Answers and Rationale – Test V Care of Clients with Physiologic and Psychosocial Alterations part 1

Answers and Rationale – Test V Care of Clients with

Physiologic and Psychosocial Alterations part 1

1. Answer: (D) Focusing

Rationale: The nurse is using focusing by

suggesting that the client discuss a specific issue.

The nurse didn’t restate the question, make

observation, or ask further question (exploring).

2. Answer: (D) Remove all other clients from the

dayroom.

Rationale: The nurse’s first priority is to consider

the safety of the clients in the therapeutic

setting. The other actions are appropriate

responses after ensuring the safety of other

clients.

3. Answer: (A) The client is disruptive.

Rationale: Group activity provides too much

stimulation, which the client will not be able to

handle (harmful to self) and as a result will be

disruptive to others.

4. Answer: (C) Agree to talk with the mother and

the father together.

Rationale: By agreeing to talk with both parents,

the nurse can provide emotional support and

further assess and validate the family’s needs.

5. Answer: (A) Perceptual disorders.

Rationale: Frightening visual hallucinations are

especially common in clients experiencing

alcohol withdrawal.

6. Answer: (D) Suggest that it takes a while before

seeing the results.

Rationale: The client needs a specific response;

that it takes 2 to 3 weeks (a delayed effect) until

the therapeutic blood level is reached.

7. Answer: (C) Superego

Rationale: This behavior shows a weak sense of

moral consciousness. According to Freudian

theory, personality disorders stem from a weak

superego.

8. Answer: (C) Skeletal muscle paralysis.

Rationale: Anectine is a depolarizing muscle

relaxant causing paralysis. It is used to reduce

the intensity of muscle contractions during the

convulsive stage, thereby reducing the risk of

bone fractures or dislocation.

9. Answer: (D) Increase calories, carbohydrates,

and protein.

Rationale: This client increased protein for tissue

building and increased calories to replace what is

burned up (usually via carbohydrates).

10. Answer: (C) Acting overly solicitous toward the

child.

Rationale: This behavior is an example of

reaction formation, a coping mechanism.

11. Answer: (A) By designating times during which

the client can focus on the behavior.

Rationale: The nurse should designate times

during which the client can focus on the

compulsive behavior or obsessive thoughts. The

nurse should urge the client to reduce the

frequency of the compulsive behavior gradually,

not rapidly. She shouldn't call attention to or try

to prevent the behavior. Trying to prevent the

behavior may cause pain and terror in the client.

The nurse should encourage the client to

verbalize anxieties to help distract attention

from the compulsive behavior.

12. Answer: (D) Exploring the meaning of the

traumatic event with the client.

Rationale: The client with PTSD needs

encouragement to examine and understand the

meaning of the traumatic event and consequent

losses. Otherwise, symptoms may worsen and

the client may become depressed or engage in

self-destructive behavior such as substance

abuse. The client must explore the meaning of

the event and won't heal without this, no matter

how much time passes. Behavioral techniques,

such as relaxation therapy, may help decrease

the client's anxiety and induce sleep. The

physician may prescribe antianxiety agents or

antidepressants cautiously to avoid dependence;

sleep medication is rarely appropriate. A special

diet isn't indicated unless the client also has an

eating disorder or a nutritional problem.

13. Answer: (C) "Your problem is real but there is no

physical basis for it. We'll work on what is going

on in your life to find out why it's happened."

Rationale: The nurse must be honest with the

client by telling her that the paralysis has no

physiologic cause while also conveying empathy

and acknowledging that her symptoms are real.

The client will benefit from psychiatric

treatment, which will help her understand the

underlying cause of her symptoms. After the

psychological conflict is resolved, her symptoms

will disappear. Saying that it must be awful not

to be able to move her legs wouldn't answer the

client's question; knowing that the cause is

psychological wouldn't necessarily make her feel

better. Telling her that she has developed

paralysis to avoid leaving her parents or that her

personality caused her disorder wouldn't help

her understand and resolve the underlying

conflict.

14. Answer: (C) fluvoxamine (Luvox) and

clomipramine (Anafranil)

Rationale: The antidepressants fluvoxamine and

clomipramine have been effective in the

treatment of OCD. Librium and Valium may be

helpful in treating anxiety related to OCD but

aren't drugs of choice to treat the illness. The

other medications mentioned aren't effective in

the treatment of OCD.

15. Answer: (A) A warning about the drugs delayed

therapeutic effect, which is from 14 to 30 days.

Rationale: The client should be informed that

the drug's therapeutic effect might not be

reached for 14 to 30 days. The client must be

instructed to continue taking the drug as

directed. Blood level checks aren't necessary.

NMS hasn't been reported with this drug, but

tachycardia is frequently reported.

16. Answer: (B) Severe anxiety and fear.

Rationale: Phobias cause severe anxiety (such as

a panic attack) that is out of proportion to the

threat of the feared object or situation. Physical

signs and symptoms of phobias include profuse

sweating, poor motor control, tachycardia, and

elevated blood pressure. Insomnia, an inability

to concentrate, and weight loss are common in

depression. Withdrawal and failure to

distinguish reality from fantasy occur in

schizophrenia.

17. Answer: (A) Antidepressants

Rationale: Tricyclic and monoamine oxidase

(MAO) inhibitor antidepressants have been

found to be effective in treating clients with

panic attacks. Why these drugs help control

panic attacks isn't clearly understood.

Anticholinergic agents, which are smoothmuscle

relaxants, relieve physical symptoms of

anxiety but don't relieve the anxiety itself.

Antipsychotic drugs are inappropriate because

clients who experience panic attacks aren't

psychotic. Mood stabilizers aren't indicated

because panic attacks are rarely associated with

mood changes.

18. Answer: (B) 3 to 5 days

Rationale: Monoamine oxidase inhibitors, such

as tranylcypromine, have an onset of action of

approximately 3 to 5 days. A full clinical

response may be delayed for 3 to 4 weeks. The

therapeutic effects may continue for 1 to 2

weeks after discontinuation.

19. Answer: (B) Providing emotional support and

individual counseling.

Rationale: Clients in the first stage of Alzheimer's

disease are aware that something is happening

to them and may become overwhelmed and

frightened. Therefore, nursing care typically

focuses on providing emotional support and

individual counseling. The other options are

appropriate during the second stage of

Alzheimer's disease, when the client needs

continuous monitoring to prevent minor

illnesses from progressing into major problems

and when maintaining adequate nutrition may

become a challenge. During this stage, offering

nourishing finger foods helps clients to feed

themselves and maintain adequate nutrition.

20. Answer: (C) Emotional lability, euphoria, and

impaired memory

Rationale: Signs of antianxiety agent overdose

include emotional lability, euphoria, and

impaired memory. Phencyclidine overdose can

cause combativeness, sweating, and confusion.

Amphetamine overdose can result in agitation,

hyperactivity, and grandiose ideation.

Hallucinogen overdose can produce

suspiciousness, dilated pupils, and increased

blood pressure.

21. Answer: (D) A low tolerance for frustration

Rationale: Clients with an antisocial personality

disorder exhibit a low tolerance for frustration,

emotional immaturity, and a lack of impulse

control. They commonly have a history of

unemployment, miss work repeatedly, and quit

work without other plans for employment. They

don't feel guilt about their behavior and

commonly perceive themselves as victims. They

also display a lack of responsibility for the

outcome of their actions. Because of a lack of

trust in others, clients with antisocial personality

disorder commonly have difficulty developing

stable, close relationships.

22. Answer: (C) Methadone

Rationale: Methadone is used to detoxify opiate

users because it binds with opioid receptors at

many sites in the central nervous system but

doesn’t have the same deterious effects as other

opiates, such as cocaine, heroin, and morphine.

Barbiturates, amphetamines, and

benzodiazepines are highly addictive and would

require detoxification treatment.

23. Answer: (B) Hallucinations

Rationale: Hallucinations are visual, auditory,

gustatory, tactile, or olfactory perceptions that

have no basis in reality. Delusions are false

beliefs, rather than perceptions, that the client

accepts as real. Loose associations are rapid

shifts among unrelated ideas. Neologisms are

bizarre words that have meaning only to the

client.

24. Answer: (C) Set up a strict eating plan for the

client.

Rationale: Establishing a consistent eating plan

and monitoring the client’s weight are very

important in this disorder. The family and friends

should be included in the client’s care. The client

should be monitored during meals-not given

privacy. Exercise must be limited and supervised.

25. Answer: (A) Highly important or famous.

Rationale: A delusion of grandeur is a false belief

that one is highly important or famous. A

delusion of persecution is a false belief that one

is being persecuted. A delusion of reference is a

false belief that one is connected to events

unrelated to oneself or a belief that one is

responsible for the evil in the world.

26. Answer: (D) Listening attentively with a neutral

attitude and avoiding power struggles.

Rationale: The nurse should listen to the client’s

requests, express willingness to seriously

consider the request, and respond later. The

nurse should encourage the client to take short

daytime naps because he expends so much

energy. The nurse shouldn’t try to restrain the

client when he feels the need to move around as

long as his activity isn’t harmful. High calorie

finger foods should be offered to supplement

the client’s diet, if he can’t remain seated long

enough to eat a complete meal. The nurse

shouldn’t be forced to stay seated at the table to

finid=sh a meal. The nurse should set limits in a

calm, clear, and self-confident tone of voice.

27. Answer: (D) Denial

Rationale: Denial is unconscious defense

mechanism in which emotional conflict and

anxiety is avoided by refusing to acknowledge

feelings, desires, impulses, or external facts that

are consciously intolerable. Withdrawal is a

common response to stress, characterized by

apathy. Logical thinking is the ability to think

rationally and make responsible decisions, which

would lead the client admitting the problem and

seeking help. Repression is suppressing past

events from the consciousness because of guilty

association.

28. Answer: (B) Paranoid thoughts

Rationale: Clients with schizotypal personality

disorder experience excessive social anxiety that

can lead to paranoid thoughts. Aggressive

behavior is uncommon, although these clients

may experience agitation with anxiety. Their

behavior is emotionally cold with a flattened

affect, regardless of the situation. These clients

demonstrate a reduced capacity for close or

dependent relationships.

29. Answer: (C) Identify anxiety-causing situations

Rationale: Bulimic behavior is generally a

maladaptive coping response to stress and

underlying issues. The client must identify

anxiety-causing situations that stimulate the

bulimic behavior and then learn new ways of

coping with the anxiety.

30. Answer: (A) Tension and irritability

Rationale: An amphetamine is a nervous system

stimulant that is subject to abuse because of its

ability to produce wakefulness and euphoria. An

overdose increases tension and irritability.

Options B and C are incorrect because

amphetamines stimulate norepinephrine, which

increase the heart rate and blood flow. Diarrhea

is a common adverse effect so option D is

incorrect.

31. Answer: (B) “No, I do not hear your voices, but I

believe you can hear them”.

Rationale: The nurse, demonstrating knowledge

and understanding, accepts the client’s

perceptions even though they are hallucinatory.

32. Answer: (C) Confusion for a time after treatment

Rationale: The electrical energy passing through

the cerebral cortex during ECT results in a

temporary state of confusion after treatment.

33. Answer: (D) Acceptance stage

Rationale: Communication and intervention

during this stage are mainly nonverbal, as when

the client gestures to hold the nurse’s hand.

34. Answer: (D) A higher level of anxiety continuing

for more than 3 months.

Rationale: This is not an expected outcome of a

crisis because by definition a crisis would be

resolved in 6 weeks.

35. Answer: (B) Staying in the sun

Rationale: Haldol causes photosensitivity. Severe

sunburn can occur on exposure to the sun.

36. Answer: (D) Moderate-level anxiety

Rationale: A moderately anxious person can

ignore peripheral events and focuses on central

concerns.

37. Answer: (C) Diverse interest

Rationale: Before onset of depression, these

clients usually have very narrow, limited

interest.

38. Answer: (A) As their depression begins to

improve

Rationale: At this point the client may have

enough energy to plan and execute an attempt.

39. Answer: (D) Disturbance in recalling recent

events related to cerebral hypoxia.

Rationale: Cell damage seems to interfere with

registering input stimuli, which affects the ability

to register and recall recent events; vascular

dementia is related to multiple vascular lesions

of the cerebral cortex and subcortical structure.

40. Answer: (D) Encouraging the client to have blood

levels checked as ordered.

Rationale: Blood levels must be checked monthly

or bimonthly when the client is on maintenance

therapy because there is only a small range

between therapeutic and toxic levels.

41. Answer: (B) Fine hand tremors or slurred speech

Rationale: These are common side effects of

lithium carbonate.

42. Answer: (D) Presence

Rationale: The constant presence of a nurse

provides emotional support because the client

knows that someone is attentive and available in

case of an emergency.

43. Answer: (A) Client’s perception of the presenting

problem.

Rationale: The nurse can be most therapeutic by

starting where the client is, because it is the

client’s concept of the problem that serves as

the starting point of the relationship.

44. Answer: (B) Chocolate milk, aged cheese, and

yogurt’”

Rationale: These high-tyramine foods, when

ingested in the presence of an MAO inhibitor,

cause a severe hypertensive response.

45. Answer: (B) 4 to 6 weeks

Rationale: Crisis is self-limiting and lasts from 4

to 6 weeks.

46. Answer: (D) Males are more likely to use lethal

methods than are females

Rationale: This finding is supported by research;

females account for 90% of suicide attempts but

males are three times more successful because

of methods used.

47. Answer: (C) "Your cursing is interrupting the

activity. Take time out in your room for 10

minutes."

Rationale: The nurse should set limits on client

behavior to ensure a comfortable environment

for all clients. The nurse should accept hostile or

quarrelsome client outbursts within limits

without becoming personally offended, as in

option A. Option B is incorrect because it implies

that the client’s actions reflect feelings toward

the staff instead of the client's own misery.

Judgmental remarks, such as option D, may

decrease the client's self-esteem.

48. Answer: (C) lithium carbonate (Lithane)

Rationale: Lithium carbonate, an antimania drug,

is used to treat clients with cyclical

schizoaffective disorder, a psychotic disorder

once classified under schizophrenia that causes

affective symptoms, including maniclike activity.

Lithium helps control the affective component of

this disorder. Phenelzine is a monoamine

oxidase inhibitor prescribed for clients who don't

respond to other antidepressant drugs such as

imipramine. Chlordiazepoxide, an antianxiety

agent, generally is contraindicated in psychotic

clients. Imipramine, primarily considered an

antidepressant agent, is also used to treat clients

with agoraphobia and that undergoing cocaine

detoxification.

49. Answer: (B) Report a sore throat or fever to the

physician immediately.

Rationale: A sore throat and fever are

indications of an infection caused by

agranulocytosis, a potentially life-threatening

complication of clozapine. Because of the risk of

agranulocytosis, white blood cell (WBC) counts

are necessary weekly, not monthly. If the WBC

count drops below 3,000/μl, the medication

must be stopped. Hypotension may occur in

clients taking this medication. Warn the client to

stand up slowly to avoid dizziness from

orthostatic hypotension. The medication should

be continued, even when symptoms have been

controlled. If the medication must be stopped, it

should be slowly tapered over 1 to 2 weeks and

only under the supervision of a physician.

50. Answer: (C) Neuroleptic malignant syndrome.

Rationale: The client's signs and symptoms

suggest neuroleptic malignant syndrome, a lifethreatening

reaction to neuroleptic medication

that requires immediate treatment. Tardive

dyskinesia causes involuntary movements of the

tongue, mouth, facial muscles, and arm and leg

muscles. Dystonia is characterized by cramps

and rigidity of the tongue, face, neck, and back

muscles. Akathisia causes restlessness, anxiety,

and jitteriness.