Nclex RN Exams Answer and Rationals Psychotic Disorders Part 2

1.Answer: b, c
Rationale: Agoraphobia is characterized by extreme anxiety and a fear of being in open places. Panic attacks and an inability to leave home are symptoms associated with the disorder. No correlation exists between fear of open spaces and hallucinations, eating disorders, alcohol consumption, or tobacco use.
2.Answer: a, c, d
Rationale: Improving stress management skills, verbalizing feelings, and anticipating and planning for stressful situations are adaptive responses to stress.Avoidance, denial, and suppression are maladaptive defense mechanisms.
3.Answer: a, c, f
Rationale: Sleep and appetite disturbances and suicidal
thoughts can appear in clients with dysthymia or major depressive disorders. Onset of symptoms are gradual and may appear over weeks or months. Delusions and other psychotic symptoms may occur in major
depression but don’t occur in dysthymia, a milder and more chronic mood disorder. Episodes of depression occurring solely in the winter are indicative of seasonal affective disorder.
4.Answer: a, b, d, e
Rationale: Clients who are depressed and feeling hopeless are often irritable and express inappropriate anger, feelings of worthlessness, and suicidal thoughts. In addition, they may demonstrate self-destructive behaviors.Preoccupation with delusions and auditory hallucinations is generally seen in clients with schizophrenia or other psychotic disorders rather than in those expressing hopelessness.
5.Answer: b, c
Rationale: A client with an adjustment disorder is likely to exhibit Impaired social interaction and Risk for
situational low self-esteem. The other diagnoses listed aren’t applicable to adjustment disorder.
6.Answer: a, f
Rationale: This client needs continuous reality-based
orientation, so the nurse should use the client’s name in all interactions. Structured activities can help the client refocus and resolve his delusion. The nurse shouldn’t contribute to the delusion by smiling at the comment or agreeing with the client. Logical arguments
and an as-needed medication aren’t likely to change the client’s beliefs.
7.Answer: a, b, c, d
Rationale: The most common physiological symptoms
observed in a client experiencing cocaine intoxication
are respiratory depression, cardiac arrhythmias,psychomotor agitation, and dilated pupils. Projectile vomiting and slurred speech aren’t associated with cocaine intoxication
8.Answer b
Rational: The most serious adverse reaction associated with high doses of MAO inhibitors is hypertensive crisis, which can lead to death.  Although not a crisis, orthostatic hypotension is also common and may
lead to syncope with high doses. Muscle spasticity (not flaccidity) is  associated with MAO inhibitor therapy. Hypoglycemia isn't an adverse reaction of MAO inhibitors.
9.Answer d
Rational: At this level of aggression, the client needs an appropriate physical outlet for the anger. She is beyond writing in a journal. Urging the client to talk to the nurse now or making threats, such as telling her that she will be restrained, is inappropriate and could lead to an escalation of her anger.
10.Answer b
Rational: Noncompliance with medications is common in the client with chronic undifferentiated schizophrenia. The nurse has the responsibility to assess this situation. Asking the mother if they've argued or if the client is mad at the mother or telling the mother to go over to the apartment and see what's going on places the blame and responsibility on the mother and therefore is inappropriate. Telling the mother not to worry ignores the seriousness of the client's symptoms.