Personality
Disorders
Disorders
A person shoplifts merchandise from a community cancer thrift shop. When confronted, the person replies, “All this stuff was donated, so I can take it.” This comment suggests features of which personality disorder?
a. Antisocial
b. Histrionic
c. Borderline
d. Schizotypal
Answer: a.
The persons exhibits callousness, entitlement, lack of remorse, and disregard for the rights of others. These characteristics are common in persons diagnosed with antisocial personality disorder.
The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client?
1. Chess
2. Writing
3. Board games
4. Group exercise
Answer: 2
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 activities that minimize stimuli and provide a constructive release for tension. The remaining options have a competitive element to them or are group activities and should be avoided because they can stimulate aggression and increase psychomotor activity.
Test-Taking Strategy: Note the strategic words, most appropriate. Eliminate options that include activities that the client cannot do alone and are competitive in nature. The correct option identifies a solitary activity.
A patient diagnosed with schizophrenia says, “I hear the voices every day. They always say bad things about me.” Which action by the nurse has the highest priority?
a. Assess the patient for suicidal thinking and plans.
b. Review the patient’s medication regimen and adherence.
c. Educate the patient about symptoms associated with schizophrenia.
d. Suggest distracters for the patient to use when auditory hallucinations occur.
Answer: a.
The daily experience of negativity creates a scenario in which the risk for suicide is high. Depressive symptoms occur frequently in schizophrenia. Suicide is the leading cause of premature death in this population.
A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly admitted client will be assigned to this client’s room. Which client would be the best choice as a roommate for the client with anorexia nervosa?
1. A client with pneumonia
2. A client undergoing diagnostic tests
3. A client who thrives on managing others
4. A client who could benefit from the client’s assistance at mealtime
Answer: 2
Rationale: The client undergoing diagnostic tests is an acceptable roommate. The client with anorexia nervosa is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which the client can focus on the nutritional needs of others or be managed by others, because this may contribute to sublimation and suppression of personal hunger.
Test-Taking Strategy: Note the strategic word, best, and note the words in a state of starvation in the question. Recalling the characteristics of anorexia nervosa and that the client is immunocompromised as a result of starvation will direct you to the correct option.
Sixteen years ago, a toddler died in a tragic accident. Once a year, the parents place flowers at the accident site. How would the nurse characterize the parents’ behavior?
a. Mourning
b. Bereavement
c. Complicated grief
d. Disenfranchised grief
Answer: a.
Mourning refers to all of the ways in which a person outwardly expresses grief and the efforts taken to manage grief. It does not have a designated time frame and may continue for many years. A once-a-year ritual is an adaptive coping technique to recognize the parents’ loss.
The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care?
1. Ask the client why he started taking illegal drugs.
2. Ask the client about the amount of drug use and its effect.
3. Ask the client how long he thought that he could take drugs without someone finding out.
4. Do not ask any questions for fear that the client is in denial and will throw the nurse out of the home.
Answer: 2
Rationale: Whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental and off-focus, and reflects the nurse’s bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse’s part and uses rationalization to avoid the therapeutic nursing intervention.
Test-Taking Strategy: Focus on the subject, assessment of a client dependent on drugs. Use of therapeutic communication techniques will assist in directing you to the correct option.
An emergency department nurse assesses a woman suspected of being abused by an intimate partner. Which assessment finding most clearly confirms the suspicion?
a. Leathery facial tone
b. Injuries in a bikini pattern
c. Reluctance to be examined
d. Lack of eye contact with the nurse
Answer: b.
The majority of the victims of reported intimate partner violence are women. Intimate partner violence is the number one cause of emergency department visits by women. Patterns of damage are often in locations that cannot be noticed easily, such as the torso, back, upper arms, upper legs, inside body orifices, and under the hair.
A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention?
1. Encouraging quiet reading and writing for the first few days
2. Identification of physical activities that will provide exercise
3. No socializing activities until the client asks to participate in milieu
4. A structured program of activities in which the client can participate
4. A structured program of activities in which the client can participate
Rationale: A client with depression often is withdrawn while experiencing difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. The remaining options are either too “restrictive” or offer little or no structure and stimulation.
Test-Taking Strategy: Focus on the subject, the plan for a client with depression. Recall that a depressed client requires a structured and stimulating program in a safe environment. The correct option is the only one that will provide a safe and effective environment.
The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include?
1. Increase socialization of the client with peers.
2. Avoid using a whisper voice in front of the client.
3. Begin to educate the client about social supports in the community.
4. Have the client sign a release of information to appropriate parties for assessment purposes.
Answer: 2
Rationale: Disturbed thought process related to paranoid personality disorder is the client’s problem, and the plan of care must address this problem. The client is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client with this disorder.
Test-Taking Strategy: Focus on the subject, interventions for paranoid personality disorder, and note the strategic word, best. Note that the client has paranoia; thinking about its definition will direct you to the correct option.
The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group’s interactions. Which intervention should the nurse initially implement?
1. Setting limits on the client’s behavior
2. Asking the client to leave the group session
3. Asking another nurse to escort the client out of the group session
4. Telling the client that they will not be able to attend any future group sessions
1. Setting limits on the client’s behavior
Rationale: Manic clients may be talkative and can dominate group meetings or therapy sessions by their excessive talking. If this occurs, the nurse initially would set limits on the client’s behavior. Initially, asking the client to leave the session or asking another person to escort the client out of the session is inappropriate. This may agitate the client and escalate the client’s behavior further. Barring the client from group sessions is also an inappropriate action because it violates the client’s right to receive treatment and is a threatening action.
Test-Taking Strategy: Note the strategic word, initially. Eliminate options that are comparable or alike and relate to the client leaving the session. Next, eliminate the option that violates the client’s right to receive treatment and is a threatening action. Remember that setting firm limits with the client initially is best.
A client says to the nurse, “The federal guards were sent to kill me.” Which is the best response by the nurse to the client’s concern?
1. “I don’t believe this is true.”
2. “The guards are not out to kill you.”
3. “Do you feel afraid that people are trying to hurt you?”
4. “What makes you think the guards were sent to hurt you?”
3. “Do you feel afraid that people are trying to hurt you?”
Rationale: It is most therapeutic for the nurse to empathize with the client’s experience. The remaining options lack this connection with the client. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate.
Test-Taking Strategy: Note the strategic word, best. Use therapeutic communication techniques. Eliminate options that show disagreement with the client or encourage any di
The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client’s room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate?
1. Interrupt the client and weigh her immediately.
2. Interrupt the client and offer to take her for a walk.
3. Allow the client to complete her exercise program.
4. Tell the client that she is not allowed to exercise rigorously.
Answer: 2
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 for appropriate exercise and place limits on rigorous activities. The correct option stops the harmful behavior yet provides the client with an activity to decrease anxiety that is not harmful. Weighing the client immediately reinforces the client’s preoccupation with weight. Allowing the client to complete the exercise program can be harmful to the client. Telling the client that she is not allowed to complete the exercise program will increase the client’s anxiety.
Test-Taking Strategy: Note the strategic words, most appropriate, and focus on the client’s diagnosis. Also, focus on the need for the nurse to maintain safety and to set firm limits with clients who have this disorder.
A recently widowed adult says, “I’ve been calling my neighbors often, but they act like they don’t want to talk to me. I just need to talk about it, you know?” What is the nurse’s best action?
a. Say to the person, “You may call me anytime you need to talk.”
b. Ask the person, “What do you mean by ‘I just need to talk about it’?”
c. Educate the person about the importance of finding alternative activities.
d. Tell the person the location and time of a local bereavement support group.
Answer: d.
This person is mourning. A grief or bereavement support group is indicated and can provide comfort.
Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply.
1. Monitor vital signs.
2. Provide a safe environment.
3. Address hallucinations therapeutically.
4. Provide stimulation in the environment.
5. Provide reality orientation as appropriate.
6. Maintain NPO (nothing by mouth) status.
Answer: 1, 2, 3, 5
Rationale: When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming self or others. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake need to be maintained.
Test-Taking Strategy: Note the strategic words, most appropriate. Thinking about the needs of the client in alcohol withdrawal and recalling the characteristics associated with alcohol withdrawal will assist in answering correctly. Also, use therapeutic communication techniques to assist in selecting the correct interventions.
The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client’s speech pattern is rapid, and affect is belligerent. Based on these observations, which is the nurse’s immediate priority of care?
1. Provide safety for the client and other clients on the unit.
2. Provide the clients on the unit with a sense of comfort and safety.
3. Assist the staff in caring for the client in a controlled environment.
4. Offer the client a less stimulating area in which to calm down and gain control.
Answer: 1
Rationale: Safety of the client and other clients is the immediate priority. The correct option is the only one that addresses the safety needs of the client as well as those of the other clients.
Test-Taking Strategy: Note the strategic words, immediate priority, and use Maslow’s Hierarchy of Needs theory to prioritize. Note the words agitated, aggressive, and belligerent. Safety is the priority focus if a physiological need does not exist. Also, the correct option is the umbrella option and addresses the safety of all.
The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, “I should get out of this bad situation.” Which is the most helpful response by the nurse?
1. “Why don’t you tell your spouse about this?”
2. “What do you find difficult about this situation?”
3. “This is not the best time to make that decision.”
4. “I agree with you. You should get out of this situation.”
Answer: 2
Rationale: The most helpful response is one that encourages the client to solve problems. Giving advice implies that the nurse knows what is best and can foster dependency. The nurse should not agree with the client, and the nurse should not request that the client provide explanations.
Test-Taking Strategy: Note the strategic word, most. Use therapeutic communication techniques. Eliminate option 1 because of the word why, which should be avoided in communication. Eliminate option 3, because this option places the client’s feelings on hold. Eliminate option 4, because the nurse is agreeing with the client. The correct option is the only one that addresses the client’s feelings.
A client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder?
1. Avoidant
2. Borderline
3. Schizotypal
4. Obsessive-compulsive
1. Avoidant
Rationale: The avoidant personality disorder is characterized by social withdrawal and extreme sensitivity to potential rejection. The person retreats to social isolation. Borderline personality disorder is characterized by unstable mood and self-image and impulsive and unpredictable behavior. Schizotypal personality disorder is characterized by the display of abnormal thoughts, perceptions, speech, and behaviors. Obsessive-compulsive personality disorder is characterized by perfectionism, the need to control others, and a devotion to work.
A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement?
1. Place the client in seclusion for 30 minutes.
2. Tell the client that the behavior is inappropriate.
3. Escort the client to their room, with the assistance of other staff.
4. Tell the client that their telephone privileges are revoked for 24 hours.
3. Escort the client to their room, with the assistance of other staff.
Rationale: The client is at risk for injury to self and others and should be escorted out of the dayroom. Seclusion is premature in this situation. Telling the client that the behavior is inappropriate has already been attempted by the nurse. Denying privileges may increase the agitation that already exists in this client.
Test-Taking Strategy: Eliminate option 2 because this intervention has already been attempted. Next, use Maslow’s Hierarchy of Needs theory to answer the question. Remember that if a physiological need is not present, focus on safety. Look for the option that promotes safety of the client, other clients, and staff.
The nurse is preparing a client with schizophrenia a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information?
1. “My medications will help my anxious feelings.”
2. “I’ll go to support group and talk about what I am feeling.”
3. “When I have command hallucinations, I’ll call a friend for help.”
4. “I need to get enough sleep and eat well to help prevent feeling anxious.”
Answer: 3
Rationale: The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. If the client is experiencing a hallucination, the nurse or health care counselor, not a friend, should be contacted to discuss whether the client has intentions to hurt herself or himself or others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. The client statements in the remaining options will aid in wellness but are not specific interventions for hallucinations, if they occur.
Test-Taking Strategy: Note the strategic words, need for additional information. These words indicate a negative event query and the need to select the incorrect statement as the answer. Focus on the subject, managing hallucinations and anxiety. The correct option is a specific agreement to seek appropriate help. The remaining options are interventions that a client can carry out to aid wellness.
When planning the discharge of a client with chronic anxiety, which is the most appropriate maintenance goal?
1. Suppressing feelings of anxiety
2. Identifying anxiety-producing situations
3. Continuing contact with a crisis counselor
4. Eliminating all anxiety from daily situations
2. Identifying anxiety-producing situations
Rationale: Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Suppressing feelings will not resolve anxiety. Elimination of all anxiety from life is impossible.
Test-Taking Strategy: Focus on the strategic words, most appropriate. Eliminate any option that contains the closed-ended word “all” or suggests that feelings should be suppressed. Note that the correct option is more client-centered and helps prepare the client to deal with anxiety should it occur.
A physician informed an adult of the results of diagnostic tests that showed lung cancer. Later in the day, the patient says to the nurse, “My doctor said I have breathing problems, right?” Which nursing diagnosis is applicable?
a. Denial related to acceptance of new diagnosis
b. Spiritual distress related to unresolved life conflicts
c. Situational low self-esteem related to the stress of new diagnosis
d. Acute confusion related to metastatic changes to cerebral function
Answer: a.
Although emotional responses to grief vary from one individual to the next, a common first response is that of denial. The person is emotionally unable to accept his or her painful loss. Denial functions as a buffer against intolerable pain and allows the person to acknowledge the reality of a loss slowly.
The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement?
1. “I no longer feel that I deserve the beatings my husband inflicts on me.”
2. “My attendance at the meetings has helped me see that I provoke my husband’s violence.”
3. “I enjoy attending the meetings because they get me out of the house and away from my husband.”
4. “I can tolerate my husband’s destructive behaviors now that I know they are common among alcoholics.”
Answer: 1
Rationale: Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. The correct option is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. Option 2 is incorrect, because the nonalcoholic partner should not feel responsible when the spouse loses control. Option 3 indicates that the group is viewed as an escape, not as a place to work on issues. Option 4 indicates that the wife remains codependent.
Test-Taking Strategy: Focus on the subject, the therapeutic effect of attending an Al-Anon group. Noting the words benefiting from attending an Al-Anon group will direct you to the correct option.
An emergency department nurse assesses a child with a fractured ulna. The nurse also observes yellow and purple bruises across the child’s back and shoulders. Which comment by the parents should prompt the nurse to consider making a report to Child Protective Services?
a. “We do not believe in immunization of our children.”
b. “This child is always creating problems for the family.”
c. “Our child would rather play alone than with other children.”
d. “We homeschool our children in order to include religious education.”
Answer: b.
The acute injury, coupled with bruises of different ages, suggest that the child may be abused. Abusive parents may perceive the child as bad or evil or project blame. The nurse is required to report suspicions of abuse to child protective services.
A client receiving tricyclic antidepressants arrives at the mental health clinic. Which observation would indicate that the client is following the medication plan correctly?
1. Client reports not going to work for the past week.
2. Client complains of not being able to “do anything” anymore.
3. Client arrives at the clinic neat and appropriate in appearance.
4. Client reports sleeping 12 hours per night and 3 to 4 hours during the day.
Answer: 3
Rationale: Depressed individuals sleep for long periods, are unable to go to work, and feel as if they cannot “do anything.” When these clients have had some therapeutic effect from their medication, they report resolution of many of these complaints and exhibit an improvement in their appearance. Options 1, 2, and 4 identify continued depression.
Test-Taking Strategy: The client’s behaviors or reports identified in options 1, 2, and 4 are comparable or alike and are symptoms of depression. The improvement in appearance indicates a therapeutic response to the medication, indicating compliance with the medication regimen.
After a power outage, a facility must serve a dinner of sandwiches and fruit to patients. Which comment is most likely from a patient diagnosed with a narcissistic personality disorder?
a. “These sandwiches are probably contaminated with bacteria.”
b “I suppose it’s the best we can hope for under these circumstances.”
c. “You should have ordered a to-go meal from a local restaurant for me.”
d. “I would rather wait to eat until the dietary department can prepare a meal.”
Answer: c.
People diagnosed with narcissistic personality disorder consider themselves special and expect special treatment. Their demeanor is arrogant and haughty. They have a sense of entitlement.
A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L (2.5 mmol/L). The nurse plans care based on which representation of this level?
1. Toxic
2. Normal
3. Slightly above normal
4. Excessively below normal
Answer: 1
Rationale: Maintenance serum levels of lithium are 0.6 to 1.2 mEq/L (0.6 to 1.2 mmol/L). Symptoms of toxicity begin to appear at levels of 1.5 mEq/L (1.5 mmol/L). Lithium toxicity requires immediate medical attention and the primary health care provider is notified if symptoms of toxicity occur.
Test-Taking Strategy: Focus on the subject, therapeutic serum medication level of lithium. Recalling that the high end of the maintenance level is 1.2 mEq/L (1.2 mmol/L) will direct you to the correct option.
The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention?
1. Ask direct questions to encourage talking.
2. Leave the client alone so as to minimize external stimuli.
3. Sit beside the client in silence with simple open-ended questions.
4. Take the client into the dayroom with other clients to provide stimulation.
Answer: 3
Rationale: Clients who are withdrawn may be immobile and mute and may require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking simple open-ended questions rather than direct questions, and pausing to provide opportunities for the client to respond. Although overstimulation is not appropriate, there is no therapeutic value in ignoring the client. The client’s safety is not the responsibility of other clients.
Test-Taking Strategy: Note the strategic words, most appropriate. Eliminate options either that are nontherapeutic or could result in overstimulation. Also eliminate options that are not examples of therapeutic communication. The correct option provides for client supervision and communication as appropriate.
A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which mental health condition?
1. Psychosis
2. Repression
3. Conversion disorder
4. Dissociative disorder
3. Conversion disorder
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 a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. Psychosis is a state in which a person’s mental capacity to recognize reality, communicate, and relate to others is impaired, interfering with the person’s ability to deal with life’s demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness.
Test-Taking Strategy: Focus on the subject, the cause of acute blindness. The key to the correct option lies in the fact that the client presents no organic reason to account for the blindness—hence, a conversion disorder.
A nurse leads a bereavement group. Which participant’s comment best demonstrates that the work of grief has been successfully completed?
a. “Our time together was too short. I only wish we had done more things together.”
b. “I know our life together was a blessing that I did not deserve. I wish I had said, ‘I love you’ more often.”
c. “Other people knew my loved one as a good and helpful person. I hope people see me in the same way.”
d. “Our best vacations always involved water. When I see pictures of the ocean, those memories come flooding in.”
Answer: d.
The work of grief is over when the bereaved can realistically remember the pleasures and the disappointments of the relationship with the lost loved one. Brief periods of intense emotions may still occur at significant times, but the person or family members have energy to reinvest in new relationships that bring shared joys, security, satisfaction, and comfort.
The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? Select all that apply.
1. Dental decay
2. Moist, oily skin
3. Loss of tooth enamel
4. Electrolyte imbalances
5. Body weight well below ideal range
Answer: 1, 3, 4
Rationale: Clients with bulimia nervosa initially may not appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, a client exhibits dental decay and loss of tooth enamel if the client has been inducing vomiting. Electrolyte imbalances are present. Dry, scaly skin (rather than moist, oily skin) is present.
Test-Taking Strategy: Focus on the subject, assessment findings in bulimia nervosa. It is necessary to recall that in anorexia nervosa the body weight is normally well below ideal body weight and that clients with bulimia nervosa are often at or slightly below ideal body weight. Also, remember that skin texture will be dry and scaly.
A woman in a relationship characterized by a long history of battering and abuse tells the nurse, “We’ve had a rough time lately. I admit it: He beat me last night but then said he was sorry.” Which event would the nurse expect to occur next in this relationship?
a. Another beating by the abusive partner
b. Love, gifts, and praise from the abusive partner
c. A brief period during which the partners ignore each other
d. The abusive partner leaving the relationship for a short time
Answer: b.
The cycle of violence consists of three phases: (1) tension-building phase, (2) acute battering phase, and (3) honeymoon phase. The question scenario shows acute battering, so a period of loving calm is likely to follow.
A patient who had a stroke 3 days ago tearfully tells the nurse, “What’s the use in living? I’m no good to anybody like this.” Which action should the nurse employ first when caring for a patient demonstrating hopelessness?
a. Implement the institutional protocol for suicide risk.
b. Support the patient to clarify and express feelings of grief.
c. Educate the patient about the success of stroke rehabilitation.
d. Offer the patient an opportunity to confer with the pastoral counselor.
Answer: a.
The patient’s comment suggests hopelessness, helplessness, and worthlessness. Physical illnesses play a role in increasing suicide risk. Suicide precautions should be initiated.
A nurse plans care for a patient diagnosed with borderline personality disorder. Which patient problem is most likely to apply to this patient?
a. Ineffective relationships related to frequent splitting
b. Social isolation related to fear of embarrassment or rejection
c. Ineffective impulse control related to violence as evidenced by cruelty to animals
d. Disturbed thought processes related to recurrent suspiciousness of people and situations
Answer: a.
People diagnosed with borderline personality disorder frequently use the defense of splitting, which strains personal relationships. Splitting is the inability to integrate both the positive and the negative qualities of an individual into one person.
Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.
1. Communicate expected behaviors to the client.
2. Ensure that the client knows that they are not in charge of the nursing unit.
3. Assist the client in identifying ways of setting limits on personal behaviors.
4. Follow through about the consequences of behavior in a nonpunitive manner.
5. Enforce rules by informing the client that he/she will not be allowed to attend therapy groups.
6. Have the client state the consequences for behaving in ways that are viewed as unacceptable.
Answer: 1, 3, 4, 6
Rationale: Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding the limits set; following through with the consequences in a nonpunitive manner; and assisting the client in identifying a means of setting limits on personal behaviors. Ensuring that the client knows that she or he is not in charge of the nursing unit is inappropriate; power struggles need to be avoided. Enforcing rules and informing the client that she or he will not be allowed to attend therapy groups is a violation of a client’s rights.
Test-Taking Strategy: Focus on the subject, manipulative behavior. Recalling clients’ rights and that power struggles need to be avoided will assist in selecting the correct interventions.
Three days after beginning a new regime of haloperidol (Haldol), the nurse observes that a hospitalized patient is drooling, has stiff and extended extremities, and has skin that is damp and hot to the touch. The patient has difficulty responding verbally to the nurse. What are the nurse’s correct analysis and action in this situation?
a. A seizure is occurring; place the patient in a lateral recumbent position and monitor.
b. Serotonin syndrome has developed; place an intravenous line and rapidly infuse D5½ normal saline (NS).
c. Neuroleptic malignant syndrome has developed; prepare the patient for immediate transfer to a medical unit.
d. An acute dystonic reaction is occurring; promptly administer an intramuscular injection of diphenhydramine (Benadryl).
Answer: c.
Neuroleptic malignant syndrome (NMS) occurs in persons who have taken antipsychotic agents and usually begins early in the course of therapy. It is characterized by a decreased level of consciousness; greatly increased muscle tone; and autonomic dysfunction, including hyperpyrexia, labile hypertension, tachycardia, tachypnea, diaphoresis, and drooling. Treatment consists of early detection, discontinuation of the antipsychotic agent, management of fluid balance, reduction of temperature, and monitoring for complications. Treatment of this problem should occur in a medical unit.
A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client’s old clothes. The client believes that the new clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior?
1. Normal behavior
2. Evidence of the client’s disturbed body image
3. Regression as the client is moving toward the community
4. Indicative of the client’s ambivalence about hospital discharge
Answer: 2
Rationale: Disturbed body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and show regressed behavior, the client’s coping pattern relates to the basic issue of disturbed body image. The nurse should address this need in the support group.
Test-Taking Strategy: Note the subject, signs of disturbed body image. Note the relationship between the information in the question and the correct option.
A nurse who has worked for a community hospice organization for 8 years says, “My patients and their families experience overwhelming suffering. No matter how much I do, it’s never enough.” Which problem should the nursing supervisor suspect?
a. The nurse is experiencing spiritual distress.
b. The nurse is at risk for burnout and compassion fatigue.
c. The nurse is not receiving adequate recognition from others.
d. The nurse is at risk for overhelping, which creates dependency.
Answer: b.
The nurse’s comment suggests a negative self-judgment. Burnout, decreased work performance, and compassion fatigue (the emotional pain or cost of working with traumatized persons) may result in stress responses for nurses.
The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings should alert the nurse to the potential for alcohol withdrawal delirium?
1. Hypotension, ataxia, hunger
2. Stupor, lethargy, muscular rigidity
3. Hypotension, coarse hand tremors, lethargy
4. Hypertension, changes in level of consciousness, hallucinations
Answer: 4
Rationale: Symptoms associated with alcohol withdrawal delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions.
Test-Taking Strategy: Focus on the subject, findings associated with withdrawal delirium. Review each option carefully to ensure that all symptoms in the option are correct. Eliminate options 1 and 3 first, knowing that hypertension rather than hypotension occurs. From the remaining options, recalling that the client who is stuporous is not likely to exhibit withdrawal delirium will direct you to the correct option.
The nurse assessed an elderly person who was abused by the caregiver. Afterward, which internal dialogue should prompt the nurse to seek guidance?
a. “Sometimes I get so discouraged and frustrated with my job.”
b. “It’s incredible that anyone could hurt a child or elderly person.”
c. “The abuser was probably a victim of abuse at some point in life.”
d. “I hope the abuser gets victimized so that they know what it feels like.”
Answer: d.
Nurses must be self-aware, particularly in highly charged situations. Wishing harm to an abuser may be understandable, but it is an indicator of the nurse’s need for guidance.
A hospitalized client is started on a monoamine oxidase inhibitor (MAOI) for the treatment of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication? Select all that apply.
1. Figs
2. Yogurt
3. Crackers
4. Aged cheese
5. Tossed salad
6. Oatmeal raisin cookies
Answer: 3, 5
Rationale: With MAOIs, the client should avoid ingesting foods that are high in tyramine. Ingestion of these foods could trigger a potentially fatal hypertensive crisis. Foods to avoid include yogurt; aged cheeses; smoked or processed meats; red wines; and fruits such as avocados, raisins, or figs.
Test-Taking Strategy: Focus on the subject, acceptable food items while taking MAOIs. Recall that phenelzine is an MAOI and that foods high in tyramine needed to be avoided. Next, from the food items listed in the question, identify the foods that are tyramine-free.