1. 1. Question
The nursing diagnosis that would be most appropriate for a 22-year
old client who uses ritualistic behavior would be:
o A. Ineffective coping
o B. Impaired adjustment
o C. Personal identity disturbance
o D. Sensory/perceptual alterations
Incorrect
Correct Answer: A. Ineffective coping
Ineffective coping is the impairment of a person’s adaptive behaviors and problem-solving abilities in meeting life’s demands; ritualistic
behavior fits under this category as a defining characteristic. During
the beginning of treatment, allow plenty of time for rituals. Do not be
judgmental or verbalize disapproval of the behavior. To deny the client
this activity can precipitate panic level of anxiety. o Option B: Gradually limit the amount of time allotted for
ritualistic behavior as the client becomes more involved in unit
activities. Anxiety is minimized when the client is able to replace
ritualistic behaviors with more adaptive ones. Encourage
independence and give positive reinforcement for independent
behaviors. Positive reinforcement enhances self-esteem and
encourages repetition of desired behaviors. o Option C: Personal identity disturbance is not a priority
diagnosis for the client. Assess client’s level of anxiety. Investigate the types of situations that increase anxiety and result in ritualistic behaviors. Helping the client recognize the
precipitating factors is the first step in teaching the client to
interrupt the escalating anxiety. Initially meet the client’s dependency needs as necessary. Sudden and complete
elimination of avenues for dependency would create anxiety and
will burden the client more. o Option D: This nursing diagnosis is appropriate, but it is not
the priority. Encourage the recognition of situations that provoke obsessive thoughts or ritualistic behaviors. Recognition of
precipitating factors is the first step in teaching the client to
interrupt escalation of anxiety. Provide positive reinforcement for
non-ritualistic behaviors. Positive reinforcement enhances self- esteem and encourages repetition of desired behaviors.
2. Question
A psychiatrist prescribes an anti-obsessional agent for a client who is
using ritualistic behavior. A common anti-anxiety medication used for
this type of client would be:
o A. fluvoxamine (Luvox)
o B. benztropine (Cogentin)
o C. amantadine (Symmetrel)
o D. diphenhydramine (Benadryl)
Incorrect
Correct Answer: A. fluvoxamine (Luvox).
This drug blocks the uptake of serotonin. Fluvoxamine is used to treat
obsessive-compulsive disorder (bothersome thoughts that won’t go
away and the need to perform certain actions over and over) and
social anxiety disorder (extreme fear of interacting with others or
performing in front of others that interferes with normal life).
Fluvoxamine is in a class of medications called selective serotonin reuptake inhibitors (SSRIs). It works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental
balance. o Option B: Benztropine belongs to the synthetic class of
muscarinic receptor antagonists (anticholinergic drug). Thus, it
has a structure similar to that of diphenhydramine and atropine.
However, it is long-acting so that its administration can be with
less frequency than diphenhydramine. It also induces less CNS
stimulation effect compared to that of trihexyphenidyl, making it
a preferable drug of choice for geriatric patients. Moreover, benztropine is FDA approved as adjunctive therapy of all forms of
parkinsonism. o Option C: Amantadine is now used mostly for Parkinson’s disease. Clinical trials have shown that amantadine decreases symptoms of bradykinesia, rigidity, and tremor. There is a
combined synergistic effect with added levodopa, which is
converted to dopamine by striatal enzymes in the CNS. There can
be a transient benefit to the drug, so short-term therapy for
patients with the mild disease is best. o Option D: Diphenhydramine, which is available as an overthe-counter medication, is a first-generation antihistamine that is
used in a variety of conditions to treat and prevent dystonias,
insomnia, pruritus, urticaria, vertigo, and motion sickness. It also
possesses local anesthetic properties for those patients who have
allergies to other, more commonly used local anesthetics;
however, this is an off-label use of the medication. An additional
off-label use is for the treatment of oral mucositis.
3. Question
A 20-year old college student has been brought to the psychiatric
hospital by her parents. Her admitting diagnosis is borderline
personality disorder. When talking with the parents, which information
would the nurse expect to be included in the client’s history? Select
all that apply.
o A. Impulsiveness
o B. Lability of mood
o C. Ritualistic behavior
o D. Psychomotor retardation
o E. Self-destructive behavior
Incorrect
Correct Answers: Answer: A, B, & E
Borderline personality disorder (BPD) is a serious psychological
condition that’s characterized by unstable moods and emotions,
relationships, and behavior. It’s one of several personality disorders recognized by the American Psychiatric Association (APA). Personality
disorders are psychological conditions that begin in adolescence or
early adulthood, continue over many years, and, when left untreated,
can cause a great deal of distress. Thankfully, the right treatments
targeted for BPD can help significantly. o Option A: Impulsivity in at least two areas that are potentially self-damaging, for example, spending, substance
abuse, reckless driving, sex, binge eating, etc. Note: Do not
include suicidal or self-mutilating behavior covered in criterion 5.
BPD is associated with a tendency to engage in risky and
impulsive behaviors, such as going on shopping sprees, drinking excessive amounts of alcohol or abusing drugs, engaging in
promiscuous or risky sex, or binge eating. Also, people with BPD are more prone to engage in self-harming behaviors, such as
cutting or burning and attempting suicide. o Option B: Affective instability caused by a marked reactivity of mood, for example, intense episodic dysphoria,
anxiety, or irritability, usually lasting a few hours and rarely more than a few days. Emotional instability is a key feature of BPD.
Individuals feel like they’re on an emotional roller coaster with
quick mood shifts (i.e., going from feeling OK to feeling extremely
down or blue within a few minutes). Mood changes can last from minutes to days and are often intense. Anger, anxiety, and
overwhelming emptiness are common as well. o Option C: Obsessive-compulsive disorder (OCD) is often a
disabling condition consisting of bothersome intrusive thoughts
that elicit a feeling of discomfort. To reduce the anxiety and
distress associated with these thoughts, the patient may employ
compulsions or rituals. These rituals may be personal and private,
or they may involve others to participate; the rituals are to
compensate for the ego-dystonic feelings of the obsessional
thoughts and can cause a significant decline in function. o Option D: Psychomotor retardation is a long established
component of depression that can have significant clinical and
therapeutic implications for treatment. Manifestations of
psychomotor retardation include slowed speech, decreased
movement, and impaired cognitive function. It is common in
patients with melancholic depression and those with psychotic
features. o Option E: Borderline personality disorder (BPD) is 1 of 4
cluster-B disorders that include borderline, antisocial, narcissistic,
and histrionic. Borderline personality disorder (BPD) is
characterized by hypersensitivity to rejection and resulting
instability of interpersonal relationships, self-image, affect, and
behavior. Borderline personality disorder causes significant
impairment and distress and is associated with multiple medical
and psychiatric co-morbidities.
4. Question
A hospitalized client, diagnosed with a borderline personality disorder, consistently breaks the unit’s rules. This behavior should be confronted
because it will help the client:
o A. Control anger
o B. Reduce anxiety
o C. Set realistic goals
o D. Become more self-aware
Incorrect
Correct Answer: D. Become more self-aware. Client’s must first become aware of their behavior before they can
change it. Occurs after the client is aware of the behavior and has a
desire to change the behavior. Review with the client the types of
cognitive distortions that affect self-esteem (e.g., self-blame, mind reading, overgeneralization, selective inattention, all-or-none thinking).
These are the most common cognitive distortions people use.
Identifying them is the first step to correcting distortions that form one’s self-view. o Option A: Maintain a neutral, calm, and respectful manner, although with some clients this is easier said than done. Helps
the client see himself or herself as respected as a person even
when behavior might not be appropriate. Keep in mind clients
with personality disorders might defend against feelings of lowself-esteem through blaming, projection, anger, passivity, and
demanding behaviors. Many behaviors seen in PD clients cover a fragile sense of self. Often these behaviors are the crux of clients’
interpersonal difficulties in all their relationships. o Option B: Focus questions in a positive and active light;
helps client refocus on the present and look to the future. For example, “What can you do differently now?” or “What have you
learned from that experience?”. Allows the client to look at past
behaviors differently, and gives the client a sense that he or she
has choices in the future. o Option C: Set goals realistically, and renegotiate goals
frequently. Remember that a client’s negative self-view and
distrust of the world took years to develop. Unrealistic goals can
set up hopelessness in clients and frustrations in nurse clinicians.
Category | NCLEX EXAM |
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