NSG322 EXAM 3 NEWEST ACTUAL EXAM

• | P a g e

pg. 1

NSG322 EXAM 3 NEWEST ACTUAL EXAM|

BEHAVIORAL HEALTH NURSING EXAM WITH 150

REAL EXAM QUESTIONS AND CORRECT DETAILED

ANSWERS (VERIFIED ANSWERS) GRADED A+|

A client diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates catatonia. Which client needs are of priority importance?

• Self-esteem
• Psychosocial
• Physiological
• Self-actualization

ANS: C

Physiological needs must be met to preserve life. A client with catatonia must be fed by hand or tube, toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Cattonia may also precipitate a risk for falls; therefore, safety is a concern. Higher level needs are of lesser concern.

A client diagnosed with schizophrenia demonstrates little spontaneous movement and has catatonia. The client's activities of daily living are severely compromised. What will be an appropriate outcome for this client?

• demonstrates increased interest in the environment by the end of week

1. 1 / 4

• | P a g e

pg. 2

• performs self-care activities with coaching by the end of day 3.
• gradually takes the initiative for self-care by the end of week 2.
• accepts tube feeding without objection by day 2.

ANS: B

Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities, difficult to measure, and unrelated to maintenance of nutrition.

A nurse observes a catatonic client standing immobile, facing the wall with one arm extended in a salute. The client remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon?

• Echolalia
• Catatonia
• Depersonalization
• Thought withdrawal

ANS: B

Catatonia is the ability to hold distorted postures for extended periods of time, as though the client were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking.

• / 4

• | P a g e

pg. 3 A nurse leads a psychoeducational group about first-generation antipsychotic medications with six adult men diagnosed with schizophrenia. The nurse will monitor for concerns regarding body image with respect to which potential side effect of these medications?

• Constipation
• Gynecomastia
• Visual changes
• Photosensitivity

ANS: B

FGAs (first-generation antipsychotic) stimulate release of prolactin, which can result in gynecomastia (enlargement of the breasts) as well as other changes in sexual function. Men may experience disturbances in body image as a result of gynecomastia. Other side effects of FGAs may be disturbing to other aspects of the client's physical health but are not likely to bother body image.

A client diagnosed with schizophrenia has taken fluphenazine 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms?

• Neuroleptic malignant syndrome
• Hepatocellular effects
• Pseudoparkinsonism
• Akathisia

ANS: C

Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson's disease. It frequently appears within the first month of treatment and is more common with first-generation 3 / 4

• | P a g e

pg. 4 antipsychotic drugs. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness.

A client diagnosed with schizophrenia is very disturbed and violent.After several doses of haloperidol, the client is calm. Two hours later the nurse sees the client's head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely?

• An acute dystonic reaction
• Tardive dyskinesia
• Waxy flexibility
• Akathisia

ANS: A

Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back. Opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies requiring immediate intervention. Tardive dyskinesia involves involuntary spasmodic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis. It appears after prolonged treatment. Waxy flexibility is a symptom seen in catatonic schizophrenia. Internal and external restlessness, pacing, and fidgeting are characteristics of akathisia.

An acutely violent client diagnosed with schizophrenia received several doses of haloperidol. Two hours later the nurse notices the client's head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated?

• / 4