Psychosocial Adaptation NCLEX Review Questions Answers and Rationale

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1.    Answer D.  Diaphoresis and tremors occur in the first phase of alcohol withdrawal. The blood pressure and heart rate increase in the first phase of alcohol withdrawal. Illusions are common in persons withdrawing from alcohol. Illusions occur most often in dim artificial lighting where the environment is not perceived accurately. Delusions of grandeur are symptomatic of manic clients, not clients withdrawing from alcohol. The symptoms and history of alcohol abuse suggest this client is in alcohol withdrawal.
2.    Answer D.  Food and fluids are necessary. However, Mr. Wilson’s hyperactivity does not allow him to sit quietly to eat. Finger foods "on the run” will provide needed nourishment. When hyperactivity decreases, then approach Mr. Wilson’s. regarding hygiene and grooming needs. Medications will be ordered. However, a thorough evaluation must be done first. Mr. Wilson has been assaultive with the landlord and it is reasonable to expect that he may be with peers and staff. His mental illness produces a hyperactive state and poor judgment and impulse control. External controls such as limiting of unit privileges will assist in feelings of security and safety.
3.    Answer B.  Reduced levels of anxiety do not indicate an improvement in depressive symptoms. Vegetative signs such as insomnia, anorexia, psychomotor retardation, constipation, diminished libido, and poor concentration are biological responses to depression. Improvement in these signs indicates a lifting of the depression. Compliance with medications does not indicate improvement in depression. Requests to talk to the nurse vary. Requests may show trust in the nurse but are not a sign that depression has diminished.
4.    Answer C. An underlying depression does not cause sundown syndrome. There is not sufficient evidence to suggest he has inadequate cerebral blood flow. Because the confusion occurs at sundown, the cause is probably changes in the sensory environment. Sundown syndrome is related to environmental and sensory abnormalities that lead to acute confusion. Fluctuating levels of oxygen exchange do not cause sundown syndrome.
5.    Answer A. Beneficial effects of ECT usually are evident after the first several treatments. Since treatments are administered at intervals of 48 hours, these effects are apparent after one week of therapy. Beneficial effects of ECT therapy are usually seen before three weeks. It takes three to four weeks for tricyclic antidepressants to take effect. Beneficial effects of ECT therapy are usually seen before four weeks. It takes three to four weeks for tricyclic antidepressants to take effect. Beneficial effects of ECT therapy are usually seen after the first few treatments.
6.    Answer D. Information about mood changes is important to assess, as bulimia is often associated with affective disorders. Family functioning is the most essential point to assess, as it reveals if binge eating is triggered by conflict within the family. Information about ability to socialize with peers is important to assess, as it is possible the problem initiated with peer relationships. It is inappropriate to ask about her sexual relationships.
7.    Answer D.  Indecisiveness and fear of being wrong are common in depression. Depression creates feelings that nothing will ever improve. The risk of depression is increased when there is a family history. Interest in sex is markedly decreased in depression.
8.    Answer A. The ability to use relaxation is basic to treatment of phobia. Clients with phobias are resistant to insight therapy. Riding the elevator accompanied by the nurse is an appropriate long-term goal. Role playing may be appropriate after the client has learned relaxation.
9.    Answer C. This is an open-ended question which is nonjudgemental and allows for further discussion. The topic is also nonthreatening yet will give the nurse insight into the client”s view of events leading up to admission. It is the only option that is client centered. The other options focus on the pills.
10.    Answer D. Infant baptism is madatory in the Roman Catholic belief especially if a neonate is not expected to live. Anyone may perform this if an infant or child is gravely ill. Option A refers to the Christian Science belief. Option B is a belief of Russian Orthodoxy. Mormons believe of devine healing with the laying on of hands, as represented in option C.
11.    Answer D. Victims develop a high tolerance for abuse. They blame themselves for being victimized. All members in the family suffer from the effects of abuse, even if they are not the actual victims. For these reasons, victims often have an extensive history of abuse and struggle for a long time before they can leave permanently.
12.    Answer A. Giving broad opening statements and making observations are examples of therapeutic communication. The other options are too specific or focused to be therapeutic.
13.    Answer C. Activity groups are used to enhance the therapeutic milieu and to meet the clinical and social needs of clients, e.g., to minimize withdrawal and regression, to develop self care skills, etc.
14.    Answer D. This gradually engages the client in interactions with others and uses positive behavioral expectation.
15.    Answer D. This type of identification band easily tracks the client’s movements and ensures safety while wandering on the unit.
16.    Answer C. This actions presents reality.
17.    Answer D. Safety is a priority of care for the depressed client. Precautions to prevent suicide must be a part of the plan.
18.    Answer B. When learning to manage stress, it is helpful to believe that one has the ability to control one’s response to stress. It is impossible to avoid stress, which is a normal experience. Stress can be positive and growth enhancing as well as harmful. The belief that one has some control can minimize the stress response.
19.    Answer C. Nonverbal, gentle touch is an important tool here. Providing appropriate forms of touch to reinforce caring feelings. Because tactile contacts vary considerably among individuals, families, and cultures, the nurse must be sensitive to the differences in attitudes and practices of clients and self.
20.    Answer D. A dispositional crisis is a response to an external situational crisis. External anger at work is the dispositional crisis displaced to his wife through abuse. An anticipated life transition crisis is a crisis that is normal in the life cycle; transitional is one over which the person has no control. Developmental crisis occurs in response to triggering emotions related to unresolved conflict in one’s life. This is called a developmental crisis based on Freudian psychology. Psychiatric emergency crisis is when the individual’s general functioning has been severely impaired, and the individual has been rendered incompetent.

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