ensure ongoing observation of the client. Therefore, the nurse should arrange for an unlicensed assistance to sit with the client. The nurse should avoid restraints, which increases anxiety, fearfulness, and risk for injury and strangulation. Administering haloperidol and moving the client to a room near the nurse’s station are possible options; however, the nurse should first use one-to one observation.

169. C

Rationale: Stimulant medication ids the most helpful intervention for improving attention span and ability to focus. Parents should use negative consequences for specific undesirable actions, such as aggression or temper tantrums. Inability to focus is the symptom of the disorder most amenable to medication. Reward-based programs help shape behaviors; however, the inability to focus associated with ADHD or ADD improves most dramatically with medication.