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89 Item Psychiatric Nursing Exam I1 Keys

89 Item Psychiatric Nursing Exam I1 Keys

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89 Item Psychiatric Nursing Exam II : Substance Abuse, Eating disorders andImpulse control disorders Correct Answers and RationaleTopic: Substance Abuse, Eating disorders, Impulse control disorders.
 http://www.pinoybsn.tk  1. An unemployed woman, age 24, seeks help because she feels depressed andabandoned and doesn't know what to do with her life. She says she has quit her last five jobs because her coworkers didn't like her and didn't train her adequately. Last week, her  boyfriend broke up with her after she drove his car into a tree after an argument. Theclient's initial diagnosis is borderline personality disorder. Which nursing observationssupport this diagnosis?A. Flat affect, social withdrawal, and unusual dressB. Suspiciousness, hypervigilance, and emotional coldness
C. Lack of self-esteem, strong dependency needs, and impulsive behavior
 D. Insensitivity to others, sexual acting out, and violenceRationale: Borderline personality disorder is characterized by lack of self-esteem, strongdependency needs, and impulsive behavior. Instability in interpersonal relationships,mood, and poor self-image also is common. Typically, the client can't tolerate beingalone and expresses feelings of emptiness or boredom. Flat affect, social withdrawal, andunusual dress are characteristic of schizoid personality disorder. Suspiciousness,hypervigilance, and emotional coldness are seen in paranoid personality disorders. Inantisocial personality disorder, clients are usually insensitive to others and act outsexually; they may also be violent2.In a toddler, which of the following injuries is most likely the result of child abuse?A. A hematoma on the occipital region of the headB. A 1-inch forehead laceration
C. Several small, dime-sized circular burns on the child's back
 D. A small isolated bruise on the right lower extremityRationale: Small circular burns on a child's back are no accident and may be fromcigarettes. Toddlers are injury prone because of their developmental stage, and falls arefrequent because of their unsteady gait; head injuries aren't uncommon. A small area of ecchymosis isn't suspicious in this age-group.3. A client is admitted to the emergency department after being found unconscious. Her  blood pressure is 82/50 mm Hg. She is 5
4" (1.6 m) tall, weighs 79 lb (35.8 kg), andappears dehydrated and emaciated. After regaining consciousness, she reports that shehas had trouble eating lately and can't remember what she ate in the last 24 hours. Shealso states that she has had amenorrhea for the past year. She is convinced she is fat andrefuses food. The nurse suspects that she has:A. bulimia nervosa.
B. anorexia nervosa.
 
 
C. depression.D. schizophrenia.Rationale: Anorexia nervosa is an eating disorder characterized by self-imposedstarvation with subsequent emaciation, nutritional deficiencies, and atrophic andmetabolic changes. Typically, the client is hypotensive and dehydrated. Depending on theseverity of the disorder, anorexic clients are at risk for circulatory collapse (indicated byhypotension), dehydration, and death. Bulimia nervosa is an eating disorder characterized by binge eating followed by self-induced vomiting. Although depression may beaccompanied by weight loss, it isn't characterized by a body image disturbance or theintense fear of obesity seen in anorexia nervosa. Schizophrenia may cause bizarre eating patterns, but it rarely causes the full syndrome of anorexia nervosa.4. A 15-year-old girl with anorexia has been admitted to a mental health unit. She refusesto eat. Which of the following statements is the best response from the nurse?A. "You don't have to eat. It's your choice."
B. "I hope you'll eat your food by mouth. Tube feedings and I.V. lines can beuncomfortable."
 C. "Why do you think you're fat? You're underweight. Here — look in the mirror."D. "You really look terrible at this weight. I hope you'll eat."Rationale: Clients with anorexia can refuse food to the point of cardiac damage. Tubefeedings and I.V. infusions are ordered to prevent such damage. The nurse is informingher of her treatment options. Option A doesn't tell the client about the consequences of choosing not to eat. Telling clients that they are too thin won't change their self-image.5. A client with a history of substance abuse has been attending Alcoholics Anonymousmeetings regularly in the psychiatric unit. One afternoon, the client tells the nurse, "I'mnot going to those meetings anymore. I'm not like the rest of those people. I'm not adrunk. "What is the most appropriate response?A. "If you aren't an alcoholic, why do you keep drinking and ending up in the hospital?"B. "It's your decision. If you don't want to go, you don't have to."
C. "You seem upset about the meetings."
 D. "You have to go to the meetings. It's part of your treatment plan."Rationale: The substance abuser uses the substance to cope with feelings and may denythe abuse. Asking if the client is upset about the meetings encourages the client toidentify and deal with feelings instead of covering them up. Arguing with the client aboutthe substance abuse (option A) or insisting that the client attend the meetings (option D)wouldn't help the client identify resistance to treatment. Option B isn't therapeutic behavior because it plays down the importance of attending meetings.6. A client is admitted to the inpatient adolescent unit after being arrested for attemptingto sell cocaine to an undercover police officer. The nurse plans to write a behavioralcontract. To best promote compliance, the contract should be written:
 
A. abstractly.B. by the client alone.
C. jointly by the client and nurse.
 D. jointly by the physician and nurse.Rationale: A contract written jointly by the client and nurse most successfully promotescooperation and consistent behavior. The most effective contract — and the type leastlikely to allow for manipulation and misinterpretation — states the behavioral terms asconcretely as possible. A contract written solely by the client may not be agreeable tostaff members; one written by the physician and nurse may not be agreeable to the client.7. During which phase of alcoholism is loss of control and physiologic dependenceevident?A. Prealcoholic phaseB. Early alcoholic phase
C. Crucial phase
D. Chronic phaseRationale: The crucial phase is marked by physical dependence. The prealcoholic phaseis characterized by drinking to medicate feelings and for relief from stress. The early phase is characterized by sneaking drinks, blackouts, rapidly gulping drinks, and preoccupation with alcohol. The chronic phase is characterized by emotional and physical deterioration.8. Which of the following is important when restraining a violent client?A. Have three staff members present, one for each side of the body and one for the head.B. Always tie restraints to side rails.
C. Have an organized, efficient team approach after the decision is made to restrainthe client.
D. Secure restraints to the gurney with knots to prevent escape.Rationale: Emergency department personnel should use an organized, team approachwhen restraining violent clients so that no one is injured in the process. The leader,located at the client's head, should take charge; four staff members are required to holdand restrain the limbs. For safety reasons, restraints should be fastened to the bed frameinstead of the side rails. For quick release, loops should be used instead of knots9. A client who's actively hallucinating is brought to the hospital by friends. They say thatthe client used either lysergic acid diethylamide (LSD) or angel dust (phencyclidine[PCP]) at a concert. Which of the following common assessment findings indicates thatthe client may have ingested PCP?A. Dilated pupils
B. Nystagmus
 C. ParanoiaD. Altered mood

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