Disorderish
What assessment effectively diagnoses a patient with autism spectrum disorder?
A. Level of depression in the patient
B. Developmental delays in the patient
C. Independent functioning in the patient
Answer: B
Rationale: Autism is diagnosed through observation of developmental delays, especially in social interaction and communication.
Which room placement would be best for a patient experiencing a manic episode?
A. A single room near the nurse’s station
B. Single room near the unit activities area
C. A shared room with a patient with dementia
Answer: A
Rationale: A quiet, single room near the nurse’s station is ideal for manic patients to reduce stimuli and allow monitoring.
Which assessment finding is associated with bulimia nervosa?
A. Dental erosion
B. Osteoporosis
C. Anemia
A – Dental erosion results from vomiting. Osteoporosis is seen in anorexia. Anemia is possible but not primary in bulimia.
Which statement best defines somatization?
A. The holistic approach to managing stress
B. The psychological and behavioral response to stress
C. The expression of stress through physical symptoms
C – Somatization is the expression of psychological distress via physical symptoms.
A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nursing actions should the nurse take?
A. Praise the client for looking at themselves in the mirror
B. Ask the client to agree to talk to a nurse whenever they feel the urge to exercise
C. Reprimand the client about the potential damage that has occurred due to overexercise in their body
Answer: B
Rationale: Therapeutic rapport is key; asking the client to talk is a non-confrontational and supportive approach. Asking the client to speak to a nurse when feeling the urge to exercise promotes therapeutic communication and behavioral regulation. It is a nonjudgmental intervention supporting the client’s autonomy while providing structure.
A nurse is discussing comorbidities associated with eating disorders with a newly admitted client. Which of the following conditions should the nurse include in the discussion? (Select all that apply)
A. Depression
B. Breathing-related sleep disorder
C. Schizophrenia
D. Obsessive-compulsive disorder
E. Anxiety
Answer: A, D, E
Rationale: Depression, OCD, and anxiety commonly coexist with eating disorders.
Which disorder can be identified when a patient experiences four or more mood episodes in a 12-month period?
A. Incongruence
B. Cyclothymia
C. Rapid cycling
Answer: C
Rationale: Rapid cycling involves four or more mood episodes in a year, associated with bipolar disorder.
Which nursing care considerations are appropriate for a patient diagnosed with dementia? Select all that apply.
A. Provide finger food to the patient.
B. Use written signs to direct the patient.
C. Ask the patient the date and time daily.
D. Place an identification bracelet on the patient.
A, D – Finger food promotes independence; ID bracelets ensure safety. Written cues and time questions may be ineffective or stressful.
. A nurse at a college campus mental health counseling center is caring for a student who just failed an examination. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms?
A. Conversion
B. Projection
C. Undoing
B – Projection involves blaming others for one’s own feelings or shortcomings—in this case, the student blaming the teacher for their failure.
. A nurse in a drug and alcohol detoxification center is planning for a client who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority?
A. Helping the client identify positive personality traits
B. Providing for adequate hydration and rest
C. Confronting the use of denial and other defense mechanisms
Answer: B
Rationale: Hydration and rest are top priorities during early alcohol withdrawal to prevent complications.
A nurse is caring for a client who has paranoid personality disorder. Which of the following findings should the nurse expect? (Select all that apply)
A. Desires to be the center of attention
B. Believes that others are deceiving them
C. Persistently holds on to grudges
Answer: B, C
Rationale: Paranoid personality disorder includes suspicion of others and holding grudges.
Which statement accurately describes patients with a personality disorder?
A. They are resistant to behavioral change
B. They have an ability to tolerate frustration and pain
C. They have little difficulty forming satisfying and intimate relationships
A – Personality disorders are marked by deeply ingrained behaviors and thought patterns that are resistant to change.
Which characteristics are associated with moderate anxiety? (Select all that apply)
A. The person engages in selective inattention
B. Learning and problem solving are no longer possible
C. Gastric discomfort and headaches sometimes are reported
D. The sympathetic nervous system begins to control vital organs
A, C, D
Rationale: Moderate anxiety causes physical symptoms and selective inattention; sympathetic nervous system activation begins.
A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is experiencing PTSD if the client makes which of the following statements?
A. My child was born with a birth defect due to an exposure I had overseas.
B. I killed four enemy soldiers with my bare hands and saved my entire battalion.
C. In my dreams, all I can see are the wounded reaching out and trying to grab me.
Answer: C
Rationale: Flashbacks and distressing dreams of traumatic events are key PTSD symptoms.
A nurse on a long-term care unit is creating a care plan for a client who has Alzheimer’s disease. Which of the following interventions should the nurse include in the plan?
A. Rotate assignment of daily caregivers
B. Provide an activity schedule that changes from day to day
C. Talk to the client through the task one step at a time
Answer: C
Rationale: Simple one-step directions help clients with Alzheimer’s understand and follow tasks.
Which disorder is characterized by the patient frequently self-scanning for signs of illness?
A. Factitious disorder
B. Conversion disorder
C. Illness anxiety disorder
C – Illness anxiety disorder involves preoccupation with health and scanning for illness
A patient says, “Sometimes I feel like I’m floating above my body, watching it from the outside.” When documenting this observation, which term applies?
A. Amnesia
B. Depersonalization
C. Derealization
B – Depersonalization is feeling detached from oneself, like floating above the body.
A nurse is caring for a client who has major depressive disorder and is scheduled for electroconvulsive therapy (ECT). The client's spouse asks the nurse about the possible side effects of the ECT. Which of the following responses should the nurse give?
A. The main side effects are temporary. It may include mild confusion, a headache, and a short-term memory loss
B. Most clients have no adverse effects to this treatment, but muscle cramping may result from the induced seizure
C. The most common side effects are directly related to the use of anesthesia
A
Temporary confusion, headache, and short-term memory loss are common, transient side effects of ECT.
Which strategy would the nurse include in the plan of care for a patient with dissociative amnesia?
A. Provide the patient with cues from the past
B. Allow the patient to rest
C. Ask the patient to recollect past events
A – Cues support memory recall in dissociative amnesia without pressuring the patient.
A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity?
A. The client runs four miles outdoors every afternoon
B. The client drinks two liters of fluids daily
C. The client eats food high in tyramine
Answer: A
Rationale: Prolonged exercise can cause dehydration and sodium loss, increasing lithium toxicity risk.
. In conducting a psychosocial assessment, which area would the nurse focus on for a patient with an antisocial personality disorder? (Select all that apply.)
A. Anxiety level
B. Substance abuse
C. Current stressors
D. Homicidal ideation
E. Chronic medical issues
A, B, C, D – Patients with antisocial personality disorder often engage in substance use, exhibit low anxiety, face life stressors poorly, and may show homicidal ideation. Chronic medical issues are not a primary focus.
Which personality traits are associated with borderline personality disorder? (Select all that apply.)
A. Shyness
B. Impulsivity
C. Disinhibition
D. Hypersensitivity
E. Aggressive disregard
F. Emotional dysregulation
B, D, F – Borderline personality disorder is characterized by impulsivity, emotional dysregulation, and hypersensitivity in relationships.
The nurse caring for a patient who is experiencing a panic attack anticipates that the psychiatrist could prescribe a STAT dose of which type of medication?
A. Standard antipsychotic medication
B. Tricyclic antidepressant medication
C. A short-acting benzodiazepine medication
Answer: C
Rationale: Short-acting benzodiazepines are used for rapid relief of acute panic symptoms.
A nurse is teaching the parents of a child who has ADHD about methylphenidate. Which of the following statements should the nurse include in the teaching?
A. Your child may gain weight while taking this medication
B. This medication might increase the amount of saliva your child produces
C. Restrict your child’s intake of caffeine while she is taking this medication
C – Caffeine can increase central nervous system stimulation, compounding the effects of methylphenidate. It should be restricted.
. A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client’s compulsive behaviors?
A. Confront the client about the senseless nature of the repetitive behaviors
B. Plan the client’s schedule to allow time for rituals
C. Set strict limits on the behavior so that the client can conform to the unit rules and schedules
Answer: B
Rationale: Initially allowing rituals reduces anxiety; they can be gradually reduced over time.
. A nurse is teaching a client who has bipolar disorder about lithium. Which statement should the nurse include?
A. This medication is so addictive you will need to discontinue in six months
B. Your provider may prescribe a diuretic if you have trouble urinating
C. We will monitor your lithium levels closely while you’re taking this medication
C – Lithium requires blood monitoring due to its narrow therapeutic range
Which behaviors describe symptoms of the manic episode of bipolar disorder? Select all that apply.
A. Distractibility
B. Low self-esteem
C. Racing thoughts
D. Increased energy
E. Talking more than usual
A, C, D, E – Common manic symptoms include distractibility, rapid thoughts/speech, and high energy.
Which priority outcome measure is considered when planning the care of a patient with withdrawal symptoms for substance use disorder?
A. Stabilization of the patient
B. Pursuit of recovery lifestyle
C. Maintenance of proper nutrition intake
A – Immediate stabilization ensures safety before recovery goals are addressed.
Which assessment findings support the diagnosis of anorexia nervosa? Select all that apply.
A. Bradycardia
B. Amenorrhea
C. Hypertension
D. Hypothyroidism
E. Constipation
A, B, D, E – These symptoms are common in anorexia. Hypertension is not typical; hypotension is more likely.
Which interventions are appropriate when caring for a patient who has symptoms of delirium? Select all that apply.
A. Interact with the patient once a day.
B. Perform regular assessment of the patient.
C. Avoid repeating the question to the patient.
D. Place a calendar and watch beside the patient.
E. Note the sleeping time of the patient.
B, D, E – Regular assessments, reorientation tools, and sleep monitoring help manage delirium. Avoiding interaction or repetition is not advised.
A nurse is creating a care plan for a client with histrionic personality disorder. Which is the priority intervention?
A. Communicate using concrete language
B. Demonstrate assertive behavior
C. Promote appropriate behavior during group therapy sessions
C – Managing attention-seeking behaviors in group therapy is a priority for histrionic PD.
A client says, “I’m too stressed. I need someone to take care of me.” The client consistently ignores chores and is late to appointments. Which defense mechanism is the client demonstrating?
A. Regression
B. Dissociation
C. Introjection
A – Regression is reverting to earlier developmental behaviors when stressed.
A nurse is planning to administer Haldol to a client with acute psychosis. What adverse effect should the nurse monitor for?
A. Increased agitation
B. Dystonia
C. Diarrhea
B – Dystonia is a serious adverse effect of Haldol and must be monitored.
DAILY DOUBLE!!!
Which schedule of drugs has a high potential for abuse, is considered dangerous, and is only available by prescription?
A. Schedule I
B. Schedule II
C. Schedule III
B – Schedule II drugs are tightly controlled due to high abuse potential.
A nurse is planning care for a client with paranoid schizophrenia. Which intervention should be included?
A. Rotate staff assignments
B. Use touch to calm the client
C. Check the client’s mouth after giving medication
C – Checking the mouth ensures medication compliance in paranoid patients.