RN mental health disorders and addictions EAQ
A female client with obsessive-compulsive disorder has become immobilized by her
elaborate handwashing and walking rituals. Which feelings does the nurse recall are
often the basis of obsessive-compulsive disorder?
1
Anxiety and guilt
2
Anger and hostility
3
Embarrassment and shame
4
Hopelessness and powerlessness - ANSWER: Anxiety and guilt
Ritualistic behavior seen in this disorder is aimed at controlling feelings of anxiety
and guilt by maintaining an absolute set pattern of action. Although the person with
an obsessive-compulsive disorder may be angry and hostile, the feelings of anger
and hostility do not precipitate the rituals. Although the person with an obsessive-
compulsive disorder may be embarrassed and ashamed by the ritual or feel hopeless
and powerless to the ritual, the basic feelings precipitating the rituals are usually
anxiety and guilt.
When answering questions from the family of a client with Alzheimer disease, how
does the nurse describe the disease?
1
Emerges in the fourth decade of life
2
Is a slow, relentless deterioration of the mind
3
Is functional in origin and occurs in the later years
4
Is diagnosed through laboratory and psychological tests - ANSWER: Is a slow,
relentless deterioration of the mind
Alzheimer disease is a slow and relentless deterioration of the mind; clients become
progressively worse over time. The disease usually appears in people 60 years of age
and older. Alzheimer disease is an organic, not a functional, disorder. At this time
there are no diagnostic tools other than autopsy that can provide a definite
confirmation of Alzheimer disease.
During a one-to-one interaction with a client with schizophrenia, paranoid type, the
client says to the nurse, "I figured out how foreign agents have infiltrated the news
media. They want to shut me up before I spill the beans." How should the nurse
describe this statement?
,1
Nihilistic delusion
2
Delusion of grandeur
3
Auditory hallucination
4
Overvaluation of the self - ANSWER: Delusion of grandeur
Thoughts of being pursued by some powerful agent or agents because of one's
special attributes or powers are fixed false beliefs and referred to as delusions of
grandeur. There is no evidence to indicate that a delusion of total or partial
nonexistence is being used. There is no evidence to indicate that a sensory-
perceptual disturbance is present. Delusions of grandeur are usually used to deny
unconscious feelings of low self-esteem.
When planning for a client's care during the detoxification phase of acute alcohol
withdrawal, what need should the nurse anticipate?
1
Checking on the client frequently
2
Keeping the client's room lights dim
3
Addressing the client in a loud, clear voice
4
Restraining the client during periods of agitation - ANSWER: Checking on the client
frequently
During detoxification frequent checks help ensure safety and prevent suicide, which
is a real threat. Bright light is preferable to dim light because it minimizes shadows
that may contribute to misinterpretation of environmental stimuli (illusions). The
client who is going through the detoxification phase of acute alcohol withdrawal
usually does not lose his sense of hearing, so there is no need to shout. Restraints
may upset the client further; they should be used only if the client is a danger to
himself or others.
A nurse has been assigned to care for a client with the diagnosis of obsessive-
compulsive disorder (OCD). Before providing care for this client, what should the
nurse remember about clients with OCD?
1
Are unaware that the ritual serves no purpose
2
Can alter the ritual depending on the situation
3
Should be prevented from performing the ritual
4
, Do not want to repeat the ritual but feel compelled to do so - ANSWER: Do not want
to repeat the ritual but feel compelled to do so
The repeated thought or act defends the client against even higher, more severe
levels of anxiety. Clients usually do recognize that the ritual serves little or no
purpose. Rituals are usually followed rigidly; setting limits on or altering a ritual
increases anxiety. Preventing the client from performing the ritual may precipitate a
panic level of anxiety.
A nurse is caring for a male client who was admitted to the mental health unit with
the diagnosis of schizophrenia. The client is hostile and experiencing auditory
hallucinations and states that the voices are saying that they are going to poison him
because he is bad. What type of schizophrenic behavior does the nurse identify?
1
Residual
2
Paranoid
3
Catatonic
4
Disorganized - ANSWER: Paranoid
Clients with paranoid schizophrenia tend to experience persecutory or grandiose
delusions and auditory hallucinations and exhibit behavioral changes such as anger,
hostility, or violence. Residual schizophrenia is characterized by the negative
symptoms of schizophrenia, but the client does not experience delusions,
hallucinations, disorganized speech, or disorganized or catatonic behavior. Catatonia
is a state in which the client displays extreme psychomotor retardation to the point
of not talking or moving. There may be brief intermittent hyperactive episodes with
catatonia. Disorganized schizophrenia is characterized by a disintegration of the
personality and withdrawn behavior.
When assessing the characteristics of an adolescent with anorexia nervosa, how
does the nurse expect to describe the adolescent?
1
Manic
2
Rebellious
3
Hypoactive
4
Perfectionistic - ANSWER: Perfectionistic
Perfectionistic standards and extremes of self-discipline are an attempt to maintain
control and meet the client's own and others' expectations. People with anorexia
nervosa are often anxious and depressed, not manic. People with anorexia nervosa
are frequently compliant in an attempt to meet the expectations of others. People
A female client with obsessive-compulsive disorder has become immobilized by her
elaborate handwashing and walking rituals. Which feelings does the nurse recall are
often the basis of obsessive-compulsive disorder?
1
Anxiety and guilt
2
Anger and hostility
3
Embarrassment and shame
4
Hopelessness and powerlessness - ANSWER: Anxiety and guilt
Ritualistic behavior seen in this disorder is aimed at controlling feelings of anxiety
and guilt by maintaining an absolute set pattern of action. Although the person with
an obsessive-compulsive disorder may be angry and hostile, the feelings of anger
and hostility do not precipitate the rituals. Although the person with an obsessive-
compulsive disorder may be embarrassed and ashamed by the ritual or feel hopeless
and powerless to the ritual, the basic feelings precipitating the rituals are usually
anxiety and guilt.
When answering questions from the family of a client with Alzheimer disease, how
does the nurse describe the disease?
1
Emerges in the fourth decade of life
2
Is a slow, relentless deterioration of the mind
3
Is functional in origin and occurs in the later years
4
Is diagnosed through laboratory and psychological tests - ANSWER: Is a slow,
relentless deterioration of the mind
Alzheimer disease is a slow and relentless deterioration of the mind; clients become
progressively worse over time. The disease usually appears in people 60 years of age
and older. Alzheimer disease is an organic, not a functional, disorder. At this time
there are no diagnostic tools other than autopsy that can provide a definite
confirmation of Alzheimer disease.
During a one-to-one interaction with a client with schizophrenia, paranoid type, the
client says to the nurse, "I figured out how foreign agents have infiltrated the news
media. They want to shut me up before I spill the beans." How should the nurse
describe this statement?
,1
Nihilistic delusion
2
Delusion of grandeur
3
Auditory hallucination
4
Overvaluation of the self - ANSWER: Delusion of grandeur
Thoughts of being pursued by some powerful agent or agents because of one's
special attributes or powers are fixed false beliefs and referred to as delusions of
grandeur. There is no evidence to indicate that a delusion of total or partial
nonexistence is being used. There is no evidence to indicate that a sensory-
perceptual disturbance is present. Delusions of grandeur are usually used to deny
unconscious feelings of low self-esteem.
When planning for a client's care during the detoxification phase of acute alcohol
withdrawal, what need should the nurse anticipate?
1
Checking on the client frequently
2
Keeping the client's room lights dim
3
Addressing the client in a loud, clear voice
4
Restraining the client during periods of agitation - ANSWER: Checking on the client
frequently
During detoxification frequent checks help ensure safety and prevent suicide, which
is a real threat. Bright light is preferable to dim light because it minimizes shadows
that may contribute to misinterpretation of environmental stimuli (illusions). The
client who is going through the detoxification phase of acute alcohol withdrawal
usually does not lose his sense of hearing, so there is no need to shout. Restraints
may upset the client further; they should be used only if the client is a danger to
himself or others.
A nurse has been assigned to care for a client with the diagnosis of obsessive-
compulsive disorder (OCD). Before providing care for this client, what should the
nurse remember about clients with OCD?
1
Are unaware that the ritual serves no purpose
2
Can alter the ritual depending on the situation
3
Should be prevented from performing the ritual
4
, Do not want to repeat the ritual but feel compelled to do so - ANSWER: Do not want
to repeat the ritual but feel compelled to do so
The repeated thought or act defends the client against even higher, more severe
levels of anxiety. Clients usually do recognize that the ritual serves little or no
purpose. Rituals are usually followed rigidly; setting limits on or altering a ritual
increases anxiety. Preventing the client from performing the ritual may precipitate a
panic level of anxiety.
A nurse is caring for a male client who was admitted to the mental health unit with
the diagnosis of schizophrenia. The client is hostile and experiencing auditory
hallucinations and states that the voices are saying that they are going to poison him
because he is bad. What type of schizophrenic behavior does the nurse identify?
1
Residual
2
Paranoid
3
Catatonic
4
Disorganized - ANSWER: Paranoid
Clients with paranoid schizophrenia tend to experience persecutory or grandiose
delusions and auditory hallucinations and exhibit behavioral changes such as anger,
hostility, or violence. Residual schizophrenia is characterized by the negative
symptoms of schizophrenia, but the client does not experience delusions,
hallucinations, disorganized speech, or disorganized or catatonic behavior. Catatonia
is a state in which the client displays extreme psychomotor retardation to the point
of not talking or moving. There may be brief intermittent hyperactive episodes with
catatonia. Disorganized schizophrenia is characterized by a disintegration of the
personality and withdrawn behavior.
When assessing the characteristics of an adolescent with anorexia nervosa, how
does the nurse expect to describe the adolescent?
1
Manic
2
Rebellious
3
Hypoactive
4
Perfectionistic - ANSWER: Perfectionistic
Perfectionistic standards and extremes of self-discipline are an attempt to maintain
control and meet the client's own and others' expectations. People with anorexia
nervosa are often anxious and depressed, not manic. People with anorexia nervosa
are frequently compliant in an attempt to meet the expectations of others. People
