Answers and Rationale – Test V Care of Clients with Physiologic and Psychosocial Alterations part 2

Answers and Rationale – Test V Care of Clients with

Physiologic and Psychosocial Alterations part 2

51. Answer: (B) Advising the client to sit up for 1

minute before getting out of bed.

Rationale: To minimize the effects of

amitriptyline-induced orthostatic hypotension,

the nurse should advise the client to sit up for 1

minute before getting out of bed. Orthostatic

hypotension commonly occurs with tricyclic

antidepressant therapy. In these cases, the

dosage may be reduced or the physician may

prescribe nortriptyline, another tricyclic

antidepressant. Orthostatic hypotension

disappears only when the drug is discontinued.

52. Answer: (D) Dysthymic disorder.

Rationale: Dysthymic disorder is marked by

feelings of depression lasting at least 2 years,

accompanied by at least two of the following

symptoms: sleep disturbance, appetite

disturbance, low energy or fatigue, low selfesteem,

poor concentration, difficulty making

decisions, and hopelessness. These symptoms

may be relatively continuous or separated by

intervening periods of normal mood that last a

few days to a few weeks. Cyclothymic disorder is

a chronic mood disturbance of at least 2 years'

duration marked by numerous periods of

depression and hypomania. Atypical affective

disorder is characterized by manic signs and

symptoms. Major depression is a recurring,

persistent sadness or loss of interest or pleasure

in almost all activities, with signs and symptoms

recurring for at least 2 weeks.

53. Answer: (C) 30 g mixed in 250 ml of water

Rationale: The usual adult dosage of activated

charcoal is 5 to 10 times the estimated weight of

the drug or chemical ingested, or a minimum

dose of 30 g, mixed in 250 ml of water. Doses

less than this will be ineffective; doses greater

than this can increase the risk of adverse

reactions, although toxicity doesn't occur with

activated charcoal, even at the maximum dose.

54. Answer: (C) St. John's wort

Rationale: St. John's wort has been found to

have serotonin-elevating properties, similar to

prescription antidepressants. Ginkgo biloba is

prescribed to enhance mental acuity. Echinacea

has immune-stimulating properties. Ephedra is a

naturally occurring stimulant that is similar to

ephedrine.

55. Answer: (B) Sodium

Rationale: Lithium is chemically similar to

sodium. If sodium levels are reduced, such as

from sweating or diuresis, lithium will be

reabsorbed by the kidneys, increasing the risk of

toxicity. Clients taking lithium shouldn't restrict

their intake of sodium and should drink

adequate amounts of fluid each day. The other

electrolytes are important for normal body

functions but sodium is most important to the

absorption of lithium.

56. Answer: (D) It's characterized by an acute onset

and lasts hours to a number of days

Rationale: Delirium has an acute onset and

typically can last from several hours to several

days.           

57. Answer: (B) Impaired communication.

Rationale: Initially, memory impairment may be

the only cognitive deficit in a client with

Alzheimer's disease. During the early stage of

this disease, subtle personality changes may also

be present. However, other than occasional

irritable outbursts and lack of spontaneity, the

client is usually cooperative and exhibits socially

appropriate behavior. Signs of advancement to

the middle stage of Alzheimer's disease include

exacerbated cognitive impairment with obvious

personality changes and impaired

communication, such as inappropriate

conversation, actions, and responses. During the

late stage, the client can't perform self-care

activities and may become mute.

58. Answer: (D) This medication may initially cause

tiredness, which should become less

bothersome over time.

Rationale: Sedation is a common early adverse

effect of imipramine, a tricyclic antidepressant,

and usually decreases as tolerance develops.

Antidepressants aren't habit forming and don't

cause physical or psychological dependence.

However, after a long course of high-dose

therapy, the dosage should be decreased

gradually to avoid mild withdrawal symptoms.

Serious adverse effects, although rare, include

myocardial infarction, heart failure, and

tachycardia. Dietary restrictions, such as

avoiding aged cheeses, yogurt, and chicken

livers, are necessary for a client taking a

monoamine oxidase inhibitor, not a tricyclic

antidepressant.

59. Answer: (C) Monitor vital signs, serum

electrolyte levels, and acid-base balance.

Rationale: An anorexic client who requires

hospitalization is in poor physical condition from

starvation and may die as a result of

arrhythmias, hypothermia, malnutrition,

infection, or cardiac abnormalities secondary to

electrolyte imbalances. Therefore, monitoring

the client's vital signs, serum electrolyte level,

and acid base balance is crucial. Option A may

worsen anxiety. Option B is incorrect because a

weight obtained after breakfast is more accurate

than one obtained after the evening meal.

Option D would reward the client with attention

for not eating and reinforce the control issues

that are central to the underlying psychological

problem; also, the client may record food and

fluid intake inaccurately.

60. Answer: (D) Opioid withdrawal

Rationale: 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.

61. Answer: (A) Regression

Rationale: An adult who throws temper

tantrums, such as this one, is displaying

regressive behavior, or behavior that is

appropriate at a younger age. In projection, the

client blames someone or something other than

the source. In reaction formation, the client acts

in opposition to his feelings. In

intellectualization, the client overuses rational

explanations or abstract thinking to decrease the

significance of a feeling or event.

62. Answer: (A) Abnormal movements and

involuntary movements of the mouth, tongue,

and face.

Rationale: Tardive dyskinesia is a severe reaction

associated with long term use of antipsychotic

medication. The clinical manifestations include

abnormal movements (dyskinesia) and

involuntary movements of the mouth, tongue

(fly catcher tongue), and face.

63. Answer: (C) Blurred vision

Rationale: At lithium levels of 2 to 2.5 mEq/L the

client will experienced blurred vision, muscle

twitching, severe hypotension, and persistent

nausea and vomiting. With levels between 1.5

and 2 mEq/L the client experiencing vomiting,

diarrhea, muscle weakness, ataxia, dizziness,

slurred speech, and confusion. At lithium levels

of 2.5 to 3 mEq/L or higher, urinary and fecal

incontinence occurs, as well as seizures, cardiac

dysrythmias, peripheral vascular collapse, and

death.

64. Answer: (C) No acts of aggression have been

observed within 1 hour after the release of two

of the extremity restraints.

Rationale: The best indicator that the behavior is

controlled, if the client exhibits no signs of

aggression after partial release of restraints.

Options , B, and D do not ensure that the client

has controlled the behavior.

65. Answer: (A) increased attention span and

concentration

Rationale: The medication has a paradoxic effect

that decreases hyperactivity and impulsivity

among children with ADHD. B, C, D. Side effects

of Ritalin include anorexia, insomnia, diarrhea

and irritability.

66. Answer: (C) Moderate

Rationale: The child with moderate mental

retardation has an I.Q. of 35- 50 Profound

Mental retardation has an I.Q. of below 20; Mild

mental retardation 50-70 and Severe mental

retardation has an I.Q. of 20-35.

67. Answer: (D) Rearrange the environment to

activate the child

Rationale: The child with autistic disorder does

not want change. Maintaining a consistent

environment is therapeutic. A. Angry outburst

can be re-channeling through safe activities. B.

Acceptance enhances a trusting relationship. C.

Ensure safety from self-destructive behaviors

like head banging and hair pulling.

68. Answer: (B) cocaine

Rationale: The manifestations indicate

intoxication with cocaine, a CNS stimulant. A.

Intoxication with heroine is manifested by

euphoria then impairment in judgment,

attention and the presence of papillary

constriction. C. Intoxication with hallucinogen

like LSD is manifested by grandiosity,

hallucinations, synesthesia and increase in vital

signs D. Intoxication with Marijuana, a

cannabinoid is manifested by sensation of

slowed time, conjunctival redness, social

withdrawal, impaired judgment and

hallucinations.

69. Answer: (B) insidious onset

Rationale: Dementia has a gradual onset and

progressive deterioration. It causes pronounced

memory and cognitive disturbances. A,C and D

are all characteristics of delirium.

70. Answer: (C) Claustrophobia

Rationale: Claustrophobia is fear of closed space.

A. Agoraphobia is fear of open space or being a

situation where escape is difficult. B. Social

phobia is fear of performing in the presence of

others in a way that will be humiliating or

embarrassing. D. Xenophobia is fear of

strangers.

71. Answer: (A) Revealing personal information to

the client

Rationale: Counter-transference is an emotional

reaction of the nurse on the client based on her

unconscious needs and conflicts. B and C. These

are therapeutic approaches. D. This is

transference reaction where a client has an

emotional reaction towards the nurse based on

her past.

72. Answer: (D) Hold the next dose and obtain an

order for a stat serum lithium level

Rationale: Diarrhea and vomiting are

manifestations of Lithium toxicity. The next dose

of lithium should be withheld and test is done to

validate the observation. A. The manifestations

are not due to drug interaction. B. Cogentin is

used to manage the extra pyramidal symptom

side effects of antipsychotics. C. The common

side effects of Lithium are fine hand tremors,

nausea, polyuria and polydipsia.

73. Answer: (C) A living, learning or working

environment.

Rationale: A therapeutic milieu refers to a broad

conceptual approach in which all aspects of the

environment are channeled to provide a

therapeutic environment for the client. The six

environmental elements include structure,

safety, norms; limit setting, balance and unit

modification. A. Behavioral approach in

psychiatric care is based on the premise that

behavior can be learned or unlearned through

the use of reward and punishment. B. Cognitive

approach to change behavior is done by

correcting distorted perceptions and irrational

beliefs to correct maladaptive behaviors. D. This

is not congruent with therapeutic milieu.

74. Answer: (B) Transference

Rationale: Transference is a positive or negative

feeling associated with a significant person in

the client’s past that are unconsciously assigned

to another A. Splitting is a defense mechanism

commonly seen in a client with personality

disorder in which the world is perceived as all

good or all bad C. Countert-transference is a

phenomenon where the nurse shifts feelings

assigned to someone in her past to the patient

D. Resistance is the client’s refusal to submit

himself to the care of the nurse

75. Answer: (B) Adventitious

Rationale: Adventitious crisis is a crisis involving

a traumatic event. It is not part of everyday life.

A. Situational crisis is from an external source

that upset ones psychological equilibrium C and

D. are the same. They are transitional or

developmental periods in life

76. Answer: (C) Major depression

Rationale: The DSM-IV-TR classifies major

depression as an Axis I disorder. Borderline

personality disorder as an Axis II; obesity and

hypertension, Axis III.

77. Answer: (B) Transference

Rationale: Transference is the unconscious

assignment of negative or positive feelings

evoked by a significant person in the client’s past

to another person. Intellectualization is a

defense mechanism in which the client avoids

dealing with emotions by focusing on facts.

Triangulation refers to conflicts involving three

family members. Splitting is a defense

mechanism commonly seen in clients with

personality disorder in which the world is

perceived as all good or all bad.

78. Answer: (B) Hypochondriasis

Rationale: Complains of vague physical

symptoms that have no apparent medical causes

are characteristic of clients with

hypochondriasis. In many cases, the GI system is

affected. Conversion disorders are characterized

by one or more neurologic symptoms. The

client’s symptoms don’t suggest severe anxiety.

A client experiencing sublimation channels

maladaptive feelings or impulses into socially

acceptable behavior

79. Answer: (C) Hypochondriasis

Rationale: Hypochodriasis in this case is shown

by the client’s belief that she has a serious

illness, although pathologic causes have been

eliminated. The disturbance usually lasts at least

6 with identifiable life stressor such as, in this

case, course examinations. Conversion disorders

are characterized by one or more neurologic

symptoms. Depersonalization refers to

persistent recurrent episodes of feeling

detached from one’s self or body. Somatoform

disorders generally have a chronic course with

few remissions.

80. Answer: (A) Triazolam (Halcion)

Rationale: Triazolam is one of a group of

sedative hypnotic medication that can be used

for a limited time because of the risk of

dependence. Paroxetine is a scrotonin-specific

reutake inhibitor used for treatment of

depression panic disorder, and obsessivecompulsive

disorder. Fluoxetine is a scrotoninspecific

reuptake inhibitor used for depressive

disorders and obsessive-compulsive disorders.

Risperidome is indicated for psychotic disorders.

81. Answer: (D) It promotes emotional support or

attention for the client

Rationale: Secondary gain refers to the benefits

of the illness that allow the client to receive

emotional support or attention. Primary gain

enables the client to avoid some unpleasant

activity. A dysfunctional family may disregard

the real issue, although some conflict is relieved.

Somatoform pain disorder is a preoccupation

with pain in the absence of physical disease.

82. Answer: (A) “I went to the mall with my friends

last Saturday”

Rationale: Clients with panic disorder tent to be

socially withdrawn. Going to the mall is a sign of

working on avoidance behaviors.

Hyperventilating is a key symptom of panic

disorder. Teaching breathing control is a major

intervention for clients with panic disorder. The

client taking medications for panic disorder; such

as tricylic antidepressants and benzodiazepines

must be weaned off these drugs. Most clients

with panic disorder with agoraphobia don’t have

nutritional problems.

83. Answer: (A) “I’m sleeping better and don’t have

nightmares”

Rationale: MAO inhibitors are used to treat sleep

problems, nightmares, and intrusive daytime

thoughts in individual with posttraumatic stress

disorder. MAO inhibitors aren’t used to help

control flashbacks or phobias or to decrease the

craving for alcohol.

84. Answer: (D) Stopping the drug can cause

withdrawal symptoms

Rationale: Stopping antianxiety drugs such as

benzodiazepines can cause the client to have

withdrawal symptoms. Stopping a

benzodiazepine doesn’t tend to cause

depression, increase cognitive abilities, or

decrease sleeping difficulties.

85. Answer: (B) Behavioral difficulties

Rationale: Adolescents tend to demonstrate

severe irritability and behavioral problems

rather than simply a depressed mood. Anxiety

disorder is more commonly associated with

small children rather than with adolescents.

Cognitive impairment is typically associated with

delirium or dementia. Labile mood is more

characteristic of a client with cognitive

impairment or bipolar disorder.

86. Answer: (D) It’s a mood disorder similar to major

depression but of mild to moderate severity

Rationale: Dysthymic disorder is a mood disorder

similar to major depression but it remains mild

to moderate in severity. Cyclothymic disorder is

a mood disorder characterized by a mood range

from moderate depression to hypomania.

Bipolar I disorder is characterized by a single

manic episode with no past major depressive

episodes. Seasonal- affective disorder is a form

of depression occurring in the fall and winter.

87. Answer: (A) Vascular dementia has more abrupt

onset

Rationale: Vascular dementia differs from

Alzheimer’s disease in that it has a more abrupt

onset and runs a highly variable course.

Personally change is common in Alzheimer’s

disease. The duration of delirium is usually brief.

The inability to carry out motor activities is

common in Alzheimer’s disease.

88. Answer: (C) Drug intoxication

Rationale: This client was taking several

medications that have a propensity for

producing delirium; digoxin (a digitalis

glycoxide), furosemide (a thiazide diuretic), and

diazepam (a benzodiazepine). Sufficient

supporting data don’t exist to suspect the other

options as causes.

89. Answer: (D) The client is experiencing visual

hallucination

Rationale: The presence of a sensory stimulus

correlates with the definition of a hallucination,

which is a false sensory perception. Aphasia

refers to a communication problem. Dysarthria is

difficulty in speech production. Flight of ideas is

rapid shifting from one topic to another.

90. Answer: (D) The client looks at the shadow on a

wall and tells the nurse she sees frightening

faces on the wall.

Rationale: Minor memory problems are

distinguished from dementia by their minor

severity and their lack of significant interference

with the client’s social or occupational lifestyle.

Other options would be included in the history

data but don’t directly correlate with the client’s

lifestyle.

91. Answer: (D) Loose association

Rationale: Loose associations are conversations

that constantly shift in topic. Concrete thinking

implies highly definitive thought processes.

Flight of ideas is characterized by conversation

that’s disorganized from the onset. Loose

associations don’t necessarily start in a cogently,

then becomes loose.

92. Answer: (C) Paranoid

Rationale: Because of their suspiciousness,

paranoid personalities ascribe malevolent

activities to others and tent to be defensive,

becoming quarrelsome and argumentative.

Clients with antisocial personality disorder can

also be antagonistic and argumentative but are

less suspicious than paranoid personalities.

Clients with histrionic personality disorder are

dramatic, not suspicious and argumentative.

Clients with schizoid personality disorder are

usually detached from other and tend to have

eccentric behavior.

93. Answer: (C) Explain that the drug is less affective

if the client smokes

Rationale: Olanzapine (Zyprexa) is less effective

for clients who smoke cigarettes. Serotonin

syndrome occurs with clients who take a

combination of antidepressant medications.

Olanzapine doesn’t cause euphoria, and

extrapyramidal adverse reactions aren’t a

problem. However, the client should be aware of

adverse effects such as tardive dyskinesia.

94. Answer: (A) Lack of honesty

Rationale: Clients with antisocial personality

disorder tent to engage in acts of dishonesty,

shown by lying. Clients with schizotypal

personality disorder tend to be superstitious.

Clients with histrionic personality disorders tend

to overreact to frustrations and

disappointments, have temper tantrums, and

seek attention.

95. Answer: (A) “I’m not going to look just at the

negative things about myself”

Rationale: As the client makes progress on

improving self-esteem, self- blame and negative

self-evaluation will decrease. Clients with

dependent personality disorder tend to feel

fragile and inadequate and would be extremely

unlikely to discuss their level of competence and

progress. These clients focus on self and aren’t

envious or jealous. Individuals with dependent

personality disorders don’t take over situations

because they see themselves as inept and

inadequate.

96. Answer: (C) Assess for possible physical

problems such as rash

Rationale: Clients with schizophrenia generally

have poor visceral recognition because they live

so fully in their fantasy world. They need to have

as in-depth assessment of physical complaints

that may spill over into their delusional

symptoms. Talking with the client won’t provide

as assessment of his itching, and itching isn’t as

adverse reaction of antipsychotic drugs, calling

the physician to get the client’s medication

increased doesn’t address his physical

complaints.

97. Answer: (B) Echopraxia

Rationale: Echopraxia is the copying of another’s

behaviors and is the result of the loss of ego

boundaries. Modeling is the conscious copying

of someone’s behaviors. Ego-syntonicity refers

to behaviors that correspond with the

individual’s sense of self. Ritualism behaviors are

repetitive and compulsive.

98. Answer: (C) Hallucination

Rationale: Hallucinations are sensory

experiences that are misrepresentations of

reality or have no basis in reality. Delusions are

beliefs not based in reality. Disorganized speech

is characterized by jumping from one topic to

the next or using unrelated words. An idea of

reference is a belief that an unrelated situation

holds special meaning for the client.

99. Answer: (C) Regression

Rationale: Regression, a return to earlier

behavior to reduce anxiety, is the basic defense

mechanism in schizophrenia. Projection is a

defense mechanism in which one blames others

and attempts to justify actions; it’s used

primarily by people with paranoid schizophrenia

and delusional disorder. Rationalization is a

defense mechanism used to justify one’s action.

Repression is the basic defense mechanism in

the neuroses; it’s an involuntary exclusion of

painful thoughts, feelings, or experiences from

awareness.

100. Answer: (A) Should report feelings of

restlessness or agitation at once

Rationale: Agitation and restlessness are adverse

effect of haloperidol and can be treated with

antocholinergic drugs. Haloperidol isn’t likely to

cause photosensitivity or control essential

hypertension. Although the client may

experience increased concentration and activity,

these effects are due to a decreased in

symptoms, not the drug itself.