Question 1

A nurse is performing an admission assessment on a patient diagnosed with schizophrenia. Which of the following should the nurse identify as a negative symptom?

Accepted Answer

Answer reason: Diminished emotional expression presents clinically as reduced facial animation and vocal inflection, making it a classic negative symptom. In contrast, delusions and hallucinations are positive symptoms because they add abnormal experiences, and disorganized speech is typically grouped with positive/disorganized symptoms rather than negative. Identifying negative symptoms matters because they often predict functional impairment and respond less robustly to treatment than positive symptoms.

Question 2

A patient is experiencing anxiety accompanied by a sense of doom, hallucinations, trembling, and diaphoresis. What level of anxiety is this patient experiencing?

Accepted Answer

Answer reason: Hallucinations and a sense of impending doom indicate severe perceptual disturbance and inability to process the environment accurately. Trembling and diaphoresis reflect intense sympathetic activation commonly seen at the panic level. In contrast, severe anxiety may include narrowed perception and physical symptoms, but typically does not progress to frank hallucinations and profound disorganization as seen in panic.

Question 3

A patient states that after yelling at their wife, they try to make things better by bringing her flowers and doing household chores. Which type of defense mechanism is this?

Accepted Answer

Answer reason: Here, the patient tries to counterbalance yelling by doing kind actions and extra chores to “fix” the emotional impact. This fits undoing because the behavior is aimed at reversing the perceived harm rather than addressing the underlying trigger. Displacement would involve redirecting anger toward a safer target, while repression and suppression involve blocking or consciously setting aside distressing thoughts rather than making reparative gestures.

Question 4

Two children from the same neglectful and abusive home show different levels of trauma response, with one child appearing significantly more affected. What is the best explanation for this difference?

Accepted Answer

Answer reason: Resilience is a core psychological concept that describes an individual’s ability to cope with and adapt to stress or trauma. Even in similar environments, children may respond differently due to variations in resilience, support systems, and coping capacity.

Question 5

A patient tells the nurse that when he gets angry, he takes out that frustration by hitting a punching bag instead of yelling at others. Which type of defense mechanism is this?

Accepted Answer

Answer reason: Sublimation is a mature defense mechanism where unacceptable impulses (e.g., anger/aggression) are channeled into a socially acceptable, constructive activity. Using a punching bag redirects anger into exercise rather than expressing it toward other people, reducing harm while still releasing tension. Displacement would involve shifting anger from the true source to a safer target person/object in a way that is still maladaptive (e.g., yelling at family after being criticized at work). Regression and repression do not fit because they involve reverting to earlier behaviors or unconsciously blocking thoughts/feelings, not transforming the impulse into an acceptable outlet.

Question 6

The most severe psychiatric disorder after childbirth is?

Accepted Answer

Answer reason: This condition can present abruptly in the early postpartum period with delusions, hallucinations, severe mood lability, disorganized behavior, and impaired judgment, making it a psychiatric emergency requiring urgent evaluation and often inpatient treatment. Compared with postpartum depression, which can be serious and include suicidality, it typically does not include frank psychosis. Postpartum blues are common, transient, and mild, and generalized anxiety symptoms alone do not match the severity and immediate safety risk of a psychotic episode.

Question 7

A client who has had many different physical illnesses in the past few years is no longer employed, rarely does housework or shopping, and states that she "just can't seem to do anything." Which of the following is a priority nursing diagnosis?

Accepted Answer

Answer reason: The client’s statement “I just can't seem to do anything” reflects a perceived lack of control over life circumstances, which is characteristic of powerlessness. While fatigue and impaired home maintenance may be present, the priority is the underlying psychological state affecting motivation and functioning. Body image disturbance is not supported by the scenario.

Question 8

Which term refers to perceptual abnormality?

Accepted Answer

Answer reason: A hallucination is a perceptual disturbance in which an individual experiences sensory input (e.g., seeing or hearing things) without an external stimulus. Delusion is a false fixed belief (thought disorder), while attention and orientation are cognitive functions, not perceptual abnormalities.

Question 9

Type of personality in which individual is outgoing, cheerful and full of energy is-?

Accepted Answer

Answer reason: Hypomanic personality traits include elevated mood, increased energy, sociability, and cheerfulness. Melancholic is associated with depression, paranoid with distrust, and cyclothymic involves mood fluctuations rather than consistently elevated, energetic behavior.

Question 10

When is a client at risk for developing a mental illness?

Accepted Answer

Answer reason: Mental illness risk is associated with maladaptive coping mechanisms that impair daily functioning. The key clinical indicator is dysfunction combined with ineffective stress responses, not merely distress or deviation from norms alone.

Question 11

The nurse is caring for a patient with depression and is assessing their ability to perform activities of daily living (ADLs). The nurse should identify the patient can perform which of the following prior to discharge?

Accepted Answer

Answer reason: Bathing is a core basic ADL that reflects whether the patient can maintain hygiene independently, which is often impaired in depression due to low energy and poor motivation. In contrast, driving, grocery shopping, and balancing a checkbook are more complex instrumental activities of daily living (IADLs) requiring higher executive functioning and community engagement. Demonstrating independence with basic ADLs is a minimum discharge readiness indicator, while IADLs can be supported with planning and community resources if needed.

Question 12

The nurse evaluates that the plan of care for a client who suddenly lost her hearing (diagnosed as a conversion disorder) was effective if the client?

Accepted Answer

Answer reason: Nursing care focuses on reducing anxiety, supporting coping, and avoiding reinforcement of the symptom as “needed” to manage stress. Symptom substitution or escalation can occur when maladaptive accommodations become the focus of care rather than recovery. Learning sign language, hearing aids, or surgery imply a structural hearing problem and may inadvertently validate and reinforce a nonorganic symptom.

Question 13

A client with conversion disorder has been eagerly preparing for his marriage. On the morning of the wedding, he is unable to move his legs. What would the nurse expect to find in the mental status examination?

Accepted Answer

Answer reason: A classic exam finding is an apparent lack of concern or inappropriate calmness about serious deficits, reflecting unconscious conflict rather than feigned illness. The timing (wedding day) suggests an acute stressor with sudden motor symptom onset, making this mood/affect feature especially likely. Depressed, anxious, or blunted mood can occur in many conditions but are not characteristic hallmark findings for conversion symptoms in an exam-style question. This expectation supports a psychosocial etiology while still requiring medical evaluation to rule out organic causes.

Question 14

Which of the following nursing interventions would support optimal memory function for a client with dementia?

Accepted Answer

Answer reason: Meaningful therapeutic activities (e.g., reminiscence-based activities, simple structured hobbies, music) leverage intact long-term memories and can improve attention, mood, and participation without increasing frustration. Trying to force recall of forgotten events can heighten anxiety and agitation because the client cannot reliably retrieve new memories. Reality orientation may be used gently in early stages, but it does not optimize memory function as well as tailored cognitive stimulation, and restraints are unsafe and can worsen confusion and agitation.

Question 15

A 7-year old recently admitted to a hospital states, "I'm not afraid of this place; I'm not afraid of anything." Which defense mechanism of the ego does the nurse recognize?

Accepted Answer

Answer reason: A newly hospitalized child is likely experiencing fear, but states the opposite (“not afraid of anything”) as an overcompensation to manage distress. This differs from repression, which involves unconsciously blocking the anxiety-provoking feeling from awareness rather than declaring the opposite. It is also not regression, which would show a return to earlier developmental behaviors (e.g., bedwetting, thumb-sucking) in response to stress.

Question 16

When the nurse informs an adolescent client that scheduled parental visit will not occur, the client throws a cup at the nurse. In order to best respond to this behavior, the nurse should conclude that the client is displaying which of the following?

Accepted Answer

Answer reason: The adolescent’s anger and disappointment about the canceled parental visit are shifted onto the nurse, who is immediately available and less emotionally risky to attack than the parent or the situation itself. Projection would involve attributing one’s own feelings to someone else (e.g., claiming the nurse is angry), which is not demonstrated here. Denial would require refusing to accept the reality of the canceled visit rather than acting out aggressively toward a substitute target.

Question 17

Situation: Based on studies of nurses working in special units like the intensive care unit and coronary care unit it is important for nurses to gather as much information to be able to address their needs for nursing care. Critically ill patient frequently complain about which of the following when hospitalized?

Accepted Answer

Answer reason: ICU/CCU environments often involve open bays, constant staff traffic, alarms, and limited ability to control who can see/hear sensitive information. This directly affects psychological safety, increases anxiety, and can worsen sleep and coping. While comfort issues like warmth can occur, privacy concerns are more consistently reported as a frequent complaint in critical care settings.

Question 18

A nurse is caring for four patients on a med/surg floor of a hospital. Based on what the nurse knows about risk factors for sensory and/or perceptual alterations, which of these patients would least likely be at risk of potentially developing this problem?

Accepted Answer

Answer reason: A brief, minimally invasive postoperative course with adequate analgesia reduces these triggers and makes new-onset perceptual disturbance less likely. In contrast, extensive burns with poorly controlled pain create severe physiologic stress and high analgesic/sedative exposure, increasing delirium risk. Even mild head trauma can impair cognition and perception and warrants observation for evolving neurologic changes.

Question 19

A nurse is caring for a patient with a depressive disorder. The patient states, “I just don’t feel any happiness or joy in my life anymore.” Which of the following terms should the nurse use when documenting this finding?

Accepted Answer

Answer reason: The patient’s report of no longer feeling happiness or joy directly reflects a loss of interest/pleasure rather than a movement disorder or lack of insight. Akathisia refers to inner restlessness (often medication-induced), and anosognosia is unawareness of illness/deficits, neither matching the statement. Anergia describes low energy, which can co-occur in depression but is not what the patient is describing here.

Question 20

A client continues to have pain despite negative neurological findings. The nurse concludes that such pain is likely to continue because of which of the following?

Accepted Answer

Answer reason: When pain behaviors are rewarded (e.g., attention, relief from responsibilities, obtaining medications, financial or interpersonal benefits), the behavior can be maintained and the pain complaint is more likely to persist. Endorphins generally modulate pain downward rather than prolong it, and tissue structural changes would more typically correlate with objective abnormalities. Derealization is a dissociative symptom and does not directly explain ongoing pain reports without physiologic correlates.

Question 21

A patient with schizophrenia says to the nurse “monkeys running green friendly books.” Which type of speech alteration is this patient experiencing?

Accepted Answer

Answer reason: The quoted phrase is a cluster of unrelated words that does not convey a meaningful idea, which best matches this pattern. Clang association would show a sound-based linkage (rhyming or punning) rather than purely random word selection. Echolalia is repetition of another’s words, and flight of ideas is rapid, loosely connected but still somewhat understandable shifting of topics (classically in mania).

Question 22

A client who has ulcerative colitis says to the nurse, "I can’t take this anymore! I’m constantly in pain, and I can’t leave my room because I need to stay by the toilet. I don’t know how to deal with this." Based on these comments, an appropriate nursing diagnosis for this client would be?

Accepted Answer

Answer reason: The client expresses inability to leave the room and distress about their condition, indicating withdrawal from social interaction. This aligns with social isolation rather than cognitive disturbance or mobility limitation.

Question 23

The nurse is conducting an in-service education session about the relationship between anxiety and bulimia nervosa. The nurse best describes the relationship by saying, "When the client has bulimia nervosa, an increase in the anxiety level will generally result in:"?

Accepted Answer

Answer reason: Increased anxiety often precipitates binge eating due to loss of perceived control and intense negative affect, followed by compensatory purging to relieve guilt and rapidly decrease tension. This pattern is characteristic of bulimia, whereas rigid control of intake is more typical of anorexia nervosa’s restrictive presentation. Overeating alone omits the defining compensatory behaviors, and alcohol use may co-occur but is not the primary, most typical immediate response within bulimia’s core symptom cycle.

Question 24

The nurse is teaching a group of young adolescents about eating disorders. The nurse would consider the sessions effective if the participants state that anorexia nervosa is best defined as an eating disorder that occurs?

Accepted Answer

Answer reason: Adolescents—most commonly females—may perceive themselves as overweight despite being underweight, which directly captures the defining psychopathology. Depression or family chaos may be associated risk factors but are not defining features and are not present in all cases. It can occur in males, but the epidemiology and hallmark cognitive distortion make this option the best definition-focused choice.

Question 25

When assessing an adolescent client for depression, it is most important for the nurse to recognize that depression in adolescents is often?

Accepted Answer

Answer reason: Recognizing these externalizing behaviors helps the nurse avoid mislabeling the problem as “just behavior” and ensures timely screening for suicidality and functional impairment. This presentation difference is a key developmental consideration in mental health assessment. The idea that it is merely situational or less serious is unsafe because adolescent depression can be severe and associated with self-harm.

Question 26

A 3-year old client has been diagnosed with attention deficit/hyperactivity disorder (ADHD). The child's parents report that a friend told them that the child will likely receive "lots of drugs". The nurse should reply that the child will most likely be given a drug such as?

Accepted Answer

Answer reason: This option is a stimulant medication classically used to treat ADHD and is therefore the best match to what the child is most likely to receive. The antidepressants listed are not standard first-line agents for ADHD symptom control, and antipsychotics are generally reserved for severe aggression/psychosis rather than primary ADHD. Nursing teaching also includes that treatment is typically individualized and may include behavioral therapy, not “lots of drugs.”.

Question 27

The client with Alzheimer’s disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting?

Accepted Answer

Answer reason: Using a toothbrush as if it were a hairbrush reflects an inability to correctly sequence and execute an ADL task with the appropriate tool. This is common in Alzheimer’s disease as cortical dysfunction affects planning and motor programming. By contrast, agnosia is failure to recognize objects, and aphasia/anomia primarily involve language deficits rather than performance of the motor task.

Question 28

Ethnocentrism is the root of?

Accepted Answer

Answer reason: Ethnocentrism is the belief that one’s own culture is the standard by which others should be judged, which commonly leads to stereotyping and negative value judgments about people from different cultural groups. That stance directly fosters biased perceptions and prejudicial attitudes, and in healthcare it can translate into inequitable communication, assumptions about adherence, and reduced cultural humility. Options describing “cultural beliefs” or meaning-making are broader, neutral concepts of culture rather than a mechanism that produces discrimination. Individualism/self-reliance is a cultural value orientation but is not the core consequence or “root” of ethnocentrism.

Question 29

The nurse is establishing outcomes for a client who is depressed. The outcomes will be entered into the nursing care plan and used by all members of the treatment team. The best stated outcome is the client will?

Accepted Answer

Answer reason: A quantified change on a validated depression rating scale provides a clear baseline-to-target metric, making progress trackable over time and across shifts. In contrast, statements about feelings or insight are subjective and difficult to measure reliably, and increased socialization may be an intervention/behavioral goal that does not directly quantify symptom severity. Using a measurable instrument-based target also supports consistent interdisciplinary communication and evaluation.

Question 30

The nurse caring for an adolescent with Cushing’s syndrome should be mindful of which nursing diagnosis specific to this patient?

Accepted Answer

Answer reason: In adolescence, identity formation and peer acceptance make appearance-related changes a dominant psychosocial stressor, increasing risk for low self-esteem and social withdrawal. This makes a body-image diagnosis particularly specific and high-yield for this population compared with more generic physiologic problems. Skin fragility can occur, but the question emphasizes what is most specific to an adolescent’s nursing needs and coping.

Question 31

A client in treatment for drug abuse makes the statement, I am a winner. You all are the losers because you can't beat this on your own. What common characteristic of persons addicted to drugs is revealed in this statement?

Accepted Answer

Answer reason: The statement shows superiority, blame, and contempt toward others, consistent with denial/externalization and inflated self-presentation rather than insight. This defensive style helps the person avoid confronting the impact of addiction and the vulnerability involved in recovery. A personality disorder may coexist but is not required to explain this common addiction-related coping mechanism, and chronic brain injury is not suggested by the content of the speech.

Question 32

The nurse is assigned to a client who is hospitalized following a motor vehicle accident. The nurse determines that the client has a strong internal locus of control after hearing the client make which of the following statements?

Accepted Answer

Answer reason: " An internal locus of control reflects the belief that one’s own actions and effort significantly influence outcomes. This statement emphasizes personal responsibility and active participation in recovery through physical therapy, demonstrating self-efficacy and control over rehabilitation. In contrast, blaming another driver or attributing recovery solely to doctors places control externally, and relying on a higher power to “take charge” reflects external control. The client’s focus on what they can do to improve recovery is the key indicator.

Question 33

A 13-year old child is brought to the clinic with a history of conduct disorder. The nursing history reveals several facts about the family. Which one is most likely to have contributed to the child's conduct problems? The parents?

Accepted Answer

Answer reason: Inconsistent consequences undermine the child’s learning of boundaries and self-control, while harsh responses model aggression as a problem-solving strategy. This combination increases escalation cycles (child misbehaves → harsh reaction → increased defiance), making conduct symptoms more persistent. By contrast, high expectations or parental overinvolvement can contribute to stress or anxiety-related issues but are less directly linked to the hallmark antisocial, rule-violating behavior pattern.

Question 34

The client has the diagnosis of acquired immunodeficiency syndrome (AIDS). The nurse observes that the client is demonstrating changes in behavior that include memory difficulties, declining attention to personal hygiene, and frequent manifestations of angry and hostile behaviors. The nurse assists the client's family and friends to understand this as an indication of which of the following?

Accepted Answer

Answer reason: The described pattern (memory problems, poor self-care, irritability/hostility) is consistent with chronic cognitive impairment rather than an acute, fluctuating change in consciousness. Delirium is typically abrupt in onset with waxing/waning attention and is more likely linked to an acute infection, medication intoxication/withdrawal, or metabolic disturbance. These changes do not specifically indicate imminent death, and while medications can cause neuropsychiatric effects, the functional decline and pervasive cognitive/behavioral change most strongly supports chronic CNS impairment.

Question 35

A nurse is caring for a client with signs of depression and self-destructive behavior. He idolizes the nurse one moment and then completely devalues them the next. Which defense mechanism is the client most likely using?

Accepted Answer

Answer reason: It is classically associated with borderline personality traits and is common in clients who have unstable relationships and self-harm behaviors. The described behavior is not explained by projection (attributing one’s unacceptable feelings to others) or sublimation (channeling impulses into acceptable activities). Recognizing this helps the nurse maintain consistent, boundaried interactions and avoid being pulled into polarization among staff.

Question 36

Which assessment data would prohibit the use of imagery with a client?

Accepted Answer

Answer reason: This increases the risk of intensifying hallucinations, delusions, or disorganized thinking, making it an unsafe nonpharmacologic technique in this population without specialized oversight. Moderate anxiety does not inherently contraindicate imagery and can be an indication for relaxation strategies when the client can participate safely. Lack of prior experience or reluctance to close the eyes are barriers that can be addressed by education and adapting the technique (e.g., eyes open, shorter sessions) rather than absolute prohibitions.

Question 37

Which finding indicates to the nurse that a client with a burn injury has a positive perception of his appearance?

Accepted Answer

Answer reason: Independently completing morning care shows acceptance of the changed appearance and an adaptive coping response rather than avoidance. In contrast, relying on family for dressing changes may signal discomfort with the wounds or dependence and does not directly demonstrate self-acceptance. Adhering to pressure dressings and discussing reconstruction are more consistent with treatment adherence and future planning than with current, positive perception of appearance.

Question 38

The dominant value orientation in North American society is?

Accepted Answer

Answer reason: Mainstream North American cultural norms generally emphasize autonomy, personal choice, and individual responsibility for health decisions and outcomes. This aligns with expectations that people seek information, advocate for themselves, and independently adhere to treatment and lifestyle recommendations. The other options more closely reflect cultural patterns commonly associated with collectivist societies or specific traditional/spiritual healing orientations. Recognizing this dominant value helps nurses avoid stereotyping while still anticipating common preferences for independence and informed decision-making in care planning.

Question 39

Kyle is a client with an anxious, fearful personality who has difficulty accomplishing work assignments because of his fear of failure. He has been referred to the employee assistance program because of repeated absences from work and evidence of an alcohol problem. Which nursing diagnosis would be most appropriate?

Accepted Answer

Answer reason: Fear of failure with inability to complete work tasks, repeated absences, and alcohol misuse are consistent with an ineffective pattern of managing anxiety and stress. This diagnosis directly captures both the functional impairment and the likely reliance on alcohol as a maladaptive strategy. Decisional conflict would require evidence of difficulty choosing among options, disturbed thought processes suggests psychosis/cognitive disorganization not described, and risk for self-directed violence is not supported without suicidal ideation or other risk indicators.

Question 40

A nurse has been told that a client’s anxiety is at the panic level. The nurse would assess the client for which manifestations expected at this level of anxiety?

Accepted Answer

Answer reason: Prominent physical symptoms such as tachycardia/palpitations, dizziness, and gastrointestinal distress (e.g., nausea) are typical because the sympathetic nervous system response peaks. By contrast, “butterflies” in the stomach is more consistent with mild anxiety where perceptual field remains broad and functioning is generally intact. Obsessive thoughts and compulsions describe an OCD pattern rather than the defining manifestations of acute panic-level anxiety, and profound fatigue/inability to stay awake is not a classic panic presentation.

Question 41

A female client with Cushing’s syndrome is admitted to the medical-surgical unit. During the admission assessment, nurse Tyzz notes that the client is agitated and irritable, has poor memory, reports loss of appetite, and appears disheveled. These findings are consistent with which problem?

Accepted Answer

Answer reason: Cushing’s syndrome (hypercortisolism) commonly causes mood and cognitive changes due to glucocorticoid effects on the CNS. Agitation/irritability, impaired concentration or memory, poor self-care/appearance, and appetite disturbance fit a depressive picture that can present with mixed anxious features. Neuropathy is not suggested by the stem because there are no sensory changes, pain, or weakness described. Hypoglycemia is unlikely in Cushing’s (more often hyperglycemia) and would more typically cause diaphoresis, tremor, palpitations, and acute confusion rather than a disheveled, depressed presentation.

Question 42

A client who recently had a gastrostomy feeding tube inserted refuses to participate in the plan of care, will not make eye contact, and does not speak to family or visitors. Which type of coping mechanism should the nurse assess the client is using?

Accepted Answer

Answer reason: Refusing to participate, avoiding eye contact, and not interacting with family/visitors are classic behavioral signs of withdrawal and detachment rather than an inability to understand. Denial would more typically involve rejecting the reality/meaning of the procedure itself (e.g., insisting nothing is wrong) instead of pervasive social disengagement. Regression would present as childlike or earlier-development behaviors, and suppression is a conscious, purposeful decision to set aside feelings while still functioning and engaging.

Question 43

A 24-year-old client presents to the emergency department protesting "I am God." The nurse identifies this as a?

Accepted Answer

Answer reason: Grandiose content such as claiming a divine identity reflects a disturbance in thought content rather than a disturbance in perception. An illusion involves misinterpreting a real external stimulus, while a hallucination is a perception without an external stimulus—neither is described here. Conversion refers to neurologic-like symptoms arising from psychological conflict, not a belief statement.

Question 44

A patient diagnosed with borderline personality disorder (BPD) yells at a nurse administering medication and demands to speak with the psychiatric physician. He states, "Only my physician knows my medication regimen!" This statement is an example of?

Accepted Answer

Answer reason: By insisting that only the physician understands the regimen while devaluing the nurse’s competence, the patient is idealizing the provider and devaluing nursing staff. This can escalate conflict and undermine consistent care unless the team maintains unified communication and boundaries. Rationalization would involve justifying behavior with seemingly logical excuses, denial would reject reality of a fact, and sublimation channels unacceptable impulses into acceptable activities—none match the staff-splitting dynamic shown here.

Question 45

The most influential text used by clinicians treating those with mental illness is?

Accepted Answer

Answer reason: The DSM-5 is the standard reference clinicians use to diagnose mental disorders. It outlines clear diagnostic criteria and gives healthcare providers a common framework when identifying and discussing conditions. The other options are policy or public health documents, not tools used in daily clinical diagnosis.

Question 46

The nurse is planning care for a client with moderate Alzheimer's disease (AD). Which of the following interventions should the nurse include in the client's plan of care?

Accepted Answer

Answer reason: Reality orientation becomes less effective as Alzheimer’s progresses, while validation and reminiscence can reduce anxiety and promote a sense of identity and comfort. Encouraging pleasant reminiscence leverages relatively preserved long-term memories in moderate dementia and supports therapeutic communication. Confronting inappropriate/agitated behavior typically escalates distress and can worsen agitation; the safer approach is de-escalation, redirection, and reassurance. Cholinesterase inhibitors may modestly slow symptom progression but do not reverse the disease course, and expecting the client to plan the day relies on executive function that is commonly impaired at this stage.

Question 47

What is the potential risk of abruptly stopping the use of antidepressants?

Accepted Answer

Answer reason: Sudden changes in central serotonergic/noradrenergic signaling may produce agitation, dysphoria, anxiety, and impulsivity, all of which elevate suicide risk. From a nursing safety perspective, any medication change that destabilizes depression requires close monitoring for suicidal ideation and emergent safety planning. Insomnia can occur with withdrawal, but it is less critical than the potentially life-threatening risk of suicidality.

Question 48

The registered nurse is leading a support group for partners of military veterans suffering from posttraumatic stress disorder (PTSD). A participant asks the nurse how to identify the typical symptoms of PTSD. The nurse responds that most individuals with PTSD report which symptoms?

Accepted Answer

Answer reason: g., heightened anxiety/irritability), intrusion (e.g., flashbacks and re-experiencing the trauma), and avoidance/negative mood changes (e.g., emotional numbing and detachment). This option directly matches those hallmark domains: anxiety reflects hyperarousal, reliving the event reflects intrusive symptoms, and detachment reflects negative alterations in cognition/mood. Options featuring hallucinations and delusions point more toward primary psychotic disorders rather than typical PTSD presentations. Daytime sleepiness is not a defining PTSD symptom and is more consistent with sleep deprivation, sedating medications, or sleep disorders.

Question 49

The nurse is caring for a hospitalized elderly client who is admitted with pneumonia. Which assessment finding is most consistent with the diagnosis of delirium?

Accepted Answer

Answer reason: Inattention is the hallmark feature and may be accompanied by perceptual disturbances such as visual hallucinations. Pneumonia is a classic precipitant due to systemic inflammation and impaired oxygenation, making this finding highly consistent with delirium. Decreased enjoyment suggests depression, and a gradual progressive decline in recent memory points more toward dementia rather than an acute confusional state.

Question 50

A mother brings her 3-year-old child in, as she is concerned because the child continuously bangs his head and bites himself. Which of the following mental disorders should the nurse assess the child for?

Accepted Answer

Answer reason: Head banging and self-biting fit the pattern of stereotypies that are rhythmic and persistent, and the key nursing concern is risk for injury and identifying associated neurodevelopmental conditions. Transient tic disorder and Tourette’s involve sudden, brief tics that wax and wane rather than sustained self-injurious repetitive behaviors. Encopresis is a toileting disorder and does not explain repetitive self-harm behaviors.

Train with a large NCLEX question bank and jump into a full exam-style simulator

Mental Health Concepts NCLEX Practice Test

Continue Learning