Nursing Practice Test V – Set B

The client’s security is increased by limit-setting; guidelines remove responsibility for behavior from the client and increase compliance with the regimen.

Displacement reduces anxiety by transferring the emotions associated with an object or person to another, emotionally safer object or person.

The crucial phase is marked by physical dependence. The prealcoholic phase is 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.

For generalized anxiety disorder, the diagnostic criteria listed in the Diagnostic and Statistic Manual of Mental Disorders, 4th edition, include unrealistic or excessive anxiety and worry about two or more life circumstances for 6 months or more, during which time these concerns exist on a majority of days.

Comparison over time is the only way for the nurse to accurately assess the mental status of a child.

The symptoms listed are specific to opioid withdrawal. Alcohol withdrawal would show elevated vital signs. There is no real withdrawal from cannibis. Symptoms of cocaine withdrawal include depression, anxiety, and agitation.

During a panic attack, the nurse's best approach is to orient the client to what is happening and provide reassurance that the client won't be left alone. The anxiety level is likely to increase and the panic attack is likely to continue if the client is told to calm down (as in option A), asked the reasons for the attack (as in option B), or left alone (as in option C).

A situational crisis is a sudden, unexpected event with which the individual is unable to cope using past coping behaviors; this time frame provides an opportunity for the individual to learn new coping behaviors.

Delirium has an acute onset and typically can last from several hours to several days.

Bulimia nervosa can lead to many complications, including diabetes, heart disease, and hypertension. The eating disorder isn't typically associated with allergies, cancer, or hepatitis A.

Commenting on the silence will encourage exploration of what is happening in the group and the member’s thoughts and feelings about it.

The client needs to be informed of the activity and when it will be done. Giving the client choices isn't desirable because he can be manipulative or refuse to do anything. Negotiating and preparing the client ahead of time also isn't therapeutic with this type of client because he may not want to perform the activity.

Diphenhydramine, 25 to 50 mg I.M. or I.V., would quickly reverse this condition. Prochlorperazine and haloperidol are both capable of causing dystonia, not reversing it. Midazolam would make this client drowsy.

This client requires external controls to minimize danger of injury and to preserve human dignity.

Preventing injury is an important goal of care for a client with Alzheimer's disease and can be achieved by providing a safe, structured environment. Other care goals include establishing effective communication with the client and family to help them adjust to the client's altered cognitive abilities, offering emotional support, teaching the client and family about the disease, and encouraging the client to exercise to help maintain mobility. Alzheimer's disease can't be reversed. Cognitive losses can't be prevented because Alzheimer's disease is an insidious, degenerative dementia that eventually causes disorientation; severe deterioration of memory, language, and motor ability; emotional lability; and physical and intellectual disability.

Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign of alcohol withdrawal. Blood pressure may be labile throughout withdrawal, fluctuating at different stages. Hypertension typically occurs in early withdrawal. Hypotension, although rare during the early withdrawal stages, may occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don't receive treatment. The nurse should monitor the client's vital signs carefully throughout the entire alcohol withdrawal process.

Clients with phobic disorders are prone to engaging in episodic alcohol or drug abuse in an attempt to overcome anxiety associated with the phobia. Therefore, a statement indicating the potential for alcohol abuse should concern the nurse. Telling the nurse that a subordinate received a promotion shows that the client trusts the nurse, who should attempt to elicit the client's feelings about this event. Using breathing and calming exercises and expressing a desire to ask someone out on a date reveal that the client is taking small steps toward overcoming his fears. In social phobias, the central fear is self-embarrassment, which compels the client to avoid scrutiny by others; asking a woman to go on a date is a progressive step toward overcoming this fear.

Empathy is the projection of self into another’s emotions to share the emotions and the other’s state of mind; this technique helps the nurse understand the meaning and significance of the experience to the client.

The correct answer is waxy flexibility, which is defined as retaining any position that the body has been placed in. Somatic delusions involve a false belief about the functioning of the body. Neologisms are invented meaningless words. Nihilistic delusions are false ideas about self, others, or the world.

Caplan’s theory states that a crisis is an internal disturbance caused by a stressful event that alters the usual way of coping with a threat to the self; this temporarily disturbs the equilibrium of the person involved.

This is a correct description of the working phase of a relationship, trust has been established and a relationship has been developed based on mutual respect.

Participating in a daily exercise group refocuses the client's time toward adaptive activities and may reduce anxiety. Option A isn't stated specifically enough to allow for evaluation; for this goal to be measurable, specific objectives must be stated such as, "The client will verbalize feeling less anxious." Option C is incorrect because identifying the underlying reasons for rituals takes time and isn't a realistic goal after 1 week. Most clients with OCD are aware that the ritual is irrational but can't stop it, making option D inappropriate as well.

Reserved for clients with acute depression who don't respond to pharmacologic or psychiatric measures, ECT is the passage of an electrical current through the brain to induce a brief seizure. According to ECT proponents, the seizure causes desirable changes in neurotransmitters and receptor sites similar to those caused by antidepressant drugs. ECT is administered by a physician or an anesthesiologist. Although ECT may reduce the severity of depression, it doesn't necessarily cure it. Before ECT, the client receives a medication that provides short-term amnesia of the entire event.

There are positive coping behaviors that can be used consciously to promote mental health.