NURS 1062 |Psychiatric Mental Health
Nursing NCLEX Questions| (Community
College of Rhode Island) 100% Verified
A 14-year-old client is brought to the clinic by her mother. Her mother
expresses concern about her daughter's weight loss and constant dieting. The
nurse conducts health history interview. Which of the following comments
indicates that the client may be suffering from anorexia nervosa?
A. "I like the way I look. I just need to keep my weight down because I'nm a
cheerleader."
B. "I don't like the food my mother cooks. I eat plenty of fast food when I'm out
with my friends."
C. "I just can't seem to get down to the weight I want to be. I'm so fat
compared to other girls."
D. "I do diet around my periods; otherwise, I just get so bloated." -
------------ANS: C. "I just can't seem to get down to the weight I want to be. I'm
so fat compared to other girls."
Rationale: Low self-esteem is the highest risk factor for anorexia nervosa.
Constant dieting to get down to a "desirable weight" is characteristic of the
disorder. Feeling inadequate when compared to peers indicates poor
self-esteem. Most clients with anorexia nervosa don't like the way they look,
and their self-perception may be distorted. A girl with cachexia may perceive
herself to be other weight when she looks in the mirror. Proffering fast food
over health food is common in this age-group. Because of the absence of
body fat necessary for proper hormone production, amenorrhea is common in
this client with anorexia nervosa.
A 24-year-old client with anorexia nervosa tells the nurse, "When I look in the
mirror, I hate what I see. I look so fat and ugly." Which strategy should the
nurse use to deal with the client's distorted perceptions and feelings?
A. Avoid discussing the client's perceptions and feelings
B. Focus discussions on food and weight
C. Avoid discussing unrealistic cultural standards regarding weight
D. Provide objective data and feedback regarding the client's weight and
attractiveness - ------------ANS: D. Provide objective data and feedback
regarding the client's weight and attractiveness
,Rationale: By focusing on reality, this strategy may help the client develop a
more realistic body image and gain self-esteem. Option A is inappropriate
because discussing the client's perceptions and feelings wouldn't help her
identify, accept, and work through them. Focusing discussions on food and
weight would the client attention for not eating, making option B incorrect.
Option C is inappropriate because recognizing unrealistic cultural standards
wouldn't help the client establish more realistic weight goals.
A 25-year-old client experiencing alcohol withdrawal is upset about going
through detoxification. Which of the following goals is a priority?
A. The client will commit to a drug-free lifestyle
B. The client will work with the nurse to remain safe
C. The client will drink plenty of fluids daily
D. The client will make a personal inventory of strengths - ------------ANS: B.
The client will work with the nurse to remain safe
Rationale: The priority goal in alcohol withdrawal is maintaining the client'
safety. Committing to a drug-free lifestyle, drinking plenty of fluids, and
identifying personal strengths are important goals, but ensure the client's
safety is the nurse's top priority.
A client whose husband just left her has a recurrence of anorexia nervosa.
The nurse caring for her realizes that this exacerbation of anorexia nervosa
results from the client's effort to:
A. Manipulate her husband
B. Gain control of one part of her life
C. Commit suicide
D. Live up to her mother's expectations - ------------ANS: B. Gain control of
one part of her life
Rationale: By refusing to eat, a client with anorexia nervosa is unconsciously
attempting to gain control over the only part of her life she feels she can
control. This eating disorder doesn't represent an attempt to manipulate others
or live up to their expectations (although anorexia nervosa has a high
incidence in families that emphasizes achievement). The client isn't attempting
to commit suicide through starvation; rather, by refusing to eat, she is
expressing feelings or despair, worthlessness,s and hopelessness.
A female client begins to experience alcoholic hallucinosis. The nurse is
aware that the best nursing intervention at this time is:
A. Keeping the client restrained in bed
B. Checking the client's blood pressure every 15 minutes and offering juices
, C. Providing a quiet environment and administering medications as needed
and prescribed
D. Restraining the client and measuring blood pressure every 30 minutes -
------------ANS: C. Providing a quiet environment and administering
medications as needed and prescribed
Rationale: Manifestations of alcoholic hallucinosis are best treated by
providing a quiet environment to reduce stimulation and administering
prescribed central nervous system depressants in dosages that control
symptom without causing oversedation. Although bed rest is indicated,
restraints are unnecessary unless the client poses a danger to himself or
others. Also, restrains may increase agitation and make the client feel trapped
and helpless when hallucinating. Offering juices is appropriate but measuring
blood pressure every 15 minutes would interrupt the client's rest. To avoid
overstimulating the client, the nurse should check blood pressure every 2
hours.
A female client is admitted to the psychiatric clinic for treatment of anorexia
nervosa. To promote the client's physical health, the nurse should plan to:
A. Severely restrict the client's physical activities
B. Weigh the client daily, after the evening meal
C. Monitor vital signs, serum electrolytes levels, and acid-base balance
D. Instruct the client to keep an accurate record of food and fluid intake -
------------ANS: C. Monitor vital signs, serum electrolyte levels, and acid-base
balance
Rationale: An anorexic client who requires hospitalization is in poor physical
condition from starvation and may die as a result of arrhythmias, hypothermia,
malnutrition, infection, or cardiac abnormalities secondary to electrolyte
imbalances. Therefore, monitoring the client's vital signs, serum electrolyte
levels, and acid-base balance is crucial. Option A may worsen anxiety. Option
B is incorrect because a weight obtained after breakfast is more accurate than
one obtained after the evening meal. Option D would reward the client with
attention for not eating and reinforce the control issues that are central to the
underlying psychological problem; also, the client may record food and fluid
intake inaccurately.
A female client who's at high risk for suicide needs close supervision. To best
ensure the client's safety, the nurse should:
A. Check on the client frequently at irregular intervals throughout the night
B. Assure the client that the nurse will hold in confidence anything the client
says
Nursing NCLEX Questions| (Community
College of Rhode Island) 100% Verified
A 14-year-old client is brought to the clinic by her mother. Her mother
expresses concern about her daughter's weight loss and constant dieting. The
nurse conducts health history interview. Which of the following comments
indicates that the client may be suffering from anorexia nervosa?
A. "I like the way I look. I just need to keep my weight down because I'nm a
cheerleader."
B. "I don't like the food my mother cooks. I eat plenty of fast food when I'm out
with my friends."
C. "I just can't seem to get down to the weight I want to be. I'm so fat
compared to other girls."
D. "I do diet around my periods; otherwise, I just get so bloated." -
------------ANS: C. "I just can't seem to get down to the weight I want to be. I'm
so fat compared to other girls."
Rationale: Low self-esteem is the highest risk factor for anorexia nervosa.
Constant dieting to get down to a "desirable weight" is characteristic of the
disorder. Feeling inadequate when compared to peers indicates poor
self-esteem. Most clients with anorexia nervosa don't like the way they look,
and their self-perception may be distorted. A girl with cachexia may perceive
herself to be other weight when she looks in the mirror. Proffering fast food
over health food is common in this age-group. Because of the absence of
body fat necessary for proper hormone production, amenorrhea is common in
this client with anorexia nervosa.
A 24-year-old client with anorexia nervosa tells the nurse, "When I look in the
mirror, I hate what I see. I look so fat and ugly." Which strategy should the
nurse use to deal with the client's distorted perceptions and feelings?
A. Avoid discussing the client's perceptions and feelings
B. Focus discussions on food and weight
C. Avoid discussing unrealistic cultural standards regarding weight
D. Provide objective data and feedback regarding the client's weight and
attractiveness - ------------ANS: D. Provide objective data and feedback
regarding the client's weight and attractiveness
,Rationale: By focusing on reality, this strategy may help the client develop a
more realistic body image and gain self-esteem. Option A is inappropriate
because discussing the client's perceptions and feelings wouldn't help her
identify, accept, and work through them. Focusing discussions on food and
weight would the client attention for not eating, making option B incorrect.
Option C is inappropriate because recognizing unrealistic cultural standards
wouldn't help the client establish more realistic weight goals.
A 25-year-old client experiencing alcohol withdrawal is upset about going
through detoxification. Which of the following goals is a priority?
A. The client will commit to a drug-free lifestyle
B. The client will work with the nurse to remain safe
C. The client will drink plenty of fluids daily
D. The client will make a personal inventory of strengths - ------------ANS: B.
The client will work with the nurse to remain safe
Rationale: The priority goal in alcohol withdrawal is maintaining the client'
safety. Committing to a drug-free lifestyle, drinking plenty of fluids, and
identifying personal strengths are important goals, but ensure the client's
safety is the nurse's top priority.
A client whose husband just left her has a recurrence of anorexia nervosa.
The nurse caring for her realizes that this exacerbation of anorexia nervosa
results from the client's effort to:
A. Manipulate her husband
B. Gain control of one part of her life
C. Commit suicide
D. Live up to her mother's expectations - ------------ANS: B. Gain control of
one part of her life
Rationale: By refusing to eat, a client with anorexia nervosa is unconsciously
attempting to gain control over the only part of her life she feels she can
control. This eating disorder doesn't represent an attempt to manipulate others
or live up to their expectations (although anorexia nervosa has a high
incidence in families that emphasizes achievement). The client isn't attempting
to commit suicide through starvation; rather, by refusing to eat, she is
expressing feelings or despair, worthlessness,s and hopelessness.
A female client begins to experience alcoholic hallucinosis. The nurse is
aware that the best nursing intervention at this time is:
A. Keeping the client restrained in bed
B. Checking the client's blood pressure every 15 minutes and offering juices
, C. Providing a quiet environment and administering medications as needed
and prescribed
D. Restraining the client and measuring blood pressure every 30 minutes -
------------ANS: C. Providing a quiet environment and administering
medications as needed and prescribed
Rationale: Manifestations of alcoholic hallucinosis are best treated by
providing a quiet environment to reduce stimulation and administering
prescribed central nervous system depressants in dosages that control
symptom without causing oversedation. Although bed rest is indicated,
restraints are unnecessary unless the client poses a danger to himself or
others. Also, restrains may increase agitation and make the client feel trapped
and helpless when hallucinating. Offering juices is appropriate but measuring
blood pressure every 15 minutes would interrupt the client's rest. To avoid
overstimulating the client, the nurse should check blood pressure every 2
hours.
A female client is admitted to the psychiatric clinic for treatment of anorexia
nervosa. To promote the client's physical health, the nurse should plan to:
A. Severely restrict the client's physical activities
B. Weigh the client daily, after the evening meal
C. Monitor vital signs, serum electrolytes levels, and acid-base balance
D. Instruct the client to keep an accurate record of food and fluid intake -
------------ANS: C. Monitor vital signs, serum electrolyte levels, and acid-base
balance
Rationale: An anorexic client who requires hospitalization is in poor physical
condition from starvation and may die as a result of arrhythmias, hypothermia,
malnutrition, infection, or cardiac abnormalities secondary to electrolyte
imbalances. Therefore, monitoring the client's vital signs, serum electrolyte
levels, and acid-base balance is crucial. Option A may worsen anxiety. Option
B is incorrect because a weight obtained after breakfast is more accurate than
one obtained after the evening meal. Option D would reward the client with
attention for not eating and reinforce the control issues that are central to the
underlying psychological problem; also, the client may record food and fluid
intake inaccurately.
A female client who's at high risk for suicide needs close supervision. To best
ensure the client's safety, the nurse should:
A. Check on the client frequently at irregular intervals throughout the night
B. Assure the client that the nurse will hold in confidence anything the client
says
