Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Introjection
involves taking on the characteristics of another.
Projection is characterized by accusing someone of
Reference: Timby, B.K., Carmack, A., & Rupert, D.L. Reference: Timby, B.K., Carmack, A., & Rupert, D.L.
Lippincott’s review for NCLEX-PN. 7th ed. (2006). Lippincott’s review for NCLEX-PN. 7th ed. (2006).
Philadelphia: Lippincott Williams & Wilkins. Philadelphia: Lippincott Williams & Wilkins.
3. D 5. A
Rationale: Displacement is a coping mechanism in Rationale: Involuntary facial movements and tongue
which a person transfers his angry feelings for one and eye movements indicate the development of
person onto someone else who is less likely to tardive dyskinesia, a negative consequence of
1
antipsychotic (neuroleptic) drug therapy. The Reference: Linda Anne Sivestri. Saunder’s
condition is usually irreversible, even after the drug Comprehensive Review for the NCLEX-RN
is discontinued. About 20% of those treated with Examination Third Ed. Elsevier Inc. 2005. CD-ROM
antipsychotic medications in the long-term develop
tardive dyskinesia. None of the other assessment
8. B.
findings is linked to antipsychotic drug withdrawal.
he/ she appear disorganized and impulsive. Clients psychiatrist, this also is not the initial action.
personal or family history of suicide attempts, Comprehensive Review for the NCLEX-RN
depression, alcoholism; or psychotic episodes. Examination Third Ed. Elsevier Inc. 2005. CD-ROM
2
sexual concerns. Therefore, options b, c and d are
incorrect.
10. D.
stages of development, between the ages of 3 and memory or consciousness. Psychosis is a state in
6, the child is in the phallic stage. At this time, the which a person’s mental capacity to recognize
child devotes much energy in examining his or her reality, communicate and relate to others is
genitalia, masturbating and expressing interest in impaired, thus interfering with the person’s ability to
deal with life’s demands. Repression is coping
3
mechanism which unacceptable feelings are kept
out of awareness.
17. B
Rationale: Solitary activities that require a short other 3 options requires the client to make a
attention span with mild physical exertion are the decision. These types of questions are inappropriate
18. B
Reference: Comprehensive Review for the NCLEX-
RATIONALE: the nurse should never promise to
RN EXAMINATION Ed. 4, 2008, Saunders et al
keep a secret. Secrets are appropriate in social
relationships but not in therapeutic relationships. The
nurse needs to be honest with the client and tell the
16. A
client that a promise cannot be made to keep a
19. A
4
partent or guardian. The nurse needs to be familiar ideas, actions or feelings by developing acceptable
with the state and facility policies and procedures. explanations that satisfies the teller and the listener.
The best nursing action is to contact the physician.
23. D
REFERENCE: SAUNDERS comprehensive review
Rationale: Short-term goals include the beginning
NCLEX-RN examination 2008, 4th edition. Page
stages of dealing with the rape trauma. Clients will
1139
be expected initially to keep appointments,
participate in care, begin to explore feelings, and
begin to heal any physical wounds that were inflicted
25. C
5
26. A (Thompson Peterson. NCLEX-PN Certification
Rationale: The manic patient may neglect to eat or Exam. Peterson’s Advision of Thompson Learning
sleep, due to excessive energy and flight of ideas. Corp.2003.p 128)
30. C
Auditory hallucinations that are “commanding” a
(Thompson Peterson. NCLEX-PN Certification
patient to hurt someone can make the patient a
Exam. Peterson’s Advision of Thompson Learning
danger to himself or others. The RN provider needs
Corp.2003.p 127)
to know that they are occurring.
31. B.
(Thompson Peterson. NCLEX-PN Certification
Exam. Peterson’s Advision of Thompson Learning Rationale: The nurse’s nonverbal behavior, moving
Corp.2003.p 128) away from the window as seethe client’s request,
would indicate agreement with the client’s false
ideas. The client’s behavior is likely to be reinforced
6
Verbal Communication would be appropriate if the safety is no longer an issue because antipsychotics
client were demonstrating less coherent speech. are beginning to take effect. Telling the client that
Social Isolation would be appropriate if the client the hallucinations are part of the illness or that the
were refusing to come out of his room. medications will help control the voices would be
appropriate once the client has developed some
insight into the symptoms of illness.
36. C
7
(Reference: www.evolve.elsevier.com) result. Options 2, 3, and 4 are not the most frequent
causes of postretirement adjustment disorder.
37: A
(Reference: www.evolve.elsevier.com)
Rationale: Controlling the impulse to self-mutilate or
self-destruct would be indicative of improved ability
to tolerate distressing thoughts. Ordinarily the patient
40. C
would impulsively act out the urge. Option 2 is not a
desired outcome. Option 3 does not suggest Rationale: Cultural practices dealing with grief and
improved management of feelings. Option 4 is not a loss differ. Failure to incorporate the significance of
38. C involvement.
39. A schedule.
42. A
8
Rationale: Change comes slowly even when
appropriate goals are set with the patient. When
(Reference: www.evolve.elsevier.com)
goals are unattainable, staff become discouraged or
frustrated with lack of progress. Regarding option 2,
when a nurse adopts the behaviors used by an
antisocial patient, it is not related to lack of progress 45. Answer: C
43. B
about one's feelings and views clouds the nurse's Rationale: Repetition of words or phrases that are
focus. 1. Previous experience may prove to be similarly in sound and in no other way (rhyming) is
helpful, but is not the most important qualification. 3. one altered thought and language pattern in
Thinking that all types of sexual dysfunction can be schizophrenia. Clang association often take the form
corrected is unrealistic. 4. Thinking that the of rhyming. Loosened associations occur when
prognosis for most sexual dysfunction disorders is individual speaks with frequent changes of subject,
poor shows lack of information. and the content is obliquely related. Echolalia is the
involuntary parrot like repetition of words spoken by
others. Word salad is the use of words with no
apparent meaning attached to them or to their
(Reference: www.evolve.elsevier.com)
relationship to one another.
Reference: Saunders Q & A Review for the NCLEX-
RN Examination by Linda Anne Silvestri, 2006,
44. D
Elsevier Inc
coping skills used in the past. After this lead-in the Rationale: By definition, an ego defense mechanism
nurse can question further to find out how effective are operations outside of a person's awareness that
the coping skills were. This option is the only the ego calls into play to protect against anxiety.
question that relates specifically to adequacy of Denial is the defense mechanism that blocks out
9
for cancer and therefore denies the illness. Reference: Saunders Q & A Review for the NCLEX-
Psychosis and delusions are not defense RN Examination by Linda Anne Silvestri, 2006,
mechanism. Displacement is the discharging of Elsevier Inc
pent-up feelings on persons less dangerous than 50. B
those initially around the feelings. Rationale: The client in manic state often has
inadequate food and fluid intake as a result of
physical agitation. Foods that the client can eat “on
Reference: Saunders Q & A Review for the NCLEX- the run” are best because the client is too active to
RN Examination by Linda Anne Silvestri, 2006, sit at meals and use utensils. Additionally, clients in
manic state should not have caffeine containing
53. C
http://www.scribd.com/doc/6389830/109-Questions-
Rationale: the depression to be improving and the and-Rationale-on-Psychotic-Disorders
57. B
55. C.
58. C
Rationale: Schizophrenia: when disorders of
perception and thoughts came in. the only diagnosis Rationale: By acknowledging that the client hears
doctor can make is among the choices of voices, the nurse conveys acceptance of the client.
schizophrenia. A, B and D can occur in normal By letting the client know that the nurse doesn't hear
individuals without altering their perceptions. the voices, the nurse avoids reinforcing the
Schizophrenia is characterized by disorders of hallucination. The nurse shouldn't touch the client
thoughts, hallucinations, delusions, illusion and with schizophrenia without advance warning. The
disorganization. hallucinating client may believe that the touch is a
threat or act of aggression and respond violently.
Being alone in his room encourages the client to
56. A withdraw and may promote more hallucinations. The
nurse should provide an activity to distract the client.
Rationale: Because of such factors as
By asking the client what the voices are saying, the
suspiciousness, anxiety, and hallucinations, the
1
1
nurse is reinforcing the hallucination. The nurse
should focus on the client's feelings, rather than the
61. D
content of the hallucination.
60. C
63. B
Rationale: The client's signs and symptoms suggest Rationale: The nurse must not reinforce the client’s
neuroleptic malignant syndrome, a life-threatening hallucinations. Telling the client to listen to the
reaction to neuroleptic medication that requires voices would reinforce the hallucinations (Option A).
immediate treatment. Tardive dyskinesia causes The nurse shouldn’t say things that may not be true
involuntary movements of the tongue, mouth, facial (Option C). The voices are real to the client, telling
muscles, and arm and leg muscles. Dystonia is him that he doesn’t hear them isn’t therapeutic
characterized by cramps and rigidity of the tongue, (Option D).
face, neck, and back muscles. Akathisia causes
restlessness, anxiety, and jitteriness. 64. A
65. C
68. B
1
3
(Reference: Saunders’ Comprehensive Review 76. A
NCLEX-RN Examination 4TH ed by Linda Anne Rationale: Clients with panic disorder tend to be
Silvestri, MSN, RN, Canada 2008.) socially withdrawn. Going to the mall is a sign of
working on avoidance behaviors. Hyperventilation is
a key symptom of panic disorder. Teaching
71. C
breathing control is a major intervention for clients
Rationale: The development of physical symptoms with panic disorder. The client taking medications for
without a physical cause is an anxiety-reducing panic disorder, such as trycyclic antidepressants and
72. B
77. D
Rationale: Mediating frustration within the real world Rationale: The client must be aware of the
is an ego function and requires ego strength. connection between sources of anxiety and the
symptoms of a panic attack. Role-playing a panic
attack isn’t useful for the client. Later in treatment,
73. B the client can develop an exercise program as part
of the overall plan to handle stress. Learning to
Rationale: Slips of the tongue also called Freudian
identify cognitive distortions is a useful strategy to
slip are material from the unconscious that slips out
teach the client after he’s begun to work on
in unguarded moments.
identifying sources of anxiety.
78. D
74. A Rationale: Stopping antianxiety dugs such as
benzodiazepines can cause the client to have
Rationale: Talking in the third person reflect poor
withdrawal symptoms. Stopping a benzodiazepine
ego boundaries and dissociation from the real self.
doesn’t tend to cause depression, increase cognitive
75. C abilities, or decrease sleeping difficulties.
81. D 85. C
Rationale: A client with a bipolar disorder and a
Rationale: Although the precise mechanism of superimposed seasonal affective depression needs
inheritance is unknown, developing a social phobia to be careful about the time of day that the
is 11% more likely if a family member has the phototherapy is utilized. Because of circardian
disorder. rhythms, it has been found that bipolar clients with
seasonal depression do best if they utilize the
phototherapy treatment in the later afternoon. If the
82. C phototherapy is used in the morning, manic
manifestations may result. Exploring appetite,
Rationale: Malingering is characterized by the
energy level, feelings of self-worth, and how much
client’s deliberate attempt to gain attention. The
money the client is spending may all be important
clinical manifestations are not confirmed by lab tests.
interventions, but determining the time of the day the
The client will bring the clinical manifestations to the
client is using phototherapy allows the nurse to
attention of others for secondary gain. The client
obtain the information that may be causing the
does not withdraw but becomes demanding of health
dramatic change and elevation in mood.
care providers and others.
(Reference: Complete Review for NCLEX-RN by
Donna Gauwitz, Thomson Asian Edition, NSNA
83. A (2007))
87. D
Rationale: The client's early arrival indicates an
expected degree of anxiety; the quiet waiting 92. C
93. B
Rationale: Toddlers struggle to identify their own society are expressed through the child’s play world.
needs. Too early and too strict toilet training results These values become part of the child’s system
in ambivalence because toddler's needs and through the process of internalization (introjection).
physical abilities are in conflict with parental Projection- if this happens, children will learn to
demands. Toddlers are faced with giving up these blame others for their own faults. Competition
91. C
Rationale: The toddler is learning autonomy, but 94. C
99. D
96. B,E,F
Rationale: Sleep deprivation can lead to
hallucinations and delusions. Uninterrupted sleep is
Rationale: Client education should cover the signs
an important nursing consideration in planning care.
and symptoms of drug toxicity as well as the need to
1
7
All other data are expected and shouldn’t cause
sleep deprivation.
104. B
100. C
Rationale: The amount of time focused on
discussing physical symptoms should be decreased. Rationale: Any behavioural therapy or learning of
Lack of positive reinforcement may help her to stop new methods of coping with situations requires
the maladaptive behavior. However, avoiding the modification of approach and attitudes; hence
statement all together demeans the client and personality is always capable of change.
106. A
Rationale: Splitting is the compartmentalization of
102. D
opposite-affect states and failure to integrate the
Rationale: Fears and anxieties about themselves positive and negative aspects of self or others.
and their possessions are common in older adults
because of a decreased self-concept and an altered 107. C
body image; these changes result in a decreased Rationale: Conscience and a sense of right and
ability to cope. wrong are expressed in the superego, which acts to
counterbalance the id’s desire for immediate
gratification.
103. A
117. A
112. C
Rationale: anxiety is a normal reaction to the
Rationale: Children view their own worth by the termination of the nurse-client relationship. The
response received from their parents. This sense of nurse should help the client explore his feelings
worth sets the basic ego strengths and is vital to the about the end of the therapeutic relationship. While
formation of the personality. anger about the termination may be a healthy
response, banging the table, shouting and other
113. D
forms of acting out aren’t appropriate behaviour.
Rationale: when acting-out against the primary
Withdrawal isn’t a healthy response to the
source of anxiety creates even further anxiety or
termination of a relationship. By rationalizing the
danger, the individual may use displacement to
termination, the client avoids expressing his feelings
express feelings on a safer person or object.
and emotions.
1
9
118. A 121. B
Rationale: The client’s memory of a traumatic Rationale: Flight of ideas is the shifting of a topic
childhood incident and her current signs and from one subject to another in a somewhat related
symptoms (nightmares, flashbacks, and related way while looseness of association is the shifting of
fears) suggests that she has PTSD with delayed a topic from one subject to another in a completely
onset. The client doesn’t occasionally lose track of unrelated way
her movements and actions, as in multiple
pigmentary retinopathy, which can’t be reversed. As situation characterized by feelings of great anxiety
written, the order allows for administering more than and inability to perform activities of daily living.
2
1
Rationale: At the height of depression, patients
usually have difficulty conceptualizing activities. The
139. D
patient’s plan to organize child care indicates that his
ability to conceptualize is working. This indicates Rationale: Responding to the feelings expressed by
recovery from depression. a client is an effective therapeutic communication
technique. The correct option is an example of the
use of restating.
(Reference: The ABC’s of Psychiatric Nursing: Core
Concepts for the Nurse Licensure Exam by Ray A.
142. B
138. D
Rationale: The nurse should initiate brief, frequent
Rationale: In the termination phase, the relationship contacts throughout the day to let the client know
comes to a close. Ending treatment sometimes may that he is important to the nurse. This will positively
be traumatic for clients who have come to value the affect the client’s self-esteem.
relationship and the help. Because loss is an issue,
any unresolved feelings related to loss may
resurface during this phase.
2
2
143. D Rationale: The client preoccupied with delusions of
the persecution, grandeur, ideas of reference, and
Rationale: The statement “I don’t think about killing
auditory hallucinations is predisposed to suicidal and
myself as much as I used to.” Indicates a lessening
violent behavior. Option A is not applicable, as this
of suicidal ideation and improvement in the client’s
would reinforce the client’s delusions of persecution.
condition.
Option B and D should be eliminated since this is
another area of concern, but safety must be first
addressed.
144. C
149. C
146. C
Rationale: Clients who are diagnosed with
Rationale: This would distract the client by offering
schizophrenic disorders have difficulty handling
alternate activity. Option A should be eliminated
complex information, so it is best to keep
never ask “why” question. The client is unable to
communication simple. Option A should be
explain this behavior. Option B is also eliminated
eliminated because the mood of the staff is not
because this response is threatening and implies
significant. Option B is also eliminated since the
misbehavior by the client. Option D is also
client deals best with simple direct sentences.
eliminated because this does not distract the client
Option D is also eliminated as client in general do
from the behavior and leaves her in the room alone
not have trouble with violent behaviors.
to continue washing her hands.
147. C
2
3
150. A Rationale: Restating is the therapeutic
communication technique in which the nurse repeats
Rationale: Major aspects of the pre-ECT stage are:
what the client says to show understanding and to
obtaining lab and diagnostic data, getting an
review what was said. Option 3 uses the therapeutic
informed consent, and reinforcing client and family
technique of restating. Option 1, the nurse is
education. Option B is not applicable. Option C it
attempting to assess the client’s ability to discuss
should be eliminated because the client is NPO after
feelings openly with family members. In option 2, the
midnight. Option D is also eliminated since this is
nurse attempts to use focusing, but the attempt to
important, but not necessarily the nurse’s
discuss central issues is premature. In option 4, the
responsibility.
nurse makes a judgment and is nontherapeutic in
2
4
156. C (Reference: NCLEX Review: Psychiatric Nursing
Practice Test Part 2)
Rationale: Antiseptic mouthwash often contains
alcohol & should be kept in locked area, unless
labeling clearly indicates that the product does not
161. B
contain alcohol.
Rationale: Confrontation is the skill of caringly however, the nurse should first use one-to one
181. D
Rationale: Initial therapeutic effects of
177. A
antidepressants occur after 2-3 weeks while full
Rationale: A patient who is taking lithium must be therapeutic effects occur after 3-4 weeks.
facilitate excretion of lithium from the body. Rationale: Respiratory depression can occur after
electro-convulsive therapy due to the muscular
relaxation effect of Anectine, so assess for
respiration
178. B
179. B 184. C
Rationale: Leaving a light on the patient’s room will
Rationale: Preventing the patient from using the
decrease visual hallucinations, which frequently
bathroom for 2 hours after eating prevents the
occur in alcohol withdrawal syndromes
patient from inducing vomiting.
185. A
Rationale: When a depressed patient suddenly
180. D becomes cheerful, it means that the patient is
recovering from depression and is n danger of
Rationale: Before the administration of antabuse, the
committing suicide.
patient must be free of alcohol for atleast 12 hours tp
prevent antabuse reaction which is usually
(Reference: “The ABC’s of Psychiatric Nursing: Core
manifested by severe nausea and vomiting,
Concepts for Nurse Licensure Exam” by Ray A.
respiratory depression and orthostatic hypotension.
Gapuz)
186 .D
Rationale: The suicidal client has difficulty
expressing anger toward others. The depressed
2
8
suicidal client frequently expresses feelings of low Rationale: The client who is confused might forget
self-worth, feelings of remorse and guilt, and a that he ate earlier. Don’t argue with the client. Simply
dependence on others; therefore, answers A, B, and get him something to eat that will satisfy him until
C are incorrect. lunch. Answers A and D are incorrect because the
nurse is dismissing the client. Answer B is validating
187.C the delusion.
Rationale: A history of cruelty to people and
animals, truancy, setting fires, and lack of guilt or (Reference: http://nursingcrib.com/nursing-board-
remorse are associated with a diagnosis of conduct exam-reviewer)
disorder in children, which becomes a diagnosis of
204. B
199. D
Rationale: Altered parenting role refers to the
Rationale: delirium tremens occur as acute alcohol
inability to create an environment that promotes
withdrawal progresses. It include symptoms such as
optimum growth and development of the child. This
clouding of sensorium, hallucinations, seizures, and
is reflected in the parent’s inability to care for the
autonomic hyperactivity.
child. A. This refers to lack of choices or inability to
mobilize one’s resources. C. Refers to change in
200. B
family relationship and function. D. Ineffective coping
Rationale: cognitive symptoms include inflated self-
is the inability to form valid appraisal of the stressor
esteem and grandiosity
or inability to use available resources
201. A
205. B
Rationale: Participating in reality orientation is the Rationale: These are manifestations of autistic
most appropriate activity for the client who is disorder. A. These manifestations are noted in
confused. Answers B, C, and D are incorrect Oppositional Defiant Disorder, a disruptive disorder
because they are not suitable activities for a client among children. C. These are manifestations of
who is confused. Attention Deficit Disorder D. These are the
manifestations of Conduct Disorder
202. B (Reference: http://nursingcrib.com/nursing-board-
exam-reviewer)
3
0
206. B compromises physiological integrity and needs to be
Rationale: Projection is the process of attributing addressed immediately.
one’s own thoughts about one’s self to others.
212. D
207.A Rationale: For the nurse to empathize with the
Rationale: This allows the agitated, angry client time client‘s experience is most therapeutic. Disagreeing
to regain self-control, telling the client that the nurse with delusions may make the client more defensive,
will return will decrease possible guilt feelings and and the client may cling to the delusions even more.
implies to the client that the nurse cares enough to Encouraging discussion regarding the delusion is
return. inappropriate.
211. B 214. A
Rationale: Mania is a mood characterized by Rationale: If a client with severe anxiety is left alone,
excitement, euphoria, hyperactivity, excessive the client may feel abandoned and become
energy, decreased need for sleep, and impaired overwhelmed. Placing the client in a quiet room is
ability to concentrate for complete a single train of also important, but the nurse must stay with the
thought. Mania is a period when the mood is client. Teaching the client deep breathing or
predominantly elevated, expansive, or irritable. All relaxation is not possible until the anxiety decreases.
options reflect a client’s possible symptomatolgy. Encouraging the client to discuss concerns and
Option B, however, clearly presents a problem that feelings would not take place until the anxiety has
decreased.
3
1
statements neither reinforce the risk of violently
215. B acting out or nor define limits for future behavior.
Rationale: Solitary activities that require a short Restraining a patient is unpleasant for all concerned,
attention span with mild physical exertion are the but disclosing this information to the patient without
most appropriate activities for a client who is addressing the dangerousness of his behavior and
exhibiting aggressive behavior. Writing (journaling), reinforcing what is expected of him is insufficient.
walks with staff, and finger painting are activities that
minimize stimuli and provide a constructive release 218. C
for tension. Competitive games should be avoided Rationale: paralanguage is the use of vocal effects,
because they can stimulate aggression and increase such as tone and tempo, to convey a message.
234. C
Rationale: All of the responses represent deviations
in adult partners’ coalition. In the schismatic pattern,
children are forced to join one or the other camp of
warring parents. The adult partners belittle and
undercut each other as a defense against closeness.
235. A
Rationale: This response acknowledges the need for
the false belief while not encouraging it or arguing
with the client, clearly states what is expected, and
offers self. Empathy is a process which people feel
with one another. Reflection is repeating the client’s
verbal or nonverbal message. The client is
demonstrating manipulative behavior.
3
5