Psychiatric Nursing NCLEX Review Part 2 Answers and Rationale

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1. Answer B. Diphenhydramine, 25 to 50 mg I.M. or I.V., would quickly reverse this condition. Prochlorperazine and haloperidol are both capable of causing dystonia, not reversing it. Midazolam would make this patient drowsy.
2. Answer B. The nurse should directly orient a delusional patient to reality, especially to place and person. Option A and C encourage further delusions by denying poisoning and offering information related to the delusion. Validating the patient’s feeling, as in option D, occurs during a later stage in the therapeutic process.
3. Answer C. Twelve-step programs focus on recovery 1 day at a time. Such programs discourage people from claiming that they will never again use a substance, because relapse is common. The belief that one may use a limit amount of an abused substance indicates denial. Substituting one abused substance for another predisposes the patient to cross-addiction.
4. Answer B. By establishing a one-to-one relationship, the nurse helps the patient learn how to interact with other people in new situations. The other options are appropriate but should take place only after the nurse-patient relationship is established.
5. Answer D. A compulsion is a repetitive act or impulse helps a person to reduce anxiety unconsciously. An obsessive-compulsive patient does not want to call attention to self and cannot control thoughts. This patient’s priority is to reduce anxiety, not maintain the safety of the home.
6. Answer A. By acknowledging how the patient feels, this response encourages further expression of thoughts and feelings. Minimizing feelings or offering empty reassurances is not therapeutic or helpful. Deep breathing or preoperative medication would be appropriate only after the patient’s fears have been expressed and dealt with.
7. Answer C. The nurse must determine whether the restraints have been applied correctly to make sure that patient’s circulation and respiration are not restricted and that adequate padding has been used. The nurse should document the patient’s response and status carefully after the restraints are applied. All staff members involved in restraining patients should be aware of hospital policy before using restraints. If p.r.n. medication is ordered, it should be given before the restraints are in place and with the assistance of other team members. The nurse should attend to the patient’s elimination and hydration needs after the patient is properly restrained.
8. Answer D. Although most phenothiazine produce some effects within minutes to hours, their antipsychotic effects may take several weeks to appear.
9. Answer C. Most states allow restraints to be used if the patient presents a danger to self or others. This danger must be reevaluated every few hours. If the patient is still a danger, restraints can be used until the violent behavior abates. No standing orders for restraints are allowed, and restraints are permitted only until more “humane” methods, such as sedatives, become more effective. Violent patients who are intoxicated with drugs or alcohol present a problem because they rarely can be sedated until the drug or alcohol is metabolized. In such cases, restraints may be needed for a longer period, but the patient must be closely observed. Obtaining consent is not always possible, especially when the patient’s violent behavior results from a psychosis, such as paranoid schizophrenia.
10. Answer C. Conditions requiring cautious use of amitriptyline include pregnancy, lactation, suicidal tendencies, cardiovascular disease, and impaired hepatic function. Hiatal hernia, hypernatremia, and hypokalemia do not affect amitriptyline therapy.
11. Answer B. Providing an opportunity for the client to express concern about a new medication and to make a choice about taking it can help the client regain a sense of control over his life. The client has the right to refuse the medication. Instead of simply ordering the client to take it, as in option 1, the nurse should provide the information the client needs to make an informed decision. Attempting to make the client feel guilty, as in option 3, or threatening the client, as option 4, would increase anxiety.
12. Answer A. Decreased libido, retrograde ejaculation, and gynecomastia are all hormonal effects that can occur with antipsychotic medications. Reassure the client that the effects can be reversed or that changing medication may be possible. Polydipsia, akinesia, and dysphasia aren’t hormonal effects.
13. Answer A. 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 behavior. Withdrawal isn’t a healthy response to the termination of a relationship. By rationalizing the termination, the client avoids expressing his feelings and emotions.
14. Answer A. The client with schizophrenia is commonly socially isolated and withdrawn; therefore, having the client spend more time by himself wouldn’t be a desirable outcome. Rather, a desirable outcome would specify that the client spend more time with other clients and staff on the unit. Delusions are false personal beliefs. Reducing or eliminating delusional thinking using talking therapy and antipsychotic medications would be a desirable outcome. Protecting the client and others from harm is a desirable client outcome achieved by close observation, removing any dangerous objects, and administering medications. Because the client with schizophrenia may have difficulty meeting his or her own self-care needs, fostering the ability to perform self-care independently is a desirable client outcome.
15. Answer A. Because a client who has attempted suicide could try again, the nurse should search the client’s belongings and room to remove any items that could be used in another suicide attempt. Expressing trust that the client won’t cause self-harm may increase guilt and pain if the client can’t live up to that trust. The nurse should search the client’s belonging because the need to maintain a safe environment supersedes the client’s right to privacy. Although frequent checks by staff members are helpful, they aren’t enough because the client may attempt suicide between checks.
16. Answer C. Displacement is a defense mechanism in which the client transfers his feelings for one person toward another person who is less threatening. Rationalization is a defense mechanism in which the client makes excuses to justify unacceptable feeling or behaviors. Repression is characterized by an involuntary blocking of unpleasant experiences from one’s consciousness. Suppression is the conscious blocking of unpleasant experiences form one’s awareness.
17. Answer C. The nurse should prepare a client for ECT in a manner similar to that for general anesthesia. For example, the client should receive nothing by mouth for 8 hours before ECT to reduce the risk of vomiting and aspiration. Also, the nurse should have the client void before treatment to decrease the risk of involuntary voiding during the procedure, remove any full denture, glasses, or jewelry to prevent breakage or loss; and make sure the client is wearing a hospital gown or loose-fitting clothing to allow unrestricted movement. Usually, these preparations aren’t indicated for a client undergoing physical therapy, neurologic examination, or cardiac stress testing.
18. Answer D. A flexible care plan needed for any client who behaves in a suspicious, withdrawn, or regressed manner or who has thought disorder. Because such a client communicates at different levels and is in control of himself at various times, the nurse must be able to adjust nursing care as the situation warrants. The nurse’s role should be clear, however, the boundaries or limits of this role should be flexible enough to meet client needs. Because a client with schizophrenia fears closeness and affection, a warm approach may be too threatening. Expressing empathy is important, but centering interventions on clear defined limits is impossible because the client’s situation may change without warning.
19. Answer D. When caring for a client with OCD, the goal is to systematically decrease the undesirable behavior. (Therapy may not completely extinguish certain behaviors.) Expecting to omit one behavior each day is unrealistic because the client may have used ritualistic behavior would perpetuate the undesirable behavior.
20. Answer D. Fluphenazine decanoate is a long-acting antipsychotic agent given by injection. Because it has a 4-week duration of action, it’s commonly prescribed for outpatients with a history of medication noncompliance. Chlorpromazine, also an antipsychotic agent, must be administered daily to maintain adequate plasma levels, which necessitates compliance with the dosage schedule. Imipramine, a tricyclic antidepressant, and lithium carbonate, a mood stabilizer, are rarely used to treat clients with chronic schizophrenia.
21. Answer A. Individuals with dependent personality disorder typically shows indecisiveness, submissiveness, and clinging behavior so that others will make decisions for them. These clients feel helpless and uncomfortable when alone and don’t show interest in solitary activities. They also pursue relationships in order to have someone to take care of them. Although clients with dependent personality disorder may become depressed and suicidal if their needs aren’t met, this isn’t a typical response.
22. Answer C. Abstract thinking is the ability to conceptualize and interpret meaning. It’s higher level of intellectual functioning than concrete thinking, in which the client explains the proverb by its literal meaning. Rational thinking involves the ability to think logically, make judgments, and be goal-directed. Tangential thinking is scattered, non-goal-directed, and hard to follow. Clients with such conditions as organic brain disease and schizophrenia typically can’t conceptualize and comprehend abstract meaning. They interpret such statement as “Don’t cry over spilled milk” in a literal sense, such as “Even if you spill your milk, you shouldn’t cry about it.”
23. Answer D. Although all these options may apply to this client, safety is the nurse’s first priority in caring for any suicidal client. The nurse can address the client’s hopelessness, ineffective coping, and spiritual distress later in therapy.
24. Answer A. Focusing on the client’s blindness can positively reinforce the blindness and further promote the use of maladaptive behaviors to obtain secondary gains. The client should be encouraged to participate in his own care as much as possible to avoid fostering dependency. To promote self-esteem, give positive reinforcement for what the client can do. Blindness and other physical symptoms in a conversion disorder aren’t under the client’s control and are real to him. Eye exercises won’t resolve the client’s blindness because no organic pathology is causing the symptoms.
25. Answer D. The aggressor is negative and hostile and uses sarcasm to degrade others. The role of the blocker is to resist group efforts. The monopolizer controls the group by dominating conversations. The recognition seeker talks about accomplishments to gain attention.
26. Answer C. Circulation 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 in permanent damage to the client’s extremities. Restraints should be removed every 2 hours, and range-of-motion exercises should be performed.
27. Answer A. When the child’s injuries are inconsistent with the history given or impossible because of the child’s age and developmental stage, the emergency department nurse should be suspicious that child abuse is occurring. The parents may tell different stories because their perception may be different regarding what happened. If they change their story when different health care workers ask the same question, this is a clue that child abuse may be a problem. Child abuse occurs in all socioeconomic groups. Parent may argue and be demanding because of the stress of having an injured child.
28. Answer C. Abuse and neglect lead to poor self-concept and confusion, the basis for unhealthy personal boundaries. Healthy boundaries are established in childhood when parent provide consistent, supportive limits and attention.
29. Answer D. This client requires a vasodilation such as nifedipine to treat hypertension, and a beta-adrenergic blocker such as esmolol to reduce the heart rate. Lidocaine, an antirrhythmic, isn’t indicated because the client doesn’t have an arrhythmia. Although nitrolycerin may be used to treat coronary vasospasm, it isn’t the drug of choice in hypertension.
30. Answer A. A structured lifestyle demonstrates acceptance and caring provides a sense of security. A critical environment erodes a person’s esteem. Inconsistent boundaries lead to feelings of insecurity and lack of concern. Physical discipline can decrease self-esteem.