Nursing Interventions for Clients with Personality Disorders, Exams of Nursing

Download Nursing Interventions for Clients with Personality Disorders and more Exams Nursing in PDF only on Docsity! 1 | P a g e PERSONALITY DISORDERS NCLEX EXAMS 2024 WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED RATIONALES ANSWERS |FREQUENTLY TESTED QUESTIONS AND SOLUTIONS |ALREADY GRADED A+ |NEWEST | LATEST UPDATE | GUARANTEED PASS Personality disorders are grouped in clusters according to their behavioral characteristics. In which cluster are the disorders correctly matched with their behavioral characteristics? A. Cluster C: antisocial, borderline, histrionic, narcissistic disorders; anxious or fearful characteristic behaviors B. Cluster A: avoidant, dependent, obsessive-complusive disorders; odd or eccentric characteristic behaviors C. Cluster A: antisocial, borderline, histrionic, narcissistic disorders; dramatic, emotional, or erratic characteristic behaviors D. Cluster C: avoidant, dependent, obsessive-complusive disorders; anxious or fearful characteristic behaviors D Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorder. Anxious or fearful is the correct description for clients diagnosed with a cluster C personality disorder. Which behavior would the nurse expect to observe if a client is diagnosed with paranoid personality disorder? A. The client sits alone at lunch and states, "Everyone wants to hurt me." B. The client is irresponsible and exploits other peers in the milieu for cigarettes C. The client is shy and refuses to talk to other because of poor self-esteem D. The client sits with peers and allows others to make decisions for the entire group A Individuals with paranoid personality disorder would be isolative and believe that others were out to get them. The behavior presented reflects a client diagnosed with this disorder. Which diagnostic criterion describes a characteristic of schizotypal personality disorder? A. Neither desires nor enjoys close relationships, including being part of a family B. Is preoccupied with unjustified doubts about the loyalty of friends and associates C. Considers relationships to be more intimate than they actually are D. Exhibits behavior or appearance that is odd, eccentric, or peculiar 2 | P a g e D Magical thinking and odd beliefs that influence behavior and are inconsistent with subcultural norms are defined as criteria for schizotypal personality disorder, which is often described as "latent schizophrenia." Clients with this diagnosis are odd and eccentric but do not decompensate to the level of schizophrenia. Which of the following diagnostic criteria describe the characteristics of borderline personality disorder? (Select all that apply) A. Arrogant, haughty behaviors or attitudes B. Frantic efforts to avoid real or imagined abandonment C. Recurrent suicidal and self-mutilating behaviors D. Unrealistic preoccupation with fears of being left to take care of self E. Chronic feelings of emptiness B,C,E -This criterion describes borderline personality disorder, which is characterized by a pervasive pattern of instability of interpersonal relationships. Having real or imagined feelings of abandonment is the first criterion of this disorder. -Recurrent suicidal and self-mutilating behavior is a diagnostic criterion that describes borderline personality disorder. -Having chronic feelings of emptiness is a diagnostic criterion that describes borderline personality disorder. Which of the following diagnostic criteria describe the characteristics of avoidant personality disorder? (Select all that apply) A. Fearing shame and/or ridicule, does not form intimate relationships B. Has difficulty making everyday decisions without reassurance from others C. Is unwilling to be involved with people unless certain of being liked D. Shows perfectionism that interferes with task completion E. Views self as socially inept, unappealing, and inferior A,C,E -Clients diagnosed with avoidant personality disorder show a pervasive pattern of social inhibitions, feelings of inadequacies, and hypersensitivity to negative evaluation and find it difficult to form intimate relationships -Clients diagnosed with avoidant personality disorder are extremely sensitive to rejection and need strong guarantees of uncritical acceptance -Although there may be a strong desire for companionship, a client with avoidant personality disorder has such a pervasive pattern of inadequacy, social inhibition, and withdrawal from life that the desire for companionship is negated. When assessing a client diagnosed with histrionic personality disorder, the nurse might identify which characteristic behavior? A. Odd beliefs and magical thinking B. Grandiose sense of self-importance C. Preoccupation with orderliness and perfection D. Attention-seeking flamboyance 5 | P a g e A. "I don't know what you mean by envisioning your future death." B. "Your future death? Can you please tell me more about that?" C. "I was wondering if you want to come to group to talk about that." D. "I can see your thoughts are bothersome. How can I help?" D Acknowledging the client's feelings about the altered thoughts is an important response. The nurse supports the client's feelings but not the altered thoughts. At the same time, the nurse explores ways to help the client feel comfortable. A suicidal client is diagnosed with borderline personality disorder. Which correctly written short-term outcome is most beneficial for the client? A. The client will be free from self-injurious behavior B. The client will express feelings without inflicting self-injury by discharge C. The client will socialize with peers in the milieu by day 3 D. The client will acknowledge his or her role in altered interpersonal relationships B The client's being able to express feelings without inflicting self-injury by discharge is an outcome that reinforces the priority for client safety, is measurable, and has a time frame. A client diagnoses with an obsessive-compulsive personality disorder has a nursing diagnosis of anxiety R/T interference with hand washing AEB "I'll go crazy if you don't let me do that." Which correctly written short-term outcome is appropriate for this client? A. During a 3-hour period after admission to the unit, the client will refrain from hand washing. B. The client will wash hands only at appropriate bathroom and meal intervals C. The client will refrain from hand washing throughout the night D. Within 72 hours of admission, the client will notify staff when signs and symptoms of anxiety escalate D This short-term outcome is stated in observable and measurable terms. This outcome sets a specific time for achievement (within 72 hours). It is specific (signs and symptoms), and it is written in positive terms. When the client can identify signs and symptoms of increased anxiety, the next step of problem-solving can begin. A client diagnosed with antisocial personality disorder demands, at midnight, to speak to the ethics committee about the involuntary commitment process. Which nursing statement is appropriate? A. "I realize you're upset; however, this is not the appropriate time to explore your concerns." B. "Let me give you a sleeping pill to help put your mind at ease." C. "It's midnight, and you are disturbing the other clients." D. "I will document your concerns in your chart for the morning shift to discuss with the ethics committee." A In this situation, the nurse empathizes with the client's concerns and then sets limits on inappropriate behaviors in a matter-of-fact manner. 6 | P a g e A client diagnosed with antisocial personality disorder is caught smuggling cigarettes into the nonsmoking clinical area. Which initial nursing intervention is appropriate? A. Confront the client about the behavior B. Tell the client's primary nurse about the situation C. Remind all clients of the no smoking policy in the community meeting D. Teach alternative coping mechanisms to assist with anxiety A It is important to address an individual's behavior in a timely manner to set appropriate limits. Limit setting is to be done in a calm, but firm, manner. A client diagnosed with antisocial personality disorder may have no regard for rules or regulations, which necessitates limit setting by the nurse. After being treated in the ED for self-inflicted lacerations to wrists and arms, a client with a diagnosis of borderline personality disorder is admitted to the psychiatric unit. Which nursing intervention takes priority? A. Administer tranquilizing drugs B. Observe client frequently C. Encourage client to verbalize hostile feelings D. Explore alternative ways of handling frustration B The priority nursing intervention is to observe the client's behavior frequently. The nurse should do this through routine activities and interactions to avoid appearing watchful and suspicious. Close observations is required so that immediate interventions can be implemented as needed. A client diagnosed with a borderline personality disorder is given a nursing diagnosis of disturbed personal identity R/T unmet dependency needs AEB the inability to be alone. Which nursing intervention would be appropriate? A. Ask the client directly, "Have you thought about killing yourself?" B. Maintain a low level of stimuli in the client's environment C. Frequently orient the client to reality and surroundings D. Help the client identify values and beliefs D This client has been diagnosed with borderline personality disorder resulting from fixation in an earlier developmental level. This disruption during the establishment of the client's value system has led to disturbed personal identity. When the nurse helps the client to identify internalized values, beliefs, and attitudes, the client begins to distinguish personal identity. A client diagnosed with a dependent personality disorder has a nursing diagnosis of social isolation R/T parental abandonment AEB fear of involvement with individuals not in the immediate family. Which nursing intervention would be appropriate? A. Address inappropriate interactions during group therapy B. Recognize when client is playing one staff member against another C. Role-model positive relationships D. Encourage client to discuss conflicts evident withing the family system 7 | P a g e C Role-modeling positive relationships would provide a motivation to initiate interactions with others outside the client's family. This is an appropriate intervention for the nursing diagnosis of social isolation. A client diagnosed with paranoid personality disorder needs information regarding medications. Which nursing intervention would best assist this client in understanding prescribed medications? A. Ask the client to join the medication education group B. Provide one-on-one teaching in the client's room C. During rounds, have the physician ask if the client has any questions D. Let the client read the medication information handout B When a client is diagnosed with paranoid personality disorder, one-on-one teaching in a client's room would decrease the client's paranoia, support a trusting relationship, and allow the client to ask questions. The nurse also would be able to evaluate the effectiveness of medication teaching. A nursing student is studying the historical aspects of personality disorder. Which entry on the examination indicates that learning has occurred? A. Zeus, in the 3rd century BC, identified, described, and applied the theory of object relations B. Hippocrates, in the 4th century BC, identified four fundamental personality styles C. Narcissus, in 923 AD introduced the word "personality" from the Greek term "persona." D. Achilles, in 866 AD, described the pathology of personality as a complex behavioral phenomenon B In the 4th century B.C., Hippocrates, also known as the father of medicine, identified four fundamental personality styles that he concluded stemmed from excesses in the four humors: the irritable and hostile choleric (yellow bile), the pessimistic melancholic (black bile), the overly optimistic and extroverted sanguine (blood), and the apathetic phlegmatic (phlegm). A nursing student is learning about narcissistic personality disorder. Which of the following student statements indicate that learning has occurred? (Select all that apply) A. "These clients have peculiarities of ideation." B. "These clients require constant approval and affirmation." C. "These clients are impulsive and self-destructive." D. "These clients express a grandiose sense of self-importance." E. These clients have a deep need for admiration." D Narcissistic personality disorder is characterized by a grandiose sense of self-importance and preoccupations with fantasies of success, power, brilliance, and beauty. These clients sometimes may exploit others for self-gratification. A nursing instructor is teaching about personality disorder characteristics. Which student statement indicates that learning has occurred? A. "Clients diagnosed with personality disorders need frequent hospitalizations." B. "Clients perceive their behaviors as uncomfortable and disorganized." 10 | P a g e A,C,E -Difficulty with social and professional relationships is a personality characteristic that can be seen with all personality disorder types. -Maladaptive response to stress is a personality characteristic that can be seen with all personality disorder types. -Difficulty understanding personal boundaries is a personality characteristic that can be seen with all personality disorder types. A 36-year-old client with paranoid schizophrenia believes the room is bugged by the Central Intelligence Agency and a roommate is a foreign spy. The client has never had a romantic relationship, has no contact with family, and hasn't been employed for the past 14 years. Based on Erikson's theories, the nurse should recognize that this client is in which stage of psychosocial development? A. Autonomy versus shame and doubt B. Generativity versus stagnation C. Integrity versus despair D. Trust versus mistrust D This client's paranoid ideation indicates difficulty in trusting others. A client with antisocial personality disorder smokes where it is prohibited and doesn't follow other unit or facility rules. The client gets others to do the laundry and other personal chores, tries to divide the staff, and works only with certain nurses. The primary focus on this client's care plan should be: A. consistently enforcing unit rules and facility policy B. isolating the client to decrease contact with easily manipulated clients C. engaging in power struggles with the client to decrease the incidence of manipulative behavior D. using behavior modification to decrease the amount of negative behavior by using negative reinforcement A Firmness and consistency about rules are the hallmarks of a care plan for a client with a personality disorder. During a private conversation, a client with borderline personality disorder asks the nurse to "keep my secret" and then displays multiple, self-inflicted, superficial lacerations on the forearms. What is the nurse's best response? A. "This type of behavior requires you to be on suicide precautions." B. "I'm going to tell your physician. Do you want to tell me why you did that?" C. "Tell me what type of instrument you used. I'm concerned about infection." D. "Whenever something important occurs, the team needs to know about it. I'll have to tell the others, but let's talk about it first." D This response informs the client of the nurse's planned actions and allows time to discuss the client's action. 11 | P a g e The nurse is assessing the client with paranoid personality disorder. Which behavior should the nurse expect? A. Able to trust only those who are fair and treat the client well B. Sees the goodwill of another when that behavior does not exist C. Acts the opposite of what the client may be thinking or feeling D. Analyzes the behavior of others to find hidden and threatening meanings D The client with paranoid personality disorder exhibits mistrust and suspicion of others such that the behavior of others is analyzed to find hidden and threatening meanings. The nurse identifies that an individual with antisocial personality disorder exhibits poor judgment, emotional distance, aggression, and impulsivity. Which step of the nursing process is being completed by the nurse? A. Assessment B. Diagnosis C. Outcome Identification D. Planning E. Implementation F. Evaluation A The nurse is completing an assessment of the client by collecting information about the client's behavior. The nurse is working with the client with paranoid personality disorder. The nurse understands that the client likely experienced what in the past? A. Little affection or approval during the childhood years B. Lack of empathy and lack of nurturing during upbringing C. Indifference and lack of affection during early upbringing D. Recognition for accomplishments only in early childhood A Individuals with paranoid personality disorder may have been subjected to parental antagonism and harassment. They served as scapegoats for displaced parental aggression and eventually gave up all hope of affection and approval. The nurse is caring for the client with paranoid personality disorder. Which approach should the nurse use when working with the client? A. Use a businesslike manner using clear, concrete, and specific words B. First use social conversation to work on developing social relationships C. Include jokes when conversing to work on reducing the client's serious behavior D. Confront the client when stating suspicious ideas to aid the client in seeing reality A Clients with paranoid personality disorder take everything seriously and are attuned to the actions and 12 | P a g e motivations of others. A businesslike approach with clear, concrete, and specific words keeps the intended message clear by decreasing ambiguity. The nurse reads in the medical record that the client with BPD has "splitting." What is the nurse's interpretation of "splitting?" A. The client is having an intense psychotic episode and has become catatonic B. The client has an identity disturbance with an unstable self-image or sense of self C. The client is using a defense mechanism in which all objects are seen as good or bad D. The client's behavior shows a pattern of unstable and intense interpersonal relationships C Splitting is a primitive defense mechanism in which all objects, individuals, or situations are seen as good or bad. Individuals with BPD have an inability to accept and integrate positive and negative feelings. The nurse is working with the client with histrionic personality disorder. Which behaviors should the nurse expect? (Select all that apply) A. Uses physical appearance to gain attention B. Shows apathy in conversations until trust is established C. Lacks close friends or companions other than first-degree relatives D. Harbors recurrent suspicions about the fidelity of his or her marital partner E. Discomfort in situations in which the client is not the center of attention A,E -The client with histrionic personality disorder requires constant affirmation of approval and acceptance from others and often uses physical appearance to gain attention and approval. -Diagnostic criteria for histrionic personality disorder include discomfort in situations in which the client is not the center of attention. The client requires constant affirmation of approval and acceptance from others. The client with BPD often attempts to manipulate staff to promote self needs. Which behavior indicates that the client is able to overcome this manipulative behavior? A. Client insists on joining other clients in the dayroom because of feeling lonely B. Client asks for a cigarette 30 minutes after being told that cigarettes are allowed once an hour C. Client states to the nurse, "You are the best nurse, and only you are allowed to care for me." D. Client self-mutilates by cutting after the HCP discussed possible discharge with the client A Wanting to join others because of loneliness is a nonmanipulative behavior. The client with BPD states to the nurse, "Hey, you know what! You are my favorite nurse. That night nurse sure doesn't understand me the way you do." Which response by the nurse is most therapeutic? A. "Hang in there. I won't enjoy coming to work as much after you are discharged." B. "I'm glad you're comfortable with me. Which night nurse doesn't understand you?" C. "I like you. Tomorrow you'll be discharged; I'm glad you will be able to return home." D. "You are my favorite patient; I'll really miss caring for you when you are discharged." 15 | P a g e E. Rationalization F. Intellectualization A,B,E,F -Isolation is a defense mechanism to separate a thought or memory from the feelings or emotions associated with it. -Undoing is a defense mechanism to symbolically negate or cancel out a previous action or experience that is found to be intolerable. -Rationalization is attempting to make excuses or formulate logical reasons to justify unacceptable feelings or behaviors. -Intellectualization is an attempt to avoid expressing actual emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis. The client on a psychiatric unit is very demanding and belittling of one of the nurses. The client is talking with others and telling them how mean the nurse is to clients. Which nursing problem should the nurse include in the client's written plan of care? A. Social isolation due to negative behavior B. Ineffective coping due to inability to interact with unit personnel C. Risk for other-directed violence due to negative verbal comments D. Chronic low self-esteem due to use of the defense splitting D Splitting is a defense mechanism in which the person is unable to integrate and accept both positive and negative feelings, and people are considered either all good or all bad. The nurse is planning a counseling session with the client who has antisocial personality disorder. The nurse should anticipate that the client would use which primary ego defense mechanism? A. Projection B. Sublimation C. Compensation D. Rationalization A Projection is attributing feelings or impulses unacceptable to oneself onto another person. The person with antisocial personality disorder will exploit and manipulate others for personal gain. The HCP writes in the client's progress notes, "Will switch medications from the older medications to a newer GABA-ergic anticonvulsant to treat client's instability of mood, transient mood crashes, and inappropriate and intense outbursts of anger." Which medication should the nurse consider when reviewing the HCP's new prescriptions? A. Lithium B. Gabapentin C. Valproic acid D. Carbamazepine 16 | P a g e B GABA is the main inhibitory neurotransmitter in the CNS. GABA-ergic anticonvulsants, such as gabapentin, appear to act by regulating neural firing in the mesolimbic area. The client with a BPD is prescribed phenelzine for decreasing impulsivity and self-destructive acts. The nurse teaches the client to avoid foods high in tyramine when taking phenelzine to prevent what effect? A. A hypotensive crisis B. A hypertensive crisis C. Poor absorption of tyramine D. Cardiac rhythm abnormalities B The combination of tyramine-containing foods and MAOIs such as phenelzine (Nardil) can result in a hypertensive crisis. The nurse teaches the communication triad to the client to manage feelings. Which components should the nurse include? (Select all that apply) A. Use an "I" statement to identify the present feelings B. Use a "you" statement to identify the cause of the feeling C. Make a nonjudgmental statement about an emotional trigger D. Identify what would restore comfort to the situation for the client E. Use a "they" statement to examine the effect of the client's feelings on others A,C,D -Using "I" statements helps to avoid judgment and is part of the communication triad. - Nonjudgemental statements are included in the communication triad to manage feelings. -A mechanism for restoring comfort is included in the communication triad to manage feelings. The nurse includes milieu therapy in the treatment plan for the client with antisocial personality disorder. What is the nurse's best rationale for including milieu therapy? A. Set's limits on the client's unacceptable behavior B. Provides a very structured setting that helps the client learn how to have C. Stimulates a social community where the client can learn to interact with peers D. Provides one-on-one interaction and reality orientation with client and nursing personnel C Milieu therapy helps the client with antisocial personality disorder learn to respond adaptively to feedback from peers. The democratic approach with specific rules and regulations, community meetings, and group therapy sessions simulates the societal situation in which the client must live. Which predisposing factor would be implicated in the etiology of paranoid personality disorder? A. The individual may have been subjected to parental demands, criticism, and perfectionistic expectations B. The individual may have been subjected to parental indifference, impassivity, or formality C. The individual may have been subjected to parental bleak and unfeeling coldness D. The individual may have been subjected to parental antagonism and harassment 17 | P a g e D Individuals diagnosed with paranoid personality disorder most likely would be subjected to parental antagonism and harassment. These individuals likely served as scapegoats for displaced parental aggression and gradually relinquished all hope of affection and approval. They learned to perceive the world as harsh and unkind, a place calling for protective vigilance and mistrust. Using interpersonal theory, which statement is true regarding development of paranoid personality disorder? A. Studies have revealed a higher incidence of paranoid personality disorder among relatives of clients with schizophrenia B. Clients diagnosed with paranoid personality disorder frequently have been family scapegoats and subjected to parental antagonism and harassment C. There is an alteration in the ego development so that the ego is unable to balance the id and superego D. During the anal stage of development, the client diagnosed with paranoid personality disorder has problems with control within his or her environment B An example of an interpersonal theory of development might involve a client whose background reflects parental emotional abuse to the extent that paranoid personality disorder eventually will be diagnosed. When confronted, a client diagnosed with narcissistic personality disorder states, "Contrary to what everyone believes, I do not think that the whole world owes me a living." This client is using what defense mechanism? A. Minimization B. Denial C. Rationalization D. Projection B Denial is used when a client refuses to acknowledge the existence of a real situation or associated feelings. When the client states, "I don't think the whole world owes me a living," denial is being used to avoid facing others' perceptions. A client diagnosed with borderline personality disorder coyly requests diazepam (Valium). When the physician refuses, the client becomes angry and demands to see another physician. What defense mechanism is the client using? A. Undoing B. Splitting C. Altruism D. Reaction formation B The client in the question is using the defense mechanism of splitting. An individual diagnosed with borderline personality disorder sees things as wither "all good" or "all bad." In the question, when the client's manipulative charm does not work in obtaining the drug from the "good" physician, the client determines that the physician is now "bad" and seeks another physician to meet his or her needs. 20 | P a g e A In the questions, the client's statement would represent a typical response from someone who was diagnosed with an antisocial personality disorder. These clients also display patterns of socially irresponsible, exploitive, and guiltless behaviors that reflect a disregard for the rights of others. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders. Clients diagnosed with cluster B personality disorders exhibit behaviors that are dramatic, emotional, or erratic. A client has been diagnosed with a cluster A personality disorder. Which of the following client statements would reflect cluster A characteristics? (Select all that apply) A. "I'm the best chef on the East Coast." B. "My dinner has been poisoned." C. "I have to wash my hands 10 times before eating." D. "I just can't eat when I'm alone." E. "When my mom died, her spirit entered my cat." B,E -This statement might be voiced by a client diagnosed with paranoid personality disorder. Cluster A includes paranoid, schizoid, and schizotypal personality disorders. This cluster's characteristic behaviors are odd or eccentric and include patterns of suspiciousness and mistrust. -This statement might be voiced by a client diagnosed with schizotypal personality disorder. This cluster's characteristic behaviors are odd or eccentric and include patterns of suspiciousness and mistrust. A patient is admitted to the hospital with CKD. The nurse understands that this condition is characterized by a. progressive irreversible destruction of the kidneys b. a rapid decrease in urine output with an elevated BUN c. an increasing creatinine clearance with a decrease in urine output d. prostration, somnolence, and confusion with coma and imminent death A Patients with CKD experience an increase incidence of cardiovascular disease related to Select all that apply a. hypertension b. vascular calcifications c. a genetic predisposition d. hyperinsulinemia causing dyslipidemia e. increased high-density lipoprotein levels ABD An ESRD patient receiving HD is considering asking a relative to donate a kidney for transplantation. In assisting the patient to make a decision about treatment, the nurse informs the patient that 21 | P a g e a. successful transplantation usually provides a better quality of life than that offered by dialysis b. if rejection of the transplanted kidney occurs, no further treatment for the renal failure is available c. HD replaces the normal function of the kidneys, and patients do not have to live with the continual fear of rejection d. the immunosuppressive therapy following transplantation makes the person ineligible to receive other forms of treatment if the kidney fails A To assess the patency of a newly placed arteriovenous graft for dialysis, the nurse should Select all that apply a. monitor the BP in the affected arm b. irrigate the graft daily with low-dose heparin c. palpate the area of the graft to feel a normal thrill d. listen with a stethoscope over the graft to detect a bruit e. frequently monitor the pulses and neurovascular status distal to the graft CDE A major advantage of peritoneal dialysis is a. the diet is less restricted and dialysis can be performed at home b. the dialysate is biocompatible and causes no long-term consequences c. high glucose concentrations of the dialysate causes a reduction in appetite, promoting weight loss d. no medications are required because of the enhances efficiency of the peritoneal membrane in removing toxins A A kidney transplant recipient complains of having fever, chills, and dysuria over the past 2 weeks. What is the first action the nurse should take? a. assess temperature and initiate workup to rule out infection b. reassure the patient that this is common after transplantation c. provide warm cover for the patient and give 1 g acetaminophen orally d. notify the nephrologist that the patient has developed symptoms of acute rejection A In replying to a patient's questions about the seriousness of her CKD, the nurse knows that the stage of CKD is based on what? a. total daily urine output b. GFR c. degree of altered mental status d. serum creatinine and urea levels 22 | P a g e B The patient with CKD is receiving dialysis, and the nurse observes excoriations on the patient's skin. What pathophysiologic changes in CKD most likely occur that can contribute to this finding? Select all that apply a. dry skin b. sensory neuropathy c. vascular calcifications d. calcium-phosphate skin deposits e. uremic crystallization from high BUN ABD What causes the GI manifestation of stomatitis in the patient with CKD? a. high serum sodium levels b. irritation of the GI tract from creatinine c. increased ammonia from bacterial breakdown of urea d. iron salts, calcium-containing phosphate binders, and limited fluid intake C The patient with CKD is brought to the ED with Kussmaul respirations. What does the nurse know about CKD that could cause this patient's Kussmaul respirations? a. uremic pleuritis is occurring b. there is decreased pulmonary macrophage activity c. they are caused by respiratory compensation for metabolic acidosis d. pulmonary edema from HF and fluid overload is occurring C Which serum laboratory value indicates to the nurse that the patient's CKD is getting worse? a. decreased BUN b. decreased sodium c. decreased creatinine d. decreased calculated GFR D 25 | P a g e c. "The drainage is bloody when I have my period." d. "I wash around the catheter with soap and water." B The nurse preparing to administer a dose of calcium acetate to a patient with chronic kidney disease (CKD). Which laboratory result will the nurse monitor to determine if the desired effect was achieved? a. Sodium b. Potassium c. Magnesium d. Phosphorus D Which statement regarding continuous ambulatory peritoneal dialysis (CAPD) would be most important when teaching a patient new to the treatment? a. "Maintain a daily written record of blood pressure and weight." b. "It is essential that you maintain aseptic technique to prevent peritonitis." c. "You will be allowed a more liberal protein diet once you complete CAPD." d. "Continue regular medical and nursing follow-up visits while performing CAPD." B A patient with end-stage renal disease (ESRD) secondary to diabetes mellitus has arrived at the outpatient dialysis unit for hemodialysis. Which assessments should the nurse perform as a priority before, during, and after the treatment? a. Level of consciousness b. Blood pressure and fluid balance c. Temperature, heart rate, and blood pressure d. Assessment for signs and symptoms of infection B A patient is recovering in the intensive care unit (ICU) 24 hours after receiving a kidney transplant. What is an expected assessment finding during the earliest stage of recovery? a. Hypokalemia b. Hyponatremia c. Large urine output d. Leukocytosis with cloudy urine output C A patient with a 25-year history of type 1 diabetes mellitus is reporting fatigue, edema, and an irregular heartbeat. On assessment, the nurse notes newly developed hypertension and uncontrolled blood sugars. Which diagnostic study is most indicative of chronic kidney disease (CKD)? 26 | P a g e a. Serum creatinine b. Serum potassium c. Microalbuminuria d. Calculated glomerular filtration rate (GFR) D A 78-yr-old patient has stage 3 CKD and is being taught about a low-potassium diet. The nurse knows the patient understands the diet when the patient selects which foods to eat? a. Apple, green beans, and a roast beef sandwich b. Granola made with dried fruits, nuts, and seeds c. Watermelon and ice cream with chocolate sauce d. Bran cereal with ½ banana and milk and orange juice A During hemodialysis, the patient develops light-headedness and nausea. What should the nurse do first? a. Administer hypertonic saline. b. Administer a blood transfusion. c. Decrease the rate of fluid removal. d. Administer antiemetic medications. C A 24-yr-old woman donated a kidney via a laparoscopic donor nephrectomy to a nonrelated recipient. The patient is experiencing significant pain and refuses to get up to walk. How should the nurse respond? a. Have the transplant psychologist convince her to walk. b. Encourage even a short walk to avoid complications of surgery. c. Tell the patient that no other patients have ever refused to walk. d. Tell the patient she is lucky she did not have an open nephrectomy. B Which findings will the nurse expect when caring for a patient with chronic kidney disease (CKD)? Select all that apply a. Anemia b. Dehydration c. Hypertension d. Hypercalcemia e. Increased risk for fractures ACE 27 | P a g e The nurse is caring for a patient with chronic kidney disease after hemodialysis. Which patient care action should the nurse delegate to the experienced unlicensed assistive personnel (UAP)? a. Assess the patient's access site for a thrill and bruit. b. Monitor for signs and symptoms of postdialysis bleeding. c. Check the patient's postdialysis blood pressure and weight. d. Instruct the patient to report signs of dialysis disequilibrium syndrome immediately. C After the insertion of an arteriovenous graft (AVG) in the right forearm, a patient complains of pain and coldness of the right fingers. Which action should the nurse take? a. Elevate the patients arm above the level of the heart. b. Report the patients symptoms to the health care provider. c. Remind the patient about the need to take a daily low-dose aspirin tablet. d. Educate the patient about the normal vascular response after AVG insertion. B Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurses teaching about management of CKD has been effective? a. I need to try to get more protein from dairy products. b. I will try to increase my intake of fruits and vegetables. c. I will measure my urinary output each day to help calculate the amount I can drink. d. I need to take the erythropoietin to boost my immune system and help prevent infection. C Which patient information will the nurse plan to obtain in order to determine the effectiveness of the prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)? a. Blood pressure b. Phosphate level c. Neurologic status d. Creatinine clearance B 30 | P a g e Which data obtained when assessing a patient who had a kidney transplant 8 years ago and who is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone (Deltasone) will be of most concern to the nurse? a. The blood glucose is 144 mg/dL. b. The patients blood pressure is 150/92. c. There is a nontender lump in the axilla. d. The patient has a round, moonlike face. C A patient with chronic kidney disease (CKD) brings all home medications to the clinic to be reviewed by the nurse. Which medication being used by the patient indicates that patient teaching is required? a. Multivitamin with iron b. Milk of magnesia 30 mL c. Calcium phosphate (PhosLo) d. Acetaminophen (Tylenol) 650 mg B This increases the magnesium level in the patient whom already has problems with hypermagnesemia Which of the following information obtained by the nurse who is caring for a patient with end-stage renal disease (ESRD) indicates the nurse should consult with the health care provider before giving the prescribed epoetin alfa (Procrit)? a. Creatinine 1.2 mg/dL b. Oxygen saturation 89% c. Hemoglobin level 13 g/dL d. Blood pressure 98/56 mm Hg C Which nursing action for a patient who has arrived for a scheduled hemodialysis session is most appropriate for the RN to delegate to a dialysis technician? a. Educate patient about fluid restrictions. b. Check blood pressure before starting dialysis. c. Assess for reasons for increase in predialysis weight. d. Determine the ultrafiltration rate for the hemodialysis. B The nurse is assessing a patient who is receiving peritoneal dialysis with 2 L inflows. Which information should be reported immediately to the health care provider? 31 | P a g e a. The patient has an outflow volume of 1800 mL. b. The patients peritoneal effluent appears cloudy. c. The patient has abdominal pain during the inflow phase. d. The patient complains of feeling bloated after the inflow. B Two hours after a kidney transplant, the nurse obtains all of the following data when assessing the patient. Which information is most important to communicate to the health care provider? a. The urine output is 900 to 1100 mL/hr. b. The blood urea nitrogen (BUN) and creatinine levels are elevated. c. The patients central venous pressure (CVP) is decreased. d. The patient has level 8 (on a 10-point scale) incisional pain. C During hemodialysis, a patient complains of nausea and dizziness. Which action should the nurse take first? a. Slow down the rate of dialysis. b. Obtain blood to check the blood urea nitrogen (BUN) level. c. Check the patients blood pressure. d. Give prescribed PRN antiemetic drugs. C Which parameter will be most important for the nurse to consider when titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation? a. Heart rate b. Blood urea nitrogen (BUN) level c. Urine output d. Creatinine clearance C A patient complains of leg cramps during hemodialysis. The nurse should first a. reposition the patient. b. massage the patients legs. c. give acetaminophen (Tylenol). d. infuse a bolus of normal saline. D 32 | P a g e A client with end-stage renal failure has an internal arteriovenous fistula in the left arm for vascular access during hemodialysis. What should the nurse instruct the client do to? Select all that apply a. remind the HCPs to draw blood from veins on the left side b. avoid sleeping on the left arm c. wear wristwatch on the right arm d. assess fingers on the left arm for warmth e. obtain BP from the left arm BCD A client with chronic renal failure is receiving hemodialysis three times a week. In order to protect the fistula, the nurse should a. take the BP in the arm with the fistula b. report the loss of a thrill or bruit on the arm with the fistula c. maintain a pressure dressing on the shunt d. start a second IV in the arm with the fistula B A client with chronic renal failure who receives hemodialysis 3 times a week is experiencing severe nausea. What should the nurse advise the client to do to manage the nausea? Select all that apply a. drink fluids before eating solid foods b. have limited amounts of fluids only when thirsty c. limit activity d. keep all dialysis appointments e. eat smaller, more frequent meals BDE The dialysis solution is warmed before use in peritoneal dialysis primarily to a. encourage the removal of serum urea b. force potassium back into the cells c. add extra warmth to the body d. promote abdominal muscle relaxation A A client is receiving peritoneal dialysis. While the dialysis solution is dwelling in the client's abdomen, the nurse should a. assess for urticaria b. observe respiratory status c. check capillary refill time d. monitor electrolyte status 35 | P a g e c. hemodialysis allows an unrestricted diet d. hemodialysis returns a balance to blood electrolytes D A nurse is preparing to initiate hemodialysis for a client who has AKI. Which of the following actions should the nurse take? Select all that apply a. review the medications the client currently takes b. assess the AV fistula for a bruit c. calculate the client's hourly urine output d. measure the client's weight e. check blood electrolytes ABDE A nurse is planning postprocedure care for a client who received hemodialysis. Which of the following interventions should the nurse include in the plan of care? Select all that apply a. check BUN and blood creatinine b. administer medications the nurse withheld prior to dialysis c. observe for findings of hypovolemia d. assess the access site for bleeding e. evaluate BP on the arm with AV access ABCD A nurse is caring for a client who develops disequilibrium syndrome after receiving hemodialysis. Which of the following actions should the nurse take? a. administer an opioid medication b. monitor for hypertension c. assess level of consiousness d. increase the dialysis exchange rate C A nurse is planning care for a client who will undergo PD. Which of the following actions should the nurse take? Select all that apply a. monitor blood glucose levels b. report cloudy dialysate return c. warm the dialysate in a microwave oven d. assess for SOB e. check the access site dressing for wetness ABDE 36 | P a g e A nurse is assessing a client who has end-stage kidney disease. Which of the following findings should the nurse expect? Select all that apply a. anuria b. marked azotemia c. crackles in the lungs d. increased calcium level e. proteinuria ABCE A nurse is planning postoperative care for a client following a kidney transplant. Which of the following actions should the nurse include? Select all that apply a. obtain daily weights b. assess dressings for bloody drainage c. replace hourly urine output with IV fluids d. expect oliguria in the first 4 hours e. monitor blood electrolytes ABCE A nurse is teaching a client who is scheduled for a kidney transplant about organ rejection. Which of the following statements should the nurse include? Select all that apply a. "expect an immediate removal of the donor kidney for a hyperacute rejection" b. "you might need to begin dialysis to monitor your kidney function for a hyperacute reaction" c. "a fever is a manifestation of an acute rejection" d. "fluid retention is a manifestation of an acute rejection" e. "your provider will increase your immunosuppressive medications for a chronic rejection" ACD The nurse is assessing the patency of a client's left arm AV fistula prior to initiating HD. Which findings indicate that the fistula is patent? a. palpation of a thrill over the fistula b. presence of a radial pulse in the left wrist c. visualization of enlarged blood vessels at the fistula site d. capillary refill <3 seconds in the nail beds of the fingers on the left hand A The nurse monitoring the client receiving PD notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all that apply a. check the level of the drainage bag b. reposition the client to their side 37 | P a g e c. contact the HCP d. place the client in good body alignment e. check the PD system for kinks ABDE A HD client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess for which manifestations of this complication? a. warmth, redness, and pain in the left hand b. ecchymosis and audible bruit over the fistula c. edema and reddish discoloration of the left arm d. pallor, diminished pulse, and pain in the left hand D The nurse is reviewing a client's record and notes that the HCP has documented that the client has CKD. On review of the laboratory results, the nurse most likely would expect to note which finding? a. elevated creatinine level b. decreased hemoglobin level c. decreased RBC d. increased number of WBC in the urine A A client with CKD returns to the nursing unit following a HD treatment. On assessment, the nurse notes that the client's temperature is 101.2. Which nursing action is most appropriate? a. encourage fluid intake b. notify the HCP c. continue to monitor vital signs d. monitor the site of the shunt for infection B The nurse is performing an assessment on a client who has returned from the dialysis unit following HD. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action? a. monitor the client b. elevate the HOB c. assess the fistula site and dressing d. notify the HCP D A week after kidney transplantation, a client develops a temperature of 101, the BP is elevated, and there is tenderness over the transplanted kidney. The serum creatinine is rising and urine output is 40 | P a g e Peritoneal dialysis actually contributes to more protein loss and increased hyperlipidemia. The fluid and creatinine removal are slower with peritoneal dialysis than hemodialysis. In which type of dialysis does the patient dialyze during sleep and leave the fluid in the abdomen during the day? a. Long nocturnal hemodialysis b. Automated peritoneal dialysis (APD) c. Continuous venovenous hemofiltration (CVVH) d. Continuous ambulatory peritoneal dialysis (CAPD) B Automated peritoneal dialysis (APD) is the type of dialysis in which the patient dialyzes during sleep and leaves the fluid in the abdomen during the day. Long nocturnal hemodialysis occurs while the patient is sleeping and is done up to six times per week. Continuous venovenous hemofiltration (CVVH) is a type of continuous renal replacement therapy used to treat AKI. Continuous ambulatory peritoneal dialysis (CAPD) is dialysis that is done with exchanges of 1.5 to 3 L of dialysate at least four times daily. To prevent the most common serious complication of PD, what is important for the nurse to do? a. Infuse the dialysate slowly. b. Use strict aseptic technique in the dialysis procedures. c. Have the patient empty the bowel before the inflow phase. d. Reposition the patient frequently and promote deep breathing. B Peritonitis is a common complication of peritoneal dialysis (PD) and may require catheter removal and termination of dialysis. Infection occurs from contamination of the dialysate or tubing or from progression of exit-site or tunnel infections and strict sterile technique must be used by health professionals as well as the patient to prevent contamination. Too-rapid infusion may cause shoulder pain and pain may be caused if the catheter tip touches the bowel. Difficulty breathing, atelectasis, and pneumonia may occur from pressure of the fluid on the diaphragm, which may be prevented by elevating the head of the bed and promoting repositioning and deep breathing. A patient on hemodialysis develops a thrombus of a subcutaneous arteriovenous (AV) graft, requiring its removal.While waiting for a replacement graft or fistula, the patient is most likely to have what done for treatment? a. Peritoneal dialysis b. Peripheral vascular access using radial artery c. Silastic catheter tunneled subcutaneously to the jugular vein d. Peripherally inserted central catheter (PICC) line inserted into subclavian vein C A more permanent, soft, flexible Silastic double-lumen catheter is used for long-term access when other forms of vascular access have failed. These catheters are tunneled subcutaneously and have Dacron cuffs that prevent infection from tracking along the catheter. 41 | P a g e A man with end-stage kidney disease is scheduled for hemodialysis following healing of an arteriovenous fistula(AVF). What should the nurse explain to him that will occur during dialysis? a. He will be able to visit, read, sleep, or watch TV while reclining in a chair. b. He will be placed on a cardiac monitor to detect any adverse effects that might occur. c. The dialyzer will remove and hold part of his blood for 20 to 30 minutes to remove the waste products. d. A large catheter with two lumens will be inserted into the fistula to send blood to and return it from the dialyzer. A While patients are undergoing hemodialysis, they can perform quiet activities that do not require the limb that has the vascular access. Blood pressure is monitored frequently and the dialyzer monitors dialysis function but cardiac monitoring is not usually indicated. The hemodialysis machine continuously circulates both the blood and the dialysate past the semipermeable membrane in the machine.Graft and fistula access involve the insertion of two needles into the site: one to remove blood from and the other to return blood to the dialyzer. What is the primary way that a nurse will evaluate the patency of an AVF? a. Palpate for pulses distal to the graft site. b. Auscultate for the presence of a bruit at the site. c. Evaluate the color and temperature of the extremity. d. Assess for the presence of numbness and tingling distal to the site. B A patent arteriovenous fistula (AVF) creates turbulent blood flow that can be assessed by listening for a bruit or palpated for a thrill as the blood passes through the graft. Assessment of neurovascular status in the extremity distal to the graft site is important to determine that the graft does not impair circulation to the extremity but the neurovascular status does not indicate whether the graft is open. A patient with AKI is a candidate for continuous renal replacement therapy (CRRT). What is the most commonindication for use of CRRT? a. Azotemia b. Pericarditis c. Fluid overload d. Hyperkalemia C Continuous renal replacement therapy (CRRT) is indicated for the patient with AKI as an alternative or adjunct to hemodialysis to slowly remove solutes and fluid in the hemodynamically unstable patient. It is 42 | P a g e especially useful for treatment of fluid overload, but hemodialysis is indicated for treatment of hyperkalemia, pericarditis, or other serious effects of uremia. An 83-year-old female patient was found lying on the bathroom floor. She said she fell 2 days ago and has not been able to take her heart medicine or eat or drink anything since then. What conditions could be causing prerenal AKI in this patient (select all that apply)? a. Anaphylaxis b. Renal calculi c. Hypovolemia d. Nephrotoxic drugs e. Decreased cardiac output CE Because the patient has had nothing to eat or drink for 2 days, she is probably dehydrated and hypovolemic.Decreased cardiac output (CO) is most likely because she is older and takes heart medicine, which is probably for heart failure or hypertension. Both hypovolemia and decreased CO cause prerenal AKI. Anaphylaxis is also a cause of prerenal AKI but is not likely in this situation. Nephrotoxic drugs would contribute to intrarenal causes of AKI and renal calculi would be a postrenal cause of AKI. A dehydrated patient is in the Injury stage of the RIFLE staging of AKI. What would the nursefirst anticipate in the treatment of this patient? a. Assess daily weight b. IV administration of fluid and furosemide (Lasix) c. IV administration of insulin and sodium bicarbonate d. Urinalysis to check for sediment, osmolality, sodium, and specific gravity B Injury is the stage of RIFLE classification when urine output is less than 0.5 mL/kg/hr for 12 hours, the serum creatinine is increased times two or the glomerular filtration rate (GFR) is decreased by 50%. This stage maybe reversible by treating the cause or, in this patient, the dehydration by administering IV fluid and a low dose of a loop diuretic, furosemide (Lasix). Assessing the daily weight will be done to monitor fluid changes but it is not the first treatment the nurse should anticipate. IV administration of insulin and sodium bicarbonate would be used for hyperkalemia. Checking the urinalysis will help to determine if the AKI has a prerenal, intrarenal, orpostrenal cause by what is seen in the urine but with this patient's dehydration, it is thought to be prerenal to begin treatment. What indicates to the nurse that a patient with oliguria has prerenal oliguria? a. Urine testing reveals a low specific gravity. b. Causative factor is malignant hypertension. c. Urine testing reveals a high sodium concentration. d. Reversal of oliguria occurs with fluid replacement. D In prerenal oliguria, the oliguria is caused by a decreasein circulating blood volume and there is no 45 | P a g e Depending on the patient's history and cause of increased potassium, instruct the patient about dietary sources of potassium; however, this would not help at this point. The nurse may want to recheck the value but until then the heart rhythm needs to be monitored. A patient with AKI has a serum potassium level of 6.7 mEq/L (6.7 mmol/L) and the following arterial blood gasresults: pH 7.28, PaCO230 mm Hg, PaO286 mm Hg, HCO3−18 mEq/L (18 mmol/L). The nurse recognizes thattreatment of the acid-base problem with sodium bicarbonate would cause a decrease in which value? a. pH b. Potassium level c. Bicarbonate level d. Carbon dioxide level B During acidosis, potassium moves out of the cell in exchange for H+ions, increasing the serum potassium level.Correction of the acidosis with sodium bicarbonate will help to shift the potassium back into the cells. A decrease in pH and the bicarbonate and PaCO2levels would indicate worsening acidosis In replying to a patient's questions about the seriousness of her chronic kidney disease (CKD), the nurse knows that the stage of CKD is based on what? a. Total daily urine output b. Glomerular filtration rate c. Degree of altered mental status d. Serum creatinine and urea levels B Stages of chronic kidney disease are based on theGFR. No specific markers of urinary output, mental status, or azotemia classify the degree of chronic kidney disease (CKD). The patient with CKD is brought to the emergency department with Kussmaul respirations. What does the nurse know about CKD that could cause this patient's Kussmaul respirations? a. Uremic pleuritis is occurring. b. There is decreased pulmonary macrophage activity. c. They are caused by respiratory compensation for metabolic acidosis. d. Pulmonary edema from heart failure and fluid overload is occurring. C Kussmaul respirations occur with severe metabolic acidosis when the respiratory system is attempting to compensate by removing carbon dioxide with exhalations.Uremic pleuritis would cause a pleural friction rub.Decreased pulmonary macrophage activity increases the risk of pulmonary infection. Dyspnea would occur with pulmonary edema. Which serum laboratory value indicates to the nurse that the patient's CKD is getting worse? 46 | P a g e a. Decreased BUN b. Decreased sodium c. Decreased creatinine d. Decreased calculated glomerular filtration rate (GFR) D As GFR decreases, BUN and serum creatinine levels increase. Although elevated BUN and creatinine indicate that waste products are accumulating, the calculated GFR is considered a more accurate indicator of kidney function than BUN or serum creatinine. A patient with chronic kidney disease (CKD) who will be undergoing long-term hemodialysis is receiving discharge instructions from the nurse in regard to the insertion of a new arteriovenous (AV) fistula in her left arm. Which statement by the patient indicates a need for further teaching? 1. "I will avoid sleeping on my left arm at night." 2. "I will continue my daily weight training exercise program to stay fit and healthy." 3. "I should have my blood pressure checked on my right arm from now on." 4. "I will avoid wearing constrictive clothing or jewelry on my left arm." 2 It is recommended that patients lift no more than 5-10 pounds with their fistula arms. Exercise for people with CKD is important because of the many health benefits, but weight lifting exercises should be discussed with a doctor first. Patients should avoid sleeping on their fistula arm because doing so can restrict blood flow distal to the fistula site. Likewise, constrictive clothing or jewelry should be avoided as well. Patients should avoid IV insertion and blood pressure monitoring on their fistula arms to prevent damage to the delicate blood vessel graft site. A nurse is providing education to a patient with chronic kidney disease who has a newly placed peritoneal dialysis catheter. The patient will be managing their dialysis at home. Which statement, if made by the patient, indicates that they understand the teaching? A) I will eat a low fiber, high protein diet. B) The fluid in the drainage bag should be clear and colorless, and equal to the amount of dialysis solution infused. C) I can slow the rate of the dialysis solution during infusion if I have pain or cramping. D) I should inspect the catheter site every few days for signs of infection, and I must wear a dressing over my catheter site at all times. C Flow rate may be adjusted if cramping or pain is experienced during the inflow stage in order to decrease discomfort. A patient undergoing hemodialysis starts to become hypotensive and is experiencing muscle cramps. What are the correct nursing actions that should be taken? (Select all that apply) 47 | P a g e A. Decrease the blood flow into the dialyzer B. Give a hypertonic saline solution C. Administer a hypertonic glucose solution D. Start an infusion of 0.9% normal saline ACD Hypotension and muscle cramps occurring during hemodialysis usually occur because of rapid removal of vascular volume; therefore, slowing down the blood flow in the dialyzer will help reverse the hypotension and cramping. It is not recommended to give a hypertonic saline solution for treatment of hypotension and muscle cramps during hemodialysis because the high sodium load can be more problematic. Administering a hypertonic glucose solution helps with muscle cramps when undergoing hemodialysis. Starting an infusion of 0.9% normal saline is part of the usual treatment for hypotension and muscle cramps associated with hemodialysis. A 48-year-old male with chronic kidney disease is starting peritoneal dialysis today with the help and supervision of a nurse with the plan being that he eventually will be able to do this in the comfort of his own home. The nurse knows the patient needs more education in regards to peritoneal dialysis with which statement? a. "If I notice cloudy drainage I should contact my provider as soon as possible." b. "When I am filling up my abdomen if I feel pain it's okay to slow down the infusion." c. "My dietary intake will need to change, I will need to be sure to increase my sodium intake while eating less protein since I am losing all my salt." d. "When I am draining the fluid out I want more to come out than what I put in." C More education needs to be given to the patient because he should be increasing his protein intake. Peritoneal dialysis leads to protein loss due to the permeability of the membrane in the peritoneum so his diet should reflect that. The client with an external arteriovenous shunt in place for hemodialysis is at risk for bleeding. The priority nurse action would be to: a. Check the shunt for the presence of bruit and thrill. b. Observe the site once as time permits during the shift. c. Check the results of the prothrombin times as they are determined. d. Ensure that small clamps are attached to the arteriovenous shunt dressing. D An arteriovenous shunt is a less common form of access site but carries a risk for bleeding when it is used because two ends of an external cannula are tunneled subcutaneously into an artery and a vein, and the ends of the cannula are joined. If accidental disconnection occurs, the client could lose blood rapidly. For this reason, small clamps are attached to the dressing that covers the insertion site for use if needed. The shunt site also should be assessed at least every 4 hours 50 | P a g e C The client may have an elevated temperature following dialysis because the dialysis machine warms the blood slightly. If the temperature is elevated excessively and remains elevated, sepsis would be suspected and a blood sample would be obtained as prescribed for culture and sensitivity determinations. The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which of the following is the most appropriate nursing action? a. Monitor the client. b. Notify the physician. c. Elevate the head of the bed. d. Medicate the client for nausea. B Disequilibrium syndrome may be caused by the rapid decreases in the blood urea nitrogen level during hemodialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs of disequilibrium syndrome and appropriate treatments with anticonvulsive medications and barbiturates may be necessary to prevent a life-threatening situation. The physician must be notified. A nurse is analyzing the posthemodialysis lab test results for a client with chronic renal failure (CRF). The nurse interprets that the dialysis is having an expected but nontherapeutic effect if the results indicate a decreased: a. Phosphorus. b. Creatinine. c. Potassium. d. Red blood cell count D Hemodialysis typically lowers the amounts of fluid, sodium, potassium, urea nitrogen, creatinine, uric acid, magnesium, and phosphate levels in the blood. Hemodialysis also worsens anemia, because RBCs are lost in dialysis from blood sampling and anticoagulation during the procedure, and from residual blood that is left in the dialyzer. Although all of these results are expected, only the lowered RBC count is nontherapeutic and worsens the anemia already caused by the disease process. A nurse is giving general instructions to a client receiving hemodialysis. Which of the following statements would be appropriate for the nurse to include? a. Several types of medications should be withheld on the day of dialysis until after the procedure. b. Medications should be double-dosed on the morning of hemodialysis to prevent loss. c. It's acceptable to exceed the fluid restriction on the day before hemodialysis. d. It's acceptable to eat whatever you want on the day before hemodialysis. 51 | P a g e A Many medications are dialyzable, which means they are extracted from the bloodstream during dialysis. Therefore, many medications may be withheld on the day of dialysis until after the procedure. It is not typical for medications to be "double-dosed," because there is no way to be certain how much of each medication is cleared by dialysis. Clients receiving hemodialysis are not routinely taught that it is acceptable to disregard dietary and fluid restrictions. A registered nurse is instructing a new nursing graduate about hemodialysis. Which statement if made by the new nursing graduate would indicate an inaccurate understanding of the procedure for hemodialysis? a. Sterile dialysate must be used. b. Warming the dialysate increases the efficiency of diffusion. c. Heparin sodium is administered during dialysis. d. Dialysis cleanses the blood from accumulated waste products. A Dialysate is made from clear water and chemicals and is free from any metabolic waste products or medications. Bacteria and other microorganisms are too large to pass through the membrane; therefore, the dialysate does not need to be sterile. The dialysate is warmed to approximately 100° F to increase the efficiency of diffusion and to prevent a decrease in the client's blood temperature. Heparin sodium inhibits the tendency of blood to clot when it comes in contact with foreign substances. Option 4 is the purpose of dialysis. A patient needing vascular access for hemodialysis asks the nurse what the differences are between an arteriovenous (AV) fistula and a graft. The nurse explains that one advantage of the fistula is that it a. can accommodate larger needles. b. increases patient mobility. c. is much less likely to clot. d. can be used sooner after surgery. C AV fistulas are much less likely to clot than grafts, although it takes longer for them to mature to the point where they can be used for dialysis. The choice of an AV fistula or a graft does not impact on needle size or patient mobility A patient with chronic kidney disease (CKD) is started on hemodialysis, and after the first treatment, the patient complains of nausea and a headache. The nurse notes mild jerking and twitching of the patient's extremities. The nurse will anticipate the need to a. increase the time for the next dialysis to remove wastes more completely. b. switch to continuous renal replacement therapy (CRRT) to improve dialysis efficiency. c. administer medications to control these symptoms before the next dialysis. d. slow the rate for the next dialysis to decrease the speed of solute removal. 52 | P a g e D The patient has symptoms of disequilibrium syndrome, which can be prevented by slowing the rate of dialysis so that fewer solutes are removed during the dialysis. Increasing the time of the dialysis to remove wastes more completely will increase the risk for disequilibrium syndrome. CRRT is a less efficient means of removing wastes and, because it is continuous, would not be used for a patient with CKD. Administration of medications to control the symptoms is not an appropriate action; rather, the disequilibrium syndrome should be avoided. A client has an arteriovenous (AV) fistula in place in the right upper extremity for hemodialysis treatments. When planning care for this client, which of the following measures should the nurse implement to promote client safely? a. take blood pressures only on the right arm to ensure accuracy b. use the fistula for all venipunctures and intravenous infusions c. ensure that small clamps are attached to the AV fistula dressing d. assess the fistula for the presence of a bruit and thrill every 4 hours D The client with chronic renal failure who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). The nurse should plan to administer this medication: a. during dialysis b. just before dialysis c. the day after dialysis d. on return form dialysis D The client with chronic renal failure is on chronic hemodialysis. Which of the following indicate improvement of the client's condition due to hemodialysis? Select all that apply a) the client's BP is 130/90 b) the client's serum potassium is 4.8 mEq/L c) the client's hemoglobin level is 10 g/dL d) the client's serum calcium is 7.7 mg/dL e) the client's serum sodium is 140 mEg/L f) the client's serum magnesium is 4 mEq/L g) the client's weight has increased from 60 kg to 63 kg ABE The client with chronic renal failure is undergoing peritoneal dialysis. He asks why the nurse monitors his blood glucose levels. Which of the following will be the most appropriate response by the nurse? a) I have to check if you have diabetes mellitus b) the dialysate contains glucose 55 | P a g e B Outflow problems may occur because the peritoneal catheter is collapsed by a portion of the intestine, and repositioning the patient will move the catheter and allow outflow to occur. If less than the ordered 2 L of dialysate is infused, the dialysis will be less effective. Administration of a laxative may also help if the patient's colon is full, but this should be tried after repositioning the patient. If the problem with outflow persists after the patient is repositioned, the health care provider should be notified. A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client? a) Impaired urinary elimination b) Toileting self-care deficit c) Risk for infection d) Activity intolerance C The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. Impaired urinary elimination, Toileting self-care deficit, and Activity intolerance may be pertinent but are secondary to the risk of infection. A male client has doubts about performing peritoneal dialysis at home. He informs the nurse about his existing upper respiratory infection. Which of the following suggestions can the nurse offer to the client while performing an at-home peritoneal dialysis? a) Perform deep-breathing exercises vigorously. b) Avoid carrying heavy items. c) Auscultate the lungs frequently. d) Wear a mask when performing exchanges. D The nurse should advise the client to wear a mask while performing exchanges. This prevents contamination of the dialysis catheter and tubing, and is usually advised to clients with upper respiratory infection. Auscultation of the lungs will not prevent contamination of the catheter or tubing. The client may also be advised to perform deep-breathing exercises to promote optimal lung expansion, but this will not prevent contamination. Clients with a fistula or graft in the arm should be advised against carrying heavy items. The nurse instructs a client with renal failure who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the menu? a. Cream of wheat, blueberries, coffee b. Sausage and eggs, banana, orange juice. c. Bacon, cantaloupe melon, tomato juice. d. Cured pork, grits, strawberries, orange juice. 56 | P a g e A The diet for a client with renal failure who is receiving hemodialysis should include controlled amounts of sodium, phosphorus, calcium, potassium, and fluids. Options 2, 3, and 4 are high in sodium, phosphorus and potassium. A client diagnosed with chronic renal failure (CRF) is scheduled to begin hemodialysis. The nurse assesses that which of the following neurological and psychosocial manifestations if exhibited by this client would be unrelated to the CRF? a. Labile emotions. b. Withdrawal. c. Euphoria. d. Depression. C The client with CRF often experiences a variety of psychosocial changes. These are related to uremia, as well as the stress associated with living with a chronic disease that is life-threatening. Clients with CRF may have labile emotions or personality changes and may exhibit withdrawal, depression, or agitation. Delusions and psychosis also can occur. Euphoria is not part of the clinical picture for the client in renal failure. A client undergoing hemodialysis has an arteriovenous (AV) fistula in the left arm. A related nursing diagnosis for the client is risk for infection. The nurse should formulate which of the following outcome goals as most appropriate for this nursing diagnosis? a. The client's temperature remains less than 101F b. The client's WBC count remains within normal limits. c. The client washes hands at least once per day. d. The client states to avoid blood pressure measurement in the left arm. B General indicators that the client is not experiencing infection include a temperature and WBC count within normal limits. The client also should use proper hand-washing technique as a general preventive measure. Hand washing once per day is insufficient. It is true that the client should avoid BP measurement in the affected arm; however, this would relate more closely to the nursing diagnosis risk for injury. A client undergoing hemodialysis is at risk for bleeding from the heparin used during the hemodialysis treatment. The nurse assesses for this occurrence by periodically checking the results of which of the following lab tests? a. Partial thromboplastin time (PTT) b. Prothrombin time (PT) c. Thrombin time (TT) d. Bleeding time 57 | P a g e A Heparin is the anticoagulant used most often during hemodialysis. The hemodialysis nurse monitors the extent of anticoagulation by checking the PTT, which is the appropriate measure of heparin effect. The PT is used to monitor the effect of warfarin (Coumadin) therapy. Thrombin and bleeding times are not used to measure the effect of heparin therapy, although they are useful in the diagnosis of other clotting abnormalities. A client with chronic renal failure is about to begin hemodialysis therapy. The client asks the nurse about the frequency and scheduling of hemodialysis treatments. The nurse's response is based on an understanding that the typical schedule is: a. 5 hours of treatment 2 days per week. b. 3 to 4 hours of treatment 3 days per week c. 2 to 3 hours of treatment 5 days per week d. 2 hours of treatment 6 days per week B The typical schedule for hemodialysis is 3 to 4 hours of treatment three days per week. Individual adjustments may be made according to variables such as the size of the client, type of dialyzer, the rate of blood flow, personal client preferences, and others. A patient begins hemodialysis after having had conservative management of chronic kidney disease. The nurse explains that one dietary regulation that will be changed when hemodialysis is started is that a. unlimited fluids are allowed since retained fluid is removed during dialysis. b. increased calories are needed because glucose is lost during hemodialysis. c. more protein will be allowed because of the removal of urea and creatinine by dialysis.d. dietary sodium and potassium are unrestricted because these levels are normalized by dialysis. C Once the patient is started on dialysis and nitrogenous wastes are removed, more protein in the diet is allowed. Fluids are still restricted to avoid excessive weight gain and complications such as shortness of breath. Glucose is not lost during hemodialysis. Sodium and potassium intake continues to be restricted to avoid the complications associated with high levels of these electrolytes A patient with acute renal failure (ARF) requires hemodialysis and temporary vascular access is obtained by placing a catheter in the left femoral vein. The nurse will plan to a. restrict the patient's oral protein intake. b. discontinue the retention catheter. c. place the patient on bed rest. d. start continuous pulse oximetry. C The patient with a femoral vein catheter must be on bed rest to prevent trauma to the vein. Protein intake is likely to be increased when the patient is receiving dialysis. The retention catheter is likely to 60 | P a g e The nurse at the dialysis clinic notes when she reviews a client's labs that the labs indicated hyperkalemia. She makes a note to make sure the client is adhering to all dietary restrictions. Of the following possibilities, which might the nurse ask about? a. fiber supplements b. intake of whole grains c. salt substitutes d. sugar substitutes C Potassium may be restricted in some clients because hyperkalemia tends to occur in end-stage renal disease. Excess potassium can cause cardiac arrest. Because of this danger, renal clients should not use salt substitutes or low-sodium milk because the sodium in these products is replaced with potassium. The nurse is assessing a dialysis patient who is asking to receive continuous ambulatory peritoneal dialysis (CAPD) instead of hemodialysis. Which of the following complications of CAPD will the nurse review with the client? a. hypercalcemia b. hypertension c. hyponatremia d. hypotension D Clients on CAPD have a more normal lifestyle than do clients on either hemodialysis or peritoneal dialysis. Complications associated with CAPD include peritonitis, hypotension, and weight gain. The diet order for a client receiving hemodialysis is written as 80-3-3. When the nurse explains the diet to the client, which of the following will be included in the teaching? Select all that apply. a. 80 grams of fat are allowed per day b. 80 grams of protein are allowed per day c. potassium is restricted to 3 grams a day d. phosphorus is restricted to 3 grams a day e. potassium is restricted to 80 mg per day f. sodium is restricted to 3 grams per day BCF The nurse is educating a client who recently had a kidney transplant about the dietary changes that will be necessary. Which of the following statements could the nurse make to the client? Select all that apply. a. additional calcium may be needed b. carbohydrates may be restricted c. extra protein may be needed d. fats may be limited 61 | P a g e e. protein may be restricted f. sodium may be restricted ABCDEF The client diagnosed with ARF has a serum potassium level of 6.8 mEq/L. Which collaborative treatment should the nurse anticipate for the client? 1.Administer a phosphate binder. 2.Type and crossmatch for whole blood. 3.Assess the client for leg cramps. 4.Prepare the client for dialysis. 4 Normal potassium level is 3.5 to5.5 mEq/L. A level of 6.8 mEq/L is life threatening and could lead to cardiac dysrhythmias. Therefore, the client may be dialyzed to decrease the potassium level quickly. This requires a health-care provider order, so it is a collaborative intervention. The client diagnosed with ARF is admitted to the intensive care unit and placed on a therapeutic diet. Which diet is most appropriate for the client? 1.A high-potassium and low-calcium diet. 2.A low-fat and low-cholesterol diet. 3.A high-carbohydrate and restricted-protein diet. 4.A regular diet with six (6) small feedings a day. 3 Which of the following should be considered in the diet of the client with end-stage-renal-disease (ESRD)? a) limit fluid intake during anuric phase b) limit phosphorus and vitamin D-rich food c) limit calcium-rich food d) limit carbohydrates A during ESRD, fluid intake of the client should be limited during anuric phase to prevent fluid overload. Fluid overload increases renal workload, pulmonary edema, and congestive heart failure. A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to: a) 3 mg/dL 62 | P a g e b) 15 mg/dL c) 29 mg/dL d) 35 mg/dL B the normal blood urea nitrogen level is 8 to 25 mg/dL Which of the following may be included in the diet of the client with chronic renal failure? a) orange slices b) watermelon slices c) cantaloupe slices d) apple slices D the client with renal failure should be given low potassium diet because of hyperkalemia. Apple contains very little potassium. So, it can be given to the client. The client has end-stage renal disease. He had undergone kidney transplant 5 days ago. Which of the following is the most important intervention for the client to prevent infection? a) observe asepsis b) increase fluid intake c) avoid clients with flu d) avoid crowded places A The client in end-stage of renal failure had undergone kidney transplant. Which of the following assessment findings indicate kidney transplant rejection? a) increased urinary output, BUN = 15 mg/dL b) HCT = 50%, Hgb = 17 g/dl c) decreased urinary output, sudden weight gain d) decreased urinary output, sudden weight loss C Which of the following anti-hypertensive medications is contraindicated for clients with renal insufficiency? a) beta-adrenergic blockers b) calcium-channel blockers c) direct-acting vasodilators d) angiotensin-converting enzyme inhibitors 65 | P a g e c. Dulcolax suppository 4 hours before procedure d. Normal saline 500 mL IV infused before procedure B The contrast dye used in IVPs is potentially nephrotoxic, and concurrent use of other nephrotoxic medications such as the nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided. The suppository and NPO status are necessary to ensure adequate visualization during the IVP. IV fluids are used to ensure adequate hydration, which helps reduce the risk for contrast-induced renal failure Which statement by a 62-year-old patient with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective? a. "I need to get most of my protein from low-fat dairy products." b. "I will increase my intake of fruits and vegetables to 5 per day." c. "I will measure my urinary output each day to help calculate the amount I can drink." d. "I need to take erythropoietin to boost my immune system and help prevent infection." C The patient with end-stage kidney disease is taught to measure urine output as a means of determining an appropriate oral fluid intake. Erythropoietin is given to increase the red blood cell count and will not offer any benefit for immune function. Dairy products are restricted because of the high phosphate level. Many fruits and vegetables are high in potassium and should be restricted in the patient with CKD. We have an expert-written solution to this problem! Which menu choice by the patient who is receiving hemodialysis indicates that the nurse's teaching has been successful? a. Split-pea soup, English muffin, and nonfat milk b. Oatmeal with cream, half a banana, and herbal tea c. Poached eggs, whole-wheat toast, and apple juice d. Cheese sandwich, tomato soup, and cranberry juice C Poached eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup would be high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and the cream would be high in phosphate Which action by a 70-year-old patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD? a. The patient leaves the catheter exit site without a dressing. b. The patient plans 30 to 60 minutes for a dialysate exchange. 66 | P a g e c. The patient cleans the catheter while taking a bath each day. d. The patient slows the inflow rate when experiencing abdominal pain. C Patients are encouraged to take showers rather than baths to avoid infections at the catheter insertion side. The other patient actions indicate good understanding of peritoneal dialysis A 55-year-old patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa (Procrit). Which information should the nurse report to the health care provider before giving the medication? a. Creatinine 1.6 mg/dL b. Oxygen saturation 89% c. Hemoglobin level 13 g/dL d. Blood pressure 98/56 mm Hg C High hemoglobin levels are associated with a higher rate of thromboembolic events and increased risk of death from serious cardiovascular events (heart attack, heart failure, stroke) when erythropoietin (EPO) is administered to a target hemoglobin of >12 g/dL. Hemoglobin levels higher than 12 g/dL indicate a need for a decrease in epoetin alfa dose. The other information also will be reported to the health care provider but will not affect whether the medication is administered A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first? a. Notify the patient's health care provider. b. Document the QRS interval measurement. c. Check the medical record for most recent potassium level. d. Check the chart for the patient's current creatinine level. C The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the most recent potassium and then notify the patient's health care provider. The BUN and creatinine will be elevated in a patient with AKI, but they would not directly affect the electrocardiogram (ECG). Documentation of the QRS interval is also appropriate, but interventions to decrease the potassium level are needed to prevent life-threatening dysrhythmias A patient has arrived for a scheduled hemodialysis session. Which nursing action is most appropriate for the registered nurse (RN) to delegate to a dialysis technician? a. Teach the patient about fluid restrictions. b. Check blood pressure before starting dialysis. 67 | P a g e c. Assess for causes of an increase in predialysis weight. d. Determine the ultrafiltration rate for the hemodialysis. B Dialysis technicians are educated in monitoring for blood pressure. Assessment, adjustment of the appropriate ultrafiltration rate, and patient teaching require the education and scope of practice of an RN. The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most important to communicate to the health care provider? a. The urine output is 900 to 1100 mL/hr. b. The patient's central venous pressure (CVP) is decreased. c. The patient has a level 7 (0 to 10 point scale) incisional pain. d. The blood urea nitrogen (BUN) and creatinine levels are elevated. B The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion and acute tubular necrosis. The other information is not unusual in a patient after a transplant The nurse is titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation. Which parameter will be most important for the nurse to consider? a. Heart rate b. Urine output c. Creatinine clearance d. Blood urea nitrogen (BUN) level B Fluid volume is replaced based on urine output after transplant because the urine output can be as high as a liter an hour. The other data will be monitored but are not the most important determinants of fluid infusion rate After receiving change-of-shift report, which patient should the nurse assess first? a. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange b. Patient with stage 4 chronic kidney disease who has an elevated phosphate level c. Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L d. Patient who has just returned from having hemodialysis and has a heart rate of 124/min D The patient who is tachycardic after hemodialysis may be bleeding or excessively hypovolemic and 70 | P a g e the direct toxic effect of alcohol on brain tissue. Increase in serotonin, reduction in iron intake, and malabsorption of riboflavin are problems that are unrelated to substance-induced persisting dementia caused by alcoholism. A 3-year-old child is found to have a pervasive developmental disorder not otherwise specified. What should the nurse consider most unusual for the child to demonstrate? Responsiveness to the parents Rationale: One of the symptoms that an autistic child displays is lack of responsiveness to others; there is little or no extension to the external environment. Music is nonthreatening, comforting, and soothing. Repetitive behavior provides comfort. Repetitive visual stimuli, such as a spinning top, are nonthreatening and soothing. During a one-on-one interaction with a client with paranoid-type schizophrenia, the client says to the nurse, "I've figured out how foreign agents have infiltrated the news media. They want to shut me up before I spill the beans." How should the nurse describe this statement when documenting this client's response? Delusions of persecution Rationale: Thoughts of being pursued by powerful agents because of one's special attributes or powers are fixed false beliefs and are referred to as delusions of persecution. There is no evidence to indicate that there are nihilistic delusions of total or partial nonexistence. There is also no evidence to support that external forces are controlling the client (delusions of control) or that the client has false beliefs of being a famous figure (delusions of grandeur). A nurse is caring for a client with a somatoform disorder. What should the nurse anticipate that this client will do? Redirect the conversation with the nurse to physical symptoms. Rationale: Clients with somatoform disorders are preoccupied with the symptoms that are being experienced and usually do not want to talk about their emotions or relate them to their current situation. Clients with somatoform disorders do not seek opportunities to discuss their feelings. Memory problems are not associated with somatoform disorders. These clients want and seek treatment, not palliative care. A nurse, understanding the possible cause of alcohol-induced amnestic disorder, should take into consideration that the client is probably experiencing which imbalance? Thiamine deficiency Rationale: The deficiency of thiamine (vitamin B 1) is thought to be a primary cause of alcohol-induced amnestic 71 | P a g e disorder. Reduced iron intake, increased serotonin, and riboflavin malabsorption are all unrelated to alcohol-induced amnestic disorder. Within a few hours of alcohol withdrawal the nurse should assess the client for the presence of what symptoms? Irritability and tremors Rationale: Alcohol is a central nervous system depressant; irritability and tremors are the body's neurological adaptation to the withdrawal of alcohol. Tachycardia, irritability, and tremors are the early signs of withdrawal and will appear 24 to 48 hours after the last ingestion of alcohol. Yawning occurs with heroin withdrawal. Convulsions (delirium tremens, or DTs) are a later sign of severe withdrawal that occurs with alcohol withdrawal delirium. Delirium (paranoia and disorientation) is not an early sign of alcohol withdrawal and occurs 48 to 72 hours after abstinence. Fever and diaphoresis may occur during prolonged periods of delirium and are a result of autonomic overactivity. The nurse is caring for a client with vascular dementia. What does the nurse identify as the cause of this problem? Disruptions in cerebral blood flow, resulting in thrombi or emboli Rationale: Vascular dementia results from the sudden closure of the lumen of arterioles, causing infarction of the brain tissue in the affected area. Inadequate nutrition may be one of the factors that bring about a general decline of health; however, there is no direct evidence that avitaminosis can cause primary degenerative dementia. Severe emotional trauma may contribute to primary degenerative dementia but does not necessarily cause it. Neural degeneration leads to permanent, not transient, changes. A client with a history of drug abuse begins group therapy. After attending the first meeting the client says to the nurse, "It helps to know that I'm not the only one with this type of problem." What concept does this statement reflect? Universality Rationale: Universality is the sense that one is not alone in any situation; one purpose of group therapy is to share feelings and gain support from others with similar thoughts and feelings. Altruism in group therapy is giving support, insight, and reassurance to others, which eventually promotes self-knowledge and growth. Catharsis involves group members relating to one another through the verbal expression of negative and positive feelings. Transference occurs when a client unconsciously assigns to the therapist feelings and attitudes originally associated with another important person in the client's life. A nurse determines that a client is pretending to be ill. What does this behavior usually indicate? Malingering Rationale: 72 | P a g e When an individual consciously pretends to have an illness with no physical basis, it is called malingering. People who are psychotic experience delusions, hallucinations, and disorganized thoughts, speech, or behavior. The use of conversion defenses is not a conscious act. A person out of contact with reality is unable to pretend to be ill. An 84-year-old woman is admitted to the hospital with a diagnosis of dementia of the Alzheimer type. What does the nurse know about this disorder? Cognitive problem that is a slow and relentless deterioration of the mind Rationale: Dementia of the Alzheimer type accounts for 80% of dementias in older adults; it may be due to a neurotransmitter deficiency and is characterized by a steady decline in intellectual function, including memory deficits, disorientation, and decreased cognitive ability. More than 90% of people with dementia of the Alzheimer type are older than 50 years. It is an organic, not functional, disorder. Dementia of the Alzheimer type is difficult to diagnose and often is made when other causes of the dementia have been ruled out. A client with a personality disorder is playing cards with another person in the lounge. When the other person cheats at cards, the client responds by aggressively scattering the cards around the room. What does the nurse conclude about the client's personality? Inadequate impulse control Rationale: The client is angry and reacts impulsively; the action is unplanned and is not under the client's control. No data are provided to suggest that the client is out of contact with reality; the client is reacting to a real situation with anger. There is no identifiable cluster of behaviors to suggest that the client has a violent personality. There is no pattern of behavior to suggest an antisocial personality, which may or may not involve impulse control. After a cocaine binge an individual is found unconscious and is admitted to the hospital with acute cocaine toxicity. What should the initial nursing action be directed toward? Establishing a patent airway Rationale: The client is unconscious and unable to meet physical needs; a patent airway, breathing, and circulation are essential needs. Understanding and support are important once the client's physical condition has stabilized. Maintaining a drug-free environment will be a priority later in the treatment program. Establishment of a therapeutic relationship will increase in importance once the client's physical condition has stabilized. A psychotic male client is admitted to the hospital for evaluation. While obtaining the history, the nurse asks why he was brought to the hospital by his parents. The client states, "They lied about me. They said I murdered my mother. You killed her. She died before I was born." What does the nurse recognize that the client is experiencing? 75 | P a g e enhance self-esteem; they control anxiety. The client may be ashamed of the rituals that cannot be stopped. A 65-year-old man is admitted to a mental health facility with a diagnosis of substance-induced persisting dementia resulting from chronic alcoholism. When conducting the admitting interview, the nurse determines that the client is using confabulation. What does the nurse recall precipitates the client's use of confabulation? Marked memory loss Rationale: A client with this disorder has a loss of memory and adapts by filling in areas that cannot be remembered with made-up information. Ideas of grandeur do not occur with this type of dementia. The use of confabulation is not attention-seeking behavior; the individual is attempting to mask memory loss. This person is not coping with the diagnosis; when confabulating, the individual is attempting to mask memory loss. A nurse is caring for a client with an obsessive-compulsive disorder. What is the basis for the obsessions and compulsions? Unconscious control of unacceptable feelings Rationale: In carrying out the compulsive ritual the client unconsciously tries to control anxiety by avoiding acting on unacceptable feelings and impulses. The client does not consciously use this method to punish herself. Hallucinations are not part of this disorder. People with obsessive-compulsive disorder feel no need to punish others. A salesman with a history of heavy drinking is on a detoxification unit. He asks the nurse's permission to skip the Alcoholics Anonymous (AA) meeting held each day. What is the nurse's initial response? "What are your feelings about going to AA meetings?" Rationale: The question "What are your feelings about going to AA meetings?" forces the client to face what going to AA meetings means to the client. The question "What is it that you dislike about going to AA meetings?" focuses the client on negative aspects; also, the client may be unable to answer this question. The response "It's all right to wait until you feel like going to AA meetings" reinforces avoidance, which delays dealing with the problem; the client may never feel like going to AA meetings. Although the response "An important part of your treatment is attending AA meetings" is true, it does not explore the client's feelings. A client with schizophrenia is speaking made-up words that have no meaning to other people. What term should the nurse use to document these verbalizations? Neologisms Rationale: 76 | P a g e Neologisms are unique words with personal meanings only to the client. Avolition is the lack of motivation associated with a reduced emotional expression (flat affect). Echolalia is parrotlike echoing of spoken words or sounds. Anhedonia is the loss of enjoyment of things that were formerly enjoyed. A 24-year-old woman states that she no longer enjoys any of the activities that she once found fun and pleasurable, such as socializing, sports, and hobbies. What term should the nurse use to describe this condition? Anhedonia Rationale: Anhedonia is the inability to experience pleasure in events or activities that once were enjoyable. Anergia is lethargy and a decreased level of energy. Grandiosity is a symptom seen during manic episodes in which an individual displays an inflated self-esteem. Learned helplessness is a theory proposing that depression occurs when an individual believes that he or she has no control over life situations. This results in the individual's giving up and becoming passive and dependent. A client who has been admitted with a diagnosis of schizophrenia says to the nurse, "Yes, it's March. March is Little Women. That's literal, you know." What do these statements illustrate? Loosening of associations Rationale: Loose associations are thoughts that are presented without the logical connections that are usually necessary for the listener to interpret the message. Echolalia is the purposeless repetition of words spoken by others or repetition of overheard sounds. Neologisms are new meaningless words coined by the client or new, unique meanings given to old words. Flight of ideas is the rapid skipping from one thought to another; these thoughts usually have only superficial or chance relationships. A nurse is assessing a child with suspected autism. At what age does the nurse determine that the signs of autism initially may be evident? 2 years Rationale: By 2 years of age the child should demonstrate an interest in others, communicate verbally, and possess the ability to learn from the environment. Before the age when these skills develop, autism is difficult to diagnose. Usually by 3 years the signs of autism become more profound. Autism can be diagnosed long before a child is 6 years old. Infantile autism may occur in an infant of 1 to 3 months, but at this age it is difficult to diagnose. An older adult client is talking to the nurse about his Vietnam experiences and shares that he still has flashbacks. While assessing him the nurse notes that he is jumpy and exhibits startle reactions and poor concentration. With which mental health disorder does the nurse associate these symptoms? Posttraumatic stress disorder (PTSD) Rationale: 77 | P a g e PTSD is a syndrome characterized by the development of symptoms after an extremely traumatic event. Symptoms include helplessness, flashbacks, intrusive thoughts, memories, images, emotional numbing, loss of interest, avoidance of any place that reminds the affected person of the traumatic event, poor concentration, irritability, startle reactions, jumpiness, and hypervigilance. Delusions are beliefs that guide one's interpretation of events and help make sense of disorder. Common delusions among older adults involve being poisoned, having their assets taken by their children, being held prisoner, and being deceived by a spouse or lover. Hallucinations are visual or auditory perceptions of nonexistent objects and sounds. Older adults with hearing and vision deficits may hear voices or see people who are not actually present. OCD is characterized by recurrent and persistent thoughts, impulses, and urges of ritualistic behaviors that improve the affected person's comfort level. A nurse knows that children with attention deficit-hyperactivity disorder (ADHD) may be learning disabled. What impact does this disability have on their education? Experience perceptual difficulties that interfere with learning Rationale: ADHD interferes with the ability to perceive and respond to sensory stimuli, resulting in a deficit in interpreting new sensory data. This makes learning difficult. It is not true that children with ADHD have intellectual deficits that interfere with learning; there is no cognitive impairment present. It is not necessarily true that children with ADHD are not self-directed learners or that they perform two grade levels below their age norm. When answering questions from the family of a client with Alzheimer disease, how does the nurse describe the disease? Is a slow, relentless deterioration of the mind Rationale: Alzheimer disease[1][2][3] is a slow and relentless deterioration of the mind; clients become progressively worse over time. The disease usually appears in people 60 years of age and older. Alzheimer disease is an organic, not a functional, disorder. At this time there are no diagnostic tools other than autopsy that can provide a definite confirmation of Alzheimer disease. A nurse is counseling clients who are attending an alcohol rehabilitation program. Which substance poses the greatest risk of addiction for these clients? Nicotine Rationale: Although polysubstance abuse is common, clients undergoing rehabilitation from alcohol dependence are more likely to use or develop a dependence on nicotine, another legal substance, than on an illegal substance such as heroin, cocaine, or marijuana. A nurse is providing information about Alcoholics Anonymous (AA) meetings to a client with a history of alcohol abuse. What will be required when the client attends AA meetings? 80 | P a g e Rationale: Amenorrhea results from endocrine imbalances that occur when fat stores are depleted. The client is dehydrated; edema is not expected. Constipation, not diarrhea, may occur because of lack of fiber in the diet. Hypotension, not hypertension, may occur because of dehydration. Addicted clients commonly expect discrimination and lack of empathy from others. How can the nurse best overcome these expectations? Demonstrating a nonjudgmental attitude Rationale: Behaviors that reflect acceptance and consistency are the best approaches to overcoming these client expectations. What the nurse does is a better indicator of acceptance than the words or explanations that are verbalized. The nurse's actions over time are better indicators of acceptance than is verbal reassurance. Confrontational measures increase anxiety and are not therapeutic. A client with the diagnosis of bulimia nervosa, purging type, is admitted to the mental health unit after an acute episode of bingeing. Which clinical manifestation is most important for the nurse to assess? Dehydration Rationale: The nurse should be alert for dehydration caused by fluid loss through vomiting in the binge-purge cycle. Weight gain is not expected because purging frequently follows a binge. Hyperactivity is not expected because many individuals with bulimia withdraw and vomit after a binge. Hyperglycemia is not expected because of the vomiting that follows a binge. What characteristic uniquely associated with psychophysiologic disorders differentiates them from somatoform disorders? Underlying pathophysiology Rationale: The psychophysiologic response (e.g., hyperfunction or hypofunction) produces actual tissue change. Somatoform disorders are unrelated to organic changes. There is an emotional component in both instances. There is a feeling of illness in both instances. There may be a restriction of activities in both instances. While caring for an older adult client, what symptom requires an immediate reassessment of the client's needs and plan of care? Memory loss or confusion Rationale: All are common signs of depression due to the aging process, however, memory loss or confusion may require immediate intervention. The development of confusion indicates that the client's ability to maintain equilibrium has not been achieved and that further disequilibrium is occurring, setting the 81 | P a g e client up for safety issues. Confusion may also be related to more serious physical conditions that can occur which require medical intervention. A client with a history of chronic alcoholism is admitted to the mental health unit. What does the nurse identify as the cause of a client's use of confabulation? Marked loss of memory Rationale: Alcoholic clients have loss of memory and adapt to this by unconsciously filling in with false information areas that cannot be remembered. Ideas of grandeur do not occur in this disease. A need to get attention is unrelated to confabulation. These individuals are not purposely lying but instead are trying to cover memory losses. A mother brings her 7-year-old son into an outpatient clinic for a follow-up appointment. The mother appears angry and agitated with the boy. Looking at the boy's medical chart, the nurse notes that the boy has a diagnosis of encopresis. What is the primary symptom of encopresis? Passing feces either voluntarily or involuntarily into inappropriate places Rationale: Encopresis is the passage of feces into inappropriate places such as clothing, closets, floors, or toy boxes, either voluntarily or involuntarily. It may severely limit a child's social development and results in parental disapproval and rejection. Encopresis does not involve self-induced vomiting or self-mutilation. The passage of urine into inappropriate places is called enuresis. A nurse is discussing Alcoholics Anonymous (AA) with a client. What behavior expected of members of AA should the nurse include in the discussion? Acknowledging an inability to control the problem Rationale: A major premise of AA is that to be successful in achieving sobriety, clients with alcohol abuse problems must acknowledge their inability to control their drinking. There are no rules about speaking at meetings, although members are encouraged strongly to do so. There are no rules of attendance at meetings, although members are encouraged strongly to attend as often as possible. Maintaining controlled drinking after 6 months is not part of AA; this group strongly supports total abstinence for life. An individual whose employment has been terminated because his company has been acquired by another company is brought by a family member to the mental health clinic because of extreme depression. While talking with the nurse the client says, "I'm a useless, worthless person. No wonder I lost my job." What type of delusion does the nurse identify? Self-deprecation Rationale: The client's statement is self-derogatory and reflects a low self-appraisal. There is no evidence that the 82 | P a g e client feels that he is the object of attention from others in the environment, that the client feels harassed, or that the client feels that others are controlling or manipulative. A client in the psychiatric hospital is attempting to communicate by stating, "Sky, flower, angry, green, opposite, blanket." The nurse recognizes what term as describing this type of communication? Word salad Rationale: Word salad is an incoherent mixture of words. Echolalia is a pathologic repetition of another's words or phrases. Confabulation is the unconscious filling in of memory gaps with imagined or untrue experiences. Flight of ideas is a speech pattern of rapid transition from topic to topic. The client's statement is too limited to be considered flight of ideas. A mental health nurse is admitting a client with anorexia nervosa. When obtaining the history and physical assessment, the nurse expects the client's condition to reveal which symptom? Amenorrhea Rationale: Amenorrhea results from endocrine imbalances that occur when fat stores are depleted. The client is dehydrated; edema is not expected. Constipation, not diarrhea, may occur because of lack of fiber in the diet. Hypotension, not hypertension, may occur because of dehydration. What does a nurse recall that language development in the autistic child resembles? Echolalia Rationale: The autistic child repeats sounds or words spoken by others, which is echolalia. Stuttering is a speech disorder in which the same syllable is repeated, usually at the beginning of a word. Scanning speech is associated with neurological disorders, not autism. Pressured speech is rapid, tense, and difficult to interrupt. This is associated with anxiety, not autism. A client with the diagnosis of alcoholism explains to the nurse that alcohol has a calming effect and states, "I function better when I'm drinking than when I'm sober." What defense mechanism does the nurse identify? Rationalization Rationale: The attempt to justify a behavior by giving it acceptable motives is an example of rationalization. Sublimation is the substitution of a maladaptive behavior for a more socially acceptable behavior. Suppression is the intentional exclusion of things, people, feelings, or events from consciousness. Compensation is the attempt to emphasize a characteristic viewed as an asset to make up for a real or imagined deficiency. 85 | P a g e A client with paralysis of the legs is found to have somatoform disorder, conversion type. What must the nurse consider when formulating a plan of care for this client? The illness is very real to the client and requires appropriate nursing care. Rationale: Individuals who have somatoform disorders are really ill; they need care in a nonthreatening environment. The client requires physiological and emotional care for treatment of motor or sensory functional deficits. A client is admitted to the psychiatric hospital after many self-inflicted nonlethal injuries over the preceding month. Of which level of suicidal behavior is the client's behavior reflective? Gestures Rationale: A suicidal gesture involves superficial, nonlethal injuries; the client has no intent to die as a result of the injuries. A suicidal threat is a person's verbal statement of intent to commit suicide; there is no action. Suicidal ideation is a person's thoughts regarding suicide; there is no definitive intent or action expressed. A suicide attempt is an actual implementation of a severe self-injurious act; there is an attempt to cause serious self-harm or death. A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive disorder (OCD). Before providing care for this client, what should the nurse remember about clients with OCD? Do not want to repeat the ritual but feel compelled to do so Rationale: The repeated thought or act defends the client against even higher, more severe levels of anxiety. Clients usually do recognize that the ritual serves little or no purpose. Rituals are usually followed rigidly; setting limits on or altering a ritual increases anxiety. Preventing the client from performing the ritual may precipitate a panic level of anxiety. A nurse, understanding the possible cause of alcohol-induced amnestic disorder, should take into consideration that the client is probably experiencing which imbalance? Thiamine deficiency Rationale: The deficiency of thiamine (vitamin B 1) is thought to be a primary cause of alcohol-induced amnestic disorder. Reduced iron intake, increased serotonin, and riboflavin malabsorption are all unrelated to alcohol-induced amnestic disorder. The nurse would recognize which behavior as being characteristic of the panic phase of crisis behavior? Being physically immobile Rationale: 86 | P a g e Being unable to physically move is a psychomotor characteristic of extreme panic, which is a characteristic of crisis behavior. Sobbing for no apparent reason, reporting great difficulties falling asleep, and startling easily to loud noises and being touched are behaviors seen in lesser degrees of anxiety. The nurse is caring for a client with vascular dementia. What does the nurse identify as the cause of this problem? Disruptions in cerebral blood flow, resulting in thrombi or emboli Rationale: Vascular dementia results from the sudden closure of the lumen of arterioles, causing infarction of the brain tissue in the affected area. Inadequate nutrition may be one of the factors that bring about a general decline of health; however, there is no direct evidence that avitaminosis can cause primary degenerative dementia. Severe emotional trauma may contribute to primary degenerative dementia but does not necessarily cause it. Neural degeneration leads to permanent, not transient, changes. A client who has been admitted with a diagnosis of schizophrenia says to the nurse, "Yes, it's March. March is Little Women. That's literal, you know." What do these statements illustrate? Loosening of associations Rationale: Loose associations are thoughts that are presented without the logical connections that are usually necessary for the listener to interpret the message. Echolalia is the purposeless repetition of words spoken by others or repetition of overheard sounds. Neologisms are new meaningless words coined by the client or new, unique meanings given to old words. Flight of ideas is the rapid skipping from one thought to another; these thoughts usually have only superficial or chance relationships. During an assessment interview, a client diagnosed with antisocial personality disorder spits, curses, and refuses to answer questions. Which is the appropriate nursing response to this behavior? 1. You are very disrespectful. You need to learn to control yourself. 2. I understand that you are angry, but this behavior will not be tolerated. 3. What behaviors could you modify to improve this situation? 4. What anti-personality disorder medications have helped you in the past? 2 ~ The appropriate nursing response is to reflect the clients feeling while setting firm limits on behavior. Clients diagnosed with antisocial personality disorder have a low tolerance for frustration, see themselves as victims, and use projection as a primary ego defense mechanism. At 11:00 p.m. a client diagnosed with antisocial personality disorder demands to phone a lawyer to file for a divorce. Unit rules state that no phone calls are permitted after 10:00 p.m. Which nursing response is most appropriate? 1. Go ahead and use the phone. I know this pending divorce is stressful. 2. You know better than to break the rules. I'm surprised at you. 3. It is after the 10:00 p.m. phone curfew. You will be able to call tomorrow. 4. A divorce shouldn't be considered until you have had a good nights sleep. 87 | P a g e 3 ~ The most appropriate response by the staff is to restate the unit rules in a calm, assertive manner. The nurse can encourage the client to verbalize frustration while maintaining an accepting attitude. The nurse may also help the client to identify the true source of frustration. A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate? 1. Provide objective evidence that reasons for violence are unwarranted. 2. Initially restrain the client to maintain safety. 3. Use clear, calm statements and a confident physical stance. 4. Empathize with the clients paranoid perceptions. 3 ~ The most appropriate nursing intervention is to use clear, calm statements and to assume a confident physical stance. A calm attitude provides the client with a feeling of safety and security. It may also be beneficial to have sufficient staff on hand to present a show of strength. A client diagnosed with borderline personality disorder brings up a conflict with the staff in a community meeting and develops a following of clients who unreasonably demand modification of unit rules. How can the nursing staff best handle this situation? 1. Allow the clients to apply the democratic process when developing unit rules. 2. Maintain consistency of care by open communication to avoid staff manipulation. 3. Allow the client spokesman to verbalize concerns during a unit staff meeting. 4. Maintain unit order by the application of autocratic leadership. 2 ~ The nursing staff can best handle this situation by maintaining consistency of care by open communication to avoid staff manipulation. Clients with borderline personality disorder can exhibit negative patterns of interaction, such as clinging and distancing, splitting, manipulation, and self- destructive behaviors. Which nursing approach should be used to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder? 1. Being firm, consistent, and empathic, while addressing specific client behaviors 2. Promoting client self-expression by implementing laissez-faire leadership 3. Using authoritative leadership to help clients learn to conform to society norms 4. Overlooking inappropriate behaviors to avoid providing secondary gains 1 ~ The best nursing approach when working with a client diagnosed with borderline personality disorder is to be firm, consistent, and empathetic while addressing specific client behaviors. Individuals with borderline personality disorder always seem to be in a state of crisis and can often have negative patterns of interaction, such as manipulation and splitting. Which adult client should a nurse identify as exhibiting the characteristics of a dependent personality disorder? 1. A physically healthy client who is dependent on meeting social needs by contact with 15 cats 2. A physically healthy client who has a history of depending on intense relationships to meet basic 90 | P a g e Which reaction to a compliment from another client should a nurse identify as a typical response from a client diagnosed with avoidant personality disorder? 1. Interpreting the compliment as a secret code used to increase personal power 2. Feeling the compliment was well deserved 3. Being grateful for the compliment but fearing later rejection and humiliation 4. Wondering what deep meaning and purpose is attached to the compliment 3 ~ The nurse should identify that a client diagnosed with avoidant personality disorder would be grateful for the compliment but would fear later rejection and humiliation. Individuals diagnosed with avoidant personality disorder are extremely sensitive to rejection and are often awkward and uncomfortable in social situations. Which factors differentiate a client diagnosed with social phobia from a client diagnosed with schizoid personality disorder? 1. Clients diagnosed with social phobia are treated with cognitive behavioral therapy, whereas clients diagnosed with schizoid personality disorder need medications. 2. Clients diagnosed with schizoid personality disorder experience anxiety only in social settings, whereas clients diagnosed with social phobia experience generalized anxiety. 3. Clients diagnosed with social phobia avoid attending birthday parties, whereas clients diagnosed with schizoid personality disorder would isolate self on a continual basis. 4. Clients diagnosed with schizoid personality disorder avoid attending birthday parties, whereas clients diagnosed with social phobia would isolate self on a continual basis. 3 ~ A client diagnosed with schizoid personality disorder exhibits a profound deficit in the ability to form personal relationships. Clients diagnosed with schizoid personality disorder prefer being alone to being with others and avoid social situations, social contacts, and activities. Which client symptoms should lead a nurse to suspect a diagnosis of obsessive-compulsive personality disorder? 1. The client experiences unwanted, intrusive, and persistent thoughts. 2. The client experiences unwanted, repetitive behavior patterns. 3. The client experiences inflexibility and lack of spontaneity when dealing with others. 4. The client experiences obsessive thoughts that are externally imposed. 3 ~ The nurse should suspect a diagnosis of obsessive-compulsive personality disorder when a client experiences inflexibility and lack of spontaneity. Individuals with this disorder are very serious, formal, and have difficulty expressing emotions. They are perfectionistic and preoccupied with rules. 91 | P a g e Which client is a nurse most likely to admit to an inpatient facility for self-destructive behaviors? 1. A client diagnosed with antisocial personality disorder 2. A client diagnosed with borderline personality disorder 3. A client diagnosed with schizoid personality disorder 4. A client diagnosed with paranoid personality disorder 2 ~ The nurse should expect that a client diagnosed with borderline personality disorder would be most likely to be admitted to an inpatient facility for self-destructive behaviors. Clients diagnosed with this disorder often exhibit repetitive, self-mutilating behaviors. Most gestures are designed to elicit a rescue response. When planning care for clients diagnosed with personality disorders, what should be the goal of treatment? 1. To stabilize the clients pathology by using the correct combination of psychotropic medications 2. To change the characteristics of the dysfunctional personality 3. To reduce personality trait inflexibility that interferes with functioning and relationships 4. To decrease the prevalence of neurotransmitters at receptor sites 3 ~ The goal of treatment for clients diagnosed with personality disorders should be to reduce inflexibility of personality traits that interfere with functioning and relationships. Personality disorders are often difficult and, in some cases, seem impossible to treat. There are no psychotropic medications approved specifically for the treatment of personality disorders. Which client situation would reflect the impulsive behavior that is commonly associated with borderline personality disorder? 1. As the day-shift nurse leaves the unit, the client suddenly hugs the nurses arm and whispers, The night nurse is evil. You have to stay. 2. As the day-shift nurse leaves the unit, the client suddenly hugs the nurses arm and states, I will be up all night if you don't stay with me. 3. As the day-shift nurse leaves the unit, the client suddenly hugs the nurses arm, yelling, Please don't go! I can't sleep without you being here. 4. As the day-shift nurse leaves the unit, the client suddenly shows the nurse a bloody arm and states, I cut myself because you are leaving me. 4 ~ The client who states, I cut myself because you are leaving me reflects impulsive behavior that is commonly associated with borderline personality disorder. Repetitive, self-mutilating behaviors are common in clients diagnosed with borderline personality disorders that result from feelings of abandonment following separation from significant others. Which nursing diagnosis should be prioritized when providing nursing care to a client diagnosed with paranoid personality disorder? 1. Risk for violence: directed toward others R/T paranoid thinking 2. Risk for suicide R/T altered thought 92 | P a g e 3. Altered sensory perception R/T increased levels of anxiety 4. Social isolation R/T inability to relate to others 1 ~ The priority nursing diagnosis for a client diagnosed with paranoid personality disorder should be risk for violence: directed toward others R/T paranoid thinking. Clients diagnosed with paranoid personality disorder have a pervasive distrust and suspiciousness of others that result in a constant threat readiness. They are often tense and irritable, which increases the likelihood of violent behavior. From a behavioral perspective, which nursing intervention is appropriate when caring for a client diagnosed with borderline personality disorder? 1. Seclude the client when inappropriate behaviors are exhibited. 2. Contract with the client to reinforce positive behaviors with unit privileges. 3. Teach the purpose of anti-anxiety medications to improve medication compliance. 4. Encourage the client to journal feelings to improve awareness of abandonment issues. 2 ~ The most appropriate nursing intervention from a behavioral perspective is to contract with the client to reinforce positive behaviors with unit privileges. Behavioral strategies offer reinforcement for positive change. A highly emotional client presents at an outpatient clinic appointment and states, "My dead husband returned to me during a sance." Which personality disorder should a nurse associate with this behavior? 1. Obsessive-compulsive personality disorder 2. Schizotypal personality disorder 3. Narcissistic personality disorder 4. Borderline personality disorder 2 ~ The nurse should associate schizotypal personality disorder with this behavior. The behaviors of people diagnosed with schizotypal personality disorder are odd and eccentric but do not decompensate to the level of schizophrenia. A nursing instructor is teaching students about clients diagnosed with histrionic personality disorder and the quality of their relationships. Which student statement indicates that learning has occurred? 1. Their dramatic style tends to make their interpersonal relationships quite interesting and fulfilling. 2. Their interpersonal relationships tend to be shallow and fleeting, serving their dependency needs. 3. They tend to develop few relationships because they are strongly independent but generally maintain deep affection. 4. They pay particular attention to details, which can interfere with the development of relationships. 2 ~ The instructor should evaluate that learning has occurred when the student describes clients diagnosed with histrionic personality disorder as having relationships that are shallow and fleeting. These types of relationships tend to serve their dependency needs. During an interview, which client statement should indicate to a nurse a potential diagnosis of schizotypal personality disorder? 1. I don't have a problem. My family is inflexible, and relatives are out to get me. 95 | P a g e C ~ The individual with a borderline personality disorder characteristically demonstrates manipulative, splitting, and self-destructive behaviors. Consistent limit setting is vital for the patients safety, as well as to prevent splitting other staff members. Why questions are not therapeutic. What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently manipulates others? The patient will: a. identify when feeling angry. b. use manipulation only to get legitimate needs met. c. acknowledge manipulative behavior when it is called to his or her attention. d. accept fulfillment of his or her requests within an hour rather than immediately. C ~ Acknowledging manipulative behavior is an early outcome that paves the way for taking greater responsibility for controlling manipulative behavior at a later time. Identifying anger relates to anger and aggression control. Using manipulation to get legitimate needs is an inappropriate outcome. Ideally, the patient will use assertive behavior to promote the fulfillment of legitimate needs. Accepting fulfillment of requests within an hour rather than immediately relates to impulsivity and immediacy control. Consider these comments made to three different nurses by a patient diagnosed with an antisocial personality disorder: Youre a better nurse than the day shift nurse said you were; Another nurse said you dont do your job right; You think youre perfect, but Ive seen you make three mistakes. Collectively, these interactions can be assessed as: a. seductive. b. detached. c. manipulative. d. guilt producing. C ~ Patients manipulate and control staff members in various ways. By keeping staff members off balance or fighting among themselves, the person with an antisocial personality disorder is left to operate as he or she pleases. Seductive behavior has sexual connotations. The patient is displaying the opposite of detached behavior. Guilt is not evidenced in the comments. A nurse reports to the interdisciplinary team that a patient diagnosed with an antisocial personality disorder lies to other patients, verbally abuses a patient diagnosed with dementia, and flatters the primary nurse. This patient is detached and superficial during counseling sessions. Which behavior most clearly warrants limit setting? a. Flattering the nurse b. Lying to other patients c. Verbal abuse of another patient d. Detached superficiality during counseling C ~ Limits must be set in areas in which the patients behavior affects the rights of others. Limiting verbal abuse of another patient is a priority intervention. The other concerns should be addressed during therapeutic encounters. A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. The psychiatrist suggests the use of a medication. Which type of medication should the nurse expect? 96 | P a g e a. Selective serotonin reuptake inhibitor (SSRI) b. Monoamine oxidase inhibitor (MAOI) c. Benzodiazepine d. Antipsychotic A ~ SSRIs are used to treat depression. Many patients with borderline personality disorder are fearful of taking something over which they have little control. Because SSRIs have a good side effect profile, the patient is more likely to comply with the medication. Low-dose antipsychotic or anxiolytic medications are not supported by the data given in this scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used for patients who are impulsive. A persons spouse filed charges of battery. The person has a long history of acting-out behaviors and several arrests. Which statement by the person suggests an antisocial personality disorder? a. I have a quick temper, but I can usually keep it under control. b. I've done some stupid things in my life, but Ive learned a lesson. c. I'm feeling terrible about the way my behavior has hurt my family. d. I hit because I'm tired of being nagged. My spouse deserved the beating. D ~ The patient with an antisocial personality disorder often impulsively acts out feelings of anger and feels no guilt or remorse. Patients with antisocial personality disorders rarely seem to learn from experience or feel true remorse. Problems with anger management and impulse control are common. What is the priority nursing diagnosis for a patient diagnosed with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects? a. Disturbed sensory perceptionauditory b. Risk for other-directed violence c. Ineffective denial d. Ineffective coping B ~ Violence against property, along with threats to harm staff, makes this diagnosis the priority. Patients with antisocial personality disorders rarely have psychotic symptoms. When patients with antisocial personality disorders use denial, they use it effectively. Although ineffective coping applies, the risk for violence is a higher priority. A patient diagnosed with a personality disorder has used manipulation to get his or her needs met. The staff decides to apply limit-setting interventions. What is the correct rationale for this action? a. It provides an outlet for feelings of anger and frustration. b. It respects the patients wishes so assertiveness will develop. c. External controls are necessary while internal controls are developed. d. Anxiety is reduced when staff members assume responsibility for the patients behavior C ~ A lack of internal controls leads to manipulative behaviors such as lying, cheating, conning, and flattering. To protect the rights of others, external controls must be consistently maintained until the patient is able to behave appropriately. A patient diagnosed with borderline personality disorder and a history of self-mutilation has now begun dialectical behavior therapy (DBT) on an outpatient basis. Counseling focuses on self-harm behavior management. Today the patient telephones to say, Im feeling empty and want to cut myself. The nurse 97 | P a g e should: a. arrange for emergency inpatient hospitalization. b. send the patient to the crisis intervention unit for 8 to 12 hours. c. assist the patient to identify the trigger situation and choose a coping strategy. d. advise the patient to take an antianxiety medication to decrease the anxiety level. C ~ The patient has responded appropriately to the urge for self-harm by calling a helping individual. A component of dialectical behavior therapy is telephone access to the therapist for coaching during crises. The nurse can assist the patient to choose an alternative to self-mutilation. The need for a protective environment may not be necessary if the patient is able to use cognitive strategies to determine a coping strategy that reduces the urge to mutilate. Taking a sedative and going to sleep should not be the first-line intervention; sedation may reduce the patients ability to weigh alternatives to mutilating behavior. The most challenging nursing intervention for patients diagnosed with personality disorders who use manipulation to get their needs met is: a. supporting behavioral change. b. monitoring suicide attempts. c. maintaining consistent limits. d. using aversive therapy. C ~ Maintaining consistent limits is by far the most difficult intervention because of the patients superior skills at manipulation. Supporting behavioral change and monitoring patient safety are less difficult tasks. Aversive therapy would probably not be part of the care plan; positive reinforcement strategies for acceptable behavior are more effective than aversive techniques. The history shows that a newly admitted patient has impulsivity. The nurse would expect behavior characterized by: a. adherence to a strict moral code. b. manipulative, controlling strategies. c. postponing gratification to an appropriate time. d. little time elapsed between thought and action. D ~ The impulsive individual acts in haste without taking time to consider the consequences of the action. None of the other options describes impulsivity. A patient tells a nurse, I sometimes get into trouble because I make quick decisions and act on them. A therapeutic response would be: a. Lets consider the advantages of being able to stop and think before acting. b. It sounds as though youve developed some insight into your situation. c. Ill bet you have some interesting stories to share about overreacting. d. Its good that youre showing readiness for behavioral change. A ~ The patient is showing openness to learning techniques for impulse control. One technique is to teach the patient to stop and think before acting impulsively. The patient can then be taught to evaluate the outcomes of possible actions and choose an effective action. The incorrect responses shift the encounter to a social level or are judgmental.