ANSWERS AND RATIONALE – PSYCHIATRIC NURSING

ANSWERS AND RATIONALE – PSYCHIATRIC
NURSING

1. Answer: C
Rationale: Total abstinence is the only effective
treatment for alcoholism

2. Answer: A
Rationale: Hallucinations are visual, auditory,
gustatory, tactile or olfactory perceptions that
have no basis in reality.

3. Answer: D
Rationale: The Nurse has a responsibility to
observe continuously the acutely suicidal client.
The Nurse should watch for clues, such as
communicating suicidal thoughts, and messages;
hoarding medications and talking about death.

4. Answer: B
Rationale: Establishing a consistent eating plan
and monitoring client’s weight are important to
this disorder.

5. Answer: C
Rationale: Appropriate nursing interventions for
an anxiety attack include using short sentences,
staying with the client, decreasing stimuli,
remaining calm and medicating as needed.

6. Answer:B
Rationale: Delusion of grandeur is a false belief
that one is highly famous and important.

7. Answer: D
Rationale: Individual with dependent personality
disorder typically shows indecisiveness
submissiveness and clinging behavior so that
others will make decisions with them.

8. Answer: A
Rationale: Clients with schizotypal personality
disorder experience excessive social anxiety that
can lead to paranoid thoughts

9. Answer: B
Rationale: Bulimia disorder generally is a
maladaptive coping response to stress and
underlying issues. The client should identify
anxiety causing situation that stimulate the
bulimic behavior and then learn new ways of
coping with the anxiety.

10. Answer: A
Rationale: An adult age 31 to 45 generates new
level of awareness.

11. Answer: A
Rationale: Neuromuscular Blocker, such as
SUCCINYLCHOLINE (Anectine) produces
respiratory depression because it inhibits
contractions of respiratory muscles.

12. Answer: C
Rationale: With depression, there is little or no
emotional involvement therefore little alteration
in affect.

13. Answer: D
Rationale: These clients often hide food or force
vomiting; therefore they must be carefully
monitored.

14. Answer: A
Rationale: These clients have severely depleted
levels of sodium and potassium because of their
starvation diet and energy expenditure, these
electrolytes are necessary for cardiac
functioning.

15. Answer: B
Rationale: Limiting unnecessary interaction will
decrease stimulation and agitation.

16. Answer: C
Rationale: Ritualistic behavior seen in this
disorder is aimed at controlling guilt and
inadequacy by maintaining an absolute set
pattern of behavior.

17. Answer: D
Rationale: The nurse needs to set limits in the
client’s manipulative behavior to help the client
control dysfunctional behavior. A consistent
approach by the staff is necessary to decrease
manipulation.

18. Answer: B
Rationale: Any suicidal statement must be
assessed by the nurse. The nurse should discuss
the client’s statement with her to determine its
meaning in terms of suicide.

19. Answer: A
Rationale: When the staff member ask the client
if he wonders why others find him repulsive, the
client is likely to feel defensive because the
question is belittling. The natural tendency is to
counterattack the threat to self-image.

20. Answer: B
Rationale: The nurse would specifically use
supportive confrontation with the client to point
out discrepancies between what the client states
and what actually exists to increase
responsibility for self.

21. Answer: C
Rationale: The nurse would most likely
administer benzodiazepine, such as lorazepan
(ativan) to the client who is experiencing
symptom: The client’s experiences symptoms of
withdrawal because of the rebound
phenomenon when the sedation of the CNS
from alcohol begins to decrease.

22. Answer: D
Rationale: Regular coffee contains caffeine
which acts as psychomotor stimulants and leads
to feelings of anxiety and agitation. Serving
coffee top the client may add to tremors or
wakefulness.

23. Answer: D
Rationale: Vomiting and diarrhea are usually the
late signs of heroin withdrawal, along with
muscle spasm, fever, nausea, repetitive,
abdominal cramps and backache.

24. Answer: D
Rationale: Moving to a client’s personal space
increases the feeling of threat, which increases
anxiety.

25. Answer: A
Rationale: Environmental (MILIEU) therapy aims
at having everything in the client’s surrounding
area toward helping the client.

26. Answer: C
Rationale: Children who have experienced
attachment difficulties with primary caregiver
are not able to trust others and therefore relate
superficially

27. Answer: A
Rationale: Children have difficulty verbally
expressing their feelings, acting out behavior,
such as temper tantrums, may indicate
underlying depression.

28. Answer: D
Rationale: The autistic child repeats sounds or
words spoken by others.

29. Answer: D
Rationale: The client statement is an example of
the use of denial, a defense that blocks problem
by unconscious refusing to admit they exist

30. Answer: A
Rationale: Discussion of the feared object
triggers an emotional response to the object.

31. Answer: B
Rationale: The nurse presence may provide the
client with support & feeling of control.

32. Answer: D
Rationale: Experiencing the actual trauma in
dreams or flashback is the major symptom that
distinguishes post-traumatic stress disorder from
other anxiety disorder.

33. Answer: C
Rationale: Confabulation or the filling in of
memory gaps with imaginary facts is a defense
mechanism used by people experiencing
memory deficits.

34. Answer: A
Rationale: These are the major signs of anorexia
nervosa. Weight loss is excessive (15% of
expected weight)

35. Answer: C
Rationale: Dental enamel erosion occurs from
repeated self-induced vomiting.

36. Answer: B
Rationale: Depression usually is both emotional
& physical. A simple daily routine is the best,
least stressful and least anxiety producing.

37. Answer: D
Rationale: The expression of these feeling may
indicate that this client is unable to continue the
struggle of life.

38. Answer: A
Rationale: Structure tends to decrease agitation
and anxiety and to increase the client’s feeling of
security.

39. Answer: B
Rationale: The rituals used by a client with
obsessive compulsive disorder help control the
anxiety level by maintaining a set pattern of
action.

40. Answer: C
Rationale: A person with this disorder would not
have adequate self-boundaries

41. Answer: D
Rationale: Loose associations are thoughts that
are presented without the logical connections
usually necessary for the listening to interpret
the message.

42. Answer: C
Rationale: Helping the client to develop feeling
of self-worth would reduce the client’s need to
use pathologic defenses.

43. Answer: B
Rationale: Open ended questions and silence are
strategies used to encourage clients to discuss
their problem in descriptive manner.

44. Answer: C
Rationale: Clients who are withdrawn may be
immobile and mute, and require consistent,
repeated interventions. Communication with
withdrawn clients requires much patience from
the nurse. The nurse facilitates communication
with the client by sitting in silence, asking openended
question and pausing to provide
opportunities for the client to respond.

45. Answer: D
Rationale: When hallucination is present, the
nurse should reinforce reality with the client.

46. Answer: A
Rationale: Personal characteristics of abuser
include low self-esteem, immaturity,
dependence, insecurity and jealousy.

47. Answer: D
Rationale: A short acting skeletal muscle relaxant
such as succinylcholine (Anectine) is
administered during this procedure to prevent
injuries during seizure.

48. Answer: C
Rationale: Recognizing situations that produce
anxiety allows the client to prepare to cope with
anxiety or avoid specific stimulus.

49. Answer: D
Rationale: Electroconvulsive therapy is an
effective treatment for depression that has not
responded to medication

50. Answer: B
Rationale: In an emergency, lives saving facts are
obtained first. The name and the amount of
medication ingested are of outmost important in
treating this potentially life threatening
situation.