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When assessing a client diagnosed with post-traumatic stress disorder (PTSD), which finding should the nurse expect?
- A. Hypervigilance
- B. Insomnia
- C. Flashbacks
- D. Suicidal ideation
Correct Answer: A
Rationale: Clients with PTSD commonly exhibit symptoms such as hypervigilance, insomnia, flashbacks, difficulty concentrating, and increased irritability. Hypervigilance refers to an enhanced state of awareness and alertness, often seen in individuals with PTSD as they are constantly on guard for potential threats. Insomnia is a common sleep disturbance associated with PTSD, where individuals may have trouble falling or staying asleep. Flashbacks involve re-experiencing the traumatic event as if it is occurring in the present moment. Suicidal ideation, while a serious concern in mental health, is not a hallmark symptom specifically associated with PTSD. Therefore, the correct finding that the nurse should expect when assessing a client diagnosed with PTSD is hypervigilance.
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Which of the following are characteristics of borderline personality disorder? Select one that does not apply.
- A. Intense fear of abandonment
- B. Unstable relationships
- C. Impulsivity
- D. Grandiosity
Correct Answer: D
Rationale: Borderline personality disorder is characterized by an intense fear of abandonment, unstable relationships, impulsivity, and chronic feelings of emptiness. Grandiosity, which involves an exaggerated sense of self-importance and superiority, is more commonly associated with narcissistic personality disorder rather than borderline personality disorder. Therefore, the correct answer is D.
When planning care for a client with schizophrenia, which of the following interventions should be included in the plan of care?
- A. Encourage reality testing
- B. Provide opportunities for socialization
- C. Monitor for command hallucinations
- D. Promote adherence to medication regimen
Correct Answer: A
Rationale: When caring for a client with schizophrenia, encouraging reality testing is essential. This intervention assists the client in distinguishing between delusions and reality, aiding in their treatment. While providing opportunities for socialization can help reduce isolation, monitoring for command hallucinations is crucial for the client's safety. Promoting adherence to the medication regimen is vital for symptom management. Addressing delusional thoughts in a therapeutic manner is preferable to outright discouragement, fostering a supportive environment for the client.
Which of the following interventions should be implemented for a client with anorexia nervosa? Select one that does not apply.
- A. Monitor daily caloric intake and weight
- B. Establish a structured eating plan
- C. Encourage the client to exercise
- D. Provide liquid supplements as prescribed
Correct Answer: C
Rationale: Interventions for a client with anorexia nervosa include monitoring daily caloric intake and weight, establishing a structured eating plan, providing liquid supplements as prescribed, and offering rewards for weight gain. However, encouraging the client to exercise is not appropriate as it may exacerbate the condition by increasing caloric expenditure and reinforcing unhealthy behaviors associated with the disorder. Exercise may further contribute to excessive weight loss and worsen the client's physical health in the context of anorexia nervosa.
A client has been diagnosed with dependent personality disorder. Which of the following behaviors should the nurse expect?
- A. Difficulty making decisions
- B. Preoccupation with orderliness
- C. Attention-seeking behavior
- D. Aggression
Correct Answer: A
Rationale: Individuals with dependent personality disorder typically struggle with making decisions independently and rely heavily on others for guidance and reassurance. This can manifest as difficulty in initiating or making choices without the input of others. Clients with this disorder often display clingy, submissive behaviors and fear being alone, which aligns with the characteristic of difficulty making decisions seen in option A. Choices B, C, and D are not typically associated with dependent personality disorder. Preoccupation with orderliness may be seen in obsessive-compulsive personality disorder, attention-seeking behavior in histrionic personality disorder, and aggression in other disorders such as antisocial personality disorder.
A healthcare provider is assessing a client with suspected bipolar disorder. Which of the following findings should the healthcare provider expect? Select one that does not apply.
- A. Periods of elevated mood
- B. Decreased need for sleep
- C. Flight of ideas
- D. Anhedonia
Correct Answer: D
Rationale: Findings in a client with bipolar disorder typically include periods of elevated mood, decreased need for sleep, and flight of ideas. Anhedonia, characterized by the inability to experience pleasure, is more commonly associated with major depressive disorder. Therefore, the healthcare provider should not expect anhedonia in a client with suspected bipolar disorder. The other choices are characteristic features of bipolar disorder, such as mania or hypomania.