When the parents ask if their child is psychotic, the nurse who is performing the initial interview is most correct in explaining which of the following as a behavior exhibited by psychotic people?
- A. They have poor response to new situations.
- B. They have difficulty in relationships.
- C. They cannot differentiate reality from unreality.
- D. They feel helpless in resolving problems.
Correct Answer: C
Rationale: Psychosis is characterized by impaired reality testing.
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If this child is typical of others the same age with a serious illness, which concept is the most commonly held belief about being ill?
- A. Illness is not life-threatening; recovery is assured.
- B. Significant others can prevent serious consequences.
- C. Illness is a punishment for some wrong-doing.
- D. Failure to comply with treatment results in parental rejection.
Correct Answer: C
Rationale: School-age children often view illness as punishment due to magical thinking.
When performing a brief check of the client's mental status, which question is most appropriate for assessing the client's orientation?
- A. What is today's date?
- B. How did you get here?
- C. Where were you born?
- D. Who is currently the U.S. president?
Correct Answer: A
Rationale: Asking the date assesses orientation to time, a key component.
Which withdrawal symptom is the nurse most likely to note while observing the newborn of a mother who used heroin during pregnancy?
- A. Tremors
- B. Lethargy
- C. Poor feeding
- D. High-pitched cry
Correct Answer: A,C,D
Rationale: Tremors, poor feeding, and high-pitched cry are common symptoms of neonatal opioid withdrawal.
Which nursing instruction is most appropriate when teaching a client who self-administers haloperidol (Haldol)?
- A. Take the pills on an empty stomach.
- B. Do not skip meals while taking the drug.
- C. Stop taking the drug if sedation occurs.
- D. Rise slowly from a sitting position.
Correct Answer: D
Rationale: Rising slowly prevents orthostatic hypotension, a common side effect.
The nurse recognizes that methylphenidate hydrochloride (Ritalin) is classified as which type of drug?
- A. Central nervous system depressant
- B. Central nervous system stimulant
- C. Antidepressant
- D. Tranquilizer
Correct Answer: B
Rationale: Methylphenidate is a CNS stimulant used for ADHD.