Answers and Rationale

Answers and Rationale retaliate with significant consequences.
Introjection
involves taking on the characteristics of another.
Projection is characterized by accusing someone of
1. B one’s own weaknesses. Compensation is

demonstrated by overcoming some inadequacy by
Rationale: Being overly talkative is a common sign of excelling at another activity.
use of amphetamines (Dexedrin). This drug is a
stimulant; staring into space and slurring words are
side effects typical of depressant type of drugs.
Reference: Timby, B.K., Carmack, A., & Rupert, D.L.
Some marijuana users wear sunglasses indoors to
Lippincott’s review for NCLEX-PN. 7th ed. (2006).
disguise their inflamed eyes.
MAD : Maladaptive Disorders | BSN 002

Philadelphia: Lippincott Williams & Wilkins.

4. C
Philadelphia: Lippincott Williams & Wilkins. Rationale: Clients with bipolar disorder, formerly
called manic-depressive disorder, have cycles in
which they display a marked change in mood
2. B between mania (abnormal highs) and depression

(lows). The disorder is called bipolar because of the
Rationale: The most common side effects of swings between the opposing poles of mood. Mania
risperidone (Risperdal) include insomnia and often affects thinking, judgment, and social behavior,
agitation. Orthostatic hypotension also occurs with causing serious problems. Bipolar disorder is a
reflex tachycardia. Risperidone (Risperdal) does not recurring illness that can be treated with long-term
increase extrapyramidal symptoms. Anticholinergic medication. The exaggerated mood is followed or
symptoms such as urine retention are not commonly preceded by an interval of normal mood. None of the
reported. Weight gain, not loss may develop. other behaviors is symptomatic of bipolar disorder.
Reference: Timby, B.K., Carmack, A., & Rupert, D.L. Reference: Timby, B.K., Carmack, A., & Rupert, D.L.
Lippincott’s review for NCLEX-PN. 7th ed. (2006). Lippincott’s review for NCLEX-PN. 7th ed. (2006).
Philadelphia: Lippincott Williams & Wilkins. Philadelphia: Lippincott Williams & Wilkins.
3. D 5. A
Rationale: Displacement is a coping mechanism in Rationale: Involuntary facial movements and tongue
which a person transfers his angry feelings for one and eye movements indicate the development of
person onto someone else who is less likely to tardive dyskinesia, a negative consequence of
1
antipsychotic (neuroleptic) drug therapy. The Reference: Linda Anne Sivestri. Saunder’s
condition is usually irreversible, even after the drug Comprehensive Review for the NCLEX-RN
is discontinued. About 20% of those treated with Examination Third Ed. Elsevier Inc. 2005. CD-ROM
antipsychotic medications in the long-term develop
tardive dyskinesia. None of the other assessment
8. B.
findings is linked to antipsychotic drug withdrawal.
Rationale:The initial nursing action would be to

assess for any physiological causes of the paralysis.
Although a component of the plan of care would be
Philadelphia: Lippincott Williams & Wilkins.
to encourage the client to discuss feelings, this

would not be the initial nursing action. To encourage
the client to use the arm without ruling out a
6. D.
physiological cause of the paralysis is not
Rationale: The client presents a lethally potential if appropriate. Although the client may be referred to a
he/ she appear disorganized and impulsive. Clients psychiatrist, this also is not the initial action.
at higher risk include those with a history of a dual

diagnosis of mental illness and substance abuse; a Reference: Linda Anne Sivestri. Saunder’s
personal or family history of suicide attempts, Comprehensive Review for the NCLEX-RN
depression, alcoholism; or psychotic episodes. Examination Third Ed. Elsevier Inc. 2005. CD-ROM
Having a plan, particularly if the method is

immediate and available, makes the client a very
9. D.
high risk.
Rationale:A person who is experiencing mania lacks
insight and judgment, has poor impulse control, and
Reference: Linda Anne Sivestri. Saunder’s
is highly excitable. The nurse must take control
Comprehensive Review for the NCLEX-RN
without creating increased stress or anxiety to the
Examination Third Ed. Elsevier Inc. 2005. CD-ROM
client. A quiet, firm approach while distracting the
client (walking her room to room and assisting her to
7. D. get dressed) achieves the goal of having her

dressed appropriately and preserving her
Rationale: Rigid and inflexible behaviours are psychosocial integrity. Ignoring the client is
characteristics of the client with obsessive- inappropriate. Telling the other clients to go into
compulsive disorder (OCD). Clients with this nursing unit day room immediately is inappropriate
disorder are not usually hostile unless they are and does not address the client’s behaviour.
prevented from engaging in the obsession or
compulsion because this behaviour is what
decreases the anxiety. Reference: Linda Anne Sivestri. Saunder’s
Comprehensive Review for the NCLEX-RN
Examination Third Ed. Elsevier Inc. 2005. CD-ROM
2
sexual concerns. Therefore, options b, c and d are
incorrect.
10. D.
Rationale: The most therapeutic response by the

nurse is the one that makes the client aware of the Reference: Comprehensive Review for the NCLEX-
verbal statement and directs the client to the RN EXAMINATION Ed. 4, 2008, Saunders et al
purpose of the. The nurse should confront the client
13. A
verbally regarding the client’s statement and refocus
the client back to the issue of the session. Rationale: According to Erickson, the caregiver
should not try to anticipate the newborn infant’s

needs at all times but must allow the newborn infant
Reference: Linda Anne Sivestri. Saunder’s to signal needs. If a newborn infant s not allowed to
Comprehensive Review for the NCLEX-RN signal a need, the newborn will not learn how to
Examination Third Ed. Elsevier Inc. 2005. CD-ROM control the environment . Erickson believed that a
delayed or prolonged response to a newborn infant’s
signal would inhibit the development of trust and
11. C
would lead to mistrust others.
Rationale: A nurse’s initial task when assessing a

client in crisis is to assess the individual or family
and the problem. The more clearly the problem can Reference: Comprehensive Review for the NCLEX-
be defined, the better the chance a solution can be RN EXAMINATION Ed. 4, 2008, Saunders et al
found. Option c will assist in determining data related
to the precipitating event that led to the crisis.
Options a and b assess situational support. Option d 14. C
assesses personal coping mechanism.
Rationale: A conversion disorder is the alteration or
loss of a physical function that cannot be explained
by any known pathophysiological mechanism. A
Reference: Comprehensive Review for the NCLEX-
conversion disorder is thought to be an expression
RN EXAMINATION Ed. 4, 2008, Saunders et al
of psychological need or conflict. In this situation, the
client witnessed an accident that was so
psychologically painful that the client became blind.
12. A
A dissociative disorder is a disturbance or alteration
Rationale: According to Freud’s psychosexual in the normally integrative function s of identity,
stages of development, between the ages of 3 and memory or consciousness. Psychosis is a state in
6, the child is in the phallic stage. At this time, the which a person’s mental capacity to recognize
child devotes much energy in examining his or her reality, communicate and relate to others is
genitalia, masturbating and expressing interest in impaired, thus interfering with the person’s ability to
deal with life’s demands. Repression is coping
3
mechanism which unacceptable feelings are kept
out of awareness.
17. B
RATIONALE: Because the client has problems with

Reference: Comprehensive Review for the NCLEX- altered thought and has self-care deficits, the nurse
RN EXAMINATION Ed. 4, 2008, Saunders et al needs to make the decisions. Simple questions and
directions are most appropriate. The client is not
15. B
capable of making decisions at this time. Asking the
Rationale: Solitary activities that require a short other 3 options requires the client to make a
attention span with mild physical exertion are the decision. These types of questions are inappropriate

most appropriate activities for a client who is in this situation.
exhibiting aggressive behavior. Writing (journaling),

walks with staff and finger painting are the activities
that minimize the stimuli and provide a constructive REFERENCE: Lippincott’s review series, Medical-
release for tension. Competitive games should be surgical nursing, Fourth edition by Ray A. Hargrove-
avoided because they can stimulate aggression and Huttel, RN, PhD. Page367.
increase psychomotor activities.
18. B
Reference: Comprehensive Review for the NCLEX-
RATIONALE: the nurse should never promise to
RN EXAMINATION Ed. 4, 2008, Saunders et al
keep a secret. Secrets are appropriate in social
relationships but not in therapeutic relationships. The
nurse needs to be honest with the client and tell the
16. A
client that a promise cannot be made to keep a
RATIONALE: The client with aphasia may need secret.
additional time to select the proper words when

speaking. It is essential for the nurse to allow the
client time to complete the sentence. Showing or REFERENCE: SAUNDERS comprehensive review
naming various objects in the environment and NCLEX-RN examination 2008, 4th edition. Page
leaving the room are inappropriate responses. 1139
Actions such as these often lead to additional client
frustration, anxiety, and feelings of low self esteem.
19. A
RATIONALE: Generally, the client seeks voluntary

REFERENCE: Lippincott’s review series, Medical-
admission. Voluntary clients have the right to
surgical nursing, Fourth edition by Ray A. Hargrove-
demand and obtain release. If the client is a minor,
Huttel, RN, PhD. Page367.
the release may be contingent on the consent of the
4
partent or guardian. The nurse needs to be familiar ideas, actions or feelings by developing acceptable
with the state and facility policies and procedures. explanations that satisfies the teller and the listener.
The best nursing action is to contact the physician.
23. D
REFERENCE: SAUNDERS comprehensive review
Rationale: Short-term goals include the beginning
NCLEX-RN examination 2008, 4th edition. Page
stages of dealing with the rape trauma. Clients will
1139
be expected initially to keep appointments,
participate in care, begin to explore feelings, and
begin to heal any physical wounds that were inflicted

20. A
at the time of rape.
RATIONALE: Denial is refusal to admit painful

reality, which is treated as if it does not exist.
24. A
REFERENCE: SAUNDERS comprehensive review
NCLEX-RN examination 2008, 4th edition. Page Rationale: One-to-one suicide precautions are
1138 required for the client who attempted suicide.
Options 2 and 3 maybe appropriate, but not at the
present time considering the situation. Option 4 also
21. A maybe an appropriate nursing intervention, but the

priority is identified in option 1. The best intervention
Rationale: In the formal operation stage, the child is constant supervision so that the nurse may
has the ability to think abstractly and logically. intervene as needed if the client attempts to cause
Option 2 identifies concrete operation stage. Option harm to self.
3 identifies sensorimotor stage. Option 4 identifies
the preoperational stage.
25. C
22. A Rationale: Hanging is a serious suicide attempt. The

plan of care must reflect action that will ensure the
Rationale: Denial is refusal to admit to a painful client’s safety. Constant observation status (one to
reality, which is treated as if it does not exist. In one) with a staff member who is never less than an
projection, a person unconsciously rejects arm’s length away is the best selection. Seclusion
emotionally unacceptable features and attributes should not be the initial intervention, and the least
them to other persons, objects, or situations. In restrictive measures should be used. Placing the
regression, the client returns to an earlier, more client in a hospital gown and requesting that a peer
comforting, although less mature way of behaving. remain with the client will not ensure a safe
Rationalization is justifying illogical or unreasonable environment.
5
26. A (Thompson Peterson. NCLEX-PN Certification
Rationale: The manic patient may neglect to eat or Exam. Peterson’s Advision of Thompson Learning
sleep, due to excessive energy and flight of ideas. Corp.2003.p 128)
30. C
Auditory hallucinations that are “commanding” a
(Thompson Peterson. NCLEX-PN Certification
patient to hurt someone can make the patient a
Exam. Peterson’s Advision of Thompson Learning
danger to himself or others. The RN provider needs
Corp.2003.p 127)
to know that they are occurring.

27. A
Rationale: Structured activities will help keep the
depressed patient active, and small groups provide
Corp.2003.p 129)
social contact without being overwhelming.
31. B.
Exam. Peterson’s Advision of Thompson Learning Rationale: The nurse’s nonverbal behavior, moving
Corp.2003.p 128) away from the window as seethe client’s request,
would indicate agreement with the client’s false
ideas. The client’s behavior is likely to be reinforced
28. A if the nurse takes to agree with the false ideas he
It is typical for the elderly to feel shamed and holds.
humiliated by the abuse they receive.
(NCLEX-RN Examination 8th Edition by Diane M.
(Thompson Peterson. NCLEX-PN Certification Bilings)

Corp.2003.p 128)
32. B
Rationale: The nursing diagnosis Disturbed Thought

29. A
Processes related to increase anxiety, as evidenced
The paranoid patient is easily threatened, and the
by delusional thinking, most accurately reflects this
most important point to remember when
client’s problem with paranoid delusions. Disturbed
approaching them is to avoid touching them or
Sensory Perception: Visual would be appropriate if
getting to close.
the client were expecting hallucinations. Impaired
6
Verbal Communication would be appropriate if the safety is no longer an issue because antipsychotics
client were demonstrating less coherent speech. are beginning to take effect. Telling the client that
Social Isolation would be appropriate if the client the hallucinations are part of the illness or that the
were refusing to come out of his room. medications will help control the voices would be
appropriate once the client has developed some
insight into the symptoms of illness.

Bilings)
Bilings)

33. A
Rationale: The nurse needs to present the reality of

35. A
the situation. By explaining that the men are
groundskeepers and probably talking about work, Rationale: Hallucination and asocial behaviors are
the nurse is reinforcing reality to encounter the typical symptoms of undifferentiated schizophrenia.
client’s illusion (misinterpretation of reality). Preoccupation with persecutory delusions and
Additionally, this response voices doubt in the hallucinations are associated with paranoid
client’s paranoid interpretation. Telling the client not schizophrenia. Grossly disorganized behaviors and
to pay attention to the men fails to address the speech are associated with disorganized type of
client’s misinterpretation and misperceptions. schizophrenia. Immobility and waxy flexibility are
Closing the drapes so that the client doesn’t see the associated with catatonic type of schizophrenia.
men ignores the client’s misperception and
misinterpretation.

Bilings)
Bilings)
36. C
Rationale: Patients with antisocial personality

34. C
disorder typically show no remorse and justify their
Rationale; Clients may act on command actions as being right for them, despite being
hallucinations and harm themselves or others. socially unacceptable. 1. Such a person would have
Therefore, the staff needs to know when the client is difficulties with interactions. 2. This person behaves
hearing such commands, to ensure safety first. bizarrely and has few interactions with others. 4.
Telling the client the voices are real but nurse This person has intense, angry relationships, is
doesn’t hear them would be an appropriate response impulsive, and may self-mutilate.
later in the client’s hospitalization when the client’s
7
(Reference: www.evolve.elsevier.com) result. Options 2, 3, and 4 are not the most frequent
causes of postretirement adjustment disorder.
37: A
(Reference: www.evolve.elsevier.com)
Rationale: Controlling the impulse to self-mutilate or
self-destruct would be indicative of improved ability
to tolerate distressing thoughts. Ordinarily the patient
40. C
would impulsively act out the urge. Option 2 is not a
desired outcome. Option 3 does not suggest Rationale: Cultural practices dealing with grief and
improved management of feelings. Option 4 is not a loss differ. Failure to incorporate the significance of

desired outcome. cultural practices into the treatment plan may
impede resolution of the patient's grieving. 1. Talking
about the loss helps the patient come to terms with
(Reference: www.evolve.elsevier.com) it. 2. Empathy is a helpful response. 4. Obtaining
help from qualified persons to assist with grief
resolution is valuable if the patient approves of their
38. C involvement.
Rationale: This question will give the nurse data

about the patient's feelings about entering treatment.
Generally, patients who are willing to become
involved derive greater benefits. 1. The question will
not alter the patient's level of anxiety. 2. The goal of
41. D
nursing assessment is to gather specific data. 4.
This question is not designed to gather this Rationale: This response is calm, matter-of-fact and
information. firm. The nurse is not permitting the patient to be
manipulative, nor is she setting up a situation in
which a power struggle is likely to arise. Option 1
(Reference: www.evolve.elsevier.com) praises the patient for her behavior. Option 2 is
manipulative on the part of the nurse. Option 3
suggests the patient will not be weighed according to
39. A schedule.
Rationale: Identity and purpose are often associated

with one's job. When one retires, loss of identity and
purpose often occur, which requires adaptation. If
adaptation does not occur, adjustment disorder may
42. A
8
Rationale: Change comes slowly even when
appropriate goals are set with the patient. When
goals are unattainable, staff become discouraged or
frustrated with lack of progress. Regarding option 2,
when a nurse adopts the behaviors used by an
antisocial patient, it is not related to lack of progress 45. Answer: C
toward goals. Regarding option 3, the antisocial

Rationale: Reducing stimulation is calming and will
patient is usually uncaring about the opinions of
allow the patient to focus his or her limited
others. Regarding option 4, antisocial patients act
intellectual skills on regaining control. 1. Behavioral
out feelings, instead of turning them inward.
responses to the patient should be positive. 2. Touch

(Reference: www.evolve.elsevier.com) can easily be misinterpreted as a threat. 4. Patients
need increased personal space during catastrophic
reactions
43. B
Rationale: The nurse who is aware of his or her (Reference: www.evolve.elsevier.com)

personal feelings and views about sexual issues can
assist a patient with a sexual disorder. Lack of clarity 46. C
about one's feelings and views clouds the nurse's Rationale: Repetition of words or phrases that are
focus. 1. Previous experience may prove to be similarly in sound and in no other way (rhyming) is
helpful, but is not the most important qualification. 3. one altered thought and language pattern in
Thinking that all types of sexual dysfunction can be schizophrenia. Clang association often take the form
corrected is unrealistic. 4. Thinking that the of rhyming. Loosened associations occur when
prognosis for most sexual dysfunction disorders is individual speaks with frequent changes of subject,
poor shows lack of information. and the content is obliquely related. Echolalia is the
involuntary parrot like repetition of words spoken by
others. Word salad is the use of words with no
apparent meaning attached to them or to their
relationship to one another.
Reference: Saunders Q & A Review for the NCLEX-
RN Examination by Linda Anne Silvestri, 2006,
44. D
Elsevier Inc
Rationale: This question asks directly about the 47. B
coping skills used in the past. After this lead-in the Rationale: By definition, an ego defense mechanism
nurse can question further to find out how effective are operations outside of a person's awareness that
the coping skills were. This option is the only the ego calls into play to protect against anxiety.
question that relates specifically to adequacy of Denial is the defense mechanism that blocks out
coping skills. painful or anxiety inducing events or feelings. In this

case, the client cannot deal the upcoming surgery
9
for cancer and therefore denies the illness. Reference: Saunders Q & A Review for the NCLEX-
Psychosis and delusions are not defense RN Examination by Linda Anne Silvestri, 2006,
mechanism. Displacement is the discharging of Elsevier Inc
pent-up feelings on persons less dangerous than 50. B
those initially around the feelings. Rationale: The client in manic state often has
inadequate food and fluid intake as a result of
physical agitation. Foods that the client can eat “on
Reference: Saunders Q & A Review for the NCLEX- the run” are best because the client is too active to
RN Examination by Linda Anne Silvestri, 2006, sit at meals and use utensils. Additionally, clients in
manic state should not have caffeine containing

Elsevier Inc
products.
Reference: Saunders Q & A Review for the NCLEX-
RN Examination by Linda Anne Silvestri, 2006,
48. A
Elsevier Inc.
Rationale: A client experiencing paranoia is
distrustful and suspicious of others. The health care
51. B
team needs to establish rapport with the client.
Laughing or whispering in front of the client would Rationale: flight of ideas: flight of ideas is a
increase the client's paranoia. Options 2,3 and 4 ask condition in which patient talks continuously and
the client to trust on multitude levels. These options then switch to unrelated topic. Loose association is
are too intrusive for a client who is paranoid somewhat similar to more obvious and completely
Reference: Saunders Q & A Review for the NCLEX- unrelated. A, C, D are all alteration in perception. A
RN Examination by Linda Anne Silvestri, 2006, refers to a person thinking that everyone is talking
Elsevier Inc about him. C and D are all sensory alterations. The
49. A difference is that, in hallucination, there is no need
Rationale: Exercising 23 to 4 hours everyday is for a stimulus. In illusion, a stimulus (a phone cord)
excessive physical activity and unrealistic fir 16 year is mistakenly identified by the client as something
old. The nurse needs to further assess this else (snake).
statement immediately to find out why the client feels
the need to exercise this much to maintain her
figure. Although it's unfortunate that her best friend
52. A
had this disease this is not considered a major threat
to the client's physical well-being. A weight that Rationale: I understand and that’s God’s voice are
exceeds 15% below the ideal weight is significant real to you, but I don’t hear anything. I will stay with
with anorexia nervosa. It is not considered abnormal you: the nurse should first ACKNOWLEDGE that the
to check weight every day. Many clients with voices are reality the patient and then PRESENT
anorexia nervosa check their weight close to 20 REALITY by telling the patient that you do not hear
times a day. anything. The third part of the nursing intervention in
hallucination is LESSENING THE SIMULI by either
1
0
staying with the patient or REMOVING the patient client with paranoid schizophrenia is at risk for
from a highly stimulating place. Telling the client that violence toward himself or others. The other options
the voices are part of his illness is not therapeutic. are also appropriate nursing diagnoses but should
People with schizophrenia think that they are ill. be addressed after the safety of the client and those
Letter C and D disregards the client’s concerns and around him is established.
therefore, not therapeutic.
53. C
http://www.scribd.com/doc/6389830/109-Questions-
Rationale: the depression to be improving and the and-Rationale-on-Psychotic-Disorders

suicidal ideation to be lessening: too obvious, no
need to rationalize.
57. B
Rationale: Option B is the action of Cogentin.

54. D
Anxiety doesn't cause extrapyramidal effects.
Rationale: “I need to call my doctor whenever I Overactivity of acetylcholine and lower levels of
notice that I have a fever or sore throat.”: clozapine dopamine are the causes of extrapyramidal effects.
causes AGRANULOCYTOSIS and bone marrow Benztropine doesn't increase norepinephrine in the
depression. Early s/s includes fever and sore throat. CNS.
The medication is to be withheld this time or the
patient might develop severe infection leading to
death. http://www.scribd.com/doc/6389830/109-Questions-
and-Rationale-on-Psychotic-Disorders
55. C.
58. C
Rationale: Schizophrenia: when disorders of
perception and thoughts came in. the only diagnosis Rationale: By acknowledging that the client hears
doctor can make is among the choices of voices, the nurse conveys acceptance of the client.
schizophrenia. A, B and D can occur in normal By letting the client know that the nurse doesn't hear
individuals without altering their perceptions. the voices, the nurse avoids reinforcing the
Schizophrenia is characterized by disorders of hallucination. The nurse shouldn't touch the client
thoughts, hallucinations, delusions, illusion and with schizophrenia without advance warning. The
disorganization. hallucinating client may believe that the touch is a
threat or act of aggression and respond violently.
Being alone in his room encourages the client to
56. A withdraw and may promote more hallucinations. The
nurse should provide an activity to distract the client.
Rationale: Because of such factors as
By asking the client what the voices are saying, the
suspiciousness, anxiety, and hallucinations, the
1
1
nurse is reinforcing the hallucination. The nurse
should focus on the client's feelings, rather than the
61. D
content of the hallucination.
Rationale: The client’s energy level is so high that a

complete night’s sleep probably is impossible. The
http://www.scribd.com/doc/6389830/109-Questions- nurse should use any “down” time to promote rest.
and-Rationale-on-Psychotic-Disorders The client’s sleep pattern, including a bedtime
routine, can be repatterned when the client’s come
down from the manic phase of the disorder (Option

59. C A). During the manic phase, the client’s energy level
is so high that enforcing seclusion during the night
Rationale: Nihilistic delusions are false ideas about isn’t likely to promote sleep (Option B). The nurse
the self, others, or the world. Somatic delusions should encourage the client to sleep or rest at any
involve a false belief about the functioning of the time to prevent physical exhaustion (Option D)
body. Body dysmorphic disorder is characterized by
a belief that the body is deformed or defective in a
specific way. Apraxia is the inability to carry out
62. A
motor activities.
Rationale: A depressed client is at great risk for
committing suicide and needs continuous
http://www.scribd.com/doc/6389830/109-Questions- observation. This client must not be left alone
and-Rationale-on-Psychotic-Disorders (Option B and D). The nurse must not relinquish

responsibilities to another client (Option C).
60. C
63. B
Rationale: The client's signs and symptoms suggest Rationale: The nurse must not reinforce the client’s
neuroleptic malignant syndrome, a life-threatening hallucinations. Telling the client to listen to the
reaction to neuroleptic medication that requires voices would reinforce the hallucinations (Option A).
immediate treatment. Tardive dyskinesia causes The nurse shouldn’t say things that may not be true
involuntary movements of the tongue, mouth, facial (Option C). The voices are real to the client, telling
muscles, and arm and leg muscles. Dystonia is him that he doesn’t hear them isn’t therapeutic
characterized by cramps and rigidity of the tongue, (Option D).
face, neck, and back muscles. Akathisia causes
restlessness, anxiety, and jitteriness. 64. A
Rationale: This response orients the client to reality

http://www.scribd.com/doc/6389830/109-Questions-
and provides the structure the client’s needs to solve
and-Rationale-on-Psychotic-Disorders
1
2
the immediate problem. The client is too anxious and Rationale: Disturbed thought process related to
regressed to engage in the problem solving required paranoia is the client’s problem, and the plan of care
by options B and C. Option D is insane because the must address this problem. The client is
client is unable to provide self care as a result of experiencing paranoia and is distrustful and
severe anxiety that interferes with problem solving suspicious of others. The members of the health
and prevents awareness of the reality. cafe team need to establish a rapport and trust with
the client. Therefore laughing or whispering in front
of the client would be counterproductive.
65. C
68. B

Rationale: Clients with anorexia nervosa commonly Rationale: Mania is a mood characterized by
communicate on a superficial level and avoid excitement, euphoria, hyperactivity, excessive
expressing feelings. Identifying feelings and learning energy, decreased need for sleep, and impaired
to express them are initial steps in decreasing ability to concentrate or complete a single train of
isolation. Clients with anorexia nervosa are usually thought. Mania is a period when the mood is
able to discuss abstract and concrete issues. predominantly elevated, expansive or irritable. All
Confrontation usually isn’t an effective options reflect a client’s possible symptomatology.
communication strategy as it may cause the client to Option B, however, clearly presents a problem that
withdraw and become more depressed. compromises a physiological integrity and need to
be addressed immediately.
(Source: Springhouse Review for NCLEX-RN 5th 69. C

edition; Page 624) Rationale: The client taking clozapine (Clozaril) may
experience agranulocytosis, which is monitored by
reviewing the result of the white blood count.
66. A
Treatment is interrupted if the white blood count
Rationale: Denial is refusal to admit a painful reality,
drops below 3000/mm3. Agranulocytosis can be fatal
which is treated as if it does not exist. In projection, a
if undetected and untreated. The other options are
person unconsciously rejects emotionally
not related specifically to the use of this medication.
unacceptable features and attributes them to other
persons, objects, or situations. In regression, the
70. B
client returns to earlier, more comforting, although
less mature, way of behaving. Rationalization is
Rationale: Clients with anorexia nervosa frequently
justifying illogical or unreasonable ideas, actions or
are preoccupied with rigorous exercise and push
feelings by developing acceptable explanations that
themselves beyond normal limits to work off caloric
the teller and the listener.
intake. The nurse must provide appropriate exercise
and place limits on rigorous activities.
67. B
1
3
(Reference: Saunders’ Comprehensive Review 76. A
NCLEX-RN Examination 4TH ed by Linda Anne Rationale: Clients with panic disorder tend to be
Silvestri, MSN, RN, Canada 2008.) socially withdrawn. Going to the mall is a sign of
working on avoidance behaviors. Hyperventilation is
a key symptom of panic disorder. Teaching
71. C
breathing control is a major intervention for clients
Rationale: The development of physical symptoms with panic disorder. The client taking medications for
without a physical cause is an anxiety-reducing panic disorder, such as trycyclic antidepressants and
mechanism. benzodiazepines, must be weaned off these drugs.

Most clients with panic disorder with agoraphobia

don’t have nutritional problems.
72. B
77. D
Rationale: Mediating frustration within the real world Rationale: The client must be aware of the
is an ego function and requires ego strength. connection between sources of anxiety and the
symptoms of a panic attack. Role-playing a panic
attack isn’t useful for the client. Later in treatment,
73. B the client can develop an exercise program as part
of the overall plan to handle stress. Learning to
Rationale: Slips of the tongue also called Freudian
identify cognitive distortions is a useful strategy to
slip are material from the unconscious that slips out
teach the client after he’s begun to work on
in unguarded moments.
identifying sources of anxiety.
78. D
74. A Rationale: Stopping antianxiety dugs such as
benzodiazepines can cause the client to have
Rationale: Talking in the third person reflect poor
withdrawal symptoms. Stopping a benzodiazepine
ego boundaries and dissociation from the real self.
doesn’t tend to cause depression, increase cognitive
75. C abilities, or decrease sleeping difficulties.
Rationale: The superego incorporates all

79. A
experiences and learning from external environment
Rationale: Use of lithium during pregnancy results in
(society, family etc.) into the external environment.
congenital defects, especially cardiac defects.
Thyroids problems don’t occur in the first trimester of
the pregnancy. In lithium toxicity, a condition called
(Reference: Mosby's Comprehensive Review of
nontoxic goiter ma occur. An adverse effect of
Nursing for NCLEX-RNR Examination Book, 2009,
lithium is polyuria, not urine retention. The rate of
by Saxton)
spontaneous abortion is no greater than for non-
users.
1
4
importance. Never try to force recall of information
80. A,B,D the client is not prepared to know. Reduction of
anxiety helps avoid the emergence of
Rationale: A client with an impulse control disorder subpersonalities.
who displays violent, aggressive, and assaultive
behavior generally functions well in other areas of
his life. The degree of aggressiveness is typically out 84. B
of proportion wit the stressor. Such a client Rationale: Telling the client who complains of seeing
commonly has a history of parental alcoholism and a UFOs that “I can tell that what you’re seeing
chaotic family life, and often verbalizes sincere

frightens you; how can I help to make you more
remorse and guilt for the aggressive behavior. comfortable?” validates the client’s feelings without
agreeing with or challenging the client’s irrational
(Reference: Lippincott Wiliams & Wilkins. NCLEX- beliefs.
RN Question and Answer p. 374)
81. D 85. C
Rationale: A client with a bipolar disorder and a
Rationale: Although the precise mechanism of superimposed seasonal affective depression needs
inheritance is unknown, developing a social phobia to be careful about the time of day that the
is 11% more likely if a family member has the phototherapy is utilized. Because of circardian
disorder. rhythms, it has been found that bipolar clients with
seasonal depression do best if they utilize the
phototherapy treatment in the later afternoon. If the
82. C phototherapy is used in the morning, manic
manifestations may result. Exploring appetite,
Rationale: Malingering is characterized by the
energy level, feelings of self-worth, and how much
client’s deliberate attempt to gain attention. The
money the client is spending may all be important
clinical manifestations are not confirmed by lab tests.
interventions, but determining the time of the day the
The client will bring the clinical manifestations to the
client is using phototherapy allows the nurse to
attention of others for secondary gain. The client
obtain the information that may be causing the
does not withdraw but becomes demanding of health
dramatic change and elevation in mood.
care providers and others.
(Reference: Complete Review for NCLEX-RN by
Donna Gauwitz, Thomson Asian Edition, NSNA
83. A (2007))
Rationale: One-to-on supervision and making a

suicide contract with a client who has a dissociative
86. A
disorder are priorities to meet the safety needs of the
client under distress. Confidentiality is of the utmost
1
5
Rationale: Mild anxiety motivates one to action, such physical and emotional dependence on the parents.
as learning or making changes. Higher levels of The major task during infancy is the development of
anxiety tends to blur the individual's perceptions and trust. School age deals with the task of industry and
interfere with functioning. developing skills for working in and relating to the
world. Preschool age deals with developing a sense
of initiative.
87. D
Rationale: The client's early arrival indicates an
expected degree of anxiety; the quiet waiting 92. C

indicates that the client has been told what to
Rationale: The child resolves oedipal conflicts by
expect.
learning to identify with the parent of the same sex
and accomplishes this by mimicking the role of his
parent. Oral stage is the earliest stage of
88. D
development and operates solely on the pleasure
Rationale: Anxiety is a human response,causing
principle, largely id oriented; this stage is concerned
both physical and emotional changes that everyone
with the development of trust. Genital stage is when
experiences when faced with stressful situations.
the interest shifts from the anal region to the genital
region and questions about sexuality arise during
this stage. Latency stage is when there is increasing
89. C sex-role development; this stage is concerned with
Rationale: The individual using sublimation attempts peer group identification.
to fulfill desires by selecting a socially acceptable
activity rather than one that is socially unacceptable.
93. B
90. B Rationale: Values and beliefs from parents and
Rationale: Toddlers struggle to identify their own society are expressed through the child’s play world.
needs. Too early and too strict toilet training results These values become part of the child’s system
in ambivalence because toddler's needs and through the process of internalization (introjection).
physical abilities are in conflict with parental Projection- if this happens, children will learn to
demands. Toddlers are faced with giving up these blame others for their own faults. Competition
needs or risking parental disapproval. happens in the later stage. Independence is

influenced by the environment and others in it rather
(Reference: Mosby’s Review of Nursing for NCLEX- than play.
RN Examination)
91. C
Rationale: The toddler is learning autonomy, but 94. C
because of the nature of development, there is still

1
6
Rationale: the child realizes that the parent of the report them to the physician. The client should be
same sex cannot be bested in a struggle for the instructed to monitor his lithium levels on a regular
affection of the parent of the opposite sex. The role basis to avoid toxicity. The nurse should explain that
and the behaviour of the same-sex parent are 7 to 21 days may pass before the client notes a
therefore assumed by the child to attract the parent change in his mood. Lithium doesn’t have addictive
of the opposite sex. Rejects the parent of the same properties. Tyramine is a potential concern for
sex – this is a conflict, not a resolution. Introjects clients taking monoamine-oxidase inhibitors.
behaviours of both parents – doing this gives rise to
a greater conflict and leaves a fragmented self. 97. B,C,E
Identifies with the parent of the opposite sex- this is Rationale: Neuroleptic malignant syndrome is a life-

in conflict with heterosexual drives. threatening adverse effect of antipsychotic
medications such as Haldol. It’s associated with a
rapid increase in temperature. The most common
95. B extrapyramidal adverse effect, akathisia, is a form of

psychomotor restlessness that can often be relieved
Rationale: Children 2 to 7 years old have difficulty b pacing. Haldol and the anticholinergic medications
distinguishing reality from fantasy; this presents the that are provided to alleviate it extrapyramidal effects
greatest challenge to the nurse. Sensorimotor stage- can result in a dry mouth. Providing the client with
children from birth to 1 year of age focus on “in the hard candy to suck on can help alleviate this
moment” thinking; preoperative preparation most problem. Haldol isn’t given subcutaneously and
likely will not be recalled. Formal operational stage- doesn’t affect blood suga levels. Urticaria is not
children 12 to 16 years of age can think in the usually associated with Haldol administration.
abstract and have the ability to solve the complex
problems; children in this stage usually do not pose 98. C
difficulties in preoperative teaching. Concrete Rationale: The preoccupation in hypochondriasis is
operational stage- children 7 to 11 years of age have related to bodily functions or physical sensations.
the ability to comprehend and visualize a series of Repeated physical examinations, diagnostic tests,
events and can think about the past and present; and reassurance from the physician don’t allay the
this stage provides less of a challenge to absorb concerns about bodily disease. There’s a belief that
preoperative teachings. a health care professional has poor insight if he sees
the concern about having a serious illness as
(Reference: Mosby’s Review of Nursing for NCLEX-
excessive or unreasonable. The other responses
RN Examination)
aren’t valid.
99. D
96. B,E,F
Rationale: Sleep deprivation can lead to
hallucinations and delusions. Uninterrupted sleep is
Rationale: Client education should cover the signs
an important nursing consideration in planning care.
and symptoms of drug toxicity as well as the need to
1
7
All other data are expected and shouldn’t cause
sleep deprivation.
104. B
100. C
Rationale: The amount of time focused on
discussing physical symptoms should be decreased. Rationale: Any behavioural therapy or learning of
Lack of positive reinforcement may help her to stop new methods of coping with situations requires
the maladaptive behavior. However, avoiding the modification of approach and attitudes; hence
statement all together demeans the client and personality is always capable of change.
doesn’t address the underlying problem. Asking the

client to further explain emphasizes physical
symptoms and prevents the client from attending 105. B
group therapy. All physical complaints need to be
evaluated for physiological causes by the physician.
Rationale: Attributing unacceptable feelings or
(Reference: Lippincott Wiliams & Wilkins. NCLEX- attributes to others is the mechanism known as
RN Question and Answer p. 307) projection, the data demonstrate use of this defense
mechanism.
101. C
Rationale: By developing skills in one area, the

individual compensates or makes up for a real or
RN Examination)
imagined deficiency, thereby maintaining a positive
self-image.
106. A
Rationale: Splitting is the compartmentalization of
102. D
opposite-affect states and failure to integrate the
Rationale: Fears and anxieties about themselves positive and negative aspects of self or others.
and their possessions are common in older adults
because of a decreased self-concept and an altered 107. C
body image; these changes result in a decreased Rationale: Conscience and a sense of right and
ability to cope. wrong are expressed in the superego, which acts to
counterbalance the id’s desire for immediate
gratification.
103. A
Rationale: Use of denial involves failure to 108. D

acknowledge the reality of a situation. Rationale: The mature personality does not respond
to the immediate gratification, demands of the id or
1
8
the oppressive control of the superego because the 114. D
ego is strong to maintain a balance between them. Rationale: when the individual experiences a threat
to self-esteem, anxiety increases and defense
mechanisms are used to protect the self.
109. A
115. A
Rationale: Repression is a coping mechanism in
Rationale: this client is using the cognitive distortions
which unacceptable feelings are kept out of
of overgeneralization and pessimism. Negative
conscious awareness; later, under stress anxiety,
events are magnified and become the focus while
thoughts or feelings surface and come into one’s
the contrary positive experiences are minimized and
conscious awareness.
ignored. By focusing on the negative, the depressive

mood is reinforced.
110. D
Rationale: Intellectualization occurs when a painful RN Examination)
emotion is avoided by means of a rational
explanation that removes the event from any
personal significance. 116. B
RN Examination) Rationale: Amphetamines are central nervous
system stimulants. They cause sympathetic
stimulation including hypertension, tachycardia,
vasoconstriction, and hyperthermia. Hot, dry skin is
111. C
seen with anticholinergic agents such as
Rationale: This is the age of Freud’s phallic stage jimsonweed. Pupils will be dilated not constricted.
and Erikson’s stage of initiative versus guilt.
117. A
112. C
Rationale: anxiety is a normal reaction to the
Rationale: Children view their own worth by the termination of the nurse-client relationship. The
response received from their parents. This sense of nurse should help the client explore his feelings
worth sets the basic ego strengths and is vital to the about the end of the therapeutic relationship. While
formation of the personality. anger about the termination may be a healthy
response, banging the table, shouting and other
113. D
forms of acting out aren’t appropriate behaviour.
Rationale: when acting-out against the primary
Withdrawal isn’t a healthy response to the
source of anxiety creates even further anxiety or
termination of a relationship. By rationalizing the
danger, the individual may use displacement to
termination, the client avoids expressing his feelings
express feelings on a safer person or object.
and emotions.
1
9
118. A 121. B
Rationale: The client’s memory of a traumatic Rationale: Flight of ideas is the shifting of a topic
childhood incident and her current signs and from one subject to another in a somewhat related
symptoms (nightmares, flashbacks, and related way while looseness of association is the shifting of
fears) suggests that she has PTSD with delayed a topic from one subject to another in a completely
onset. The client doesn’t occasionally lose track of unrelated way
her movements and actions, as in multiple

personality disorder. Her anxiety isn’t primary but
results from severe emotional trauma. Although she 122. C
experiences flashbacks, these aren’t psychotic
episodes, as in schizophrenia. Rationale: elevated temperature, elevated blood
pressure and diaphoresis are indicative of
Neuroleptic malignant syndrome, which is a medical
emergency.
119. B
Rationale: the nurse must question this order

immediately. Thioridazine (Mellaril) has and absolute 123. A
dosage ceiling of 800 mg / day. Any dosage above
this level places the client at high risk for toxic Rationale: Disorganization is the phase of s crisis
pigmentary retinopathy, which can’t be reversed. As situation characterized by feelings of great anxiety
written, the order allows for administering more than and inability to perform activities of daily living.
the maximum 800 mg / day; it should be corrected

immediately, before the client’s health is
jeopardized. 124. C
Rationale: Patients who are narcissistic feels that

they are special and they demand special attention
120. B
from others.
Rationale: Diarrhea is the most common physiologic

response to stress and anxiety. The other options
could also be related to stress and anxiety but they 125. C
don’t occur as frequently or as commonly as
Rationale: Catatonic schizophrenia is usually
diarrhea
manifested by stuporous withdrawal, hallucinations,
delusions, waxy flexibilities and catatonic rigidity.

RN Examination)
2
0
(Reference: The ABC’s of Psychiatric Nursing: Core
Concepts for the Nurse Licensure Exam by Ray A.
Gapuz)
126. D Gapuz)
Rationale: Giving broad opening provides an

opportunity for a patient to choose the topic of
131. C
conversation, hence it is appropriate to use when
initiating interaction. Rationale: Tardive dyskinesia is usually manifested

by lip smacking and tongue twitching. Oculogyric
crisis is usually manifested by upward rolling of the
127. A eyeballs.
Rationale: Aged cheese, cheddar cheese and Swiss

cheese are high in tyramine and are therefore to be
132. C
avoided. Cottage cheese and cream cheese are
allowed. Rationale: Initial therapeutic effects of
antidepressants occur after 2-3 weeks while full
therapeutic effects occur after 3-4 weeks.
128. B
Rationale: The therapeutic use of self requires self

133. C
awareness initially, therefore the nurse has to deal
with her feelings first. Rationale: Projection is attributing to others one’s
unconscious wishes/fear. Usually it is seen in
paranoid patients.
129. A
Rationale: The ritual preformed by the obsessive-

134. D
compulsive patient is their way of expressing fears
and tensions. Rationale: Interacting with parents with autistic
thinking requires thorough analysis of speech
patterns, the meanings of their expressions and the
130. A relationship of these to their covert needs. This
situation usually poses great difficulty on the part of
Rationale: Depressed patients usually turn their
the nurse.
hostile feelings towards themselves. Providing an
outlet for theses aggressive feelings will make the
patient feel less guilty.
135. A
2
1
Rationale: At the height of depression, patients
usually have difficulty conceptualizing activities. The
139. D
patient’s plan to organize child care indicates that his
ability to conceptualize is working. This indicates Rationale: Responding to the feelings expressed by
recovery from depression. a client is an effective therapeutic communication
technique. The correct option is an example of the
use of restating.

Gapuz) 140. C
Rationale: Option C uses the therapeutic

communication technique of restatement. Although
136. D
restatement is a technique that has a prompting
Rationale: The client must first deal with feelings and component to it, it repeats the client’s major theme,
negative responses before the client can work which assists the nurse to obtain a more specific
through the meaning of the crisis. perception of the problem from the client.
137. A (Reference: Silvestri, “Comprehensive Review

th
NCLEX-RN Examamination, 4 ed”, 2008)
Rationale: Denial is refusal to admit to a painful
reality and may be a response by a victim of sexual
abuse. Projection is transferring one’s internal
141. C
feelings, thoughts, and unacceptable ideas and traits
to someone else. Rationalization is justifying the Rationale: When the nurse and client agree to work
unacceptable attributes about oneself. together, a contract should be established, the
Intellectualization is the excessive use of abstract length of the relationship should be discussed in
thinking or generalizations to decrease painful terms of its ultimate termination.
thinking.
142. B
138. D
Rationale: The nurse should initiate brief, frequent
Rationale: In the termination phase, the relationship contacts throughout the day to let the client know
comes to a close. Ending treatment sometimes may that he is important to the nurse. This will positively
be traumatic for clients who have come to value the affect the client’s self-esteem.
relationship and the help. Because loss is an issue,
any unresolved feelings related to loss may
resurface during this phase.
2
2
143. D Rationale: The client preoccupied with delusions of
the persecution, grandeur, ideas of reference, and
Rationale: The statement “I don’t think about killing
auditory hallucinations is predisposed to suicidal and
myself as much as I used to.” Indicates a lessening
violent behavior. Option A is not applicable, as this
of suicidal ideation and improvement in the client’s
would reinforce the client’s delusions of persecution.
condition.
Option B and D should be eliminated since this is
another area of concern, but safety must be first
addressed.
144. C

Rationale: The drug of choice for a client
experiencing extra pyramidal side effects from 148. C
haloperidol (Haldol) is benztropine mesylate

Rationale: Client with paranoid schizophrenia
(cogentin) because of its anti cholinergic properties.
frequently seclude themselves from others because
of their suspiciousness, which results in their
reluctance to trust people. Option A should be
145. D eliminated because fear of being alone is not the
appropriate nursing diagnosis. Option B is also
Rationale: An aloof, detached, withdrawn posture is
eliminated since this response has to do with
a means of protecting the self by withdrawing and
suspiciousness and persecutory feelings but it is
maintaining a safe, emotional distance.
incorrect because it is an example of circular
nursing. Option D is also eliminated as for impaired
social skills is not also the appropriate nursing
(Reference: NCLEX Review: Psychiatric Nursing
diagnosis.
Practice Test Part 2)
149. C
146. C
Rationale: Clients who are diagnosed with
Rationale: This would distract the client by offering
schizophrenic disorders have difficulty handling
alternate activity. Option A should be eliminated
complex information, so it is best to keep
never ask “why” question. The client is unable to
communication simple. Option A should be
explain this behavior. Option B is also eliminated
eliminated because the mood of the staff is not
because this response is threatening and implies
significant. Option B is also eliminated since the
misbehavior by the client. Option D is also
client deals best with simple direct sentences.
eliminated because this does not distract the client
Option D is also eliminated as client in general do
from the behavior and leaves her in the room alone
not have trouble with violent behaviors.
to continue washing her hands.
147. C
2
3
150. A Rationale: Restating is the therapeutic
communication technique in which the nurse repeats
Rationale: Major aspects of the pre-ECT stage are:
what the client says to show understanding and to
obtaining lab and diagnostic data, getting an
review what was said. Option 3 uses the therapeutic
informed consent, and reinforcing client and family
technique of restating. Option 1, the nurse is
education. Option B is not applicable. Option C it
attempting to assess the client’s ability to discuss
should be eliminated because the client is NPO after
feelings openly with family members. In option 2, the
midnight. Option D is also eliminated since this is
nurse attempts to use focusing, but the attempt to
important, but not necessarily the nurse’s
discuss central issues is premature. In option 4, the
responsibility.
nurse makes a judgment and is nontherapeutic in

the one-to-one relationship.
(Reference: Meyer, J. (2003) “The Princeton

th
Review, cracking the NCLEX-RN”, 7 edition, New
154. D
York: Random House Inc.)
Rationale: Clients who are admitted involuntarily do
not lose their right to informed consent. Clients must
151. D be considered legally competent until they have

been declared incompetent through a legal
Rationale: Option d helps the client focus on the proceeding. The informed consent needs to be
emotion underlying the delusion but does not argue obtained from the client.
with it. Option 1 places the client in a position that
requires a response. Option 2 avoids the client.
Option3 is an attempt to convince the client to
155. D
believe another thought. This response may cause
the client to hold the delusion more strongly. Rationale: False imprisonment is an act with the
intent to confine a person to a specific area. A nurse
can be charged with false imprisonment if the nurse
152. D prohibits a client from leaving the hospital if the client

has been admitted voluntarily and if no agency or
Rationale: The client must first deal with feelings and legal policies exist for detaining the client. However,
negative responses before the client can work if the client has been admitted involuntarily or had
through the meaning of the crisis. Option 4 pertains agreed to an evaluation before discharge, the
directly to the client’s feelings. Option 1 and 2 do not nurse’s actions are reasonable.
directly address the client’s feelings. Option 3 is
more of an assessment question.

153. C Gapuz)
2
4
156. C (Reference: NCLEX Review: Psychiatric Nursing
Practice Test Part 2)
Rationale: Antiseptic mouthwash often contains
alcohol & should be kept in locked area, unless
labeling clearly indicates that the product does not
161. B
contain alcohol.
Rationale: A is a characteristic of a borderline

personality disorder. Client with antisocial

157. D personality disorder do not experience disordered
thoughts. Poor judgment is a result of not paying to
Rationale: Monitoring of vital signs provides the best
the legality of their actions
information about the client’s overall physiologic
status during alcohol withdrawal & the physiologic
response to the medication used.
162. D
Rationale: Avoidant is characterized by a pervasive

158. D pattern of social discomfort. Dependent personality
disorder is characterized by a pervasive and
Rationale: Barbiturates are CNS depressants; the
excessive need to be taken care of. Antisocial is
nurse would be especially alert for the possibility of
characterized by a pervasive pattern of disregard for
respiratory failure. Respiratory failure is the most
and violation of the rights of others. Clients with
likely cause of death from barbiturate over dose.
passive-aggressive personality disorder express
resistance through procrastination,
FORGETFULNESS, and stubbornness
159. A
Rationale: The nurse would facilitate progressive

review of the accident and its consequence to help 163. A
the client integrate feelings & memories and to begin

Rationale: A is a verbal communication because it
the grieving process.
consists of words a person uses to speak to one or
more listeners. B is an observation which means
watching the speaker’s nonverbal customs. Nodding
160. A of head is a body language which is also a
nonverbal communication.
Rationale: A moderate level of cognitive impairment
due to dementia is characterized by increasing
dependence on environment & social structure and
by increasing psychologic rigidity with accentuated 164. D
previous traits & behaviors.

2
5
Rationale: Introjection is accepting another person’s Instead, the nurse makes assumptions that may
attributes, beliefs, and values as one’s own. seem like accusations
Displacement is ventilation of intense feeling
towards persons less threatening. Undoing is
exhibiting acceptable behavior to make up for or 167. B
negate unacceptable behavior. Projection is
unconsciously blaming of unacceptable inclinations Rationale: Clients older than 18 years old,
or thoughts on an external object. diagnosed with a conduct disorder before 17 years,

possessing a history of fighting, lying and stealing,
as well as problems with the criminal justice system,

may have antisocial personality disorder. The
165. A
behaviors are not associated with borderline,
Rationale: Antisocial personality disorder is narcissistic and histrionic personality disorder.
characterized by a pervasive pattern of disregard for
and violation of the rights of others and with the
central characteristics of deceit and 168. C
MANIPULATION.
Rationale: The first immediate intervention is to
ensure ongoing observation of the client. Therefore,
the nurse should arrange for an unlicensed
(Reference: Videbeck, “Psychiatric Mental Health
assistance to sit with the client. The nurse should
Nursing”)
avoid restraints, which increases anxiety,
fearfulness, and risk for injury and strangulation.
Administering haloperidol and moving the client to a
166. B
room near the nurse’s station are possible options;
Rationale: Confrontation is the skill of caringly however, the nurse should first use one-to one
pointing out discrepancies between what a client observation.
says and does. In this case, the client displayed

developing trust in the nurse, but then seemed to
engage in avoidance. The nurse uses a three-part 169. C
formula, called a perception check, increasing
Rationale: Stimulant medication ids the most helpful
communication without accusing the client or making
intervention for improving attention span and ability
assumptions about his behaviors. The first option
to focus. Parents should use negative consequences
follows the formula for assertive statements, which
for specific undesirable actions, such as aggression
this scenario does not call for at this time. Telling the
or temper tantrums. Inability to focus is the symptom
client feelings for his wife does not describe, offer
of the disorder most amenable to medication.
possible interpretations of, or ask for feedback about
Reward-based programs help shape behaviors;
the confusing behavior. With the last statement, the
however, the inability to focus associated with ADHD
nurse neither describes nor interprets the behavior.
or ADD improves most dramatically with medication.
2
6
Social skills training will help the child improve
relationships, but will not affect attention span.
173. A
Rationale: The client with mania is seldom sitting

170. D long enough to eat and burns many calories for
energy. Answer B is incorrect because the client
Rationale: Controlled breathing techniques can
should be treated the same as other clients. Small
dampen sympathetic arousal and correct
meals are not a correct option for this client. Allowing
hyperventilation during a panic attack. In addition,
her into the kitchen gives her privileges that other
regular practice may help prevent panic attacks. A

clients do not have and should not be allowed, so
therapist uses Desensitization for clients with
answer D is incorrect.
phobias. Nothing suggests the need for lifestyle
changes. Panic attacks usually have no identifiable
trigger. Problem solving techniques are more
174. C
beneficial for clients with Generalized Anxiety
disorder who tend to catastrophize about decision- Rationale: The nurse would most likely administer
making. benzodiazepine, such as Lorazepam (Ativan) to the
client who is experiencing symptoms: tremors,
diaphoresis and hyperactivity. The client
171. A experiences symptoms of withdrawal because of the
rebound phenomenon when the sedation of the CNS
Rationale: If the client is a threat to the staff and to
from alcohol begins to decrease.
other clients the nurse should call for help and
prepare to administer a medication such as Haldol to
sedate him. Answer B is incorrect because simply
175. C
telling the client to calm down will not work. Answer
C is incorrect because telling the client that if he Rationale: Clients who are withdrawn may be
continues he will be punished is a threat and may immobile and mute, and require consistent, repeated
further anger him. Answer D is incorrect because if interventions. Communication with withdrawn clients
the client is left alone he might harm himself. requires much patience from the nurse. The nurse
facilitates communication with the client by sitting in
silence, asking open-ended question and pausing to
172. C provide opportunities for the client to respond.
Rationale: The client who is confused might forget

that he ate earlier. Don’t argue with the client. Simply
(Reference: NCLEX-RN Exam Practice Question
get him something to eat that will satisfy him until
Exam Cram By Rinehart & Associates)
lunch. Answers A and D are incorrect because the
nurse is dismissing the client. Answer B is validating
the delusion.
2
7
176. C (Reference: The ABC’s of Psychiatric Nursing: Core
Rationale: Providing assistance during recovery
Gapuz)
period falls under rehabilitation, which is a tertiary
level of prevention strategy.
181. D
Rationale: Initial therapeutic effects of
177. A
antidepressants occur after 2-3 weeks while full
Rationale: A patient who is taking lithium must be therapeutic effects occur after 3-4 weeks.

placed in a normal (3gms), high fluid diet (3L) or high
sodium (6-10 gms), high fluid diet. This is done to 182. B
facilitate excretion of lithium from the body. Rationale: Respiratory depression can occur after
electro-convulsive therapy due to the muscular
relaxation effect of Anectine, so assess for
respiration
178. B
Rationale: Rationalization is justifying one’s actions 183. D

which are based on other motives. It is usually seen Rationale: Identifying alternate coping skills facilitate
among alcoholics. rehabilitation of the patient. Alcoholic patients
usually cope with problems by drinking alcohol.
179. B 184. C
Rationale: Leaving a light on the patient’s room will
Rationale: Preventing the patient from using the
decrease visual hallucinations, which frequently
bathroom for 2 hours after eating prevents the
occur in alcohol withdrawal syndromes
patient from inducing vomiting.
185. A
Rationale: When a depressed patient suddenly
180. D becomes cheerful, it means that the patient is
recovering from depression and is n danger of
Rationale: Before the administration of antabuse, the
committing suicide.
patient must be free of alcohol for atleast 12 hours tp
prevent antabuse reaction which is usually
(Reference: “The ABC’s of Psychiatric Nursing: Core
manifested by severe nausea and vomiting,
Concepts for Nurse Licensure Exam” by Ray A.
respiratory depression and orthostatic hypotension.
Gapuz)
186 .D
Rationale: The suicidal client has difficulty
expressing anger toward others. The depressed
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suicidal client frequently expresses feelings of low Rationale: The client who is confused might forget
self-worth, feelings of remorse and guilt, and a that he ate earlier. Don’t argue with the client. Simply
dependence on others; therefore, answers A, B, and get him something to eat that will satisfy him until
C are incorrect. lunch. Answers A and D are incorrect because the
nurse is dismissing the client. Answer B is validating
187.C the delusion.
Rationale: A history of cruelty to people and
animals, truancy, setting fires, and lack of guilt or (Reference: http://nursingcrib.com/nursing-board-
remorse are associated with a diagnosis of conduct exam-reviewer)
disorder in children, which becomes a diagnosis of

antisocial personality disorder in adults. Answer A is 191. B.
incorrect because the client with antisocial Rationale: For the client with bulimia, binges involve
personality disorder does not hold consistent a lost of control that results in thoughts of self
employment. Answer B is incorrect because the IQ depreciation.
is usually higher than average. Answer D is incorrect
because of a lack of guilt or remorse for wrong- 192. D
doing. Rationale: When working with a client who is
withdrawn and speaks little, answers briefly, and
looks at the floor, the nurse should focus on the
188. D
simplest type of behaviour. (i.e. behaviour requiring
Rationale: Leaving a nightlight on during the evening
the least effort for the client.)
and night shifts helps the client remain oriented to
the environment and fosters independence. Answers
193. B
A and B will not decrease the client’s confusion.
Rationale: To promote a therapeutic relationship with
Answer C will increase the likelihood of confusion in
a suspicious client, it is best to spend brief intervals
an elderly client.
with the client each day to develop trust, respect and
rapport.
189.A
Rationale: If the client is a threat to the staff and to
194. D.
other clients the nurse should call for help and
Rationale: When the client feels unworthiness, she
prepare to administer a medication such as Haldol to
reflects low self esteem. Presenting another set of
sedate him. Answer B is incorrect because simply
facts in a manner that is accepting of the client but
telling the client to calm down will not work. Answer
avoids a power struggle is helpful.
C is incorrect because telling the client that if he
continues he will be punished is a threat and may
195. D.
further anger him. Answer D is incorrect because if
Rationale: The nurse sets limit on an unacceptable
the client is left alone he might harm himself.
or threatening behaviour to help the client regain
control and preserve his self esteem.
190.C
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9
(Reference: Lippincott’s Review for NCLEX- RN Rationale: Confusion, disorientation, behavioral
examination 8th Edition.) changes, and alterations in judgment are early signs
of dementia. Answers A, C, and D do not relate to
196. B – protective gear helps prevent infections that the question; therefore, they are incorrect.
may gain entry through
openings in the skin, the eyes, and the mouth
203. A
Rationale: The child with mental retardation should
197. A
not be overprotected but need protection from injury
Rationale: schizophrenia has a multifocal origin and
and the teasing of other children. B,C, and D

its cause may include a genetic component. Support
Children with mental retardation have learning
is needed for both patients and caregivers.
difficulty. They should be taught with patience and
repetition, start from simple to complex, use visuals
198. B and compliment them for motivation. Realistic
Rationale: a suicide attempt is a serious and self- expectations should be set and optimize their
destructive behavior that demands searching for capability.
weapons and harmful materials to increase safety.
204. B
199. D
Rationale: Altered parenting role refers to the
Rationale: delirium tremens occur as acute alcohol
inability to create an environment that promotes
withdrawal progresses. It include symptoms such as
optimum growth and development of the child. This
clouding of sensorium, hallucinations, seizures, and
is reflected in the parent’s inability to care for the
autonomic hyperactivity.
child. A. This refers to lack of choices or inability to
mobilize one’s resources. C. Refers to change in
200. B
family relationship and function. D. Ineffective coping
Rationale: cognitive symptoms include inflated self-
is the inability to form valid appraisal of the stressor
esteem and grandiosity
or inability to use available resources
201. A
205. B
Rationale: Participating in reality orientation is the Rationale: These are manifestations of autistic
most appropriate activity for the client who is disorder. A. These manifestations are noted in
confused. Answers B, C, and D are incorrect Oppositional Defiant Disorder, a disruptive disorder
because they are not suitable activities for a client among children. C. These are manifestations of
who is confused. Attention Deficit Disorder D. These are the
manifestations of Conduct Disorder
202. B (Reference: http://nursingcrib.com/nursing-board-
exam-reviewer)
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206. B compromises physiological integrity and needs to be
Rationale: Projection is the process of attributing addressed immediately.
one’s own thoughts about one’s self to others.
212. D
207.A Rationale: For the nurse to empathize with the
Rationale: This allows the agitated, angry client time client‘s experience is most therapeutic. Disagreeing
to regain self-control, telling the client that the nurse with delusions may make the client more defensive,
will return will decrease possible guilt feelings and and the client may cling to the delusions even more.
implies to the client that the nurse cares enough to Encouraging discussion regarding the delusion is
return. inappropriate.

208.C 213. C
Rationale: All behavior has meaning; before Rationale: A conversion disorder is the alteration or
planning intervention, the nurse must try to loss of a physical function that cannot be explained
understand what the behavior means to the client. by any known pathophysiological mechanism. A
conversion disorder is thought to be an expression
209.D of a psychological need or conflict. In this situation,
Rationale: When acceptance is reached the the client witnessed an accident that was so
individual is beginning to withdraw; communication is psychologically painful that the client became blind.
simple, concise, and most often nonverbal. A dissociative disorder is a disturbance or alteration
in the normally integrative functions of identity,
210.B memory, or consciousness. Psychosis is a state in
Rationale: Intellectually the person knows the which the person’s mental capacity to recognize
compulsive acts are senseless but is unable to stop reality, communicate, and relate to others is
doing them because they control anxiety. impaired, thus interfering width the person’s ability to
deal with life’s demands. Repression is a coping
(Reference: Mosby’s Review Questions for the mechanism in which unacceptable feelings are kept
NCLEX-RN® Examination, 6th Edition) out of awareness.
211. B 214. A
Rationale: Mania is a mood characterized by Rationale: If a client with severe anxiety is left alone,
excitement, euphoria, hyperactivity, excessive the client may feel abandoned and become
energy, decreased need for sleep, and impaired overwhelmed. Placing the client in a quiet room is
ability to concentrate for complete a single train of also important, but the nurse must stay with the
thought. Mania is a period when the mood is client. Teaching the client deep breathing or
predominantly elevated, expansive, or irritable. All relaxation is not possible until the anxiety decreases.
options reflect a client’s possible symptomatolgy. Encouraging the client to discuss concerns and
Option B, however, clearly presents a problem that feelings would not take place until the anxiety has
decreased.
3
1
statements neither reinforce the risk of violently
215. B acting out or nor define limits for future behavior.
Rationale: Solitary activities that require a short Restraining a patient is unpleasant for all concerned,
attention span with mild physical exertion are the but disclosing this information to the patient without
most appropriate activities for a client who is addressing the dangerousness of his behavior and
exhibiting aggressive behavior. Writing (journaling), reinforcing what is expected of him is insufficient.
walks with staff, and finger painting are activities that
minimize stimuli and provide a constructive release 218. C
for tension. Competitive games should be avoided Rationale: paralanguage is the use of vocal effects,
because they can stimulate aggression and increase such as tone and tempo, to convey a message.

psychomotor activity. Appearance is to the way people look. Kinetics
involves body language or movement. Proxemics is
(Reference: Silvestri, Linda Anne, Saunders the use of spatial relationships (distance between
Comprehensive Review NCLEX RN EXAMINATION people) during interaction to communicate learning.
4th ed., © 2008 Canada: Saunders.)
219. A
216. B Rationale: The priority nursing diagnostic category is
Rationale: Rationalization is the offering of a socially Anxiety, severe to panic-level, as evidenced by J.'s
acceptable or logical reason for doing, feeling, or extreme withdrawal and attempt to protect himself
behaving in a way that might not be otherwise from the environment. The nurse must act
acceptable. Reaction formation is the development immediately to reduce his anxiety and to protect the
of attitudes or behaviors that are opposite of what patient and others from possible injury. Impaired
one actually feels or wants to do. Denial is avoiding verbal communication, as evidenced by
reality by ignoring unpleasant events. Regression is noncommunicativeness. Altered thought processes,
a return to behaviors that reflect an earlier as evidenced by an inability to understand the
developmental level situation, and Dressing and grooming self-care
deficit, as evidenced by a disheveled appearance,
217. C are all appropriate nursing diagnostic categories but
Rationale: the most therapeutic response to J.'s are not the priority in this situation.
apology should incorporate a realistic statement
acknowledging, in a nonpunitive but serious manner, 220. D
the possible consequences of his violent behavior. Rationale: J.'s statement combines truth (the ozone
The nurse should also set clear limits by describing layer is being destroyed), some exaggeration that
the expected behavior and the consequences the may be delusional (the earth is doomed), and some
patient will face if he again loses control. Violent projection of his own fears (the nurse should get
behavior is dangerous to both the patient and others away). By choosing to respond to the underlying
and should not be excused or made light by saying message about J.'s fear of being destroyed, the
"I know you didn't mean to hurt us..." or "Let's see nurse attempts to help him identify and express his
how well you control yourself from now on." Such feelings in a more direct and appropriate manner.
3
2
Reflecting doubt about delusional statements can Rationale: Response A indicates improvement in the
help the patient see that the nurse does not share concrete thinking. Response B indicates
his belief. However, such reflection should not be improvement in the core problem of poor attention
stated judgmentally ("You are Overacting"). Pursuing span and difficulty completing a task. Responses C
a discussion about the ozone layer or ignoring his and D indicate improvement in the core problem of
comments completely are nontherapeutic being able to distinguish background from
approaches because they do not acknowledge his foreground information.
fear.
225. D
(Reference: http://www.blogcatalog.com/blog/nclex- Rationale: Dissociation involves the separating of

and-local-board-prc-sample-exam) any group of mental or behavioral processes from
the rest of consciousness. In isolation, there is a
221. B splitting off the emotional and thought components
Rationale: Identifying symptoms that trigger a of the emotional and thought components of a
relapse allows the client and family to take situation. Regression involves a retreat to behavior
preventive action. Responses A,C, and D indicate characteristic of an earlier developmental period due
that the client has learned strategies for coping with to stress.
hallucinations.
(Reference: Hoyson, Patricia McLean & Kimberly A.
222. A Serroka, NCLEX-RN Review 2008, Jones and
Rationale: Negative symptoms of psychosis involve Bartlett Publichers Sudbury, Massachusetts; pages
a diminution or loss of normal functioning. They 334-335 and 365-336)
include affective flattening, alogia (restricted thought
and speech), avolution/apathy (lack of behavior 226. A
initiation),and anhedonia/asociality (inability to Rationale: Narcolepsy involves brief periods of deep
experience pleasure or maintain social contacts?. sleep and an irresistible desire to sleep. It is usually
Positive symptoms of psychosis involve an excess associated with cataplexy and sleep paralysis.
or distortion of normal functioning. These include Primary hypersomnia involves prolonged sleep that
psychotic disorders of thinking (delusions) and interferes with functioning. Primary insomnia is
disorganization of speech (illogicality) and behavior. difficulty falling to sleep. Sleep apnea is an absence
of breathing usually related to upper airway collapse.
223. B
Rationale: Assessment (identification) comes before
implementation. Responses controlling the physical
effects of anxiety, beginning breathing exercises, 227. C
and using problem-solving are implementation Rationale: Many clients in withdrawal are
activities that are appropriate longer-term goals. dehydrated. Fluid up to 3000ml per day should be
encouraged. The peak time of DTs after the last
224. A drink is 24-48 hours. Antabuse blocks an enzyme
3
3
that metabolizes highly toxic acetaldehyde, (Reference: Hoyson, Patricia McLean & Kimberly A.
producing nausea and hypotension. Naltrexone Serroka, NCLEX-RN Review 2008, Jones and
(ReVia, Trexan) blocks the craving for alcohol. Bartlett Publichers Sudbury, Massachusetts; pages
Alcohol interferes with the absorption of the B 334-335 and 365-336)
vitamins. Thus, they should be supplemented.
231. D
228. C Rationale: Depressed clients see the future as a
Rationale: Religious objections are usually upheld by blank and have given up all hope where the anxious
the courts. When ruling against psychiatric clients’ client has not. All other symptoms are shared by
rights to refuse treatment, courts look for benefits of clients experiencing the two conditions. Both also

treatment outweighing risks and side effects that are experience difficulty concentrating, appetite
not permanent. In the case of involuntary changes, and nonspecific cardio pulmonary
commitment of a competent client, a hearing is held complaints.
before an independent psychiatrist where the client
has a right to legal counsel. 232. B
Rationale: This assurance is a limit-setting
229. C intervention and promotes a sense of safety to the
Rationale: Advocacy is acting in support of a client’s client. The intervention of discontinuing external
right. Clients have a right to understand and limits as soon as the client is able to self-regulate
participate in treatment decision-making. empowers the client to use self-control. The
Encouraging client feedback, explaining unit rules intervention of all staff consistently enforcing limits
and policies, and making sure clients understand promotes behavior shaping. Accepting the client
expectations for participation are strategies for while rejecting inappropriate behavior protects self-
working with the client in a therapeutic environment. esteem.
Explaining unit rules and policies relates to safety,
while encouraging client feedback relates to self- 233. A
understanding. Clarifying expectations for a client’s Rationale: Demonstrating less impulsive behavior is
participation relates to structure. an appropriate goal for Cluster B PDs including
borderline PD (impulsive and unpredictable
230. B behavior), histrionic PD (dramatic and reactive
Rationale: Treatment for severe depression begins behavior), narcissistic PD (grandiose self-
with a mood stabilizer and an antidepressant. If importance), and anti-social PD (manipulative
psychosis is present in the manic client, treatment behavior in conflict with the society). Identifying
begins with a mood stabilizer and an atypical behaviors that maximize social interactions and
antipsychotic. Diuretics have no role in treatment of participating in activity groups are appropriate goals
mania or depression. If a diuretic is given in for cluster A PDs, which include the odd-eccentric
combination with lithium, blood lithium levels will disorders of paranoid PD, schizoid PD, and
increase along with the potential for lithium toxicity. schizotypal PD. Making decisions independently is
an appropriate goal for cluster C PDs, which
3
4
includes anxious and fearful disorders such as
avoidant PD, dependent PD, and obsessive-
compulsive PD.
234. C
Rationale: All of the responses represent deviations
in adult partners’ coalition. In the schismatic pattern,
children are forced to join one or the other camp of
warring parents. The adult partners belittle and
undercut each other as a defense against closeness.

In the disengaged coalition, adult members are
oblivious to the effects of their actions on others. In
the enmeshed pattern, there is one over-controlling
adult with high intensity interactions between the
partners. In the skew pattern, one mate is severely
dysfunctional and the other is passive with regard to
the dysfunction.
235. A
Rationale: This response acknowledges the need for
the false belief while not encouraging it or arguing
with the client, clearly states what is expected, and
offers self. Empathy is a process which people feel
with one another. Reflection is repeating the client’s
verbal or nonverbal message. The client is
demonstrating manipulative behavior.
(Reference: Hoyson, Patricia McLean & Kimberly A.

Serroka, NCLEX-RN Review 2008, Jones and
Bartlett Publichers Sudbury, Massachusetts; pages
334-335 and 365-336)
3
5

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Answers and Rationale retaliate with significant consequences.

1. B one’s own weaknesses. Compensation is

MAD : Maladaptive Disorders | BSN 002

Reference: Timby, B.K., Carmack, A., & Rupert, D.L.

2. B between mania (abnormal highs) and depression

Rationale:The initial nursing action would be to

MAD : Maladaptive Disorders | BSN 002

at higher risk include those with a history of a dual

Having a plan, particularly if the method is

7. D. get dressed) achieves the goal of having her

Rationale: The most therapeutic response by the

MAD : Maladaptive Disorders | BSN 002

Rationale: A nurse’s initial task when assessing a

Rationale: According to Freud’s psychosexual in the normally integrative function s of identity,

RATIONALE: Because the client has problems with

MAD : Maladaptive Disorders | BSN 002

exhibiting aggressive behavior. Writing (journaling),

RATIONALE: The client with aphasia may need secret.

additional time to select the proper words when

RATIONALE: Generally, the client seeks voluntary

MAD : Maladaptive Disorders | BSN 002

RATIONALE: Denial is refusal to admit painful

21. A maybe an appropriate nursing intervention, but the

22. A Rationale: Hanging is a serious suicide attempt. The

MAD : Maladaptive Disorders | BSN 002

28. A if the nurse takes to agree with the false ideas he

It is typical for the elderly to feel shamed and holds.

humiliated by the abuse they receive.

(NCLEX-RN Examination 8th Edition by Diane M.

(Thompson Peterson. NCLEX-PN Certification Bilings)

Exam. Peterson’s Advision of Thompson Learning

Rationale: The nursing diagnosis Disturbed Thought

(NCLEX-RN Examination 8th Edition by Diane M.

MAD : Maladaptive Disorders | BSN 002

Rationale: The nurse needs to present the reality of

(NCLEX-RN Examination 8th Edition by Diane M.

Rationale: Patients with antisocial personality

MAD : Maladaptive Disorders | BSN 002

Rationale: This question will give the nurse data

Rationale: Identity and purpose are often associated

toward goals. Regarding option 3, the antisocial

MAD : Maladaptive Disorders | BSN 002

Rationale: The nurse who is aware of his or her (Reference: www.evolve.elsevier.com)

Rationale: This question asks directly about the 47. B

coping skills. painful or anxiety inducing events or feelings. In this

MAD : Maladaptive Disorders | BSN 002

MAD : Maladaptive Disorders | BSN 002

Rationale: Option B is the action of Cogentin.

Rationale: The client’s energy level is so high that a

MAD : Maladaptive Disorders | BSN 002

http://www.scribd.com/doc/6389830/109-Questions- observation. This client must not be left alone

and-Rationale-on-Psychotic-Disorders (Option B and D). The nurse must not relinquish

Rationale: This response orients the client to reality

MAD : Maladaptive Disorders | BSN 002

(Source: Springhouse Review for NCLEX-RN 5th 69. C

mechanism. benzodiazepines, must be weaned off these drugs.

MAD : Maladaptive Disorders | BSN 002

Rationale: The superego incorporates all

MAD : Maladaptive Disorders | BSN 002

Rationale: One-to-on supervision and making a

MAD : Maladaptive Disorders | BSN 002

90. B Rationale: Values and beliefs from parents and

needs or risking parental disapproval. happens in the later stage. Independence is