Psychiatric Nursing NCLEX Review Part 1 Answers and Rationale

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1. Answer A. As individuals become older, their livers metabolize drugs at a slower rate. Cumulative effects can occur and increase the risk of adverse reactions. Level of activity typically doesn’t affect a person’s reaction to medication. Elderly clients typically need lower doses, not higher.

2. Answer B. Stimulants produce mood swings, weight loss, and tachycardia. The other symptoms indicate CNS depression.

3. Answer B. A psychiatric aide can sit with the client and provide safety. The nurse is still responsible for assessing the client and ensuring that one-to-one supervision occurs. Aides are capable of providing one-to-one observation. It isn’t illegal to delegate observation to an aide.

4. Answer C. It’s extremely important that the nurse establish trust and rapport. The nurse shouldn’t offer advice. Instead, she should help the client develop the coping mechanisms necessary to solve his own problems. Setting limits is also important as developing trust and rapport.

5. Answer C. Abuse and neglect lead to poor self-concept and role confusion, which are the basis for unhealthy personal boundaries. Healthy boundaries are established in childhood when parents provide consistent, supportive environment, and direction and attention.

6. Answer C. The basic element of assertive behavior includes the ability to express feelings and thoughts while respecting the rights of others. Doing so at the expense of others and expressing superiority are aggressive behaviors, and avoiding unpleasant situation is a form of passive behavior.

7. Answer A. Asking the client to summarize his point redirects the clients to focus his comments and allows him to make his point. Telling the client that his behavior is obnoxious is judgmental, and ignoring the behavior doesn’t help facilitate communication. Expressing frustration focuses more on the nurse than on the client’s need.

8. Answer D. ECT is indicated for major depression. ECT isn’t indicated severe agitation, antisocial behavior, or treatment noncompliance.

9. Answer D. Breach of confidentiality occurs when a nurse shares information that can cause harm to an individual. Assault is an act that results in fear that one will be touched without consent.
   Battery involves unconsented touching of another person. Neglect is the failure to do what’s deemed reasonable in a situation.

10. Answer B. The nurse violated confidentiality by informing the officer that the client wasn’t in treatment. Even with law enforcement agents, the nurse must be a client advocate and protect the client’s confidentiality. Because it’s unknown in this question whether the client is actually in treatment, it can’t be concluded that the nurse is misleading the officer because her statement may be truthful. Information can be legally withheld when a court order isn’t in place.

11. Answer D. The nurse’s release of information to the client’s employer without the client’s consent is a breach of confidentiality. The stigma associated with psychiatric illness may affect the client’s employment; therefore, it’s better to maintain confidentiality and refrain from disclosing any information about the client, including whether she’s a client in the hospital.

12. Answer A. Confining a voluntary client against his will be considered false imprisonment. Limit setting is a therapeutic technique used to achieve a desired behavior, and wouldn’t involve confining a voluntary client. Slander is oral defamation of character. The nurse hasn’t given out any information about the client, so confidentiality hasn’t been violated.

13. Answer C. The Nurse Practice Act outlines acceptable standards for nursing. Practicing within those guidelines will protect the nurse from liability. Physicians may not be aware of guidelines for nurses and may inadvertently delegate inappropriate treatment of practice for the nurse. The client doesn’t know standards of care and isn’t responsible for the nurse’s actions. Insurance won’t prevent a liability suit, but only assist the nurse if a suit would be filed.

14. Answer C. Circulatory as well as skin and nerve damage can occur within 15 minutes. Checking every hour, 2 hours, or 8 hours isn’t often enough and could result is permanent damage to the client’s extremities.

15. Answer C. One of the criteria for involuntary commitment is an emergency in which the client is a threat to himself or others, such as a man who threatens to kill his wife. A parent might have a child removed from the home because of neglect, but that doesn’t meet the criteria for involuntary commitment. Many individuals with schizophrenia can learn to live with hallucinations and delusions and don’t require hospitalization. To meet criteria for involuntary commitment, a depressed individual must have a suicide plan and be a direct threat to himself.

16. Answer D. To determine care plan for clients who are noncompliant with medications, the nurse should consult with the physician. Unless the client presents a danger to himself of others, medications can’t be forced on a client. A dose shouldn’t be omitted without first checking with the physician. Intentionally deceiving of misleading a client violates the therapeutic relationship.

17. Answer D. When working with a dying patient and his family, the nurse uses active listening to assess their feelings, coping skills, and immediate and long-term needs. It also helps the nurse select other appropriate strategies, such as reflection and clarification. Interpretation should be used sparingly to avoid making false interference or putting the client on the defensive.

18. Answer B. Tolerance occurs when the body requires higher doses of substances, such alcohol, opioids, or benzodiazepines, to achieve desired effect. Increased response indicates a need for less of a drug to achieve the same effects. Allergic reactions are autoimmune response to a particular drug or class of drugs. A client may be able to take, or tolerate, the same drug for an extended period; however this isn’t the definition of developing tolerance.

19. Answer B. The goal of crisis intervention is the resolution of an immediate problem. The client must learn to solve his own problems. Although some clients do enter long-term therapy or are admitted to an acute care facility, neither is the goal of crisis intervention.

20. Answer D. The nurse is using observation to give the client feedback about his behavior and attitude. A broad statement doesn’t give feedback to the client. The nurse didn’t reassure the client or ask him to explain his actions (clarifying).

21. Answer A. Firmness and consistency regarding rules are the hallmarks of a plan of care for a patient with a personality disorder. Isolation is inappropriate and would violate the patient’s rights. Power struggles should be avoided because the patient may try to manipulate people through them. Behavior modification usually fails because of staff inconsistency and patient manipulation.

22. Answer A. A liquid phenothiazine preparation will produce effects in 2 to 4 hours. The onset with tablet is unpredictable.

23. Answer B. An antiparkinsonian agent, such as amantadine, may be used to control pseudoparkinsonism, diphenhydramine or benztropine may be used to control other extrapyramidal effects.

24. Answer A. Physiological needs, particularly breathing, are the first priorities during a panic attack. Having the patient breathe deeply into a paper bag corrects hyperventilation; restoring a normal breathing pattern should relieve the patient’s other symptoms. Orientation usually is unnecessary because most patients respond to external control and reduce stimulation. During a panic attack, the patient is not likely to act out but may strike out if feeling threatened. An anxiolytic agent may be effective but is not the first priority.

25. Answer C. Family violence usually is a learned behavior begets violence, putting this couple at risk. Repeated slapping may indicate poor, not moderate, impulse control. Violent people commonly are jealous and possessive and feel insecure in their relationships.

26. Answer B. The therapeutic nurse-patient relationship consists of four phases: preinteraction, introduction or orientation, working and termination. During the working phase, the nurse and patient together evaluate and refine the goals established during the orientation phase, in addition, major therapeutic work takes place and insight is integrated into a plan of action. The orientation phase involves assessing the patient, formulating a contract, exploring feelings, and establishing expectation about relationship. During the termination phase, the nurse prepares the patient for separation and explores feelings about the end of the relationship.

27. Answer B. In adolescents, depression typically manifests as truancy, a change of friends, social withdrawal, and oppositional behavior. In adults, it usually produces helplessness, hopelessness, hypersomnolence, and anorexia. Drug use may lead to curfew breaking, stealing, truancy, and oppositional behavior. Adolescents normally display hypersomnelence, and obsession with body image, and valuing of peer’s opinions.

28. Answer D. During a panic attack, the nurse’s best approach is to orient the patient to what is happening and provide reassurance that the patient will not be left alone. The anxiety level is likely to increase and the panic attack is likely to continue—if the patient is told to calm down (as in option A), asked the reasons for the attack (as in option B), or left alone (as in option C).

29. Answer B. Conversion disorder, or hysterical neurosis, is characterized by alteration or loss of physical function with no physiological basis; the patient’s symptoms result from psychological conflict. For example, a patient may report blindness after having observed a distressing act. None of the other opinions causes conversion disorder.

30. Answer C. The patient is exhibiting the defense mechanism of regression—a return to behavior characteristic of an earlier developmental level. Dependent, attention—getting behavior is an attempt to relieve anxiety. Repression would manifest as ignoring the symptoms. Somatization is the channeling of anxiety into a preoccupation with physical complaints. Conversion involves transfer of a mental conflict into a physical symptom to relieve anxiety.