Which of the following descriptions of a client’s experience and behavior can be assessed as an illusion?
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Solution
The client looks at the shadow on a wall and tells the nurse she sees frightening faces on the wall.
Option D: 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.
Options A, B, and C: Other options would be included in the history data but don’t directly correlate with the client’s lifestyle.
Nurse Ron enters a client’s room, the client says, “They’re crawling on my sheets! Get them off my bed!” Which of the following assessment is the most accurate?
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Solution
The client is experiencing visual hallucination
Option D: The presence of a sensory stimulus correlates with the definition of a hallucination, which is a false sensory perception.
Option A: Aphasia refers to a communication problem.
Option B: Dysarthria is difficulty in speech production.
Option C: Flight of ideas is rapid shifting from one topic to another.
Loretta, a newly admitted client was diagnosed with delirium and has history of hypertension and anxiety. She had been taking digoxin, furosemide (Lasix), and diazepam (Valium) for anxiety. This client’s impairment may be related to which of the following conditions?
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Solution
Drug intoxication
Option C: This client was taking several medications that have a propensity for producing delirium; digoxin (a digitalis glycoside), furosemide (a thiazide diuretic), and diazepam (a benzodiazepine).
Options A, B, and D: Sufficient supporting data don’t exist to suspect the other options as causes.
The nurse is aware that the following ways in vascular dementia different from Alzheimer’s disease is:
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Solution
Vascular dementia has more abrupt onset
Option A: Vascular dementia differs from Alzheimer’s disease in that it has a more abrupt onset and runs a highly variable course.
Option B: The duration of delirium is usually brief.
Option C: Personality change is common in Alzheimer’s disease.
Option D: The inability to carry out motor activities is common in Alzheimer’s disease.
Ricardo, an outpatient in psychiatric facility is diagnosed with dysthymic disorder. Which of the following statement about dysthymic disorder is true?
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Solution
It’s a mood disorder similar to major depression but of mild to moderate severity
Option D: Dysthymic disorder is a mood disorder similar to major depression but it remains mild to moderate in severity.
Option A: Cyclothymic disorder is a mood disorder characterized by a mood range from moderate depression to hypomania.
Option B: Bipolar I disorder is characterized by a single manic episode with no past major depressive episodes.
Option C: Seasonal Affective Disorder is a form of depression occurring in the fall and winter.
Jennifer, an adolescent who is depressed and reported by his parents as having difficulty in school is brought to the community mental health center to be evaluated. Which of the following other health problems would the nurse suspect?
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Solution
Behavioral difficulties
Option B: Adolescents tend to demonstrate severe irritability and behavioral problems rather than simply a depressed mood.
Option A: Anxiety disorder is more commonly associated with small children rather than with adolescents.
Option C: Cognitive impairment is typically associated with delirium or dementia.
Option D: Labile mood is more characteristic of a client with cognitive impairment or bipolar disorder.
Mark, with a diagnosis of generalized anxiety disorder wants to stop taking his lorazepam (Ativan). Which of the following important facts should nurse Betty discuss with the client about discontinuing the medication?
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Solution
Stopping the drug can cause withdrawal symptoms
Option D: Stopping anti-anxiety drugs such as benzodiazepines can cause the client to have withdrawal symptoms.
Options A, B, and C: Stopping a benzodiazepine doesn’t tend to cause depression, increase cognitive abilities, or decrease sleeping difficulties.
The effectiveness of monoamine oxidase (MAO) inhibitor drug therapy in client with posttraumatic stress disorder can be demonstrated by which of the following client self–reports?
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Solution
“I’m sleeping better and don’t have nightmares”
Option A: MAO inhibitors are used to treat sleep problems, nightmares, and intrusive daytime thoughts in individual with posttraumatic stress disorder.
Options B, C, and D: MAO inhibitors aren’t used to help control flashbacks or phobias or to decrease the craving for alcohol.
David is diagnosed with panic disorder with agoraphobia is talking with the nurse in-charge about the progress made in treatment. Which of the following statements indicates a positive client response?
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Solution
“I went to the mall with my friends last Saturday”
Option A: Clients with panic disorder tend to be socially withdrawn. Going to the mall is a sign of working on avoidance behaviors.
Option B: Hyperventilating is a key symptom of panic disorder. Teaching breathing control is a major intervention for clients with panic disorder.
Option C: The client taking medications for panic disorder; such as tricyclic antidepressants and benzodiazepines, must be weaned off these drugs.
Option D: Most clients with panic disorder with agoraphobia don’t have nutritional problems.
Aldo, with a somatoform pain disorder may obtain secondary gain. Which of the following statement refers to a secondary gain?
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Solution
It promotes emotional support or attention for the client
Option D: Secondary gain refers to the benefits of the illness that allow the client to receive emotional support or attention.
Option C: Primary gain enables the client to avoid some unpleasant activity.
Option A: A dysfunctional family may disregard the real issue, although some conflict is relieved.
Option B: Somatoform pain disorder is a preoccupation with pain in the absence of physical disease.