During an assessment interview, a open communication to avoid staff 2.

Clients diagnosed with schizoid

client diagnosed with antisocial manipulation. personality disorder exhibit delusions
personality disorder spits, curses, 3. Allow the client spokesman to and hallucinations, while clients
and refuses to answer questions. verbalize concerns during a unit staff diagnosed with avoidant personality
Which is the appropriate nursing meeting. disorder do not.
response to this behavior? 4. Maintain unit order by the 3. Clients diagnosed with avoidant
1. You are very disrespectful. You application of autocratic leadership. personality disorder are eccentric,
need to learn to control yourself. and clients diagnosed with schizoid
2. I understand that you are angry, Which nursing approach should be personality disorder are dull and
but this behavior will not be used to maintain a therapeutic vacant.
tolerated. relationship with a client diagnosed 4. Clients diagnosed with schizoid
3. What behaviors could you modify with borderline personality disorder? personality disorder have a history of
to improve this situation? 1. Being firm, consistent, and psychosis, while clients diagnosed
4. What anti-personality disorder empathic, while addressing specific with avoidant personality disorder
medications have helped you in the client behaviors remain based in reality.
past? 2. Promoting client self-expression
by implementing laissez-faire Which nursing diagnosis should a
Egosyntonic- In psychoanalysis, leadership nurse identify as appropriate when
egosyntonic refers to the behaviors, 3. Using authoritative leadership to working with a client diagnosed with
values, and feelings that are in help clients learn to conform to schizoid personality disorder?
harmony with or acceptable to the society norms 1. Altered thought processes R/T
needs and goals of the ego, or 4. Overlooking inappropriate increased stress
consistent with one's ideal self- behaviors to avoid providing 2. Risk for suicide R/T loneliness
image. secondary gains 3. Risk for violence: directed toward
others R/T paranoid thinking
Egodystonic (or ego alien) is the Which adult client should a nurse 4. Social isolation R/T inability to
opposite, referring to thoughts and identify as exhibiting the relate to others
behaviors (dreams, compulsions, characteristics of a dependent
desires, etc.) that are in conflict, or personality disorder? Looking at a slightly bleeding paper
dissonant, with the needs and goals 1. A physically healthy client who is cut, the client screams, somebody
of the ego, or, further, in conflict with dependent on meeting social needs help me quick! I’m bleeding. Call
a person's ideal self-image. by contact with 15 cats 911! A nurse should identify this
2. A physically healthy client who has behavior as characteristic of which
At 11:00 p.m. a client diagnosed with a history of depending on intense personality disorder?
antisocial personality disorder relationships to meet basic needs 1. Schizoid personality disorder
demands to phone a lawyer to file for 3. A physically healthy client who 2. Obsessive-compulsive personality
a divorce. Unit rules state that no lives with parents & depends on disorder
phone calls are permitted after 10:00 public transportation 3. Histrionic personality disorder
p.m. Which nursing response is most 4. A physically healthy client who is 4. Paranoid personality disorder
appropriate? serious, inflexible, perfectionistic,
1. Go ahead and use the phone. I lacks spontaneity & depends on rules When planning care for a client
know this pending divorce is to provide security diagnosed with borderline
stressful. personality disorder, which self-harm
2. You know better than to break the A client expresses low self-worth, behavior should a nurse expect the
rules. I'm surprised at you. has much difficulty making decisions, client to exhibit?
3. It is after the 10:00 p.m. phone avoids positions of responsibility & 1. The use of highly lethal methods
curfew. You will be able to call has a behavioral pattern of suffering to commit suicide
tomorrow. in silence. Which statement best 2. The use of suicidal gestures to
4. A divorce shouldn't be considered explains the etiology of this client’s elicit a rescue response from others
until you have had a good night’s personality disorder? 3. The use of isolation and starvation
sleep. 1. Childhood nurturance was as suicidal methods
provided from many sources, and 4. The use of self-mutilation to
A client diagnosed with paranoid independent behaviors were decrease endorphins in the body
personality disorder becomes violent encouraged.
on a unit. Which nursing intervention 2. Childhood nurturance was A nurse tells a client that the nursing
is most appropriate? provided exclusively from one staff will start alternating weekend
1. Provide objective evidence that source, and independent behaviors shifts. Which response should a
reasons for violence are were discouraged. nurse identify as characteristic of
unwarranted. 3. Childhood nurturance was clients diagnosed with obsessive-
2. Initially restrain the client to provided exclusively from one compulsive personality disorder?
maintain safety. source, and independent behaviors 1. You really don't have to go by that
3. Use clear, calm statements and a were encouraged. schedule. I'd just stay home sick.
confident physical stance. 4. Childhood nurturance was 2. There has got to be a hidden
4. Empathize with the clients’ provided from many sources, and agenda behind this schedule change.
paranoid perceptions. independent behaviors were 3. Who do you think you are? I
discouraged. expect to interact with the same
A client diagnosed with borderline nurse every Saturday.
personality disorder brings up a Family members of a client ask the 4. You can't make these kinds of
conflict with the staff in a community nurse to explain the difference changes! Isn't there a rule that
meeting and develops a following of between schizoid & avoidant governs this decision?
clients who unreasonably demand personality disorders. Which is the
modification of unit rules. How can appropriate nursing response? Which reaction to a compliment from
the nursing staff best handle this 1. Clients diagnosed with avoidant another client should a nurse identify
situation? personality disorder desire intimacy as a typical response from a client
1. Allow the clients to apply the but fear it, and clients diagnosed diagnosed with avoidant personality
democratic process when developing with schizoid personality disorder disorder?
unit rules. prefer to be alone. 1. Interpreting the compliment as a
2. Maintain consistency of care by secret code used to increase
personal power 4. To decrease the prevalence of serving their dependency needs.
2. Feeling the compliment was well neurotransmitters at receptor sites 3. They tend to develop few
deserved relationships because they are
3. Being grateful for the compliment Which client situation would reflect strongly independent but generally
but fearing later rejection and the impulsive behavior that is maintain deep affection.
humiliation commonly associated with borderline 4. They pay particular attention to
4. Wondering what deep meaning personality disorder? details, which can interfere with the
and purpose is attached to the 1. As the day-shift nurse leaves the development of relationships.
compliment unit, the client suddenly hugs the
nurses arm and whispers, The night During an interview, which client
Which factors differentiate a client nurse is evil. You have to stay. statement should indicate to a nurse
diagnosed with social phobia from a 2. As the day-shift nurse leaves the a potential diagnosis of schizotypal
client diagnosed with schizoid unit, the client suddenly hugs the personality disorder?
personality disorder? nurses arm and states, I will be up all 1. I don't have a problem. My family
1. Clients diagnosed with social night if you don't stay with me. is inflexible, and relatives are out to
phobia are treated with cognitive 3. As the day-shift nurse leaves the get me.
behavioral therapy, whereas clients unit, the client suddenly hugs the 2. I am so excited about working with
diagnosed with schizoid personality nurses arm, yelling, Please don't go! you. Have you noticed my new nail
disorder need medications. I can't sleep without you being here. polish, Ruby Red Roses?
2. Clients diagnosed with schizoid 4. As the day-shift nurse leaves the 3. I spend all my time tending my
personality disorder experience unit, the client suddenly shows the bees. I know a whole lot of
anxiety only in social settings, nurse a bloody arm and states, I cut information about bees.
whereas clients diagnosed with myself because you are leaving me. 4. I am getting a message from the
social phobia experience generalized beyond that we have been involved
anxiety. Which nursing diagnosis should be with each other in a previous life.
3. Clients diagnosed with social prioritized when providing nursing
phobia avoid attending birthday care to a client diagnosed with Which nursing diagnosis should be
parties, whereas clients diagnosed paranoid personality disorder? prioritized when providing nursing
with schizoid personality disorder 1. Risk for violence: directed toward care to a client diagnosed with
would isolate self on a continual others R/T paranoid thinking avoidant personality disorder?
basis. 2. Risk for suicide R/T altered 1. Risk for violence: directed toward
4. Clients diagnosed with schizoid thought others R/T paranoid thinking
personality disorder avoid attending 3. Altered sensory perception R/T 2. Risk for suicide R/T altered
birthday parties, whereas clients increased levels of anxiety thought
diagnosed with social phobia would 4. Social isolation R/T inability to 3. Altered sensory perception R/T
isolate self on a continual basis. relate to others increased levels of anxiety
4. Social isolation R/T inability to
Which client symptoms should lead a From a behavioral perspective, which relate to others
nurse to suspect a diagnosis of nursing intervention is appropriate
obsessive-compulsive personality when caring for a client diagnosed A nurse is admitting a client with a
disorder? with borderline personality disorder? new diagnosis of a personality
1. The client experiences unwanted, 1. Seclude the client when disorder. Which of the following
intrusive, and persistent thoughts. inappropriate behaviors are would make the nurse question this
2. The client experiences unwanted, exhibited. diagnosis? (SATA)
repetitive behavior patterns. 2. Contract with the client to 1. The client has been diagnosed
3. The client experiences inflexibility reinforce positive behaviors with unit with sickle cell anemia.
and lack of spontaneity when dealing privileges. 2. The client has an inflated self-
with others. 3. Teach the purpose of anti-anxiety appraisal and feels a sense of
4. The client experiences obsessive medications to improve medication entitlement.
thoughts that are externally compliance. 3. The client has a history of a
imposed. 4. Encourage the client to journal substance use disorder.
feelings to improve awareness of 4. The client is odd and eccentric but
Which client is a nurse most likely to abandonment issues. not delusional.
admit to an inpatient facility for self- 5. The client has an intellectual
destructive behaviors? A highly emotional client presents at developmental disorder.
1. A client diagnosed with antisocial an outpatient clinic appointment and
personality disorder states, "My dead husband returned Which statements represent positive
2. A client diagnosed with borderline to me during a sance." Which outcomes for clients diagnosed with
personality disorder personality disorder should a nurse narcissistic personality disorder?
3. A client diagnosed with schizoid associate with this behavior? (SATA)
personality disorder 1. Obsessive-compulsive personality 1. The client will relate one
4. A client diagnosed with paranoid disorder empathetic statement to another
personality disorder 2. Schizotypal personality disorder client in group by day two.
3. Narcissistic personality disorder 2. The client will identify one
When planning care for clients 4. Borderline personality disorder personal limitation by day one.
diagnosed with personality disorders, 3. The client will acknowledge one
what should be the goal of A nursing instructor is teaching strength that another client
treatment? students about clients diagnosed possesses by day two.
1. To stabilize the client’s pathology with histrionic personality disorder 4. The client will list four personal
by using the correct combination of and the quality of their relationships. strengths by day three.
psychotropic medications Which student statement indicates 5. The client will list two lifetime
2. To change the characteristics of that learning has occurred? achievements by discharge.
the dysfunctional personality 1. Their dramatic style tends to
3. To reduce personality trait make their interpersonal A nurse is caring for a client
inflexibility that interferes with relationships quite interesting and diagnosed with antisocial personality
functioning and relationships fulfilling. disorder. Which factors should the
2. Their interpersonal relationships nurse consider when planning this
tend to be shallow and fleeting, clients care? (SATA)
1. This client has personality traits As a nurse prepares to administer a c. Benzodiazepine
that are deeply ingrained and medication to a patient diagnosed d. Antipsychotic.
difficult to modify. with a borderline personality
2. This client needs medication to disorder, the patient says, just leave A person’s spouse filed charges of
treat the underlying physiological it on the table. I’ll take it when I battery. The person has a long
pathology. finish combing my hair. What is the history of acting-out behaviors and
3. This client uses manipulation, nurses best response? several arrests. Which statement by
making the implementation of a. Reinforce this assertive action by the person suggests an antisocial
treatment problematic. the patient. Leave the medication on personality disorder?
4. This client has poor impulse the table as requested. a. I have a quick temper, but I can
control that hinders compliance with b. Respond to the patient, Im worried usually keep it under control.
a plan of care. that you might not take it. I will come b. I've done some stupid things in my
5. This client is likely to have back later. life, but Ive learned a lesson.
secondary diagnoses of substance c. Say to the patient, I must watch c. I'm feeling terrible about the way
abuse and depression. you take the medication. Please take my behavior has hurt my family.
it now. d. I hit because I'm tired of being
A client is being assessed for d. Ask the patient, why don’t you nagged. My spouse deserved the
antisocial personality disorder. want to take your medication now? beating.
According to the DSM-5, which of the
following symptoms must the client What is an appropriate initial What is the priority nursing diagnosis
meet in order to be assigned this outcome for a patient diagnosed with for a patient diagnosed with
diagnosis? (SATA) a personality disorder who frequently antisocial personality disorder who
1. Ego-centrism and goal setting manipulates others? The patient will: has made threats against staff,
based on personal gratification. a. identifies when feeling angry. ripped art off the walls, and thrown
2. Incapacity for mutually intimate b. use manipulation only to get objects?
relationships. legitimate needs met. a. Disturbed sensory perception
3. Frequent feelings of being down c. acknowledges manipulative auditory
miserable and/or hopeless. behavior when it is called to his or b. Risk for other-directed violence
4. Disregard for and failure to honor her attention. c. Ineffective denial
financial and other obligations. d. accept fulfillment of his or her d. Ineffective coping
5, Intense feelings of nervousness, requests within an hour rather than
A patient diagnosed with a
tenseness, or panic. immediately.
personality disorder has used
Schizoid personality disorder is Consider these comments made to manipulation to get his or her needs
characterized by a profound defect three different nurses by a patient met. The staff decides to apply limit-
in the ability to form personal diagnosed with an antisocial setting interventions. What is the
relationships or to respond to others personality disorder: Youre a better correct rationale for this action?
in any meaningful emotional way. nurse than the day shift nurse said a. It provides an outlet for feelings of
Histrionic personality disorder is you were; Another nurse said you anger and frustration.
characterized by colorful, dramatic, dont do your job right; You think b. It respects the patient’s wishes so
and extraverted behavior in youre perfect, but Ive seen you make assertiveness will develop.
excitable, emotional people. three mistakes. Collectively, these c. External controls are necessary
interactions can be assessed as: while internal controls are
Dependent personality disorder is a. seductive. developed.
characterized by a pervasive and b. detached. d. Anxiety is reduced when staff
excessive need to be taken care of c. manipulative. members assume responsibility for
that leads to submissive and clinging d. guilt producing. the patient’s behavior
behavior and fears of separation.
A nurse reports to the A patient diagnosed with borderline
Paranoid personality disorder is a interdisciplinary team that a patient personality disorder and a history of
pervasive distrust and diagnosed with an antisocial self-mutilation has now begun
suspiciousness of others, such that personality disorder lies to other dialectical behavior therapy (DBT) on
their motives are interpreted as patients, verbally abuses a patient an outpatient basis. Counseling
malevolent. diagnosed with dementia, and focuses on self-harm behavior
flatters the primary nurse. This management. Today the patient
A therapist recently convicted of telephones to say, Im feeling empty
patient is detached and superficial
multiple counts of Medicare fraud and want to cut myself. The nurse
during counseling sessions. Which
says, Sure I overbilled. Why not? should:
behavior most clearly warrants limit
Everyone takes advantage of the a. arranges for emergency inpatient
setting?
government, so I did too. These hospitalization.
a. Flattering the nurse
statements show: b. send the patient to the crisis
b. Lying to other patients
a. shame. intervention unit for 8 to 12 hours.
c. Verbal abuse of another patient
b. suspiciousness. c. assist the patient to identify the
d. Detached superficiality during
c. superficial remorse. trigger situation and choose a coping
counseling
d. lack of guilt feelings. strategy.
A patient diagnosed with borderline d. advise the patient to take an
Which intervention is appropriate for personality disorder has a history of antianxiety medication to decrease
a patient diagnosed with an self-mutilation and suicide attempts. the anxiety level.
antisocial personality disorder who The patient reveals feelings of
frequently manipulates others? The most challenging nursing
depression and anger with life. The
a. Refer the patients requests and intervention for patients diagnosed
psychiatrist suggests the use of a
questions to the case manager. with personality disorders who use
medication. Which type of
b. Explore the patients’ feelings of manipulation to get their needs met
medication should the nurse expect?
fear and inferiority. is:
a. Selective serotonin reuptake
c. Provide negative reinforcement for a. supporting behavioral change.
inhibitor (SSRI)
acting-out behavior. b. monitoring suicide attempts.
b. Monoamine oxidase inhibitor
d. Ignore, rather than confront, c. maintaining consistent limits.
(MAOI)
inappropriate behavior. d. using aversive therapy.
The history shows that a newly d. urges a suspicious patient to hit A nurse set limits for a patient
admitted patient has impulsivity. The anyone who stares. diagnosed with a borderline
nurse would expect behavior personality disorder. The patient tells
characterized by: A nurse in the emergency the nurse, you used to care about
a. adherence to a strict moral code. department tells an adult, Your me. I thought you were wonderful.
b. manipulative, controlling mother had a severe stroke. The Now I can see I was mistaken. Youre
strategies. adult tearfully says, who will take terrible. This outburst can be
c. postponing gratification to an care of me now? My mother always assessed as:
appropriate time. told me what to do, what to wear, a. denial.
d. little time elapsed between and what to eat. I need someone to b. splitting.
thought and action. reassure me when I get anxious. c. reaction formation.
Which term best describes this d. separation-individuation
A patient tells a nurse, I sometimes behavior? strategies.
get into trouble because I make a. Histrionic
quick decisions and act on them. A b. Dependent Which characteristic of individuals
therapeutic response would be: c. Narcissistic diagnosed with personality disorders
a. Let’s consider the advantages of d. Borderline makes it most necessary for staff to
being able to stop and think before schedule frequent meetings?
acting. Others describe a worker as very shy a. Ability to achieve true intimacy
b. It sounds as though you’ve and lacking in self-confidence. This b. Flexibility and adaptability to
developed some insight into your worker stays in an office cubicle all stress
situation. day and never comes out for breaks c. Ability to evoke interpersonal
c. I’ll bet you have some interesting or lunch. Which term best describes conflict
stories to share about overreacting. this behavior? d. Inability to develop trusting
d. It’s good that you’re showing a. Avoidant relationships
readiness for behavioral change. b. Dependent
c. Histrionic Which common assessment finding
A patient diagnosed with borderline d. Paranoid would be most applicable to a
personality disorder is hospitalized patient diagnosed with any
several times after self-inflicted What is the priority intervention for a personality disorder? The patient:
lacerations. The patient remains nurse beginning a therapeutic a. demonstrates behaviors that
impulsive. Dialectical behavior relationship with a patient diagnosed cause distress to self rather than to
therapy starts on an outpatient with a schizotypal personality others.
basis. Which nursing diagnosis is the disorder? b. has self-esteem issues, despite his
focus of this therapy? a. Respect the patients need for or her outward presentation.
a. Risk for self-mutilation periods of social isolation. c. usually becomes psychotic when
b. Impaired skin integrity b. Prevent the patient from violating exposed to stress.
c. Risk for injury the nurses’ rights. d. does not experience real distress
d. Powerlessness c. Engage the patient in many from symptoms.
community activities.
Which statement made by a patient d. Teach the patient how to match A nurse plans the care for an
diagnosed with borderline clothing. individual diagnosed with antisocial
personality disorder indicates the personality disorder. Which
treatment plan is effective? A patient diagnosed with borderline characteristic behaviors will the
a. I think you are the best nurse on personality disorder self-inflicted nurse expect? (SATA)
the unit. wrist lacerations after gaining new a. Reclusive behavior
b. I’m never going to get high on privileges on the unit. The cause of b. Callous attitude
drugs again. the self-mutilation is probably c. Perfectionism
c. I hate my doctor for not giving me related to: d. Aggression
what I ask for. a. inherited disorder that manifests e. Clinginess
d. I felt empty and wanted to cut itself as an incapacity to tolerate f. Anxiety
myself, so I called you. stress.
b. use of projective identification and For which patients diagnosed with
When preparing to interview a splitting to bring anxiety to personality disorders would a family
patient diagnosed with narcissistic manageable levels. history of similar problems be most
personality disorder, a nurse can c. constitutional inability to regulate likely? (SATA)
anticipate the assessment findings affect, predisposing to psychic a. Obsessive-compulsive
will include: disorganization. b. Antisocial
a. preoccupation with minute details; d. fear of abandonment associated c. Dependent
perfectionism. with progress toward autonomy and d. Schizotypal
b. charm, drama, seductiveness; independence. e. Narcissistic
seeking admiration.
c. difficulty being alone; A patient diagnosed with borderline A patient diagnosed with borderline
indecisiveness, submissiveness. personality disorder has self-inflicted personality disorder often exhibits alternating
d. grandiosity, attention seeking, and wrist lacerations. The health care clinging and distancing behaviors with staff. A
arrogance. provider prescribes daily dressing therapeutic nursing intervention with this
changes. The nurse performing this type of behavior would be to:
For which behavior would limit care should: a. Encourage patient to establish trust in one
setting be most essential? The a. encourages the patient to express person, with whom all therapeutic
patient: anger. interactions take place.
a. clings to the nurse and asks for b. provide care in a matter-of-fact
b. Secure a verbal contract indicating that the
advice about inconsequential manner.
patient will not demonstrate these behaviors.
matters. c. be very kind, sympathetic, and
c. Withdraw attention from the patient if
b. is flirtatious and provocative with concerned.
these behaviors continue.
staff members of the opposite sex. d. offer to listen to the patients’
c. is hypervigilant and refuses to feelings about cutting. d. Rotate staff that that the patient will learn
attend unit activities. to relate to more than one person.
Which of the following are examples of personality disorder? provoked a great deal of anxiety for her."
manipulative behaviors in the patient a. Belittling themselves and their abilities. d. "I wonder if all this could have been
diagnosed with borderline personality b. Suspicious and mistrustful of others. avoided if I would have clued you in. This is a
disorder? Select all that apply. c. Overreacting inappropriately to minor usual pattern for this patient. She burned me
stimuli. once when I first started to work here."
a. Refusal to stay in room alone, stating, "It is d. A lifelong pattern of social withdrawal.
so lonely." Which characteristic in a patient with a
b. Asking the nurse for Ativan, knowing the Which intervention would be most personality disorder makes it most necessary
assigned nurse has explained the need to wait therapeutic for a patient diagnosed with for staff to schedule frequent staff meetings?
1 hour for additional medication. antisocial personality disorder who has a a. The patient's flexibility and adaptability to
c. Stating to the nurse, "I really like having you nursing diagnosis of, Defensive coping related stress.
for my nurse. You're the best one around to manipulation of others? b. The patient's ability to achieve true
here." a. Provide negative reinforcement for acting- intimacy.
d. Cutting arms with a plastic knife after out behavior. c. The patient's ability to evoke interpersonal
discussing discharge plans with the b. Refer requests and questions related to conflicts.
psychiatrist. care to the primary care nurse. d. The need for staff to develop strategies to
c. Ignore, rather than confront inappropriate interpret patient behaviors.
Splitting by the patient with borderline behavior.
personality disorder indicates: d. Encourage patient to discuss feelings of A patient, who is homeless, is brought to the
a. Evidence of precocious behavior. fear and inferiority. hospital's emergency department after having
b. A primitive defense in which the patient been badly beaten. The patient is delusional
sees objects as all good or all bad. The nurse is assigned to perform an and thinks the hospital is a federal prison. The
c. A brief psychotic episode in which the assessment of a patient diagnosed with patient is withdrawn and does not want to
patient loses contact with reality. paranoid personality disorder. When the speak with anyone. The patient is thought to
d. Two distinct personalities within the interview is documented in the medical have a schizoid personality disorder. Which of
patient with borderline personality disorder. record, the nurse describes the patient as: the following approaches would be useful for
a. Superficially charming working with this patient?
Which of the following characteristics would b. Intense and impulsive a. Give detailed information about what
you expect to assess in a patient with c. Manipulative happened and what steps will be taken while
antisocial personality disorder? d. Guarded and suspicious in the ED.
a. Insight into one's behavior. b. Simply and clearly tell the patient what you
b. Lack of guilt for wrongdoing. The nurse assigned to the patient with a are going to do before you provide an
c. Ability to learn from past experiences. paranoid personality disorder reports to the intervention.
d. Compliance with authority. charge nurse, "I tried caring and nurturing, c. Alternate between being warm and friendly
but the patient just kept telling me to stay and neutral and business-like.
Milieu therapy is a therapeutic choice for away." The experienced charge nurse can be d. Try to inject a bit of humor into the
patients with antisocial personality disorder helpful by advising, "Patients with paranoid situation to relieve tension.
since this therapy: personality disorders respond best to:
a. Provides a system of punishment and a. A cynical, joking approach." Which statement made by a patient with
reward for behavior modification. b. Interpretation of their behavior." borderline personality disorder indicates that
b. Emulates a social community in which the c. Active friendliness." the treatment plan is effective in helping the
patient may learn to improve social d. A neutral, but courteous and concerned patient attain goals?
engagement. manner. a. "I think you are the best nurse on the unit."
c. Provides mostly one-to-one interaction b. "I hate my doctor. She never gives me what
between the patient and therapist. A patient with borderline personality disorder I ask for."
d. Provides a structured setting in which the has had multiple admissions to the psychiatric c. "I feel empty and want to cut myself, so I
patients have little input into planning of their facility. Each admission was precipitated by a called you."
care. suicide attempt, usually resulting in superficial d. "I'm never going to get high on drugs
cuts on both arms. During this admission, the again."
Which of the following behaviors would be patient has developed a relationship with
considered the most significant indication of Nurse Jones, who has been highly supportive. Mary Alice is a 37-year-old patient
positive change in a patient diagnosed with The patient has progressed to receiving a pass referred to the mental health clinic
antisocial personality disorder? to spend an afternoon interviewing at board with a suspected personality
a. Patient became angry only once in group and care homes. Nurse Jones was "shocked" disorder. She is withdrawn and
this week. when the ED called to inform the staff that suspicious and states she has always
b. Patient was able to wait a full hour without the patient was brought in to the ED with preferred to be alone. She describes
verbally abusing the staff. multiple self-inflicted lacerations. Nurse Jones herself as having "special powers"
c. On his own initiative, the patient wrote a asked her peers, "Why? Everything was going and states that she is thinking of
note of apology to another patient he had well. How could she do this to me?" What opening a business where she gives
injured in a physical altercation. response by the other nurses reflects an "readings" to people about their
d. Patient stated that he would no longer start understanding of the patient's behavior? future. She states, "I believe we can
all read each other's thoughts at
fights with his peer group.
times." Based on this presentation,
a. "I know what you mean. You put a lot of
Which of the following behavioral patterns is you suspect:
energy into working with this patient. It must
characteristic of individuals with narcissistic be disappointing to have her do something
personality disorder? A. obsessive-compulsive personality
like this." disorder.
a. Overly self-centered and exploitative of b. "I could have told you this would happen. B. narcissistic personality disorder.
others. This type of patient always gets you in the C. avoidant personality disorder.
b. Suspicious and mistrustful of others. end. I hope this will teach you not to get so D. schizotypal personality disorder
c. Rule conscious and disapproving of change. involved." (STPD).
d. Anxious and socially isolated. c. "I know this patient's behavior seems
personal, but it is not. Patients with Belinda is a 24-year-old patient with
Which of the following behavioral patterns is borderline personality disorder
borderline personality disorder act out to
characteristic of individuals with schizotypal (BPD). She is admitted to the
relieve anxiety, and I suspect the pass
inpatient psychiatric unit following a of how their behavior is affecting B. becoming indecisive about
suicide attempt. You are caring for others. planned interventions.
Belinda. Which of the following G. Frontal lobe dysfunction is a brain C. developing a prejudicial, blaming
statements by Belinda illustrates a change identified in APD. orientation.
primary coping style of persons with D. stringent enforcement of
BPD? Which behavior would be boundaries and limits.
inconsistent with defining
A. "My provider says I might get out characteristics for the nursing Clients demonstrating characteristics
of here tomorrow. Do you think I'm diagnosis of ineffective coping? of personality disorders have various
ready to go?" self-defeating behaviors and
B. "Last night the nurse let me go A. Difficulty in relationships interpersonal problems despite
outside and smoke. I can't believe B. High levels of anxiety having near-normal ego functioning
you aren't letting me. I used to think C. Manipulation and intact reality testing. A nursing
you were the best nurse here." D. Interdependence diagnosis that addresses this sort of
C. "I will never again speak to any of interpersonal dysfunction is
When providing care for a client
my messed-up family members. I
diagnosed with borderline A. spiritual distress.
know that this will help me be more
personality disorder, the nurse will B. defensive coping.
functional."
need to consider strategies for C. impaired social interaction.
D. "I promise I am not feeling
dealing with the client's D. disturbed sensory perception
suicidal. I won't hurt myself."

Which is true of pharmacological A. mood shifts, impulsivity, and When confronted, a pt with
therapies for treatment of splitting. narcissistic PD says, "contrary to
personality disorders? B. grief, anger, and social isolation. what everyone believes, I don't think
C. altered sensory perceptions and the whole world owes me a living."
A. Although there are no FDA- suspicion. This pt is using which defense
approved drugs specific to the D. perfectionism and preoccupation mechanism?
treatment of personality disorders, with detail. A. minimization B. denial
patients benefit from specific off- C. rationalization D. projection
A newly admitted client has an axis II
label uses of antipsychotics, mood
diagnosis of schizoid personality
stabilizers, and antidepressants, A pt dx w/borderline personality
disorder. The nursing intervention of
depending on which personality disorder coyly requests diazepam.
highest priority will be to
disorder is evident. When the physician refuses, the pt
B. Research has shown that currently becomes angry and demands to see
A. set firm limits on behavior.
available psychotropic drugs have another physician. What defense
B. respect need for social isolation.
not been shown to be effective in mechanism is the pt using?
C. encourage expression of feelings.
treating personality disorders. A. undoing B. splitting
D. involve in milieu and group
C. Patients with narcissistic C. altruism D.
activities.
personality disorder and obsessive- reaction formation
compulsive personality disorder have A client diagnosed with obsessive-
shown the most benefit from the use compulsive personality disorder A diabetic pt admitted to a medical
of antianxiety medications along takes the nurse aside and mentions, floor for medication stabilization has
with use of selective serotonin "I've observed you interacting with a hx of antisocial PD. Which
reuptake inhibitors. that new patient. You are not documented behaviors does the
D. Patients with personality disorders approaching him properly. You nurse recognize as this dx?
have been shown to be resistant to should be more forceful with him." A. "labile mood and affect and old
accepting medication, and as a The best response for the nurse scars noted on wrists bilaterally."
result most providers do not would be B. "appears younger than stated age
prescribe psychotropic drugs to
these patients. with flamboyant hair and makeup."
A. "I will be continuing to follow the C. 'began cursing when confronted
care plan for the patient." with drug-seeking behaviors."
Patients with borderline personality
B. "I see you are trying to control D. 'demands foods prepared by
disorder (BPD) exhibit negative
that patient's therapy as well as your personal chef to be delivered to
effect, which includes emotional
own." room.'
lability, described as rapidly moving
C. "Your eye for perfection extends
from one emotional extreme to
even to my nursing interventions." A pt dx w/a PD insists that a
another.
D. "That patient's care is really of no grandma, thru reincarnation, has
concern to you or to other clients." come back to life as a pet kitten. The
thought process described is
Which of the following are true of The priority nursing intervention for reflective of which personality
antisocial personality disorder (APD)? a client diagnosed with borderline disorder?
(Select all that apply): personality disorder is to A. Obsessive-Compulsive PD
B. Schizotypal PD
A. It is the least studied of the A. protect other clients from C. Borderline PD
personality disorders. manipulation. D. Schizoid PD
B. It is characterized by rigidity and B. respect the client's need for social
inflexible standards of self and isolation. A pt dx w/a PD states, "you are the
others. C. assess for suicidal and self- very best nurse here and not like a
C. Persons with APD display magical mutilating behaviors. that mean nurse who never lets us
thinking. D. provide clear, consistent limits stay up past 10 pm." This statement
D. Persons with APD are concerned and boundaries. would tell the nurse the pt has which
with personal pleasure and power. PD?
E. It is characterized by A nurse who is idealized by a client is A. Borderline
deceitfulness, disregard for others, at risk for B. Schizoid
and manipulation. C. Dependent
F. Persons with APD usually present A. becoming overinvolved and being D. Paranoid
for treatment because of awareness protective and indulgent.
Which of the following are A. pt making sexual advances toward statement as an example of which of
characteristic of borderline PD? a staff member the following defense mechanisms?
Select All That Apply B. pt telling staff that another staff A. Regression B. Splitting
A. arrogant, haughty behaviors or member allows food in the bedroom C. Undoing D.
attitudes C. pt verbally provoking another pt Identification
B. frantic efforts to avoid real or who is paranoid
imagined abandonment D. pt refusing meds to receive A nurse is assisting with a court-
C. recurrent suicidal and self- secondary gains ordered evaluation of a client who
mutilating behaviors has antisocial personality disorder.
D. unrealistic preoccupation with A pt w/antisocial PD demands at Which of the following findings
fears of being left to care for self midnight, to speak with the ethics should the nurse expect? (Select all
E. chronic feelings of emptiness committee about the involuntary that apply)
commitment process. Which nursing A. Demonstrates extreme anxiety
Which of the following are statement is appropriate in this when placed in a social situation
characteristic of avoidant PD? Select situation? B. Has difficulty making even simple
All That Apply A. I realize you're upset; however, decisions
A. fearing shame and/or ridicule, this is not the appropriate time to C. Attempts to convince other clients
doesn't form intimate relationships explore your concerns to give him their belongings
B. has difficulty making everyday B. let me give you a sleeping pill to D. Becomes agitated if his personal
decisions w/o reassurance from help put our mind at ease area is not near and orderly
others C. it's midnight, and you are E. Blames others for his past and
C. unwilling to be involved with disturbing the other pts current problems
people unless certain of being liked D. I will document your concerns in
D. shows perfectionism that your medical record for the morning A charge nurse is preparing a staff
interferes with task completion shift to discuss with the ethics education session on personality
E. views self as socially inept, committee. disorders. Which of the following
unappealing, and inferior personality characteristics
A pt dx w/borderline PD is admitted associated with all of the personality
When assessing a pt dx w/histrionic from the ER to the psych unit for disorders should the charge nurse
PD, the nurse may identify which self-inflicted lacerations to wrists and include in the teaching? (Select all
characteristic behavior? arms. Which nursing intervention that apply)
A. odd beliefs and magical thinking does the nurse know is priority? A. Difficulty in getting along with
B. grandiose sense of self- A. administer tranquilizing drugs other members of a group
importance B. observe pt frequently B. Belief in the ability to become
C. preoccupation with orderliness C. encourage pt to verbalize hostile invisible during times of stress
and perfection feelings C. Display of defense mechanisms
D. a need for the spotlight D. explore alternative ways of when routines are changed
w/flamboyance handling frustration D. Claiming to be more important
than other persons
A pt dx with antisocial PD states, "my A nurse manage is discussing the E. Difficulty understanding why it is
kids are so busy with their lives, they care of a client who has a personality inappropriate to have a personal
don't even miss me or even know I disorder with a newly licensed nurse. relationship with staff
am gone." Which nursing Dx applies Which of the following statements by
to this pt? the newly licensed nurse indicates A 36-year-old client with paranoid
A. risk for injury an understanding of the teaching? schizophrenia believes the room is
B. risk for violence: self-directed A. "I can promote my client's sense bugged by the Central Intelligence
C. ineffective denial of control by establishing a Agency and a roommate is a foreign
D. powerlessness schedule." spy. The client has never had a
B. "I should encourage clients who romantic relationship, has no contact
A pt dx w/schizoid PD chooses have a schizoid personality disorder with family, and hasn't been
solidary activities, lacks close to increase socialization." employed for the past 14 years.
friends, and appears indifferent to C. "I should practice limit-setting to Based on Erikson's theories, the
criticism. Which nursing dx should be help prevent client manipulation." nurse should recognize that this
documented? D. "I should implement assertiveness client is in which stage of
A, anxiety r/t poor self-esteem AEB training with clients who have psychosocial development?
lack of close friends antisocial personality disorder." A. Autonomy versus shame and
B. ineffective coping r/t inability to doubt
communicate AEB indifference to A nurse is caring for a client who has B. Generativity versus stagnation
criticism avoidant personality disorder. Which C. Integrity versus despair
C. altered sensory perception r/t of the following statements is D. Trust versus mistrust
threat to self-concept AEB magical expected from a client who has this
thinking type of personality disorder? Before eating a meal, a client with
D. social isolation r/t discomfort with A. "I'm scared that you're going to obsessive-compulsive disorder must
human interaction AEB avoiding leave me." wash his hands for 18 minutes, comb
others B. "I'll go to group therapy if you'll let his hair 444 strokes, and switch the
me smoke." bathroom light on and off 44 times.
A pt with narcissistic PD is being C. "I need to feel that everyone What is the most appropriate long-
discharged. The nurse/treatment admires me." term treatment goal for this client?
team would most likely recommend D. "I sometimes feel better if I cut A. Omit one unacceptable behavior
which employment opportunity? myself." each day
A. home construction B. Increase the client's acceptance of
B. air traffic controller A nurse is caring for a client who has therapeutic drug use
C. night watchman at the petting zoo borderline personality disorder. The C. Allow ample time for the client to
D. prison warden client says, "The nurse on the complete all rituals before each meal
evening shift is always nice! You are D. Systematically decrease the
Which pt situation requires the the meanest nurse ever!" The nurse amount of time spent in - and the
prioritization of limit setting to be should recognize the client's number of repetitions of - rituals
implemented by the nurse?
 D image or sense of self
allowing the client to carry out rituals C. The client is using a defense
The nurse counsels a client with is important because such behavior mechanism in which all objects are
obsessive-compulsive disorder. is aimed at preventing or reducing seen as good or bad
Which statement by the client distress or preventing some dreaded D. The client's behavior shows a
indicates the need for reassessment? event or situation from occurring. pattern of unstable and intense
A. "I must work overtime every night interpersonal relationships
this week or the job won't get done The nurse is assessing the client with
right." paranoid personality disorder. Which The nurse is working with the client
B. "I'm working on developing a behavior should the nurse expect? with histrionic personality disorder.
relationship with one coworker whom A. Able to trust only those who are Which behaviors should the nurse
I like." fair and treat the client well expect? (Select all that apply)
C. "I've decided I won't be able to go B. Sees the goodwill of another when A. Uses physical appearance to gain
to the islands for my vacation." that behavior does not exist attention
D. "I may never have many people in C. Acts the opposite of what the B. Shows apathy in conversations
my life except for my family." client may be thinking or feeling until trust is established
D. Analyzes the behavior of others to C. Lacks close friends or companions
A client with antisocial personality find hidden and threatening other than first-degree relatives
disorder smokes where it is meanings D. Harbors recurrent suspicions
prohibited and doesn't follow other about the fidelity of his or her marital
unit or facility rules. The client gets D partner
others to do the laundry and other The client with paranoid personality E. Discomfort in situations in which
personal chores, tries to divide the disorder exhibits mistrust and the client is not the center of
staff, and works only with certain suspicion of others such that the attention
nurses. The primary focus on this behavior of others is analyzed to find
client's care plan should be: hidden and threatening meanings. The client with bipolar personality is
A. consistently enforcing unit rules taking lithium 300mg tid and has the
and facility policy The nurse identifies that an lithium level 4 months ago 1.0, 2
B. isolating the client to decrease individual with antisocial personality months ago 1.2, and today 1.5. The
contact with easily manipulated disorder exhibits poor judgment, nurse receives an order to add
clients emotional distance, aggression, and fluoxetine 20 mg bid and to
C. engaging in power struggles with impulsivity. Which step of the administer the client's first dose.
the client to decrease the incidence nursing process is being completed What should the nurse do? (Select all
of manipulative behavior by the nurse? that apply)
D. using behavior modification to A. Assessment D. Planning A. Question the dose of lithium
decrease the amount of negative B. Diagnosis E. Implementation B. Question the dose of fluoxetine
behavior by using negative C. Outcome Identification F. C. Notify the HCP of the lab results
reinforcement Evaluation D. Administer the dose of fluoxetine
E. Question the addition of fluoxetine
During a private conversation, a The nurse is working with the client
client with borderline personality with paranoid personality disorder. The client with BPD often attempts to
disorder asks the nurse to "keep my The nurse understands that the manipulate staff to promote self
secret" and then displays multiple, client likely experienced what in the needs. Which behavior indicates that
self-inflicted, superficial lacerations past? the client is able to overcome this
on the forearms. What is the nurse's A. Little affection or approval during manipulative behavior?
best response? the childhood years A. Client insists on joining other
A. "This type of behavior requires B. Lack of empathy and lack of clients in the dayroom because of
you to be on suicide precautions." nurturing during upbringing feeling lonely
B. "I'm going to tell your physician. C. Indifference and lack of affection B. Client asks for a cigarette 30
Do you want to tell me why you did during early upbringing minutes after being told that
that?" D. Recognition for accomplishments cigarettes are allowed once an hour
C. "Tell me what type of instrument only in early childhood C. Client states to the nurse, "You
you used. I'm concerned about are the best nurse, and only you are
The nurse is caring for the client with
infection." allowed to care for me."
paranoid personality disorder. Which
D. "Whenever something important D. Client self-mutilates by cutting
approach should the nurse use when
occurs, the team needs to know after the HCP discussed possible
working with the client?
about it. I'll have to tell the others, discharge with the client
A. Use a businesslike manner using
but let's talk about it first."
clear, concrete, and specific words The client with BPD states to the
D B. First use social conversation to nurse, "Hey, you know what! You are
This response informs the client of work on developing social my favorite nurse. That night nurse
the nurse's planned actions and relationships sure doesn't understand me the way
allows time to discuss the client's C. Include jokes when conversing to you do." Which response by the
action. work on reducing the client's serious nurse is most therapeutic?
behavior A. "Hang in there. I won't enjoy
Which nursing intervention is most D. Confront the client when stating coming to work as much after you
appropriate for a client with suspicious ideas to aid the client in are discharged."
obsessive-compulsive disorder? seeing reality B. "I'm glad you're comfortable with
A. Encouraging the client to me. Which night nurse doesn't
concentrate on and pay attention to The nurse reads in the medical understand you?"
unwanted thoughts record that the client with BPD has C. "I like you. Tomorrow you'll be
B. Giving antipsychotic medications "splitting." What is the nurse's discharged; I'm glad you will be able
as needed interpretation of "splitting?" to return home."
C. Interrupting the client's ritual to A. The client is having an intense D. "You are my favorite patient; I'll
empower the client in gaining control psychotic episode and has become really miss caring for you when you
over the ritual catatonic are discharged."
D. Allowing the client to carry out his B. The client has an identity
rituals disturbance with an unstable self-
The nurse receives an order to The client with OCD is being A. Projection B. Sublimation
administer phenelzine 15 mg tid to admitted to a mental health unit. The C. Compensation D. Rationalization
the client diagnosed with BPD. Based client is refusing treatment for hand
on the finding of the client's and face wounds caused by The HCP writes in the client's
medication record, which should be excessive washing, and treatment progress notes, "Will switch
the nurse's reasoning for questioning for the mental health diagnosis. medications from the older
the medication order? What actions should be taken by the medications to a newer GABA-ergic
Fluoxetine 20 mg daily 0900, nurse? (Select all that apply) anticonvulsant to treat client's
Carbamazepine 400 mg bid 0900 A. Do not treat the client; the client instability of mood, transient mood
and 2100, Alprazolam 0.5 bid 0900 is competent crashes, and inappropriate and
and 2100 B. Treat the client's injuries; the intense outbursts of anger." Which
A. The combination phenelzine and client is incompetent medication should the nurse
fluoxetine will drastically lower the C. Notify the client's family; the consider when reviewing the HCP's
blood pressure client is incompetent new prescriptions?
B. Tension headaches may result D. Notify the HCP of the refusal; the A. Lithium B.
when carbamazepine and alprazolam client is competent Gabapentin
are combined E. Notify the HCP of the refusal; the C. Valproic acid D. Carbamazepine
C. MAOIs are not used to treat client is incompetent
The client with a BPD is prescribed
borderline personality disorder due
During an initial home visit with the phenelzine for decreasing impulsivity
to the risk of suicide
client, the nurse discovers cluttered and self-destructive acts. The nurse
D. Phenelzine and fluoxetine should
possessions taking up 75% of the teaches the client to avoid foods
not be taken together due to
living space and obstructing access high in tyramine when taking
excessive serotonin release
into the home and all rooms expect phenelzine to prevent what effect?
The client with no psychiatric history the bathroom. What should the A. A hypotensive crisis
is admitted to an ED after physically nurse's interpretation of the client's B. A hypertensive crisis
assaulting his wife. The client is behavior? C. Poor absorption of tyramine
frightened by his loss of control, A. Inability to focus related to D. Cardiac rhythm abnormalities
which he states was precipitated by possible passive-aggressive
The nurse is checking the MAR listed
his wife's complaining and lack of personality disorder
below for the 75-year-old client
support. The client tells the nurse he B. An attention-seeking behavior
newly admitted to a behavioral
is self-employed, recently expanded related to possible histrionic
health unit. Which medication should
his company nationally, and has personality disorder
the nurse question with the HCP?
many well-known friends. The C. Hoarding behavior related to
A. Risperidone 2 mg at 0900
client's wife states, "The business is possible obsessive-compulsive
B. Fluoxetine 10 mg at 0900
losing money, yet he continues his personality disorder
C. Carbamazepine 200 mg at 0900
lavish lifestyle; what's important to D. Inattentiveness to surroundings
and 2100
him is who he knows and how it related to possible borderline
D. Docusate sodium 100 mg at 0900
looks!" The nurse determines that personality disorder
the client's behavior is typical of The nurse teaches the
which disorder? The nurse observes that the client
communication triad to the client to
A. Schizoid personality disorder diagnosed with OCPD is exhibiting
manage feelings. Which components
B. Borderline personality disorder reaction formation. The nurse should
should the nurse include? (Select all
C. Narcissistic personality disorder plan to assess for which other
that apply)
D. Dependent personality disorder defense mechanisms commonly
A. Use an "I" statement to identify
associated with this disorder? (Select
the present feelings
The nurse is developing the plan of all that apply)
B. Use a "you" statement to identify
care for the client with schizoid A. Isolation
the cause of the feeling
personality disorder. Which primary B. Undoing
C. Make a nonjudgmental statement
outcome should the nurse include? C. Projection
about an emotional trigger
A. Recognizes limits D. Introjection
D. Identify what would restore
B. Able to cope and control emotions E. Rationalization
comfort to the situation for the client
C. Validates ideas before taking F. Intellectualization
E. Use a "they" statement to
action
The client on a psychiatric unit is examine the effect of the client's
D. Able to function independently in
very demanding and belittling of one feelings on others
the community
of the nurses. The client is talking
The nurse includes milieu therapy in
The nurse is planning care for the with others and telling them how
the treatment plan for the client with
client with avoidant personality mean the nurse is to clients. Which
antisocial personality disorder. What
disorder. Which interventions should nursing problem should the nurse
is the nurse's best rationale for
the nurse plan? (Select all that include in the client's written plan of
including milieu therapy?
apply) care?
A. Set's limits on the client's
A. Use reframing technique A. Social isolation due to negative
unacceptable behavior
B. Explore positive self-aspects behavior
B. Provides a very structured setting
C. Practice social skills with client B. Ineffective coping due to inability
that helps the client learn how to
D. Use DE catastrophizing technique to interact with unit personnel
have
E. Identify negative responses from C. Risk for other-directed violence
C. Stimulates a social community
others due to negative verbal comments
where the client can learn to interact
D. Chronic low self-esteem due to
The nurse is working with the with peers
use of the defense splitting
individual with OCPD. Which D. Provides one-on-one interaction
approach should the nurse use? The nurse is planning a counseling and reality orientation with client
A. Inflexible and autocratic session with the client who has and nursing personnel
B. Calm and nonconfrontational antisocial personality disorder. The
Which predisposing factor would be
C. Direct, hurried, and organized nurse should anticipate that the
implicated in the etiology of paranoid
D. Uninterrupted and confrontational client would use which primary ego
personality disorder?
defense mechanism?
A. The individual may have been
subjected to parental demands, support this diagnosis? (Select all nurse expect?
criticism, and perfectionistic that apply) A. Sarcastically states, “That group is
expectations A. "Labile mood and affect and old only for crazy people with problems."
B. The individual may have been scares noted on wrists bilaterally." B. Scornfully states, "no, can't you
subjected to parental indifference, B. "Appears younger than stated age see that I'm having a seance with my
impassivity, or formality with flamboyant hair and makeup." mom?"
C. The individual may have been C. "Began cursing when confronted C. Suspiciously states, "No, that
subjected to parental bleak and with drug-seeking behaviors." room has been bugged."
unfeeling coldness D. "Demands foods prepared by D. Hesitantly states, "OK, by only if I
D. The individual may have been personal chef to be delivered to can sit next to you."
subjected to parental antagonism room."
and harassment E. "Attempted to use insincere A client has been diagnosed with a
flattery to obtain extra snacks." cluster A personality disorder. Which
The nurse is assessing a client of the following client statements
diagnosed with borderline Irresponsible, guiltless behavior is to would reflect cluster A
personality disorder. According to a client diagnosed with cluster B characteristics? (Select all that
Mahler's theory of object relations, personality disorder as avoidant, apply)
which describes the client's unmet dependent behavior is to a client A. "I'm the best chef on the East
developmental need? diagnosed with a: Coast."
A. The need for survival and comfort A. Cluster A personality disorder B. "My dinner has been poisoned."
B. The need for awareness of an B. Cluster B personality disorder C. "I have to wash my hands 10
external source for fulfillment C. Cluster C personality disorder times before eating."
C. The need for awareness of D. Cluster D personality disorder D. "I just can't eat when I'm alone."
separateness of self E. "When my mom died, her spirit
D. The need for internalization of a A client tells the nurse, "When I was entered my cat."
sustained image of a love a waiter I used to spit in the dinners
object/person of annoying customers." This Personality disorders are grouped in
statement would be associated with clusters according to their behavioral
Using interpersonal theory, which which personality trait? characteristics. In which cluster are
statement is true regarding A. Paranoid personality trait the disorders correctly matched with
development of paranoid personality B. Schizoid personality trait their behavioral characteristics?
disorder? C. Passive-aggressive personality A. Cluster C: antisocial, borderline,
A. Studies have revealed a higher trait histrionic, narcissistic disorders;
incidence of paranoid personality D. Antisocial personality trait anxious or fearful characteristic
disorder among relatives of clients behaviors
with schizophrenia A client diagnosed with a personality B. Cluster A: avoidant, dependent,
B. Clients diagnosed with paranoid disorder insists that a grandmother, obsessive-complusive disorders; odd
personality disorder frequently have through reincarnation, has come or eccentric characteristic behaviors
been family scapegoats and back to life as a pet kitten. The C. Cluster A: antisocial, borderline,
subjected to parental antagonism though process described is histrionic, narcissistic disorders;
and harassment reflective of which personality dramatic, emotional, or erratic
C. There is an alteration in the ego disorder? characteristic behaviors
development so that the ego is A. Obsessive-compulsive personality D. Cluster C: avoidant, dependent,
unable to balance the id and disorder obsessive-complusive disorders;
superego B. Schizotypal personality disorder anxious or fearful characteristic
D. During the anal stage of C. Borderline personality disorder behaviors
development, the client diagnosed D. Schizoid personality disorder
with paranoid personality disorder Which behavior would the nurse
A client diagnosed with a personality expect to observe if a client is
has problems with control within his
disorder states, "You are the very diagnosed with paranoid personality
or her environment
best nurse on the unit and not at all disorder?
When confronted, a client diagnosed like that mean nurse who never lets A. The client sits alone at lunch and
with narcissistic personality disorder us stay up later than 9 pm." This states, "Everyone wants to hurt me."
states, "Contrary to what everyone statement would be associated with B. The client is irresponsible and
believes, I do not think that the which personality disorder? exploits other peers in the milieu for
whole world owes me a living." This A. Borderline personality disorder cigarettes
client is using what defense B. Schizoid personality disorder C. The client is shy and refuses to
mechanism? C. Dependent personality disorder talk to other because of poor self-
A. Minimization B. Denial D. Paranoid personality disorder esteem
C. Rationalization D. Projection D. The client sits with peers and
A male client diagnosed with a allows others to make decisions for
A client diagnosed with borderline personality disorder boasts to the the entire group
personality disorder coyly requests nurse that he has to fight off female
diazepam (Valium). When the attention and is the highest paid in Which diagnostic criterion describes
physician refuses, the client his company. These statements are a characteristic of schizotypal
becomes angry and demands to see reflective of which personality personality disorder?
another physician. What defense disorder? A. Neither desires nor enjoys close
mechanism is the client using? A. Obsessive-compulsive personality relationships, including being part of
A. Undoing B. disorder a family
Splitting B. Avoidant personality disorder B. Is preoccupied with unjustified
C. Altruism D. C. Schizotypal personality disorder doubts about the loyalty of friends
Reaction formation D. Narcissistic personality disorder and associates
C. Considers relationships to be more
A diabetic client admitted to a A nurse encourages an angry client intimate than they actually are
medical floor for medication to attend group therapy. Knowing D. Exhibits behavior or appearance
stabilization has a history of that the client has been diagnosed that is odd, eccentric, or peculiar
antisocial personality disorder. Which with a cluster B personality disorder,
documented behaviors would which client response might the
Which of the following diagnostic B. Risk for violence: self-directed with schizotypal personality disorder.
criteria describe the characteristics C. Ineffective denial The client states, "I envision my
of borderline personality disorder? D. Powerlessness future death by fire." Which is the
(Select all that apply) most appropriate nursing response?
A. Arrogant, haughty behaviors or A client diagnosed with borderline A. "I don't know what you mean by
attitudes personality disorder superficially cut envisioning your future death."
B. Frantic efforts to avoid real or both wrists, is disruptive in group, B. "Your future death? Can you
imagined abandonment and is "splitting" staff. Which nursing please tell me more about that?"
C. Recurrent suicidal and self- diagnosis would take priority? C. "I was wondering if you want to
mutilating behaviors A. Risk for self-mutilation R/T need come to group to talk about that."
D. Unrealistic preoccupation with for attention D. "I can see your thoughts are
fears of being left to take care of self B. Ineffective coping R/T inability to bothersome. How can I help?"
E. Chronic feelings of emptiness deal directly with feelings
C. Anxiety R/T fear of abandonment A suicidal client is diagnosed with
Which of the following diagnostic AEB "splitting" staff borderline personality disorder.
criteria describe the characteristics D. Risk for suicide R/T past suicide Which correctly written short-term
of avoidant personality disorder? attempt outcome is most beneficial for the
(Select all that apply) client?
A. Fearing shame and/or ridicule, A client diagnosed with schizoid A. The client will be free from self-
does not form intimate relationships personality disorder chooses solitary injurious behavior
B. Has difficulty making everyday activities, lacks close friends, and B. The client will express feelings
decisions without reassurance from appears indifferent to criticism. without inflicting self-injury by
others Which nursing diagnosis would be discharge
C. Is unwilling to be involved with appropriate for this client's problem? C. The client will socialize with peers
people unless certain of being liked A. Anxiety R/T poor self-esteem AEB in the milieu by day 3
D. Shows perfectionism that lack of close friends D. The client will acknowledge his or
interferes with task completion B. Ineffective coping R/T inability to her role in altered interpersonal
E. Views self as socially inept, communicate AEB indifference to relationships
unappealing, and inferior criticism
C. Altered sensory perception R/T A client diagnosed with an avoidant
When assessing a client diagnosed threat to self-concept AEB magical personality disorder has the nursing
with histrionic personality disorder, thinking diagnosis of social isolation R/T
the nurse might identify which D. Social isolation R/T discomfort severe malformation of the spine
characteristic behavior? with human interaction AEB avoiding AEB "I can't be around people,
A. Odd beliefs and magical thinking others looking like this." Which correctly
B. Grandiose sense of self- written short-term outcome is
importance A client exhibiting passive- appropriate for this client's problem?
C. Preoccupation with orderliness aggressive personality traits A. The client will see self as straight
and perfection continuously complains to the and tall by the time of discharge
D. Attention-seeking flamboyance marriage counselor about a nagging B. The client will see self as valuable
husband who criticizes her after attending assertiveness
When assessing a client exhibiting indecisiveness. Which nursing training courses
passive-aggressive personality traits, diagnosis reflects this client's C. The client will be able to
which characteristic behavior might problem? participate in one therapy group by
the nurse identify? A. Social isolation R/T decreased self- end of shift
A. The client exhibits behaviors that esteem D. The client will join in a charade
attempt to "split" the staff B. Impaired social interaction R/T game to decrease social isolation
B. The client shows reckless inability to express feelings openly
disregard for the safety of self or C. Powerlessness R/T spousal abuse A client diagnoses with an obsessive-
others D. Self-esteem disturbance R/T compulsive personality disorder has
C. The client has unjustified doubts unrealistic expectations of husband a nursing diagnosis of anxiety R/T
about the trustworthiness of friends interference with hand washing AEB
D. The client seeks subtle retribution A nurse is discharging a client "I'll go crazy if you don't let me do
when feeling others have wronged diagnosed with narcissistic that." Which correctly written short-
him or her personality disorder. Which term outcome is appropriate for this
employment opportunity is most client?
Although there are differences likely to be recommended by the A. During a 3-hour period after
among the three personality disorder treatment team? admission to the unit, the client will
clusters, there also are some traits A. Home construction refrain from hand washing.
common to all individuals diagnosed B. Air traffic controller B. The client will wash hands only at
with personality disorders. Which of C. Night watchman at the zoo appropriate bathroom and meal
the following are common traits? D. Prison warden intervals
(Select all that apply) C. The client will refrain from hand
A. Failure to accept the Which client situation requires the washing throughout the night
consequences of their own behavior nurse to prioritize the D. Within 72 hours of admission, the
B. Self-injurious behaviors implementation of limit setting? client will notify staff when signs and
C. Reluctance in taking personal risks A. A client making sexual advances symptoms of anxiety escalate
D. Cope by altering environment toward a staff member
instead of self B. A client telling staff that another A client diagnosed with antisocial
E. Lack of insight staff member allows food in the personality disorder demands, at
bedrooms midnight, to speak to the ethics
A client diagnosed with antisocial C. A client verbally provoking committee about the involuntary
personality disorder states, "My kids another client who is paranoid commitment process. Which nursing
are so busy at home and school, they D. A client refusing medications to statement is appropriate?
don't miss me or even know I'm receive secondary gains A. "I realize you're upset; however,
gone." Which nursing diagnosis this is not the appropriate time to
applies to this client? A client newly admitted to an in- explore your concerns."
A. Risk for injury patient psychiatric unit is diagnosed
B. "Let me give you a sleeping pill to the immediate family. Which nursing A client is diagnosed with
help put your mind at ease." intervention would be appropriate? intermittent explosive disorder. The
C. "It's midnight, and you are A. Address inappropriate interactions clinic nurse should anticipate
disturbing the other clients." during group therapy potentially teaching about which of
D. "I will document your concerns in B. Recognize when client is playing the following medication? (Select all
your chart for the morning shift to one staff member against another that apply)
discuss with the ethics committee." C. Role-model positive relationships A. Sertraline (Soloft)
D. Encourage client to discuss B. Paliperidone (Invea)
A client diagnosed with antisocial conflicts evident withing the family C. Buspirone (BuSpar)
personality disorder is caught system D. Phenelzine (Nardil)
smuggling cigarettes into the E. Valproate sodium (Depakote)
nonsmoking clinical area. Which A client diagnosed with paranoid
initial nursing intervention is personality disorder needs A client diagnosed with dependent
appropriate? information regarding medications. personality disorder has a nursing
A. Confront the client about the Which nursing intervention would diagnosis of altered sleep pattern R/T
behavior best assist this client in impending divorce. The client is
B. Tell the client's primary nurse understanding prescribed prescribed oxazepam (Serax) prn.
about the situation medications? Which is an appropriate correctly
C. Remind all clients of the no A. Ask the client to join the written outcome for this nursing
smoking policy in the community medication education group diagnosis?
meeting B. Provide one-on-one teaching in A. The client verbalizes a decrease in
D. Teach alternative coping the client's room tension and racing thoughts
mechanisms to assist with anxiety C. During rounds, have the physician B. The client expresses
ask if the client has any questions understanding about the medication
After being treated in the ED for self- D. Let the client read the medication side effects by day 2
inflicted lacerations to wrists and information handout C. The client sleep 4 to 6 hours a
arms, a client with a diagnosis of night by day 3
borderline personality disorder is A nursing student is studying the D. The client notifies the nurse when
admitted to the psychiatric unit. historical aspects of personality the medication is needed
Which nursing intervention takes disorder. Which entry on the
priority? examination indicates that learning A client diagnosed with paranoid
A. Administer tranquilizing drugs has occurred? personality disorder is prescribed
B. Observe client frequently A. Zeus, in the 3rd century BC, risperidone (Risperdal). The client is
C. Encourage client to verbalize identified, described, and applied the noted to have restlessness and
hostile feelings theory of object relations weakness in the lower extremities
D. Explore alternative ways of B. Hippocrates, in the 4th century and is drooling. Which nursing
handling frustration BC, identified four fundamental intervention would be most
personality styles important?
A 15 year-old client living in a C. Narcissus, in 923 AD introduced A. Hold the next dose of risperidone
residential facility has a nursing the word "personality" from the and document the findings
diagnosis of ineffective coping R/T Greek term "persona." B. Monitor vital signs and encourage
abuse AEB defiant responses to adult D. Achilles, in 866 AD, described the the client to rest in his or her room
rules. Which of the following pathology of personality as a C. Give the ordered prn dose of
interventions would address this complex behavioral phenomenon trihexyphenidyl (Artane)
nursing diagnosis appropriately? D. Get a fasting blood sugar
(Select all that apply) A nursing student is learning about measurement because of potential
A. Set limits on manipulative narcissistic personality disorder. hyperglycemia
behavior Which of the following student
B. Refuse to engage in controversial statements indicate that learning has A client diagnosed with obsessive-
and argumentative encounters occurred? (Select all that apply) compulsive personality disorder is
C. Obtain an order for tranquilizing A. "These clients have peculiarities of admitted to a psychiatric unit in a
medications ideation." highly agitated state. The physician
D. Encourage the discussion of angry B. "These clients require constant prescribes a benzodiazepine. Which
feelings approval and affirmation." of the following medications should
E. Remove all dangerous objects C. "These clients are impulsive and the nurse expect to administer?
from the client's environment self-destructive." (Select all that apply)
D. "These clients express a A. Clonazepam (Klonopin)
A client diagnosed with a borderline grandiose sense of self-importance." B. Lithium carbonate (Lithium)
personality disorder is given a E. These clients have a deep need C. Clozapine (Clozaril)
nursing diagnosis of disturbed for admiration." D. Olanzapine (Zyprexa)
personal identity R/T unmet E. Chlordiazepoxide (Librium)
dependency needs AEB the inability A nursing instructor is teaching
to be alone. Which nursing about personality disorder A nurse assists a client with a
intervention would be appropriate? characteristics. Which student diagnosis of obsessive-compulsive
A. Ask the client directly, "Have you statement indicates that learning has disorder (OCD) in his preparations for
thought about killing yourself?" occurred? bedtime. One hour later the client
B. Maintain a low level of stimuli in A. "Clients diagnosed with calls the nurse and says that he is
the client's environment personality disorders need frequent feeling anxious; he asks the nurse to
C. Frequently orient the client to hospitalizations." sit and talk for a while. Which is the
reality and surroundings B. "Clients perceive their behaviors appropriate initial nursing action?
D. Help the client identify values and as uncomfortable and disorganized." A. Sit and talk with the client.
beliefs C. "Personality disorders cannot be B. Ask the unlicensed assistive
cured or controlled successfully with personnel to sit with the client.
A client diagnosed with a dependent medication." C. Administer the prescribed as-
personality disorder has a nursing D. "Practitioners have a good needed antianxiety medication.
diagnosis of social isolation R/T understanding about the etiology of D. Tell the client that it is time for
parental abandonment AEB fear of personality disorder."
involvement with individuals not in
sleep and that you will talk with him Which statement is descriptive of A. unconsciously represses
tomorrow. clients with personality disorders? undesirable aspects of self.
A. They are resistant to behavioral B. places responsibility for his or her
A nurse is planning care for a group change. behavior outside the self.
of clients on a mental health unit. B. They have an ability to tolerate C. sees things as divided into "all
The nurse notes that most of the frustration and pain. good" or "all bad."
assigned clients require C. They usually seek help to change D. evidences lack of personal
interventions commonly used to maladaptive behaviors. boundaries.
treat anxiety disorders. Such D. They have little difficulty forming
antianxiety interventions would be satisfying and intimate relationships. A 16-year-old has stolen money from
appropriate for which clients? Select his invalid grandmother, uses drugs
all that apply. Research has indicated that and alcohol, and frequently beats up
A. A client with panic disorder antisocial personality may be acquaintances who disagree with
B. Generalized anxiety disorder characterized by: him. Arrested for an assault in which
C. A client with multiple personality A. social isolation. he beat a classmate and caused
disorder B. lack of remorse. brain damage; he stated in court
D. A client with posttraumatic stress C. learning difficulties. "The guy deserved everything he
disorder (PTSD) D. difficulty with reality testing. got." The behaviors described are
E. A client with obsessive-compulsive most consistent with the clinical
disorder (OCD) The primary goal of milieu therapy picture of
for clients with personality disorders A. antisocial personality disorder.
A nurse is preparing to admit a client is B. borderline personality disorder.
with a diagnosis of obsessive- A. manage the affect behavior has C. schizotypal personality disorder.
compulsive disorder (OCD) to the on the entire group. D. narcissistic personality disorder.
mental health unit. The nurse would B. one-on-one therapy.
expect to note which behaviors in C. to help the client remain Which behavior would be
the client? uninvolved with other patients. inconsistent with defining
A. Suspicious and hostile D. a laissez faire attitude. characteristics for the nursing
B. Flexible and adaptable diagnosis of ineffective coping?
C. Frightened and delusional Characteristic behaviors the nurse A. Difficulty in relationships
D. Rigidness in thought and will assess in the narcissistic client B. High levels of anxiety
inflexibility are C. Manipulation
A. dramatic expression of emotion, D. Interdependence
A nurse is performing an assessment being easily led.
on a client admitted to the mental B. perfectionism and preoccupation A nurse is assigned to work with a
health unit. The client tells the nurse with detail. client with borderline personality
that she cannot leave home without C. grandiose, exploitive, and rage- disorder. The nurse will need to
checking numerous times that the filled behavior. consider strategies for dealing with
iron and coffee pot have been shut D. angry, highly suspicious, aloof, the client's
off. The client states that this activity withdrawn behavior. A. mood shifts, impulsivity, and
makes her late for many functions splitting.
and that she misses engagements on Which client with a personality B. grief, anger, and social isolation.
occasion because of it. The nurse disorder is most likely to be admitted C. altered sensory perceptions and
would expect to note which anxiety to a psychiatric unit? suspicion.
disorder documented in the client's A. Mr. A, with paranoid personality D. perfectionism and preoccupation
record? disorder who is suspicious of his with detail.
A. A phobia neighbors
B. Generalized anxiety disorder B. Mr. B, with narcissistic personality A client has been diagnosed with
C. Posttraumatic stress disorder disorder who is highly self-important dependent personality disorder.
(PTSD) C. Ms. C, with borderline personality Which behavior descriptions can the
D. Obsessive-compulsive disorder disorder who is impulsive nurse expect to assess?
(OCD) D. Mrs. D, with dependent A. Anxious, fearful
personality disorder who clings to B. Odd, eccentric
A nurse is performing an assessment her husband C. Dramatic, emotional, erratic
on a client admitted to the mental D. Disoriented, disorganized
health unit. The nurse notes that the Characteristics the nurse will assess
client's diagnosis is documented as in the client with antisocial
obsessive-compulsive disorder. The personality disorder are
A. deceitfulness, impulsiveness, and A newly admitted client has an axis II
nurse plans care knowing that the
lack of empathy. diagnosis of schizoid personality
client is most likely to experience
B. perfectionism, preoccupation with disorder. The nursing intervention of
which type of compulsive behavior?
detail, and verbosity. highest priority will be to
A. Fears B. Actions
C. avoidance of interpersonal contact A. set firm limits on behavior.
C. Illusions D.
and preoccupation with being B. respect need for social isolation.
Thoughts
criticized. C. encourage expression of feelings.
A nurse caring for a client who has D. need for others to assume D. involve in milieu and group
been diagnosed with a personality responsibility for decision-making activities.
disorder should expect that the client and seeks nurture.
A client with dependent personality
will exhibit which of the following
Playing one staff member against disorder who had been living with
characteristics?
another is an example of her newly married son was admitted
A. Frequent episodes of psychosis
A. devaluation. a week ago for treatment of
B. Constant involvement with the
B. splitting. depression, which began after her
needs of significant others
C. impulsiveness. son suggested that she move out.
C. Inflexible and maladaptive
D. social ineptitude. Which remark by the client would the
responses to stress
nurse evaluate as showing
D. Abnormal ego functioning
Splitting is a process in which the improvement in the client's
client condition?
A. "My son's suggestion hurt me personality disorder spits, curses, D. Maintain unit order by the
greatly." and refuses to answer questions. application of autocratic leadership.
B. "My son is less at fault than my Which is the most appropriate
daughter-in-law." nursing statement to address this Which nursing approach should be
C. "I'm going to need help to afford behavior? used to maintain a therapeutic
to rent an apartment." A. "You are very disrespectful. You relationship with a client diagnosed
D. "How will I ever live alone with no need to learn to control yourself." with borderline personality disorder?
one to look after my affairs?" B. "I understand that you are angry, A. Being firm, consistent, and
but this behavior will not be empathic, while addressing specific
A client with histrionic personality tolerated." client behaviors
disorder winks at an attractive nurse C. "What behaviors could you modify B. Promoting client self-expression
and states, "You and I should be able to improve this situation?" by implementing laissez-faire
to turn those resident physicians into D. "What anti-personality-disorder leadership
jelly if you'd wear your skirts about medications have helped you in the C. Using authoritative leadership to
two inches shorter." The nurse's past?" help clients learn to conform to
reply should be based on the society norms
understanding that the client's use of A client diagnosed with antisocial D. Overlooking inappropriate
seductive behavior is personality disorder comes to a behaviors to avoid promoting
A. a response to stress. nurses' station at 11:00 p.m. secondary gains
B. based on a need to dominate. requesting to phone a lawyer to
C. seated in primitive rage. discuss filing for a divorce. The unit Which adult client should a nurse
D. callous disregard for others. rules state that no phone calls are identify as exhibiting the
permitted after 10:00 p.m. Which characteristics of a dependent
A client with obsessive-compulsive nursing reply is most appropriate? personality disorder?
personality disorder takes the nurse A. "Go ahead and use the phone. I A. A physically healthy client who is
aside and mentions "I've observed know this pending divorce is dependent on meeting social needs
you interacting with Mr. D. You are stressful." by contact with 15 cats
not approaching him properly. You B. "You know better than to break B. A physically healthy client who
should be more forceful with him." the rules. I'm surprised at you." has a history of depending on
The best response for the nurse C. "It is after the 10:00 p.m. phone intense relationships to meet basic
would be curfew. You will be able to call needs
A. "I will be continuing to follow the tomorrow." C. A physically healthy client who
care plan for Mr. D." D. "The decision to divorce should lives with parents and relies on
B. "I see you are trying to control Mr. not be considered until you have had public transportation
D's therapy as well as your own." a good night's sleep." D. A physically healthy client who is
C. "Your eye for perfection extends serious, inflexible, perfectionistic,
even to my nursing interventions." A client diagnosed with paranoid and depends on rules to provide
D. "Mr. D's care is really of no personality disorder becomes violent security
concern to you or to other clients." on a unit. Which nursing intervention
is most appropriate? A pessimistic client expresses low
The priority nursing intervention for A. Provide objective evidence, that self-worth, has much difficulty
a client with borderline personality violence is unwarranted. making decisions, avoids positions of
disorder is to B. Initially restrain the client to responsibility, and has a behavioral
A. protect other clients from maintain safety. pattern of "suffering" in silence.
manipulation. C. Use clear, calm statements and a Which underlying cause of this
B. respect the client's need for social confident physical stance. client's personality disorder should a
isolation. D. Empathize with the client's nurse recognize?
C. assess for suicidal and self- paranoid perceptions. A. "Nurturance was provided from
mutilating behaviors. many sources, and independent
D. provide clear, consistent limits A highly emotional client presents at behaviors were encouraged."
and boundaries. an outpatient clinic appointment B. "Nurturance was provided
wearing flamboyant attire, spiked exclusively from one source, and
A danger of working with a client heels, and theatrical makeup. Which independent behaviors were
who idealizes the nurse is personality disorder should a nurse discouraged."
A. becoming overinvolved and being associate with this assessment data? C. "Nurturance was provided
protective and indulgent. A. Compulsive personality disorder exclusively from one source, and
B. becoming indecisive about B. Schizotypal personality disorder independent behaviors were
planned interventions. C. Histrionic personality disorder encouraged."
C. developing a prejudicial, blaming D. Manic personality disorder D. "Nurturance was provided from
orientation. many sources, and independent
D. stringent enforcement of A client diagnosed with borderline behaviors were discouraged."
boundaries and limits. personality disorder brings up a
conflict with the staff in a community Family members of a client ask a
Clients with personality disorders meeting and develops a following of nurse to explain the difference
have various self-defeating clients who unreasonably demand between schizoid and avoidant
behaviors and interpersonal modification of unit rules. How can personality disorders. Which is the
problems despite having near- the nursing staff best handle this appropriate nursing reply?
normal ego functioning and intact situation? A. "Clients diagnosed with avoidant
reality testing. A nursing diagnosis A. Allow the clients to apply the personality disorder desire intimacy
that addresses this sort of democratic process when developing but fear it, and clients diagnosed
interpersonal dysfunction is unit rules. with schizoid personality disorder
A. spiritual distress. B. Maintain consistency of care by prefer to be alone."
B. defensive coping. open communication to avoid staff B. "Clients diagnosed with schizoid
C. impaired social interaction. manipulation. personality disorder exhibit odd,
D. disturbed sensory perception. C. Allow the client spokesman to bizarre, and eccentric behavior,
verbalize concerns during a unit staff while clients diagnosed with avoidant
During an assessment interview, a meeting. personality disorder do not."
client diagnosed with antisocial
C. "Clients diagnosed with avoidant Which client situation should a nurse behavior as characteristic of which
personality disorder are eccentric, identify as reflective of the impulsive personality disorder?
and clients diagnosed with schizoid behavior that is commonly A. Schizoid personality disorder
personality disorder are dull and associated with borderline B. Obsessive-compulsive personality
vacant." personality disorder? disorder
D. "Clients diagnosed with schizoid A. As the day shift nurse leaves the C. Histrionic personality disorder
personality disorder have a history of unit, the client suddenly hugs the D. Paranoid personality disorder
psychotic thought processes, while nurse's arm and whispers, "The night
clients diagnosed with avoidant nurse is evil. You have to stay." Which reaction to a compliment from
personality disorder remain based in B. As the day shift nurse leaves the another client should a nurse identify
reality." unit, the client suddenly hugs the as a typical response from a client
nurse's arm and states, "I will be up diagnosed with avoidant personality
During an interview, which client all night if you don't stay with me." disorder?
statement indicates to a nurse that a C. As the day shift nurse leaves the A. Interpreting the compliment as a
potential diagnosis of schizotypal unit, the client suddenly hugs the secret code used to increase
personality disorder should be nurse's arm, yelling, "Please don't personal power
considered? go! I can't sleep without you being B. Feeling the compliment was well
A. "I really don't have a problem. My here." deserved
family is inflexible, and every relative D. As the day shift nurse leaves the C. Being grateful for the compliment
is out to get me." unit, the client suddenly shows the but fearing later rejection and
B. "I am so excited about working nurse a bloody arm and states, "I cut humiliation
with you. Have you noticed my new myself because you are leaving me." D. Wondering what deep meaning
nail polish: 'Ruby Red Roses'?" and purpose are attached to the
C. "I spend all my time tending my Which nursing diagnosis should be compliment
bees. I know a whole lot of prioritized when providing care to a
information about bees." client diagnosed with paranoid Which client symptoms should lead a
D. "I am getting a message from the personality disorder? nurse to suspect a diagnosis of
beyond that we have been involved A. Risk for violence: directed toward obsessive-compulsive personality
with each other in a previous life." others R/T suspicious thoughts disorder?
B. Risk for suicide R/T altered A. The client experiences unwanted,
A nursing instructor is teaching thought intrusive, and persistent thoughts.
students about clients diagnosed C. Altered sensory perception R/T B. The client experiences unwanted,
with histrionic personality disorder increased levels of anxiety repetitive behavior patterns.
and the quality of their relationships. D. Social isolation R/T inability to C. The client experiences inflexibility
Which student statement indicates relate to others and lack of spontaneity when dealing
that learning has occurred? with others.
A. "Their dramatic style tends to From a behavioral perspective, which D. The client experiences obsessive
make their interpersonal nursing intervention is most thoughts that are externally
relationships quite interesting and appropriate when caring for a client imposed.
fulfilling." diagnosed with borderline
B. "Their interpersonal relationships personality disorder? Which client is a nurse most likely to
tend to be shallow and fleeting, A. Seclude the client when admit to an inpatient facility for self-
serving their dependency needs." inappropriate behaviors are destructive behaviors?
C. "They tend to develop few exhibited. A. A client diagnosed with antisocial
relationships because they are B. Contract with the client to personality disorder
strongly independent but generally reinforce positive behaviors with unit B. A client diagnosed with borderline
maintain deep affection." privileges. personality disorder
D. "They pay particular attention to C. Teach the purpose of antianxiety C. A client diagnosed with schizoid
details which can frustrate the medications to improve medication personality disorder
development of relationships." compliance. D. A client diagnosed with paranoid
D. Encourage the client to journal personality disorder
Which nursing diagnosis should a feelings to improve awareness of
nurse identify as appropriate when When planning care for clients
abandonment issues.
working with a client diagnosed with diagnosed with personality disorders,
schizoid personality disorder? A nurse tells a client that the nursing what should be the anticipated
A. Altered thought processes R/T staff will start alternating weekend treatment outcome?
increased stress shifts. Which response should a A. To stabilize pathology with the
B. Risk for suicide R/T loneliness nurse identify as characteristic of correct combination of medications
C. Risk for violence: directed toward clients diagnosed with obsessive- B. To change the characteristics of
others R/T paranoid thinking compulsive personality disorder? the dysfunctional personality
D. Social isolation R/T inability to A. "You really don't have to go by C. To reduce inflexibility of
relate to others that schedule. I'd just stay home personality traits that interfere with
sick." functioning and relationships
When planning care for a client B. "There has got to be a hidden D. To decrease the prevalence of
diagnosed with borderline agenda behind this schedule neurotransmitters at receptor sites
personality disorder, which self-harm change."
behavior should a nurse expect the The nurse plans to confront a client
C. "Who do you think you are? I
client to exhibit? about secondary gains related to
expect to interact with the same
A. The use of highly lethal methods extreme dependency on spouse.
nurse every Saturday."
to commit suicide Which nursing statement would be
D. "You can't make these kinds of
B. The use of suicidal gestures to most appropriate?
changes! Isn't there a rule that
evoke a rescue response from others A. "Do you believe dependency
governs this decision?"
C. The use of isolation and starvation issues have been a lifelong concern
as suicidal methods Looking at a slightly bleeding paper for you?"
D. The use of self-mutilation to cut, the client screams, "Somebody B. "Have you noticed any anxiety
decrease endorphins in the body help me, quick! I'm bleeding. Call during times when your husband
911!" A nurse should identify this makes decisions."
C. "What do you know about
individuals who depend on others for While improving, a client demands to E. The client will list two lifetime
direction?" have a phone installed in the achievements by discharge.
D. "How have the specifics of your intensive care unit (ICU) room. When
relationship with your spouse a nurse states, "This is not allowed. It A nurse is caring for a group of
benefited you?" is a unit rule." The client angrily clients within the DSM-IV-TR cluster
demands to see the doctor. Which B category of personality disorders.
The nurse should recognize which approach should the nurse use in Which factors should the nurse
factors that distinguish personality this situation? consider when planning client care?
disorders from psychosis? A. Provide an explanation for the (Select all that apply.)
A. Functioning is more limited in necessity of the unit rule. A. These clients have personality
personality disorders than in B. Assist the client to discuss anger traits that are deeply ingrained and
psychosis. and frustrations. difficult to modify.
B. Major disturbances of thought are C. Call the physician and relay the B. These clients need medications to
absent in personality disorders. request. treat the underlying physiological
C. Personality disordered clients D. Arrange for a phone to be pathology.
require hospitalization more installed in the client's unit room. C. These clients use manipulation,
frequently. making the implementation of
D. Personality disorders do not affect Which nursing statement reflects a treatment problematic.
family relationships as much as common characteristic of a client D. These clients have poor impulse
psychosis. diagnosed with paranoid personality control that hinders compliance with
disorder? a plan of care.
Which client statement would A. "This client consistently criticizes E. These clients commonly have
demonstrate a common care and has difficulty getting along secondary diagnoses of substance
characteristic of Cluster "B" with others." abuse and depression.
personality disorder? B. "This client is shy and fades into
A. "I wish someone would make that the background." Nurse Isabelle enters the room of a
decision for me." C. "This client expects special client with a cognitive impairment
B. "I built this building by using treatment and setting limits will be disorder and asks what day of the
materials from outer space." necessary." week it is; what the date. month. and
C. "I'm afraid to go to group because D. "This client is expressive during year are; and where the client is. The
it is crowded with people." group and is very pleased with self." nurse is attempting to assess:
D. "I didn't have the money for the A. Confabulation B. Delirium
ring, so I just took it." A client exhibits dependency on staff C. Orientation D. Perseveration
and peers and expresses fear of
When a client on an acute care abandonment. Using Mahler's theory A student nurse was asked which of
psychiatric unit demonstrates of object relations, which should the the following best describes
behaviors and verbalizations nurse expect to note in this client's dementia. Which of the following
indicating a lack of guilt feelings, childhood? best describes the condition?
which nursing intervention would A. Lack of fulfillment of basic needs A. Memory loss occurring as part of
help the client to meet desired by parental figures the natural consequence of aging
outcomes? B. Absence of the client's maternal B. Difficulty coping with physical and
A. Provide external limits on client figure during symbiosis psychological change
behavior. C. Difficulty establishing trust with C. Severe cognitive impairment that
B. Foster discussions of rationales for the maternal figure occurs rapidly
behavioral change. D. Inconsistency by the maternal D. Loss of cognitive abilities.
C. Implement interventions figure during individuation impairing ability to perform activities
consistently by only one staff of daily living
member. A client diagnosed with cluster "C"
D. Encourage the client to involve traits sits alone and ignores other's Which of the following will Nurse
self in care. attempts to converse. When ask to Dory use when communicating with
join a group the client states, "No a client who has cognitive
Which characteristics should a nurse thanks." In this situation, which impairment.
recognize as being exhibited by should the nurse assign as an initial A. Complete explanations with
individuals diagnosed with any nursing diagnosis? multiple details
personality disorders? A. Fear R/T hospitalization B. Pictures or gestures instead of
A. These clients accept and are B. Social isolation R/T poor self- words
comfortable with their altered esteem C. Stimulating words and phrases to
behaviors. C. Risk for suicide R/T to capture the client’s attention
B. These clients understand that hopelessness D. Short words and simple sentences
their altered behaviors result from D. Powerlessness R/T dependence
anxiety. issues Mrs. Mendoza is a 75-year-old client
C. These clients seek treatment to
who has dementia of the Alzheimer’s
avoid interpersonal discomfort. Which statements represent positive
type and confabulates. The nurse
D. These clients avoid relationships outcomes for clients diagnosed with
understands that this client:
due to past negative experiences. narcissistic personality disorder?
A. Denies confusion by being jovial
(Select all that apply.)
A nurse would expect a client B. Pretends to be someone else
A. The client will relate one
diagnosed with schizotypal C. Rationalizes various behaviors
empathetic statement toward
personality disorder to exhibit which D. Fills in memory gaps with fantasy
another client in group by day 2.
characteristic? B. The client will identify one
A. The client keeps to self and has Which ability should Nurse Rebecca
personal limitation by day 1.
few, if any relationships. expect from a client in the mild stage
C. The client will acknowledge one
B. The client has many brief but of dementia of the Alzheimer’s type?
strength that another client
intense relationships. A. Remembering the daily schedule
possesses by day 2.
C. The client experiences incorrect B. Recalling past events
D. The client will list four personal
interpretations of external events. C. Coping the anxiety
strengths by day 3.
D. The client exhibits lack of tender D. Solving problems of daily living
feelings toward others.
82-year-old Mr. Robeson together imagery in an effort to elicit instructor gave me a failing grade on
with his daughter arrived at the automatic thoughts." my research paper. I know it's
medical-surgical unit for diagnostic C. "The therapist provides because the instructor doesn't like
confirmation and management of information about how cognitive me." Which cognitive error does a
probable delirium. Which statement therapy works." nurse recognize in this student's
by the client’s daughter best D. "The therapist uses reading statement?
supports the diagnosis? assignments to reinforce learning." A. Dichotomous thinking C.
A. “Maybe it’s just caused by aging. Magnification
This usually happens by age 82.” A 90-year-old patient is admitted to B. Catastrophic thinking D.
B. “The changes in his behavior the hospital. Shortly after admission, Overgeneralization
came on so quickly! I wasn’t sure the family notices that the patient is
what was happening.” exhibiting disorientation and An advanced practice nurse
C. “Dad just didn’t seem to know agitation. When questioned about recommends that a client participate
what he was doing. He would forget the behavior by the family, the nurse in cognitive therapy. The client asks,
what he had for breakfast.” states that the patient is at risk for "What's cognitive therapy and how
D. “Dad has always been so developing which common can it help me?" Which is the nurse's
independent. He’s lived alone for complication of hospitalization in most appropriate reply?
years since mom died.” older adults? A. "It is a system of techniques in
A. Delirium. B. which you use positive thinking to
Mrs. Jordan is an elderly client Dementia. improve your mood."
diagnosed with Alzheimer’s disease. C. Alzheimer's disease. D. B. "It is a long-term interpersonal
She becomes agitated and Sundowner syndrome. approach that emphasizes the role of
combative when a nurse approaches early childhood experiences."
A community health nurse is C. "It is a interpersonal treatment
to help with morning care. The most
preparing a course on protecting approach that specifically targets
appropriate nursing intervention in
cognitive function. Which population magical thinking."
this situation would be to:
group should the nurse target for D. "It is a type of psychotherapy that
A. Tell the client firmly that it is time
teaching? focuses treatment on the
to get dressed
A. Older male adults with diabetes. modification of distorted thinking
B. Obtain assistance to restrain the
B. Older female adults who are and maladaptive behaviors."
client for safety
overweight.
C. Remain calm and talk quietly to
C. Young adults living in school The nurse is establishing a
the client
dormitories. therapeutic environment for a
D. Call the doctor and request an
D. Adolescents attending summer patient admitted with dementia and
order for sedation
camps influenza. Which intervention would
be important for the nurse to
Which goal is a priority for a client The nurse is reviewing the needs of a implement?
with a DSM-IV-TR diagnosis of patient with cognitive impairment. A. Keep a radio on all the time to
delirium and the nursing diagnosis What is the priority concern that the provide sound for the patient.
Acute confusion related to recent nurse should address for this B. Decrease patient confusion by
surgery secondary to traumatic hip patient? limiting verbal interactions.
fracture? A. Promoting at least 6 hours of C. Limit family visits to one person
A. The client will complete activities sleep a night. for 30 minutes per day.
of daily living. B. Encouraging an oral intake of D. Provide a quiet environment in a
B. The client will maintain safety. 1200 calories per day. private room.
C. The client will remain oriented. C. Managing the patient's pain from
D. The client will understand arthritis. A welder has been selected as
communication. D. Supervising medication employee of the year. The welder
administration. wants to ask for a promotion but is
Which of the following is not included hampered by poor self-esteem. The
in the care of plan of a client with a A psychiatric nurse is counseling a employee health nurse provides
moderate cognitive impairment client who has thought patterns assistance. Which technique should
involving dementia of the consisting of rapid responses to a the nurse use to help the employee
Alzheimer’s type? situation without rational analysis. request the promotion?
A. Daily structured schedule What assessment data will the nurse
B. Positive reinforcement for document on this client? A. Socratic questioning
performing activities of daily living A. "Thought patterns are triggered B. Activity scheduling
C. Stimulating environment by specific stressful stimuli." C. Distraction
D. Use of validation techniques B. "Thought patterns contain the D. Cognitive rehearsal
client's fundamental beliefs and
In clients with a cognitive assumptions." ANS: D
impairment disorder. the C. "Thought patterns are flexible and Cognitive rehearsal allows the
phenomenon of increased confusion based on personal experience." employee to uncover potential
in the early evening hours is called: D. "Thought patterns include a automatic thoughts in advance of his
A. Aphasia B. Agnosia predominance of automatic or her meeting to request a
C. Sundowning D. Confabulation thoughts." promotion. This allows the employee
to develop strategies to modify any
A nursing instructor is teaching A successful business executive dysfunctional thinking.
about the didactic aspects of continually thinks that job
cognitive therapy. Which student accomplishments are not adequate. An advanced practice nurse is
statement indicates a deficit in A nurse recognizes that the client's counseling a client diagnosed with
meeting the learning objectives of thinking is reflective of which generalized anxiety disorder. The
this content? cognitive error? nurse plans to use activity
A. "The therapist provides A. Minimization scheduling to address this client's
information about the process of C. Arbitrary inference concerns. What is the purpose of this
cognitive therapy." B. Dichotomous thinking nursing intervention?
B. "The therapist uses guided D. Personalization A. To identify important areas
A nursing student states, "The needing concentration during
therapy indicates to the nurse the use of the will help you move on."
B. To increase self-esteem and cognitive error, selective D. "Can anyone predict when a car
decrease feelings of helplessness abstraction? accident will happen?"
C. To modify maladaptive behaviors A. "My baby is refusing to nurse, and
by the use of role-play I know it's because she hates me." Which client statement would
D. To divert away from intrusive B. "My baby needs to be under the exemplify the cognitive changes that
thoughts and depressive ruminations 'bilirubin lights,' but I resent her time you would expect to see in mild
away from me." anxiety?
When a client's husband comes C. "My baby is wonderful, but I'm A. "Right now, I feel as sharp as a
home late from work, the wife upset and depressed because I tack."
immediately fears infidelity. The wanted twins." B. "I'm having a tough time
advanced practice nurse therapist D. "My baby has an elevated focusing."
encourages the wife to consider bilirubin, and I know it will get worse C. "Sometimes I feel like I'm having
other explanations for her husband's and she will die." an out-of-body experience."
tardiness. What technique is the D. "All I seem to focus on is my
nurse using? A client admitted to a Veterans anger."
A. Examination of the evidence Administration (VA) hospital with a
B. Decatastrophizing diagnosis of major depressive When using a cognitive approach,
C. Generating alternatives disorder tells the nurse, "I failed my which point would a nurse include
D. Reattribution battalion by giving the wrong order. when teaching a client about panic
Fortunately, no one was injured." disorder?
A nursing student evaluates her Which nursing diagnosis should the A. "You might want to stay in the
group project partner as nurse assign to this client? house when you notice the
irresponsible because of minimal A. Chronic low self-esteem symptoms beginning."
participation in planning. When told B. Risk for self-directed violence B. "Medications such as lorazepam
of this situation, the nursing C. Powerlessness (Ativan) should be taken when
instructor plans to use the cognitive D. Situational low self-esteem symptoms start."
technique of "examining the C. "Remind yourself that symptoms
evidence." Which response The director of nursing (DON) sets up of a panic attack are time limited
exemplifies this technique? a meeting with the newly appointed and will end."
A. "Let's look at the potential reasons nurse manager who, to this point, D. "Keep a journal in order to note
why your partner has not has done an excellent job. The nurse feelings surrounding the panic
participated." manager anticipates job termination. attacks."
B. "How would you define What is the best description of the
irresponsibility?" cognitive error being employed by Using a cognitive approach, which is
C. "Has it occurred to you that your the nurse manager? an effective nursing intervention for
partner may be working on the A. Thinking from an "all-or-nothing" assisting clients to manage their
project at home?" perspective anger without the use of violence?
D. "Are you telling me that you feel B. Always thinking the worst will A. Assist the client to identify
totally responsible for this project?" occur without considering positive thoughts that trigger anger and
outcomes substitute reality-based thinking.
A nursing assistant has failed a C. Viewing only selected negative B. Provide consequences, such as
prerequisite course toward evidence while editing out positive removal from group therapy, in
admission to nursing school and aspects response to angry outbursts.
states, "I will always be only a D. Undervaluing the positive C. Administer antipsychotic
nursing assistant and never an RN." significance of an event medications and use limit-setting
Her nursing advisor understands this such as a room restriction.
is an example of which automatic A nursing instructor is teaching D. Administer anti-anxiety
thought? about dichotomous thinking. Which medication and encourage
A. Arbitrary inference student statement indicates that participation in a group on
B. Overgeneralization learning has occurred? medication actions.
C. Dichotomous thinking A. "Dichotomous thinking is when an
D. Personalization individual views situations as being A client recovering from alcohol
'good or bad' or 'black or white.'" toxicity is using minimization. Which
A high school basketball player B. "Dichotomous thinking is when an statement reflects this cognitive
sustains a serious knee injury and individual takes complete distortion?
states to the school nurse, "I will responsibility for situations without A. "I can't give up alcohol right now
never get to college if I don't receive considering other circumstances." because I just gave up smoking."
a basketball scholarship." Which C. "Dichotomous thinking is when an B. "I just read that red wine has
nursing reply would assist the individual exaggerates the negative health benefits."
student to see a broader range of significance of an event." C. "I may have a minor problem, but
possibilities? D. "Dichotomous thinking is when an I can handle it."
individual undervalues the positive D. "I don't drink as much as my wife
A. "Let's look at the alternatives for significance of an event." and nobody thinks she has a
funding your college education." problem."
B. "I know you are feeling helpless A client states, "I keep having
now, but you are looking at this from horrible nightmares about the car A client is experiencing auditory
only one perspective." accident that killed my daughter. I hallucinations. Using a cognitive
C. "Can your family afford knee shouldn't have taken her with me to strategy, which should the nurse
surgery?" the store." Using a cognitive encourage the client to do?
D. "You now need to prioritize your approach, which nursing reply would A. "Try singing Happy Birthday until
academics and not focus on be most therapeutic? the voices are gone."
basketball." A. "Are other issues from your past B. "Document what the voices are
affecting your ability to move on?" saying to note cause and effect."
A labor and delivery nurse listens to B. "Describe your current feelings C. "Try listening to music using
a new mother relate thoughts about your loss." headphones for distraction."
regarding her healthy, 8-pound baby C. "Let's talk about something that D. "Remind yourself that the voices
girl. Which statement by the mother are symptoms of your disease."
A client diagnosed with borderline Which assessment information C. "Wait, let me think about that."
personality disorder states, "Get out obtained by the nurse about the D. "Who are those people over
of here. No one cares about me or patient indicates that the patient is there?"
my situation!" Which nursing reply is experiencing delirium rather than
an example of a cognitive dementia? A 71-year-old patient is diagnosed
intervention? A. The patient is disoriented to place with moderate dementia as a result
A. "You have an anti-anxiety and time but oriented to person. of multiple strokes. During
medication ordered. It may make B. The patient has a history of assessment of the patient, the nurse
you feel better." increasing confusion over several would expect to find
B. "It sounds like you are feeling years. A. excessive nighttime sleepiness.
really frustrated." C. The patient's speech is B. variable ability to perform simple
C. "Can you explain further you’re fragmented and incoherent. tasks.
thinking about your situation?" D. The patient was oriented and alert C. difficulty eating and swallowing.
D. "No one cares about you?" when admitted. D. loss of recent and long-term
memory.
A nursing instructor is lecturing When developing a plan of care for a
about cognitive therapy. Which of hospitalized patient with moderate Coexisting dementia and depression
the following are objectives when dementia, which intervention will the are identified in a patient with
implementing this therapy? (Select nurse include? Parkinson's disease. The nurse
all that apply.) A. Reminding the patient frequently anticipates that the greatest
A. To modify automatic thoughts to about being in the hospital improvement in the patient's
promote minimization of negative B. Placing suction at the bedside to condition will occur with
cognitions decrease the risk for aspiration administration of
B. To apply a variety of methods to C. Providing complete personal A. antipsychotic drugs.
create change in an individual's hygiene care for the patient B. anticholinergic agents.
thinking D. Repositioning the patient C. dopaminergic agents and
C. To apply cognitive principles in frequently to avoid skin breakdown antidepressant drugs.
order to change an individual's basic D. selective serotonin reuptake
schema When administering a mental status inhibitor (SSRI) agents.
D. To modify belief systems in an examination to a patient with
delirium, the nurse should A 62-year-old patient is brought to
effort to bring about emotional
A. give the examination when the the clinic by a family member who is
change
patient is well-rested. concerned about the patient's
E. To modify belief systems in an
B. reorient the patient as needed increasing sleep disturbances and
effort to bring about behavioral
during the examination. inability to solve common problems.
change
C. choose a place without distracting To obtain information about the
A nurse practitioner uses cognitive environmental stimuli. patient's current mental status,
therapy with depressed clients. The D. medicate the patient first to which question should the nurse ask
nurse asks clients to keep a daily reduce anxiety. the patient?
record of dysfunctional thoughts. A. "Where were you were born?"
Which of the following are To protect a patient from injury B. "Do have any feelings of
appropriate nursing replies to a during an episode of delirium, the sadness?"
client questioning the purpose of this most appropriate action by the nurse C. "What day of the week is it
exercise? (Select all that apply.) is to today?"
A. "The purpose of this exercise is to A. have a close family member D. "How positive is your self-image?"
identify automatic thoughts." remain with the patient and provide
reassurance. When teaching the spouse of a
B. "The purpose of this exercise is to
B. assign a staff member to stay with patient who is being evaluated for
identify rational alternatives."
the patient and offer frequent Alzheimer's disease (AD) about the
C. "The purpose of this exercise is to
reorientation. disorder, the nurse explains that
modify cognitive errors."
C. ask the health care provider about A. the most important risk factor for
D. "The purpose of this exercise is to
ordering an antipsychotic drug. AD is a family history of the disorder.
eliminate irrational beliefs."
D. secure the patient in bed with a B. a diagnosis of AD can be made
E. "The purpose of this exercise is to
soft chest restraint. only when other causes of dementia
monitor thoughts related to self-
have been ruled out.
esteem."
A family member of a patient with C. new drugs have been shown to
Which of the following client possible Alzheimer's disease asks the reverse AD dramatically in some
statements would indicate that nurse the purpose of the Mini-Mental patients.
teaching about benzodiazepines has State Examination (MMSE). Which D. the presence of brain atrophy
been successful? (Select all that response by the nurse is detected by MRI confirms the
apply.) appropriate? diagnosis of AD in patients with
A. "I can't drink alcohol when taking A. The MMSE helps in establishing dementia.
lorazepam (Ativan)." the diagnosis of Alzheimer's disease
(AD). A home-health patient with
B. "If I abruptly stop taking buspirone
B. The MMSE is useful in determining Alzheimer's disease (AD) and mild
(BuSpar), I may have a seizure."
the degree of mental impairment. dementia has a new prescription for
C. "Valium can make me drowsy, so I
C. The MMSE determines the choice donepezil (Aricept). Which nursing
shouldn't drive for a while."
of the most appropriate treatment. action will be most effective in
D. "My new diet cannot include aged
D. The MMSE aids in differentiating ensuring compliance with the
cheese or pickled herring."
acute delirium from chronic medication?
E. "When the fluoxetine (Prozac)
dementia. A. Setting the medications up weekly
begins working, I can stop the
in a medication box
alprazolam (Xanax)."
When administering a mental status B. Calling the patient daily with a
----------
examination to a patient, the nurse reminder to take the medication
A 72-year-old patient hospitalized suspects depression when the C. Having the patient's spouse
with pneumonia is disoriented and patient responds with administer the medication
confused 2 days after admission. A. "I don't know." D. Posting reminders to take the
B. "Is that the right answer?" medications in the patient's house
Risperidone (Risperdal) is prescribed During the morning change-of-shift 3. Stage 6. Moderate-to-Severe
for an outpatient with moderate report at the long-term care facility, Cognitive Decline
Alzheimer's disease (AD). Which the nurse learns that the patient with 4. Stage 7. Severe Cognitive Decline
information obtained by the nurse at dementia has had sundowning.
the next clinic appointment indicates Which nursing action should the A client is diagnosed in stage seven
that the medication is effective? nurse take while caring for the of AD. To address the client's
A. The patient has less agitation. patient? symptoms, which nursing
B. The patient is dressed A. Move the patient to a quieter intervention should take priority?
appropriately. room at night. 1. Improve cognitive status by
C. The patient is able to swallow a B. Open the blinds in the patient's encouraging involvement in social
pill. room and provide frequent activities. activities.
D. The patient's speech is clearer. C. Have the patient take a brief mid- 2. Decrease social isolation by
morning nap. providing group therapies.
The nurse has identified the nursing D. Provide hourly orientation to time 3. Promote dignity by providing
diagnosis of disturbed thought of day. comfort, safety, and self-care
processes related to effects of measures.
dementia for a patient with late- A geriatric nurse is teaching the 4. Facilitate communication by
stage Alzheimer's disease (AD). An client's family about the possible providing assistive devices.
appropriate intervention for this cause of delirium. Which statement
problem is to by the nurse is most accurate? Which is the reason for the
A. maintain a consistent daily routine 1. "Taking multiple medications may proliferation of the diagnosis of
for the patient's care. lead to adverse interactions or NCDs?
B. encourage the patient to discuss toxicity." 1. Increased numbers of
events from the past. 2. "Age-related cognitive changes neurotransmitters have been
C. reorient the patient to the date may lead to alterations in mental implicated in the proliferation of
and time every few hours. status." NCD.
D. provide the patient with current 3. "Lack of rigorous exercise may 2. Similar symptoms of NCD and
newspapers and magazines. lead to decreased cerebral blood depression lead to misdiagnoses,
flow." increasing numbers of NCD.
A patient with Alzheimer's disease 4. "Decreased social interaction may 3. Societal stress contributes to the
(AD) is hospitalized with a urinary lead to profound isolation and increase in this diagnosis.
tract infection. The spouse tells the psychosis." 4. More people now survive into the
nurse, "I am just exhausted from the high-risk period for neurocognitive
constant care and worry. We don't A husband has agreed to admit his disorders.
have any children and we can't spouse, diagnosed with Alzheimer's
afford a nursing home. I don't know disease (AD), to a long-term care A client diagnosed recently with AD
what to do." The most appropriate facility. He is expressing feelings of is prescribed donepezil (Aricept). The
nursing diagnosis for the spouse is guilt and symptoms of depression. client's spouse inquires, "How does
A. anxiety related to limited financial Which appropriate nursing diagnosis this work? Will this cure him?" Which
resources. and subsequent intervention would is the appropriate nursing response?
B. ineffective health maintenance the nurse document? 1. "This medication delays the
related to stress. 1. Dysfunctional grieving; AD support destruction of acetylcholine, a
C. caregiver role strain related to group chemical in the brain necessary for
limited resources for caregiving. 2. Altered thought process; AD memory processes. Although most
D. social isolation related to support group effective in the early stages, it
unrelieved caregiving 3. Major depressive episode; serves to delay, but not stop, the
responsibilities. psychiatric referral progression of the disease."
4. Caregiver role strain; psychiatric 2. "This medication encourages
A long-term care patient with referral production of acetylcholine, a
moderate dementia develops chemical in the brain necessary for
increased restlessness and agitation. A client diagnosed with vascular memory processes. It delays the
The nurse's initial action should be to neurocognitive disorder (NCD) is progression of the disease."
A. administer the PRN dose of discharged to home under the care 3. "This medication delays the
lorazepam (Ativan). of his wife. Which information should destruction of dopamine, a chemical
B. reorient the patient to time and cause the nurse to question the in the brain necessary for memory
place. client's safety? processes. Although most effective in
C. assess the patient for anything 1. His wife works from home in the early stages, it serves to delay,
that might be causing discomfort. telecommunication. but not stop, the progression of the
D. have a nursing assistant stay with 2. The client has worked the disease."
the patient to ensure safety. nightshift his entire career. 4. "This medication encourages
3. His wife has minimal family production of dopamine, a chemical
When assessing a patient with support. in the brain necessary for memory
Alzheimer's disease (AD) who is 4. The client smokes one pack of processes. It delays the progression
being admitted to a long-term care cigarettes per day. of the disease."
facility, the nurse learns that the
patient has had several episodes of A client diagnosed with AD can no Which symptom should a nurse
wandering away from home. Which longer ambulate, does not recognize identify that differentiates clients
nursing action will the nurse include family members, and communicates diagnosed with NCDs from clients
in the plan of care? with agitated behaviors and diagnosed with mood disorders?
A. Ask the patient why the wandering incoherent verbalizations. The nurse 1. Altered sleep
episodes have occurred. recognizes these symptoms as 2. Altered concentration
B. Reorient the patient to the new indicative of which stage of the 3. Impaired memory
living situation several times daily. illness? 4. Impaired psychomotor activity
C. Place the patient in a room close 1. Stage 4: Mild-to-Moderate
to the nurses' station. Cognitive Decline A client diagnosed with AD exhibits
D. Have the family bring in familiar 2. Stage 5. Moderate Cognitive progressive memory loss, diminished
items from the patient's home. Decline cognitive functioning, and verbal
aggression upon experiencing
frustration. Which nursing 3. Diazepam (Valium) experiencing? Tactile
intervention is most appropriate? 4. Sertraline (Zoloft) Hallucinations
1. Organize a group activity to
present reality. 15. A client diagnosed with NCD is A patient with fluctuating levels of
2. Minimize environmental lighting. disoriented and ataxic and wanders. consciousness, disturbed orientation,
3. Schedule structured daily routines. Which is the priority nursing and perceptual alteration begs,
4. Explain the consequences for diagnosis? "Someone get these bugs off me."
aggressive behaviors. 1. Disturbed thought processes What is the nurse's best response? "I
don't see any bugs, but I can tell you
After one week of continuous mental 2. Self-care deficit are frightened. I will stay with you."
confusion, an older African American
client is admitted with a preliminary 3. Risk for injury What is the priority nursing diagnosis
diagnosis of AD. What should cause 4. Altered health-care maintenance for a patient with fluctuating levels of
the nurse to question this diagnosis? Which statement accurately consciousness, disturbed orientation,
1. AD does not typically occur in differentiates mild NCD from major and visual and tactile hallucinations?
African American clients. NCD? Risk for injury related to altered
2. The symptoms presented are 1. Major NCD involves disorientation cerebral function, fluctuating levels
more indicative of Parkinsonism. that develops suddenly, whereas of consciousness, disturbed
3. AD does not develop suddenly. mild NCD develops more slowly. orientation, and misperception of the
4. There has been no T3- or T4-level 2. Major NCD involves impairment of environment
evaluation ordered. abstract thinking and judgment,
What is the priority intervention for a
whereas mild NCD does not.
A client diagnosed with AD has patient diagnosed with delirium who
3. Major NCD criteria requires
impairments of memory and has fluctuating levels of
substantial cognitive decline from a
judgment and is incapable of consciousness, disturbed orientation,
previous level of performance, and
performing activities of daily living. and perceptual alterations? Careful
mild NCD requires modest decline.
Which nursing intervention should observation and supervision
4. Major NCD criteria requires decline
take priority? from a previous level of performance A patient diagnosed with delirium is
1. Present evidence of objective in three of the listed domains, and experiencing perceptual alterations.
reality to improve cognition. mild NCD requires only one. Which environmental adjustment
2. Design a bulletin board to
should the nurse make for this
represent the current season. Which statement accurately
patient? Provide a well-lit room
3. Label the client's room with name differentiates NCD from
without glare or shadows. Limit noise
and number. pseudodementia (depression)?
and stimulation.
4. Assist with bathing and toileting. 1. NCD has a rapid onset, whereas
pseudodementia does not. Which assessment finding would be
A client diagnosed with major NCD is 2. NCD symptoms include likely for a patient experiencing a
exhibiting behavioral problems on a disorientation to time and place, and hallucination? The patient: States, "I
daily basis. At change of shift, the pseudodementia does not. feel bugs crawling on my legs and
client's behavior escalates from 3. NCD symptoms improve as the biting me."
pacing to screaming and flailing. day progresses, but symptoms of
Which action should be a nursing pseudodementia worsen. Consider these health problems:
priority? 4. NCD causes decreased appetite, Lewy body disease, frontal-temporal
1. Consult the psychologist regarding whereas pseudodementia does not. lobar degeneration, and Huntington's
behavior-modification techniques. disease. Which term unifies these
2. Medicate the client with prn Which of the following conditions problems? Dementia
antianxiety medications. have been known to precipitate
3. Assess environmental triggers and delirium in some individuals? (Select Which medication prescribed to
potential unmet needs. all that apply.) patients diagnosed with Alzheimer's
4. Anticipate the behavior and 1. Febrile illness disease antagonizes N-Methyl-D-
restrain when pacing begins. 2. Seizures Aspartate (NMDA) channels rather
3. Migraine headaches than cholinesterase? Memantine
A client with a history of 4. Herniated brain stem
cerebrovascular accident (CVA) is 5. Temporomandibular joint An older adult was stopped by police
brought to an emergency syndrome for driving through a red light. When
department experiencing memory asked for a driver's license, the adult
problems, confusion, and Which of the following medications hands the police officer a pair of
disorientation. Based on this client's that have been known to precipitate sunglasses. What sign of dementia is
assessment data, which diagnosis delirium? (Select all that apply.) evident? Agnosia
would the nurse expect the physician 1. Antineoplastic agents
to assign? 2. H2-receptor antagonists An older adult drove to a nearby
1. Delirium due to adverse effects of 3. Antihypertensives store but was unable to remember
cardiac medications 4. Corticosteroids how to get home or state an address.
2. Vascular neurocognitive disorder 5. Lipid-lowering agents When police intervened, they found
3. Altered thought processes that this adult was wearing a heavy
4. Alzheimer's disease An older adult patient takes multiple coat and hat, even though it was
medications daily. Over 2 days, the July. Which stage of Alzheimer's
An older client has recently moved to patient developed confusion, slurred disease is evident? Moderately
a nursing home. The client has speech, an unsteady gait, and severe cognitive decline
trouble concentrating and socially fluctuating levels of orientation.
isolates. A physician believes the These findings are most Consider these diagnostic findings:
client would benefit from medication characteristic of Delirium apolipoprotein E (apoE) malfunction,
therapy. Which medication should neurofibrillary tangles, neuronal
the nurse expect the physician to A patient with fluctuating levels of degeneration in the hippocampus,
prescribe? awareness, confusion, and disturbed and brain atrophy. Which health
1. Haloperidol (Haldol) orientation shouts, "Bugs are problem corresponds to these
2. Donepezil (Aricept) crawling on my legs. Get them off!" diagnostic findings? Alzheimer's
Which problem is the patient disease
A patient with stage 3 Alzheimer's when they visit. What is the nurse's Impaired level of consciousness
disease tires easily and prefers to best reply? "It is disappointing when Disorientation to place and time
stay home rather than attend social someone you love no longer Wandering attention
activities. The spouse does the recognizes you."
grocery shopping because the Which nursing diagnoses are most
patient cannot remember what to A patient with severe dementia no applicable for a patient diagnosed
buy. Which nursing diagnosis applies longer recognizes family members with severe Alzheimer's disease?
at this time? Impaired memory and becomes anxious and agitated Select all that apply.
when they attempt reorientation.
A patient has progressive memory Which alternative could the nurse Urinary incontinence
deficits associated with dementia. suggest to the family members? Disturbed sleep pattern
Which nursing intervention would Focus interaction on familiar topics. Risk for caregiver role strain
best help the individual function in
What is the priority need for a The nurse notes signs if uncreased
the environment? Assist the patient
patient with late-stage dementia? ICP in a kid who has undergone
to perform simple tasks by giving
Maintenance of nutrition and insertion of a shunt to tx.
step-by-step directions.
hydration hydrocephalus. What should the
Two patients in a residential care nurse do?
facility have dementia. One shouts to An older adult is prescribed digoxin
(Lanoxin) and hydrochlorothiazide An early sign is a change in the level
the other, "Move along, you're
daily as well as lorazepam (Ativan) of consciousness, HA, N&V, diplopia
blocking the road." The other patient
as needed for anxiety. Over 2 days, or visual disturbances and seizures.
turns, shakes a fist, and shouts,
the patient developed confusion, *normally the DR. orders the kid to
"You're trying to steal my car." What
slurred speech, an unsteady gait, be kept flat to avoid rapid reduction
is the nurse's best action? Separate
and fluctuating levels of orientation. of intracranial fluid. If increased ICP
and distract the patients. Take one
What is the most likely reason for the occurs the HOB should be elevated
to the day room and the other to an
patient's change in mental status? 15-30 degrees and enhance flow,
activities area.
Drug actions and interactions surgeon notified STAT
An older adult patient in the
A hospitalized patient diagnosed with What is the earliest indication of an
intensive care unit has visual and
delirium misinterprets reality, while a improvement or deterioration of the
auditory illusions. Which intervention
patient diagnosed with dementia neurological condition? The child's
will be most helpful? Using the
wanders about the home. Which level of consciousness
patient's glasses and hearing aids
outcome is the priority in both
A high shrill cry in an infant can be a
A patient diagnosed with Alzheimer's scenarios? The patients will: Remain
sign of what? Increased ICP
disease calls the fire department safe in the environment.
saying, "My smoke detectors are The parents of a kid recently dx. with
going off." Firefighters investigate An elderly patient is admitted with
CP asks the nurse about the disorder.
and discover that the patient delirium secondary to a urinary tract
The nurse bases the response on the
misinterpreted the telephone ringing. infection. The family asks whether
understanding that CP is what type
Which problem is this patient the patient will ever recover. Select
of condition?
experiencing? Agnosia the nurse's best response. "The
1. An infectious disease of the CNS
confusion will probably get better as
2. An inflammation of the brain as a
During morning care, a nurse asks a we treat the infection."
result of a viral illness
patient diagnosed with dementia,
An elderly person presents with 3. A congenital condition that results
"How was your night?" The patient
symptoms of delirium. The family in moderate to severe retardation
replies, "It was lovely. I went out to
reports, "Everything was fine until 4. A chronic disability characterized
dinner and a movie with my friend."
yesterday." What is the most by impaired muscle movement and
Which term applies to the patient's
important assessment information posture
response? Confabulation
for the nurse to gather? A list of all
The nurse notes a kid has a positive
A nurse counsels the family of a medications the person currently
Kernig's sign. Which observation is
patient diagnosed with Alzheimer's takes
characteristic of this sign?
disease who lives at home and
A nurse gives anticipatory guidance 1. The kid c/o muscle and joint pain
wanders at night. Which action is
to the family of a patient diagnosed 2. petechial and purpuric rashes are
most important for the nurse to
with stage 3, mild cognitive decline noted on the child's trunk
recommend to enhance safety?
Alzheimer's disease. Which problem 3. neck flexion causes adduction and
Place locks at the tops of doors.
common to that stage should the flexion movements of the lower
Goals of care for an older adult nurse address? Communication extremities
patient diagnosed with delirium deficits 4. The child in not able to extend the
caused by fever and dehydration will leg when the thigh is flexed
focus on returning to premorbid A patient diagnosed with moderately anteriorly at the hip
levels of function. severe Alzheimer's disease has a
self-care deficit of dressing and A 5 year old arrives at ER and mom
An older adult with moderately grooming. Designate appropriate states he fell off bunk bed. What is a
severe dementia forgets where the interventions to include in the late sign of increased ICP?
bathroom is and has episodes of patient's plan of care. Select all that 1. Nausea 3. HA
incontinence. Which intervention apply 2. Irritability 4. bradycardia
should the nurse suggest to the
patient's family? Label the bathroom Provide clothing with elastic and
door hook-and-loop closures
Label clothing with the patient's
A older patient diagnosed with name and name of the item 8 yr old with basilar skull fx.; Which
severe, late-stage dementia no order should the nurse question and
longer recognizes family members. Which assessment findings would call the HCP
The family asks how long it will be the nurse expect in a patient 1. Suction as needed
before this patient recognizes them experiencing delirium? Select all that 3. clean liquids
apply
2. daily wt. What manifestations of cognitive the neighbors' names and forgot
4. maintain patent IV line impairment are primarily their
characteristic of delirium (select all granddaughter's birthday. What kind
The nurse is reviewing notes on kid that apply)? of loss does the nurse recognize this
with increased ICP, What are a. Reduced awareness to be?
characteristics of decerebrate b. Impaired judgments a. Delirium
posturing? c. Words difficult to find b. Memory loss in AD
1. flaccid paralysis d. Sleep/wake cycle reversed c. Normal forgetfulness
2. adduction of the arms at the e. Distorted thinking and perception d. Memory loss in mild cognitive
shoulders f. Insidious onset with prolonged impairment
3. rigid extension and pronation of duration
the arms and legs The newly admitted patient has
4. abnormal flexion of the upper Which statement accurately moderate AD. What does the nurse
extremities and extension of the describes dementia? know this patient will need help
lower ones a. Overproduction of β-amyloid with?
protein causes all dementias. a. Eating c. Dressing
A kids is Dx. with Reye's syndrome. b. Dementia resulting from b. Walking d. Self-
Which intervention should be added neurodegenerative causes can be care activities
to the plan? prevented.
1. assess hearing loss c. Dementia caused by hepatic or What is one focus of collaborative
2. monitor urine output renal encephalopathy cannot be care of patients with AD?
3. change position q 2 hr reversed. a. Replacement of deficient
4. provide quiet room with dim d. Vascular dementia can be acetylcholine in the brain
lighting diagnosed by brain lesions identified b. Drug therapy for cognitive
with neuroimaging. problems and undesirable behaviors
What should be bedside in a patient c. The use of memory-enhancing
with tonic clonic seizures? A patient with Alzheimer's disease techniques to delay disease
1. emergency cart (AD) dementia has manifestations of progression
2. trach set depression. The nurse knows that d. Prevention of other chronic
3. padded tongue blade treatment of the patient with diseases that hasten the progression
4. suctioning and O2 antidepressants will most likely do of AD
what?
A LP is done on a kid who is The patient is receiving donepezil
a. Improve cognitive function
suspected of having bacterial (Aricept), lorazepam (Ativan),
b. Not alter the course of either
meningitis and CSF is obtained. risperidone (Risperdal), and
condition
Which result would be positive for sertraline (Zoloft) for the
c. Cause interactions with the drugs
meningitis? management of AD. What
used to treat the dementia
1. Clear CNS, decreased pressure, & benzodiazepine medication is being
d. Be contraindicated because of the
elevated protein level used to help manage this patient's
central nervous system (CNS)-
2. Clear CNS, ^protein, decreased behavior?
depressant effect of antidepressants
glucose level a. Sertraline (Zoloft)
3. Cloudy CNS, ^protein, decreased For what purpose would the nurse b. Donepezil (Aricept)
glucose use the Mini-Mental State c. Lorazepam (Ativan)
4. Cloudy CNS, decreased protein Examination to evaluate a patient d. Risperidone (Risperdal)
and glucose with cognitive
impairment? The wife of a patient who is
What precautionary intervention manifesting deterioration in memory
a. It is a good tool to determine the
should be in place for a pt. with asks the nurse whether her husband
etiology of dementia.
bacterial meningitis? has AD. The nurse explains that a
b. It is a good tool to evaluate mood
1. maintain enteric precautions diagnosis of AD is usually made
and thought processes.
2. maintain neutropenic precautions when what happens?
c. It can help to document the
3. no precautions are required as a. A urine test indicates elevated
degree of cognitive impairment in
long as an ATB has been started levels of isoprostanes
delirium and dementia.
4. maintain resp. isolation b. All other possible causes of
d. It is useful for initial evaluation of
precautions for at least 24 hrs after dementia have been eliminated
mental status but additional tools are
the initiation of ATB c. Blood analysis reveals increased
needed to evaluate changes in
cognition over time. amounts of β-amyloid protein
The nurse is caring for a pt with d. A computed tomography (CT) scan
hydrocephalus that is scheduled for During assessment of a patient with of the brain indicates brain atrophy
surgery. What is the priority dementia, the nurse determines that
intervention in the preop period? What N-methyl-d-aspartate (NMDA)
the condition is potentially reversible
1. test urine for protein receptor antagonist is frequently
when finding out what about the
2. reposition the infant frequently used for a patient with AD who is
patient?
3. provide a stimulating environment experiencing decreased memory and
a. Has long-standing abuse of alcohol
4. Bp q 15 minutes cognition?
b. Has a history of Parkinson's
disease a. Trazodone (Desyrel)
What interventions should be done if
c. Recently developed symptoms of b. Olanzapine (Zyprexa)
a kid has a seizure?
hypothyroidism c. Rivastigmine (Exelon)
SELECT ALL
d. Was infected with human d. Memantine (Namenda)
1. time it
immunodeficiency virus (HIV) 10
2. restrain the kid
years ago The son of a patient with early-onset
3. place in prone position AD asks if he will get AD. What
4. move furniture away from kid The husband of a patient is should the nurse tell this man about
5. stay with the kid complaining that his wife's memory the genetics of AD?
6. insert tongue blade has been decreasing lately. When a. The risk of early-onset AD for the
asked for children of parents with it is about
examples of her memory loss, the 50%.
husband says that she is forgetting b. Women get AD more often than
men do, so his chances of getting AD isolation related to diminishing social c. The report of emergency
are slim. relationships and behavioral personnel that he was
c. The blood test for the ApoE gene problems of the patient with AD. noncommunicative when they
to identify this type of AD can predict What is a nursing intervention that arrived at the accident scene
who will develop it. would be appropriate to provide d. The report of his family that
d. This type of AD is not as complex respite care and allow the wife to although he has heart disease and is
as regular AD, so he does not need have satisfactory contact with "very hard of hearing," this behavior
to worry about getting AD. significant others? is
a. Help the wife to arrange for adult unlike him
A patient with AD in a long-term care day care for the patient.
facility is wandering the halls very b. Encourage permanent placement What should be included in the
agitated, asking for her "mommy" management of a patient with delirium?
of the patient in the Alzheimer's unit
and a. The use of restraints to protect the
of a long-term care facility. patient from injury
crying. What is the best response by c. Refer the wife to a home health b. The use of short-acting
the nurse? agency to arrange daily home benzodiazepines to sedate the
a. Ask the patient, "Why are you nursing visits to assist with the patient
behaving this way?" patient's care. c. Identification and treatment of
b. Tell the patient, "Let's go get a d. Arrange for hospitalization of the underlying causes when possible
snack in the kitchen." patient for 3 or 4 days so that the d. Administration of high doses of an
c. Ask the patient, "Wouldn't you like wife can visit out-of-town friends and antipsychotic drug such as
to lie down now?" relatives. haloperidol (Haldol)
d. Tell the patient, "Just take some
deep breaths and calm down." When caring for a patient in the
severe stage of AD, what diversion or
The sister of a patient with AD asks distraction activities would be
the nurse whether prevention of the appropriate?
disease is possible. In responding, a. Watching TV
the nurse explains that there is no b. Playing games
known way to prevent AD but there c. Books to read
are ways to keep the brain healthy. d. Mobiles or dangling ribbons
What is included in the ways to keep
the brain healthy (select all that The health care provider is trying to
apply)? differentiate the diagnosis of the
patient between dementia and
a. Avoid trauma to the brain. dementia with Lewy bodies (DLB).
b. Recognize and treat depression What observations by the nurse
early. support a diagnosis of DLB (select all
c. Avoid social gatherings to avoid that apply)?
infections. a. Tremors
d. Do not overtax the brain by trying b. Fluctuating cognitive ability
to learn new skills. c. Disturbed behavior, sleep, and
e. Daily wine intake will increase personality
circulation to the brain. d. Symptoms of pneumonia,
f. Exercise regularly to decrease the including congested lung sounds
risk for cognitive decline e. Bradykinesia, rigidity, and postural
instability without tremor
A patient with moderate AD has a
nursing diagnosis of impaired Delegation Decision: The RN in
memory related to effects of charge at a long-term care facility
dementia. What is an appropriate could delegate which activities to
nursing intervention for this patient? unlicensed
a. Post clocks and calendars in the assistive personnel (UAP) (select all
patient's environment. that apply)?
b. Establish and consistently follow a a. Assist the patient with eating.
daily schedule with the patient. b. Provide personal hygiene and skin
c. Monitor the patient's activities to care.
maintain a safe patient environment. c. Check the environment for safety
d. Stimulate thought processes by hazards.
asking the patient questions about d. Assist the patient to the bathroom
recent activities at regular intervals.
e. Monitor for skin breakdown and
The family caregiver for a patient swallowing difficulties.
with AD expresses an inability to
make decisions, concentrate, or A 68-year-old man is admitted to the
sleep. The nurse determines what emergency department with multiple
about the caregiver? blunt trauma following a one-vehicle car
a. The caregiver is also developing accident. He is restless; disoriented to
person, place, and time; and agitated. He
signs of AD.
resists attempts at examination and calls
b. The caregiver is manifesting out the name "Janice." Why should the
symptoms of caregiver role strain. nurse suspect delirium rather than
c. The caregiver needs a period of dementia in this patient?
respite from care of the patient. a. The fact that he wouldn't have
d. The caregiver should ask other been allowed to drive if he had
family members to participate in the dementia
patient's care. b. His hyperactive behavior, which
differentiates his condition from the
The wife of a man with moderate AD hypoactive behavior of dementia
has a nursing diagnosis of social