A 35-year-old female has intense fear of riding an elevator. She claims “ As if I will die inside.” The client is suffering from:
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Solution
Claustrophobia
Option C: Claustrophobia is fear of closed space.
Option A: Agoraphobia is fear of open space or being a situation where escape is difficult.
Option B: Social phobia is fear of performing in the presence of others in a way that will be humiliating or embarrassing.
Option D: Xenophobia is fear of strangers.
Nurse Pauline is aware that Dementia unlike delirium is characterized by:
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Solution
insidious onset
Option B: Dementia has a gradual onset and progressive deterioration. It causes pronounced memory and cognitive disturbances.
Options A, C, and D: These are all characteristics of delirium.
Jeremy is brought to the emergency room by friends who state that he took something an hour ago. He is actively hallucinating, agitated, with irritated nasal septum.
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Solution
cocaine
Option B: The manifestations indicate intoxication with cocaine, a CNS stimulant.
Option A: Intoxication with heroine is manifested by euphoria then impairment in judgment, attention and the presence of papillary constriction.
Option C: Intoxication with hallucinogen like LSD is manifested by grandiosity, hallucinations, synesthesia, and increase in vital signs.
Option D: Intoxication with Marijuana, a cannabinoid is manifested by sensation of slowed time, conjunctival redness, social withdrawal, impaired judgment, and hallucinations.
The therapeutic approach in the care of Armand an autistic child include the following EXCEPT:
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Solution
Rearrange the environment to activate the child
Option D: The child with autistic disorder does not want change. Maintaining a consistent environment is therapeutic.
Option A: Angry outburst can be re-channeling through safe activities.
Option B: Acceptance enhances a trusting relationship.
Option C: Ensure safety from self-destructive behaviors like head banging and hair pulling.
Kitty, a 9 year old child has very limited vocabulary and interaction skills. She has an I.Q. of 45. She is diagnosed to have Mental retardation of this classification:
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Solution
Moderate
Option C: The child with moderate mental retardation has an I.Q. of 35- 50.
Option A: Profound Mental retardation has an I.Q. of below 20;
Option B: Mild mental retardation 50-70 and;
Option D: Severe mental retardation has an I.Q. of 20-35.
Nurse Irish is aware that Ritalin is the drug of choice for a child with ADHD. The side effects of the following may be noted by the nurse:
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Solution
increased attention span and concentration
Option A: The medication has a paradoxical effect that decreases hyperactivity and impulsivity among children with ADHD.
Options B, C, and D: Side effects of Ritalin include anorexia, insomnia, diarrhea and irritability.
Nurse Jannah is monitoring a male client who has been placed in restraints because of violent behavior. Nurse determines that it will be safe to remove the restraints when:
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Solution
No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints.
Option C: The best indicator that the behavior is controlled if the client exhibits no signs of aggression after partial release of restraints.
Options A, B, and D: These do not ensure that the client has controlled the behavior.
Dennis has a lithium level of 2.4 mEq/L. The nurse immediately would assess the client for which of the following signs or symptoms?
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Solution
Blurred vision
Option C: At lithium levels of 2 to 2.5 mEq/L the client will experience blurred vision, muscle twitching, severe hypotension, and persistent nausea and vomiting.
Options A and B: With levels between 1.5 and 2 mEq/L the client experiencing vomiting, diarrhea, muscle weakness, ataxia, dizziness, slurred speech, and confusion.
Option D: At lithium levels of 2.5 to 3 mEq/L or higher, urinary and fecal incontinence occurs, as well as seizures, cardiac dysrhythmias, peripheral vascular collapse, and death.
Nurse Anne is caring for a client who has been treated long term with antipsychotic medication. During the assessment, Nurse Anne checks the client for tardive dyskinesia. If tardive dyskinesia is present, Nurse Anne would most likely observe:
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Solution
Abnormal movements and involuntary movements of the mouth, tongue, and face.
Option A: 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 (flycatcher tongue), and face.
Mr. Garcia, an attorney who throws books and furniture around the office after losing a case is referred to the psychiatric nurse in the law firm’s employee assistance program. Nurse Beatriz knows that the client’s behavior most likely represents the use of which defense mechanism?
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Solution
Regression
Option A: An adult who throws temper tantrums, such as this one, is displaying regressive behavior, or behavior that is appropriate at a younger age.
Option B: In projection, the client blames someone or something other than the source.
Option C: In reaction formation, the client acts in opposition to his feelings.
Option D: In intellectualization, the client overuses rational explanations or abstract thinking to decrease the significance of a feeling or event.