Adaptive Quizzing for the NCLEX-RN Exam - Mental Health Disorders

Adaptive Quizzing for the NCLEX-RN Exam - Mental Health Disorders and Addictions (70+ Questions and Answers )

For which clinical indication should a nurse observe a child in whom autism is suspected? - answerLack of eye contact

Rationale:

Children with autism usually have a pervasive impairment of reciprocal social interaction. Lack of eye contact is a typical behavior associated with autism. Crying for attention, rigidity, and parallel play are not indicative of autism.The nurse is assigned to work with a 20-year-old client on an inpatient unit. In assessing the woman, the nurse notes that she is mute, does not show any type of movement, is unresponsive, and appears unaware of her surroundings. What is the best term for the nurse to use to describe these symptoms? - answrCatatonia

Rationale:

Catatonia is the term to describe stupor, rigidity, or extreme flexibility of the limbs; excitability; confusion; and lack of verbal expression. Alogia is a term used to describe an inability to speak or near-absence of speech. Echopraxia is the term for the mimicking or repetition of the actions of another person. Affective flattening is the term for blunted or constricted facial expression.When planning for a client's care during the detoxification phase of acute alcohol withdrawal, what need should the nurse anticipate? - answerChecking on the client frequently

Rationale:

During detoxification frequent checks help ensure safety and prevent suicide, which is a real threat. Bright light is preferable to dim light because it minimizes shadows that may contribute to misinterpretation of environmental stimuli (illusions). The client who is going through the detoxification phase of acute alcohol withdrawal usually does not lose his sense of hearing, so there is no need to shout. Restraints may upset the client further; they should be used only if the client is a danger to himself or others.A female client with obsessive-compulsive disorder has become immobilized by her elaborate handwashing and walking rituals. Which feelings does the nurse recall are often the basis of obsessive-compulsive disorder? - answerAnxiety and guilt

Rationale:

Ritualistic behavior seen in this disorder is aimed at controlling feelings of anxiety and guilt by maintaining an absolute set pattern of action. Although the person with an obsessive-compulsive disorder may be angry and hostile, the feelings of anger and hostility do not precipitate the rituals. Although the person with an obsessive-compulsive disorder may be embarrassed and ashamed by the ritual or feel hopeless and powerless to the ritual, the basic feelings precipitating the rituals are usually anxiety and guilt.A nurse is planning care for a client with substance-induced persisting dementia resulting from long-term alcohol use. Which nutritional problem, in addition to the effect of alcohol on brain tissue, has contributed to substance-induced persisting dementia? - answerDeficiency of thiamine

Rationale:

Substance-induced persistent dementia is caused by a prolonged deficiency of vitamin B1 (thiamine) and the direct toxic effect of alcohol on brain tissue. Increase in serotonin, reduction in iron intake, and malabsorption of riboflavin are problems that are unrelated to substance-induced persisting dementia caused

by alcoholism.A 3-year-old child is found to have a pervasive developmental disorder not otherwise specified. What should the nurse consider most unusual for the child to demonstrate? - answerResponsiveness to the parents

Rationale:

One of the symptoms that an autistic child displays is lack of responsiveness to others; there is little or no extension to the external environment. Music is nonthreatening, comforting, and soothing. Repetitive behavior provides comfort. Repetitive visual stimuli, such as a spinning top, are nonthreatening and soothing.During a one-on-one interaction with a client with paranoid-type schizophrenia, the client says to the nurse, "I've figured out how foreign agents have infiltrated the news media. They want to shut me up before I spill the beans." How should the nurse describe this statement when documenting this client's response? - answerDelusions of persecution

Rationale:

Thoughts of being pursued by powerful agents because of one's special attributes or powers are fixed false beliefs and are referred to as delusions of persecution. There is no evidence to indicate that there are nihilistic delusions of total or partial nonexistence. There is also no evidence to support that external forces are controlling the client (delusions of control) or that the client has false beliefs of being a famous figure (delusions of grandeur).A nurse is caring for a client with a somatoform disorder. What should the nurse anticipate that this client will do? - answerRedirect the conversation with the nurse to physical symptoms.

Rationale:

Clients with somatoform disorders are preoccupied with the symptoms that are being experienced and usually do not want to talk about their emotions or relate them to their current situation. Clients with somatoform disorders do not seek opportunities to discuss their feelings. Memory problems are not associated with somatoform disorders. These clients want and seek treatment, not palliative care.A nurse, understanding the possible cause of alcohol-induced amnestic disorder, should take into consideration that the client is probably experiencing which imbalance? - answerThiamine deficiency

Rationale:

The deficiency of thiamine (vitamin B 1) is thought to be a primary cause of alcohol-induced amnestic disorder. Reduced iron intake, increased serotonin, and riboflavin malabsorption are all unrelated to alcohol-induced amnestic disorder.Within a few hours of alcohol withdrawal the nurse should assess the client for the presence of what symptoms? - answerIrritability and tremors

Rationale:

Alcohol is a central nervous system depressant; irritability and tremors are the body's neurological adaptation to the withdrawal of alcohol. Tachycardia, irritability, and tremors are the early signs of withdrawal and will appear 24 to 48 hours after the last ingestion of alcohol. Yawning occurs with heroin withdrawal.Convulsions (delirium tremens, or DTs) are a later sign of severe withdrawal that occurs with alcohol withdrawal delirium. Delirium (paranoia and disorientation) is not an early sign of alcohol withdrawal and occurs 48 to 72 hours after abstinence. Fever and diaphoresis may occur during prolonged periods of delirium and are a result of autonomic overactivity.The nurse is caring for a client with vascular dementia. What does the nurse identify as the cause of this

problem? - answerDisruptions in cerebral blood flow, resulting in thrombi or emboli

Rationale:

Vascular dementia results from the sudden closure of the lumen of arterioles, causing infarction of the brain tissue in the affected area. Inadequate nutrition may be one of the factors that bring about a general decline of health; however, there is no direct evidence that avitaminosis can cause primary degenerative dementia.Severe emotional trauma may contribute to primary degenerative dementia but does not necessarily cause it.Neural degeneration leads to permanent, not transient, changes.A client with a history of drug abuse begins group therapy. After attending the first meeting the client says to the nurse, "It helps to know that I'm not the only one with this type of problem." What concept does this statement reflect? - answerUniversality

Rationale:

Universality is the sense that one is not alone in any situation; one purpose of group therapy is to share feelings and gain support from others with similar thoughts and feelings. Altruism in group therapy is giving support, insight, and reassurance to others, which eventually promotes self-knowledge and growth.Catharsis involves group members relating to one another through the verbal expression of negative and positive feelings. Transference occurs when a client unconsciously assigns to the therapist feelings and attitudes originally associated with another important person in the client's life.A nurse determines that a client is pretending to be ill. What does this behavior usually indicate? - answerMalingering

Rationale:

When an individual consciously pretends to have an illness with no physical basis, it is called malingering.People who are psychotic experience delusions, hallucinations, and disorganized thoughts, speech, or behavior. The use of conversion defenses is not a conscious act. A person out of contact with reality is unable to pretend to be ill.An 84-year-old woman is admitted to the hospital with a diagnosis of dementia of the Alzheimer type. What does the nurse know about this disorder? - answerCognitive problem that is a slow and relentless deterioration of the mind

Rationale:

Dementia of the Alzheimer type accounts for 80% of dementias in older adults; it may be due to a neurotransmitter deficiency and is characterized by a steady decline in intellectual function, including memory deficits, disorientation, and decreased cognitive ability. More than 90% of people with dementia of the Alzheimer type are older than 50 years. It is an organic, not functional, disorder. Dementia of the Alzheimer type is difficult to diagnose and often is made when other causes of the dementia have been ruled out.A client with a personality disorder is playing cards with another person in the lounge. When the other person cheats at cards, the client responds by aggressively scattering the cards around the room. What does the nurse conclude about the client's personality? - answerInadequate impulse control

Rationale:

The client is angry and reacts impulsively; the action is unplanned and is not under the client's control. No data are provided to suggest that the client is out of contact with reality; the client is reacting to a real situation with anger. There is no identifiable cluster of behaviors to suggest that the client has a violent personality. There is no pattern of behavior to suggest an antisocial personality, which may or may not involve impulse control.

After a cocaine binge an individual is found unconscious and is admitted to the hospital with acute cocaine toxicity. What should the initial nursing action be directed toward? - answerEstablishing a patent airway

Rationale:

The client is unconscious and unable to meet physical needs; a patent airway, breathing, and circulation are essential needs. Understanding and support are important once the client's physical condition has stabilized.Maintaining a drug-free environment will be a priority later in the treatment program. Establishment of a therapeutic relationship will increase in importance once the client's physical condition has stabilized.A psychotic male client is admitted to the hospital for evaluation. While obtaining the history, the nurse asks why he was brought to the hospital by his parents. The client states, "They lied about me. They said I murdered my mother. You killed her. She died before I was born." What does the nurse recognize that the client is experiencing? - answerPersecutory delusions

Rationale:

The client's verbalization reflects feelings that others are blaming the client for negative actions. There are no data to demonstrate the client is having feelings of greatness or power. There are no data to demonstrate the client is experiencing confusing misinterpretations of stimuli. There are no data to demonstrate the client is hearing voices at this time.A nurse is caring for a client with an obsessive-compulsive personality disorder that involves rituals. What should the nurse conclude about the ritual? - answerIt seems illogical but is needed by the person

Rationale:

The client's exact adherence to the compulsive ritual relieves anxiety, at least temporarily. Furthermore, it meets a need and is necessary to the client. The compulsive act is purposeless repetition and useful only in that it temporarily eases the client's anxiety. Urging has no effect getting the the client to start or stop the ritualistic behavior. The person cannot stop the activity; it is not under his voluntary control.A nurse is assessing a client with major depression. Which clinical manifestation reflects a disturbance in affect related to depression? - answerHopelessness

Rationale:

Feelings of hopelessness are symptomatic of depression; the individual feels unable to find any solution to problems and therefore feels overwhelmed. Echolalia, the pathological meaningless repetition of another's words or phrases, is associated with schizophrenia, not with depression. Delusions are associated with psychotic disorders such as schizophrenia, not depression. Confusion is not common because these individuals are in contact with reality.An older adult is admitted for evaluation of anemia and unsteady gait. While obtaining a health history, the nurse notes that the client seems to make up stories to fill in for memory lapses. How should the nurse document what the client is doing? - answerConfabulating

Rationale:

Confabulation is the filling in of memory gaps as a protective mechanism. Lying is false or dishonest behavior that is conscious and deliberate and is used in an attempt to deceive or mislead; there is no evidence of this behavior. Denying is a refusal to believe or accept reality and is used as a protective defense mechanism; there is no evidence of this behavior. Fantasizing is a more-or-less connected series of mental images, such as those that occur in daydreams, that usually involve some unfulfilled desire; there is no evidence of this behavior.A nurse is caring for a male client who was admitted to the mental health unit with the diagnosis of schizophrenia. The client is hostile and experiencing auditory hallucinations and states that the voices are