1.
Kyle is a client with an anxious, fearful personality who has difficulty accomplishing work assignments because of his fear of failure. He has been referred to the employee assistance program because of repeated absences from work and evidence of an alcohol problem. Which nursing diagnosis would be most appropriate?
Correct Answer
A. Ineffective coping
Explanation
"Ineffective Coping" would be the most appropriate nursing diagnosis for Kyle. His anxious and fearful personality, difficulty in completing tasks due to fear of failure, repeated absences from work, and evidence of an alcohol problem indicate an inability difficulty in occupational functioning and coping with stressors, which aligns with the "Ineffective Coping" diagnosis.
2.
Tekla is hospitalized at a Medical Center following a suicide attempt. His history reveals a previous diagnosis of schizoid personality disorder. Which of the following behaviors would be atypical of a client with this disorder?
Correct Answer
A. Actions designed to please the nurse
Explanation
A client with schizoid personality disorder is typically detached, aloof and socially isolated. He has no interest in seeking the approval of others and would not behave in ways to please the nurse. The behaviors included in the remaining options are characteristic of someone with schizoid personality disorder.
3.
The community nurse is following up on Mrs. Jenner who was hospitalized at the Medical Center due to depressive disorder, not otherwise specified, following the death of her spouse. In reviewing the client’s chart, the nurse notes that Mrs. Jenner has an Axis II diagnosis of dependent personality disorder. Which behavior would the nurse anticipate in this client?
Correct Answer
A. Difficulty making decisions, lack of self-confidence
Explanation
The client with a dependent personality disorder typically demonstrates anxious and fearful behavior and is reluctant to make decisions. Lack of self-confidence is reflective of chronic low self-esteem. The behavior in option B is characteristic of someone with dramatic, emotional, erratic personality disorder, such as narcissistic personality. The behavior in option C is characteristic of schizoid or schizotypal personality disorder, in which odd, eccentric behavior is displayed. Option D characterizes borderline personality disorder.
4.
Ralph is admitted at the Medical Center with the diagnosis of bipolar disorder with single manic episode. Which of the following behaviors would the nurse expect to assess?
Correct Answer
C. Elation hyperactivity and impaired judgment
Explanation
A client with bipolar disorder, manic episode, would demonstrate flight of ideas and hyperactivity as part of the increased psychomotor activity. The mood is one of elation, and the feeling is that one is invincible. Therefore, their judgment may be quite impaired. The symptoms in option A would be more characteristic of an individual with long-term schizophrenia. The symptoms in option B would be more characteristic of someone with an anxiety disorder, although a manic individual may also not sleep because of excessive energy. The symptoms in option D are more characteristic of schizophrenia.
5.
In a day treatment program, a manic client is creating considerable chaos, behaving in a dominating and manipulative way. Which nursing intervention is most appropriate?
Correct Answer
B. Describe acceptable behavior and set realistic limits with the client.
Explanation
In this situation, it would be appropriate for the nurse to suggest alternative behaviors in place of unacceptable ones to help the client gain self-control. Option A: The peer group is not responsible for monitoring the client’s behavior. Option C: The client’s behavior does not warrant hospitalization. Option D is inappropriate because the client is told only what is unacceptable and is not given any alternatives.
6.
An individual with depression has a deficiency in which neurotransmitters, based on the biogenic amine theory?
Correct Answer
D. Serotonin and norepinepHrine
Explanation
The biogenic amine theory of depression describes deficiencies in the neurotransmitters serotonin and norepinephrine. Antidepressants medications increase the levels of these neurotransmitters and therefore help to relieve depressive symptoms. Options A, B and C are not right because according to current research, dopamine, thyroxin, GABA, acetylcholine, cortisone and epinephrine are not directly related to depression.
7.
Nurse Rica is teaching a client and her family about the causes of depression. Which of the following causative factors should the nurse emphasize as the most significant?
Correct Answer
B. Chemical imbalance
Explanation
Chemical imbalance of neurotransmitters in the brain is the most significant factor in depression. However, the exact cause has not been established, so other factors may also be involved. Option C: A person’s social environment, including lack of support systems, may also increase the risk of depression. Option D: Although genetic transmission certainly may be a factor, no definite pattern of transmission has been identified.
8.
Clara is under evaluation for imminent suicide risk. Which information given by her would be most significant?
Correct Answer
D. Reference to suicide as best solution to identified problems
Explanation
An individual who talks about suicide as a solution to a problem is at high risk. This client’s suicidal threats need to be taken seriously because he does not see any other variable solutions to problems in living. Options A, B and C: All of the factors included in the other options would increase the client’s risk for depression. However, actual statements about suicidal intent are red flags indicating imminent danger.
9.
Rendell is admitted in an acute psychiatric unit at the Medical Center. He suddenly tells Nurse Matt about his plans for suicide. The nurse’s priority is to:
Correct Answer
C. Follow agency protocol for suicide precautions.
Explanation
The nurse must act to safeguard the client from danger, including self-harm implementing the specific agency protocol for suicidal precautions would best protect the client. Option A: A client with suicidal intent should not be left alone. One-to-one observations are generally part of suicide precautions. Options B and D: Encouraging the client to use problem solving and stimulating his interest in activities would be helpful for someone with depression. However, the nurse’s priority is to protect the client by initiating suicide precautions.
10.
Which mood disorder is characterized by the client feeling depressed most of the day for a 2-year period?
Correct Answer
B. Dysthymia
Explanation
Dysthymia is characterized by at least a 2-year history of depression, occurring most of the day for more days than not. Option A: Cyclothymia is characterized by at least two years of several periods of hypomanic symptoms. Option C: Melancholic depressive disorder is characterized by either anhedonia in relation to all activities or lack of mood reactivity to usually pleasurable stimuli. Option D: Seasonal affective disorder is characterized by depressed feelings in fall and winter, associated with loss of sunlight.