NCLEX PN MENTAL
1. Shortly after being told that he has 90blockage of three major coronary arteries and needs emergency coronary artery bypass surgery,
... [Show More] the patient is noted by the nurse to appear dazed. His thoughts are scattered, as evidenced by the fact that his conversation jumps from topic to topic. He frequently states, “I’m overwhelmed. I don’t know what to do.” He is unable to give direction to his wife when she asks him whom he wants her to notify. His pulse rate rises 15 points. The level of anxiety the patient is experiencing: “Severe Anxiety”
2. Which nursing intervention would be helpful in caring for patients with anxiety disorders?
“Help the patient link feelings and behaviors”
3. An effective treatment for patient with obsessive-compulsive disorder is:
“clomipramine(Anafranil)”
4. A patient tells the nurse, “I feel as though something terrible is going to happen to me.” Assessment findings include increased vital signs, dilated pupils, urinary frequency, rigid muscles, and decreased hearing. Which level of anxiety is evident? “Severe”
5. What is the most appropriate nursing diagnosis for a patient with anxiety and the following assessment findings: avoidance, poor concentration, nightmares, hypervigilance, exaggerated startle response, detachment, numbing, and flashbacks? “Post-trauma syndrome”
6. Select the most appropriate discharge criterion for a patient with generalized anxiety disorder. The patient will: “Identify situations and events that trigger anxiety”
7. Which comment by a patient who washes hands compulsively identifies the thinking typical of a person with obsessive-compulsive disorder? “I feel driven to wash my hands, although I don’t like doing it.”
8. Which assessment finding for a patient experiencing severe anxiety would indicate possibility of posttraumatic stress disorder? “I keep reliving the rape.”
9. Nursing interventions helpful in lowering a patients’ level of anxiety from severe to moderate include: “listening for themes the patient expresses”
10. Ms. Turner is preoccupied with persistent intrusive thoughts and impulses and performs ritualistic acts repetitively. She expresses distress and that her attention is so consumed that she cannot accomplish her usual daily activities. Which DSM-IV-TR diagnosis should the nurse anticipate? “Obsessive-compulsive disorder”
11. What is the best criterion for evaluation of the anxiety level of a patient with anxiety disorder? “ Attention Span and Concentration”
12. One possible explanation of the existence of anxiety disorders may be: “abnormalities of benzodiazepines receptors”
13. A strategy nurses can employ to help patients with anxiety disorders replace negative self-talk is: “counseling to promote cognitive restructuring”
14. A patient is hospitalized with agoraphobia accompanied by panic attacks. Which symptom should the nurse expect the patient to experience during a panic attack? “paresthesias”
15. Defense mechanisms are: “a means of managing conflict”
16. For a patient experiencing panic-level anxiety, which intervention is the priority? “reduce stimuli”
17. In addition to prescribing SSRIs to treat a patients’ panic disorder, which type of therapy will the nurse psychotherapist likely implement? “cognitive-behavioral therapy”
18. A nurse plans health teaching for a patient with generalized anxiety disorder who began a new prescription for lorazepam(Ativan) . Which topic should be included? “caffeine restriction”
19. One year ago, the patient was driving across a bridge when an earthquake caused it to collapse. The patient continues to have nightmares and feelings of fear and isolation associated with being trapped in a car in swirling water. He avoids driving on bridges and complains that relationships have not been “normal” since the event. The data collected are consistent with which diagnosis? “Posttraumatic stress disorder”
Chapter 19 Personality Disorders
20. Which best describes people with personality disorders? “have difficulty working with and loving others”
21. Which assessment finding should a nurse expect to find in a patient diagnosed with schizotypal personality disorder? “incorrect interpretation of external events”
22. Which finding indicates improvement in a patient with the nursing diagnosis risk for self-mutilation related to feelings of abandonment and impulsivity? “controls self-destructive impulses when feeling empty or upset”
23. An individual demonstrates behaviors and verbalizations that indicate a lack of guilt feelings. Desired outcomes will be facilitated by interventions that: “provide external limits on the individual’s behavior”
24. Which nursing diagnosis should be considered for an individual with any personality disorder?
“impaired social interaction”
25. For which patient should the nurse make minimization of overtly manipulative behavior a priority intervention? A patient who has been diagnosed with : “borderline PD”
26. Which assessment finding will be most likely for an individual with any personality disorder?
“behaviors are flexible and dysfunctional”
27. Which emotional state should the nurse anticipate in a patient with a personality disorder?
“anger”
28. A nurse caring for an individual with schizoid personality disorder should expect which assessment finding? “few interactions with others and little verbalization”
29. A nursing intervention undertaking by the nurse dealing with patients with personality disorders is: “setting limits”
30. Which behavior should a nurse expect while interacting with an individual with narcissitic behavior personality disorder? “attention-seeking”
31. Limit setting would be an essential intervention for which behavior? “manipulation”
32. When planning limit-setting strategies for use with manipulative patient, which step(s) would be most important? Select all that apply.
• Establish realistic limits
• Inform the patient of limits
• Ensure that the limits are enforceable
• Inform the patient of consequences for violating limits
33. A nurse working with an individual with borderline personality disorder must anticipate strategies for intervening with: “mood shifts, impulsivity, and manipulation”
34. Which distinguish characteristic of antisocial personality disorder is absent in most other personality disorders? “disregarding the rights of others”
35. If a nurse wants to assess patient’s interpersonal relationships, which comment would elicit most data? “describe your relationship with friends”
36. Which statement provides a foundation for understanding patients with personality disorders?
“The tendency to develop a PD may have biological determinants”
37. Which problem is most likely to when a nurse sets unrealistically high goals for an individual with an antisocial personality disorder? “The nurse becomes frustrated and angry with the individual when goals are not met”
38. When caring for a patient with dependent personality disorder, which behavior should the nurse reinforce positively? “choosing which outfit to wear”
39. A patient with paranoid personality disorder tells the nurse, “Most people don’t like me and some even want to hurt me.” Which defense mechanism is evident? “Projection”
40. An individual who undergoes a court-ordered psychiatric examination after an arrest for embezzlement from an employer blames others for problems, becomes defensive and angry when criticized, and says , “I didn’t do anything wrong. My company didn’t pay me what I’m worth, so I took what was due to me.” These findings are most closely associated with which personality disorder? “Antisocial”
Chapter 18 Addictive Disorders
41. A psychiatric mental health nurse conducts a community health education series on substance abuse. What description of abuse and addiction should the nurse include? “addiction is characterized by both psychological and physiological withdrawal symptoms”
42. The wife of a patient with alcoholism says, “I ended all outside relationships over the past 20 years ad devoted my life to helping my husband remain sober.” The nurse assesses the wife behavior as an indication of: “enmeshment”
43. Alcohol dependence is differentiated from abuse by: “ a physiological need to use the substance”
44. Which findings would support a nurse’s suspicion that a patient has been abusing inhalants?
“Confusion, mouth ulcers, ataxia”
45. The optimal time to begin group therapy for a patient with dual diagnosis is: “during inpatient treatment”
46. A patient with paranoid schizophrenia and cocaine abuse tells the nurse, “I don’t think I ever be well and maybe I don’t want to. The voices insult me, but when I use cocaine, I like the good feelings I get.” Which nursing diagnosis is most appropriate? “Impaired adjustment related to lack of intention to change maladaptive behavior”
47. Which statement provides a basis for planning care for a patient who has abused CNS stimulants? “symptoms of intoxication include dilation of the pupils, dryness of the oronasal cavity, and excessive motor activity”
48. The probability of the occurrence of withdrawal symptoms in a patient with a long-term alcohol abuse is most accurately assessed by determining: “drinking history, quantity consumed, and the time of last drink”
49. A patient is hospitalized for treatment of pneumonia and has a history of substance abuse. Twenty-four hours after admission, the patient shows tremulousness, anorexia, hypertension, and confusion. The nurse should recognize these as signs of: “alcohol withdrawal delirium”
50. Milieu management for a patient who has injested a hallucinogen should create what type of environment? Select all that apply
• Safe
• Simple
51. A principle of initial counseling intervention that should be observed by the nurse caring for a chemically dependent patient is to: “look for therapeutic leverage by making sobriety and abstinence worthwhile”
52. As the nurse evaluates the patient’s progress, which treatment outcome would indicate a poor general prognosis for long-term recovery from substance abuse? The patient demonstrates: “positive expectations for ongoing drug use”
53. The provision of optimal care for patients withdrawing from substances and of abuse is facilitated when the nurse understands that severe morbidity and mortality are often associated with withdrawal from: “Alcohol and CNS Depressants”
54. A patient has had severe depression for a year and responded poorly to antidepressants. Which statement by the patient supports a dual diagnosis? “When I drink, things look better and I feel almost human.”
55. A patient with chronic pain tells the nurse, “I’ve been using increased doses of oxycodone because the smaller doses didn't work anymore.” The nurse should assess this phenomenon as a result of: “tolerance”
56. At a meeting for family members of alcoholics, one woman describes trying to help her husband keep his job by calling the employer and lying when he was too intoxicated to go to work. This type of behavior is known as: “codependence”
57. When intervening with a patient who is intoxicated from alcohol, it is useful for the nurse to first: “ask what drugs other than alcohol the patient has recently used”
58. Which goal of treatment of alcoholism is the priority? “achieving physiological stability”
CHAPTER 22 Somatorm & Dissociative Disorders
59. Which nursing diagnosis will likely apply to a patient with hypochondriasis? “Deficient diversional activity”
60. When working with a patient that has dissociative amnesia, the nurse should begin by: “identifying and supporting patient’s strength”
61. Which nursing diagnosis is most appropriate for a patient with somatoform disorder who has little energy for activities or interactions with friends? “Impaired social interaction”
62. Which symptom should a nurse expect is a patient dissociative fugue? “patient will travel away from home and assumption of new identity”
63. The wife of a patient with hypochondriasis tells the nurse, “I don’t know what to do. Just when I think we’ve solved our financial problems. He gets sick and takes time off. I worked a full-time and part-time job, do all the work at home and take care of him. “Based on this data, the nurse should consider which nursing diagnosis? “Caregiver Role Strain”
64. Which principle should be applied when caring for a patient that has conversion disorder? “give attention to patient, not the symptom”
65. A patient presents with a history of having an assumed new identity in a distant locale and having no recollection of his former identity? Which DSM-IV-TR diagnosis should the nurse expect the Psychiatrist to assign? “Dissociative Fugue”
66. If a patient has pain in at least four different sites, and cannot be explained by a known general medical condition, which diagnosis is most likely? “Somatoform Disorder”
67. Which intervention should the nurse select to help a patient with chronic pain disorder cope more effectively? “Relaxation Techniques”
68. Which intervention would be more effective when addressing memory problems with a patient with dissociative disorders? “observe for cues that the patient ready to receive information”
69. The information that is least relevant when assessing a patient with suspected somatoform disorder? “potential for violence”
70. During assessment of a patient with somatoform disorder, which finding is most likely? The patient: “exaggerates misinterpretation physical symptoms”
71. Select the appropriate nursing intervention to assist a patient with somatoform disorder increase self-esteem? “focus attention on the patient as an individual rather than on the symptoms”
72. Dissociative identity disorders is thought to be related to: “severe childhood trauma”
73. What is a suitable outcome criterion for the nursing diagnosis ineffective coping related to dependence on pain relievers to treat chronic pain of psychological disorder? “cope adaptively as evidenced by use of alternative coping stratigies”
74. Which nursing diagnosis would be least likely to be considered for a patient with hypochondrosis? “Ineffective Denial”
75. Which assessment question would help to identify secondary gains? “What can’t you do now that you were formerly able to do”
Chapter 17 Cognitive Disorders
76. When formulating long-term goals for a patient with Alzheimer’s disease , the nurse should be aware of the need to: “modify expectations as the patient’s abilities deteriorate”
77. Which action should a nurse recommend for a family that has a member with moderate Alzheimer’s? “Apply an identification bracelet to the person”
78. What is the appropriate nursing intervention for a patient with dementia who develops a catastrophic reaction? “Eliminate or reduce environmental stimulation”
79. Which is the best example of a cognitive impairment? “inability to name a familiar object”
80. When a nurse gives anticipatory guidance the family of a patient with early Alzheimer’s disease, which behavioral problem common to that stage of the disease should be mentioned? “inability to carry on an in-depth conversation”
81. A reasonable outcome that would be appropriate of a patient with cognitive impairment related to delirium would be that the patient will: “return to premorbid level of functioning”
82. Medications approved for the treatment of cognitive impairment in patients with Alzheimer’s disease include: “cholinesterase inhibitors”
83. Which intervention should a nurse incorporate into the care plan for a patient with dementia in order to support short-term memory? “Daily activity schedule”
84. An objective sign that frequently accompanies symptoms of delirium is: “disturbed sleep/wake cycle”
85. Which nursing technique is appropriate for successful interaction with a patient diagnosed with Alzheimer’s disease? “encourage communication and maintain a calm demeanor”
86. A nurse notes that an older adult patient has fluctuating levels of awareness and seems anxious. The patient says, “I saw my granddaughter standing at the foot of the bed during the night.” Later, the nurse sees the patient’s hands waving and picking things out of the air. The nurse should suspect which problem? “Delirium”
87. The husband of a patient with moderately advanced Alzheimer’s disease tells the nurse, “My wife becomes very distressed several times a week. She sees strangers walking around the house and thinks they are taking her things.” How the nurse should responds? Select all that apply:
• Suggest he try to divert her attention through alternative activities
• Recognize how challenging and frustrating these experiences can be
88. The nurse assessing patient with suspected delirium should expect to find that the symptoms developed: “over a period of hours to days”
89. A nurse note that an older adult patient has fluctuating levels of awareness and seems anxious. The patient says, “I saw my granddaughter standing at the foot of my bed during the night,” later, the nurse sees that patient hands waving and picking out things out of the air. The nurse should suspect which problem? “Delirium”
90. A patient with delirium is unable to name a knife but describes the function as “the thing you cut meat with.” Which term should the nurse use to document this finding? “Agnosia”
91. If a patient is hospitalized with delirium of unknown etiology, which assessment finding should the nurse suspect? “fluctuating levels of consciousness”
92. The nurse should recognize that a patient is experiencing an illusion when the patient: “misinterprets shadows on a wall as frightening faces”
93. The nursing diagnosis of the highest priority for patients with Alzheimer’s disease is: “risk for injury”
Chapter 26- Child, Older Adult, and Intimate Partner Abuse
94. Identifying people at high risk and providing health teaching about recognizing behaviors and situations that might trigger abuse and violence are examples of: “Primary Prevention”
95. When making assessments, the nurse should bear in mind that a common characteristic of an abusing parent is: “having poor coping skills”
96. Which of the following is a “red flag” for suspecting physical violence during assessment of a patient? “Explanation does not match the injury”
97. Which example of thinking is not a misconception that would keep a woman locked in an abusive relationship? “no adult has the right to control or harm another”
98. Which nursing diagnosis should be considered for the following family? The husband is disabled, unable to work, drinks episodically, and abuses the two preschool children when in this cycle. The wife works outside the home. “disabled family coping”
CHAPTER 16-Eating Disorders
99. When assessing a patient newly admitted an eating disorders unit, the nurse asks, “How do you feel about being here today?” The purpose of this question is to: “determine the patient’s willingness to engage in treatment.”
100. Which medication, prescribed by the physician, will the nurse most likely administer to patients with eating disorders? “An SSRI such as Fluoxetine”
101. Which behavior modification approach would be most appropriate for a patient with anorexia nervosa? “restriction to the unit until patient has gained 3 pounds”
102. While monitoring the weight-restoration phase, the nurse recognizes that a patient with anorexia nervosa should not gain more than 5lb per week to avoid: “pulmonary edema”
103. When a patient with anorexia nervosa is hospitalized, the nurse’s priority intervention will be directed toward: “supervision of patient activities”
104. Which assessment finding should the nurse expect among individuals with eating disorders? “deficits in hunger and satiety sensations”
105. Which of the following is the most persuasive cognitive distortion nurses will identify among patients with eating disorders? “thinness equates self-worth”
106. Which patient with an eating disorder will be at greatest risk for hypokalemia? “A patient with anorexia, who purges to promote weight loss”
107. Which risk factor for eating disorders is most commonly identified in the histories of adolescents with eating disorders? “dieting”
108. A patient with an eating disorder asks to be excused from the meal to use the restroom. What is the best response by the nurse? “I will go to the restroom with you”
109. Nursing assessment of a bulimic patient often reveals: “hoarseness”
110. The nurse performs a physical assessment of a patient bulimia nervosa. Which assessment findings would confirm the patient’s use of purging behaviors? Select all that apply
• Enlarged parotid glands
• Dental erosions
111. Select the priority nursing diagnosis for a patient who restricts food and is more than 15% underweight. “imbalanced nutrition, less than body requirements”
112. What behavior by a nurse caring for a patient with anorexia nervosa indicates a need for supervision? “using an accepting, nonjudgmental manner”
113. When assessing a patient with binge-purge type bulimia, the nurse should be particularly alert for signs and symptoms of: “hypokalemia”
114. Which assessment finding should the nurse attribute to purging? “dental enamel erosion”
115. A patient with anorexia nervosa tells the nurse, “I can’t get weighed this morning because I drank glass of juice a few minutes before breakfast.” What is the best response by the nurse? “This is weighed day. Please step on the scale”
116. Which intervention should be initiated first for a newly admitted patient with anorexia nervosa who has malnutrition, extreme weight loss, weakness and fatigue? “determine electrolyte levels”
117. An early step in the nurse-patient relationship with a patient with anorexia nervosa is: “formulating a nurse-patient contract”
118. A nurse teaches patients with eating disorders and their family members about the disorder, symptoms, and management. What is the rationale for including family in this teaching? “knowledge promotes power and reduces fear and anxiety” [Show Less]