A client is admitted to the psychiatric unit with a diagnosis of borderline personality disorder. The nurse expects the assessment to reveal:
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Solution
unpredictable behavior and intense interpersonal relationships.
Option A: A client with borderline personality disorder displays a pervasive pattern of unpredictable behavior, mood, and self-image. Interpersonal relationships may be intense and unstable and behavior may be inappropriate and impulsive.
Option B: Although the client’s impaired ability to form relationships may affect parenting skills, inability to function as a responsible parent is more typical of antisocial personality disorder.
Option C: Somatic symptoms characterize avoidant personality disorder.
Option D: Coldness, detachment, and lack of tender feelings typify schizoid and schizotypal personality disorders.
Tourette syndrome is characterized by the presence of multiple motor and vocal tics. A vocal tic that involves repeating one’s own sounds or words is known as:
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Solution
palilalia. Palilalia is defined as the repetition of sounds and words.
Option A: Echolalia is the act of repeating the words of others.
Option C: Apraxia is the inability to carry out motor activities.
Option D: aphonia is the inability to speak
Which of the following groups are considered to be at highest risk for suicide?
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Solution
Adolescents, men over age 45, and persons who have made previous suicide attempts
Option A: Studies of those who commit suicide reveal the following high-risk groups: adolescents; men over age 45; persons who have made previous suicide attempts. Although more women attempt suicide than men, they typically choose less lethal means and therefore are less likely to succeed in their attempts.
Options B, C, and D: Divorced, widowed, and separated persons; professionals, such as physicians, dentists, and attorneys; students; unemployed persons; persons who are depressed, delusional, or hallucinating; alcohol or substance abusers; and persons who live in urban areas are also at risk.
Which of the following drugs may be abused because of tolerance and physiologic dependence.
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Solution
alprazolam (Xanax) and phenobarbital (Luminal)
Option C: Both benzodiazepines, such as alprazolam, and barbiturates, such as phenobarbital, are addictive, controlled substances.
Options A, B, and D: All the other drugs listed aren’t addictive substances.
A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see:
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Solution
tension and irritability.
Option A: 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: These are incorrect because amphetamines stimulate norepinephrine, which increases the heart rate and blood flow.
Option D: Diarrhea is a common adverse effect, so option D is incorrect.
A client is admitted to the psychiatric unit with a diagnosis of anorexia nervosa. Although she is 5′ 8″ (1.7 m) tall and weighs only 103 lb (46.7 kg), she talks incessantly about how fat she is. Which measure should the nurse take first when caring for this client?
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Solution
Establish a trusting relationship with the client.
Option B: A client with an eating disorder may be secretive and unwilling to admit that a problem exists. Therefore, the nurse first must establish a trusting relationship to elicit the client’s feelings and thoughts.
Option A: The anorexic client may spend long hours discussing nutrition or handling and preparing food in an effort to stall or avoid eating food; the nurse shouldn’t reinforce her preoccupation with food.
Option C: Although cultural stereotypes may play a prominent
role in anorexia nervosa, discussing these factors isn’t the first action the nurse should take.Option D: Exploring the reasons why the client doesn’t eat would increase her emotional investment in food and eating.
A client with a history of polysubstance abuse is admitted to the facility. She complains of nausea and vomiting 24 hours after admission. The nurse assesses the client and notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through which of the following withdrawals?
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Solution
Opioid withdrawal
Option D: The symptoms listed are specific to opioid withdrawal.
Option A: Alcohol withdrawal would show elevated vital signs.
Option B: There is no real withdrawal from cannabis.
Option C: Symptoms of cocaine withdrawal include depression, anxiety, and agitation.
The nurse is caring for an adolescent female who reports amenorrhea, weight loss, and depression. Which additional assessment finding would suggest that the woman has an eating disorder?
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Solution
Excessive and ritualized exercise
Option D: A client with an eating disorder will normally exercise to excess in an effort to burn as many calories as possible.
Option A: The client will usually wear loose-fitting clothing to hide what she considers to be a fat body.
Options B and C: Skin and nails become dry and brittle and blood pressure and body temperature drop from excessive weight loss.
A 38-year-old client is admitted for alcohol withdrawal. The most common early sign or symptom that this client is likely to experience is:
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Solution
perceptual disorders.
Option D: Perceptual disorders, especially frightening visual hallucinations, are very common with alcohol withdrawal.
Option A: Coma isn’t an immediate consequence.
Option B: Manipulative behaviors are part of the alcoholic client’s personality but aren’t signs of alcohol withdrawal.
Option C: Suppression is a conscious effort to conceal unacceptable thoughts, feelings, impulses, or acts and serves as a coping mechanism for most alcoholics.
The nurse is assessing a 15-year-old female who’s being admitted for treatment of anorexia nervosa. Which clinical manifestation is the nurse most likely to find?
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Solution
Parotid gland tenderness
Option C: Frequent vomiting causes tenderness and swelling of the parotid glands.
Options A and B: The reduced metabolism that occurs with severe weight loss produces bradycardia and cold extremities.Option D: Soft, downlike hair (called lanugo) may cover the extremities, shoulders, and face of an anorexic client.