Answers and Rationale

Answers and Rationale

retaliate with significant consequences. Introjection involves taking on the characteristics of another. Projection is characterized by accusing someone of one’s

1. B

own

weaknesses.

Compensation

is

demonstrated by overcoming some inadequacy by Rationale: Being overly talkative is a common sign of

excelling at another activity.

use of amphetamines (Dexedrin). This drug is a stimulant; staring into space and slurring words are Some marijuana users wear sunglasses indoors to disguise their inflamed eyes.

Reference: Timby, B.K., Carmack, A., & Rupert, D.L. Lippincott’s review for NCLEX-PN. 7th ed. (2006). Philadelphia: Lippincott Williams & Wilkins.

Reference: Timby, B.K., Carmack, A., & Rupert, D.L. Lippincott’s review for NCLEX-PN. 7th ed. (2006). Philadelphia: Lippincott Williams & Wilkins.

4. C Rationale: Clients with bipolar disorder, formerly called manic-depressive disorder, have cycles in which they display a marked change in mood between mania (abnormal highs) and depression

2. B

(lows). The disorder is called bipolar because of the Rationale: The most common side effects of

swings between the opposing poles of mood. Mania

risperidone

and

often affects thinking, judgment, and social behavior,

agitation. Orthostatic hypotension also occurs with

causing serious problems. Bipolar disorder is a

reflex tachycardia. Risperidone (Risperdal) does not

recurring illness that can be treated with long-term

increase extrapyramidal symptoms. Anticholinergic

medication. The exaggerated mood is followed or

symptoms such as urine retention are not commonly

preceded by an interval of normal mood. None of the

reported. Weight gain, not loss may develop.

other behaviors is symptomatic of bipolar disorder.

Reference: Timby, B.K., Carmack, A., & Rupert, D.L.

Reference: Timby, B.K., Carmack, A., & Rupert, D.L.

Lippincott’s review for NCLEX-PN. 7th ed. (2006).

Lippincott’s review for NCLEX-PN. 7th ed. (2006).

Philadelphia: Lippincott Williams & Wilkins.

Philadelphia: Lippincott Williams & Wilkins.

3. D

5. A

Rationale: Displacement is a coping mechanism in

Rationale: Involuntary facial movements and tongue

which a person transfers his angry feelings for one

and eye movements indicate the development of

person onto someone else who is less likely to

tardive dyskinesia, a negative consequence of

(Risperdal)

include

insomnia

MAD : Maladaptive Disorders | BSN 002

side effects typical of depressant type of drugs.

1

antipsychotic

(neuroleptic)

drug

therapy.

The

Reference:

Linda

Anne

Review

Sivestri. for

the

Saunder’s

condition is usually irreversible, even after the drug

Comprehensive

NCLEX-RN

is discontinued. About 20% of those treated with

Examination Third Ed. Elsevier Inc. 2005. CD-ROM

antipsychotic medications in the long-term develop tardive dyskinesia. None of the other assessment findings is linked to antipsychotic drug withdrawal. Reference: Timby, B.K., Carmack, A., & Rupert, D.L. Lippincott’s review for NCLEX-PN. 7th ed. (2006). Philadelphia: Lippincott Williams & Wilkins.

8. B. Rationale:The initial nursing action would be to assess for any physiological causes of the paralysis. Although a component of the plan of care would be would not be the initial nursing action. To encourage the client to use the arm without ruling out a

6. D.

physiological

cause

of

the

paralysis

is

not

Rationale: The client presents a lethally potential if

appropriate. Although the client may be referred to a

he/ she appear disorganized and impulsive. Clients

psychiatrist, this also is not the initial action.

at higher risk include those with a history of a dual diagnosis of mental illness and substance abuse; a

Reference:

Linda

Anne

personal or family history of suicide attempts,

Comprehensive

depression, alcoholism; or psychotic episodes.

Examination Third Ed. Elsevier Inc. 2005. CD-ROM

Review

Sivestri. for

the

Saunder’s NCLEX-RN

Having a plan, particularly if the method is immediate and available, makes the client a very high risk.

9. D. Rationale:A person who is experiencing mania lacks

Reference:

Linda

Comprehensive

Anne

Review

Sivestri. for

the

Saunder’s NCLEX-RN

Examination Third Ed. Elsevier Inc. 2005. CD-ROM

MAD : Maladaptive Disorders | BSN 002

to encourage the client to discuss feelings, this

insight and judgment, has poor impulse control, and is highly excitable. The nurse must take control without creating increased stress or anxiety to the client. A quiet, firm approach while distracting the client (walking her room to room and assisting her to get dressed) achieves the goal of having her

7. D.

dressed

appropriately

and

preserving

her

Rationale: Rigid and inflexible behaviours are

psychosocial

characteristics

inappropriate. Telling the other clients to go into

compulsive

of

the

disorder

client

(OCD).

with Clients

obsessivewith

this

disorder are not usually hostile unless they are

integrity.

Ignoring

the

client

is

nursing unit day room immediately is inappropriate and does not address the client’s behaviour.

prevented from engaging in the obsession or compulsion

because

decreases the anxiety.

this

behaviour

is

what Reference:

Linda

Comprehensive

Anne

Review

Sivestri. for

the

Saunder’s NCLEX-RN

Examination Third Ed. Elsevier Inc. 2005. CD-ROM

2

sexual concerns. Therefore, options b, c and d are incorrect.

10. D. Rationale: The most therapeutic response by the nurse is the one that makes the client aware of the

Reference: Comprehensive Review for the NCLEX-

verbal statement and directs the client to the

RN EXAMINATION Ed. 4, 2008, Saunders et al

purpose of the. The nurse should confront the client verbally regarding the client’s statement and refocus the client back to the issue of the session.

13. A Rationale:

According to Erickson, the caregiver

needs at all times but must allow the newborn infant Reference:

Linda

Comprehensive

Anne

Review

Sivestri. for

the

Saunder’s

to signal needs. If a newborn infant s not allowed to

NCLEX-RN

signal a need, the newborn will not learn how to

Examination Third Ed. Elsevier Inc. 2005. CD-ROM

control the environment . Erickson believed that a delayed or prolonged response to a newborn infant’s signal would inhibit the development of trust and

11. C

would lead to mistrust others.

Rationale: A nurse’s initial task when assessing a client in crisis is to assess the individual or family and the problem. The more clearly the problem can

Reference: Comprehensive Review for the NCLEX-

be defined, the better the chance a solution can be

RN EXAMINATION Ed. 4, 2008, Saunders et al

found. Option c will assist in determining data related to the precipitating event that led to the crisis. Options a and b assess situational support. Option d

MAD : Maladaptive Disorders | BSN 002

should not try to anticipate the newborn infant’s

14. C

assesses personal coping mechanism. Rationale: A conversion disorder is the alteration or loss of a physical function that cannot be explained Reference: Comprehensive Review for the NCLEXRN EXAMINATION Ed. 4, 2008, Saunders et al

by any known pathophysiological mechanism. A conversion disorder is thought to be an expression of psychological need or conflict. In this situation, the client

witnessed

an

accident

that

was

so

psychologically painful that the client became blind.

12. A

A dissociative disorder is a disturbance or alteration According to Freud’s psychosexual

in the normally integrative function s of identity,

stages of development, between the ages of 3 and

memory or consciousness. Psychosis is a state in

6, the child is in the phallic stage. At this time, the

which a person’s mental capacity to recognize

child devotes much energy in examining his or her

reality,

genitalia, masturbating and expressing interest in

impaired, thus interfering with the person’s ability to

Rationale:

communicate

and relate

to others

is

deal with life’s demands. Repression is coping

3

mechanism which unacceptable feelings are kept out of awareness.

17. B RATIONALE: Because the client has problems with

Reference: Comprehensive Review for the NCLEX-

altered thought and has self-care deficits, the nurse

RN EXAMINATION Ed. 4, 2008, Saunders et al

needs to make the decisions. Simple questions and directions are most appropriate. The client is not

15. B Solitary activities that require a short

other 3 options requires the client to make a

attention span with mild physical exertion are the

decision. These types of questions are inappropriate

most appropriate activities for a client who is

in this situation.

Rationale:

exhibiting aggressive behavior. Writing (journaling), walks with staff and finger painting are the activities that minimize the stimuli and provide a constructive

REFERENCE: Lippincott’s review series, Medical-

release for tension. Competitive games should be

surgical nursing, Fourth edition by Ray A. Hargrove-

avoided because they can stimulate aggression and

Huttel, RN, PhD. Page367.

increase psychomotor activities.

18. B Reference: Comprehensive Review for the NCLEXRN EXAMINATION Ed. 4, 2008, Saunders et al

RATIONALE: the nurse should never promise to keep a secret. Secrets are appropriate in social relationships but not in therapeutic relationships. The

16. A RATIONALE: The client with aphasia may need

MAD : Maladaptive Disorders | BSN 002

capable of making decisions at this time. Asking the

nurse needs to be honest with the client and tell the client that a promise cannot be made to keep a secret.

additional time to select the proper words when speaking. It is essential for the nurse to allow the client time to complete the sentence. Showing or

REFERENCE: SAUNDERS comprehensive review

naming various objects in the environment and

NCLEX-RN examination 2008, 4th edition. Page

leaving the room are inappropriate responses.

1139

Actions such as these often lead to additional client frustration, anxiety, and feelings of low self esteem. 19. A REFERENCE: Lippincott’s review series, Medicalsurgical nursing, Fourth edition by Ray A. HargroveHuttel, RN, PhD. Page367.

RATIONALE: Generally, the client seeks voluntary admission. Voluntary clients have the right to demand and obtain release. If the client is a minor, the release may be contingent on the consent of the

4

partent or guardian. The nurse needs to be familiar

ideas, actions or feelings by developing acceptable

with the state and facility policies and procedures.

explanations that satisfies the teller and the listener.

The best nursing action is to contact the physician.

23. D REFERENCE: SAUNDERS comprehensive review NCLEX-RN examination 2008, 4th edition. Page 1139

Rationale: Short-term goals include the beginning stages of dealing with the rape trauma. Clients will be

expected

initially

to

keep

appointments,

begin to heal any physical wounds that were inflicted

20. A

at the time of rape.

RATIONALE: Denial is refusal to admit painful reality, which is treated as if it does not exist. REFERENCE: SAUNDERS comprehensive review

24. A

NCLEX-RN examination 2008, 4th edition. Page

Rationale:

1138

required for the client who attempted suicide.

One-to-one

suicide

precautions

are

Options 2 and 3 maybe appropriate, but not at the present time considering the situation. Option 4 also maybe an appropriate nursing intervention, but the

21. A

priority is identified in option 1. The best intervention Rationale: In the formal operation stage, the child

is constant supervision so that the nurse may

has the ability to think abstractly and logically.

intervene as needed if the client attempts to cause

Option 2 identifies concrete operation stage. Option

harm to self.

MAD : Maladaptive Disorders | BSN 002

participate in care, begin to explore feelings, and

3 identifies sensorimotor stage. Option 4 identifies the preoperational stage. 25. C Rationale: Hanging is a serious suicide attempt. The

22. A

plan of care must reflect action that will ensure the Rationale: Denial is refusal to admit to a painful

client’s safety. Constant observation status (one to

reality, which is treated as if it does not exist. In

one) with a staff member who is never less than an

projection,

rejects

arm’s length away is the best selection. Seclusion

emotionally unacceptable features and attributes

should not be the initial intervention, and the least

them to other persons, objects, or situations. In

restrictive measures should be used. Placing the

regression, the client returns to an earlier, more

client in a hospital gown and requesting that a peer

comforting, although less mature way of behaving.

remain with the client will not ensure a safe

Rationalization is justifying illogical or unreasonable

environment.

a

person

unconsciously

5

26. A

(Thompson

Peterson.

NCLEX-PN

Certification

Rationale: The manic patient may neglect to eat or

Exam. Peterson’s Advision of Thompson Learning

sleep, due to excessive energy and flight of ideas.

Corp.2003.p 128) 30. C

Peterson.

NCLEX-PN

Certification

Exam. Peterson’s Advision of Thompson Learning Corp.2003.p 127)

patient to hurt someone can make the patient a danger to himself or others. The RN provider needs to know that they are occurring.

27. A Rationale: Structured activities will help keep the depressed patient active, and small groups provide social contact without being overwhelming.

(Thompson

Auditory hallucinations that are “commanding” a

Peterson.

NCLEX-PN

Certification

(Thompson

Peterson.

NCLEX-PN

Certification

Exam. Peterson’s Advision of Thompson Learning Corp.2003.p 129)

31. B.

Exam. Peterson’s Advision of Thompson Learning

Rationale: The nurse’s nonverbal behavior, moving

Corp.2003.p 128)

away from the window as seethe client’s request, would indicate agreement with the client’s false ideas. The client’s behavior is likely to be reinforced

MAD : Maladaptive Disorders | BSN 002

(Thompson

if the nurse takes to agree with the false ideas he

28. A It is typical for the elderly to feel shamed and

holds.

humiliated by the abuse they receive. (NCLEX-RN Examination 8th Edition by Diane M. (Thompson

Peterson.

NCLEX-PN

Certification

Bilings)

Exam. Peterson’s Advision of Thompson Learning Corp.2003.p 128) 32. B Rationale: The nursing diagnosis Disturbed Thought

29. A The paranoid patient is easily threatened, and the most

important

point

to

remember

when

approaching them is to avoid touching them or getting to close.

Processes related to increase anxiety, as evidenced by delusional thinking, most accurately reflects this client’s problem with paranoid delusions. Disturbed Sensory Perception: Visual would be appropriate if the client were expecting hallucinations. Impaired

6

Verbal Communication would be appropriate if the

safety is no longer an issue because antipsychotics

client were demonstrating less coherent speech.

are beginning to take effect. Telling the client that

Social Isolation would be appropriate if the client

the hallucinations are part of the illness or that the

were refusing to come out of his room.

medications will help control the voices would be appropriate once the client has developed some insight into the symptoms of illness.

(NCLEX-RN Examination 8th Edition by Diane M. Bilings) (NCLEX-RN Examination 8th Edition by Diane M.

33. A Rationale: The nurse needs to present the reality of the situation. By explaining that the men are

35. A

groundskeepers and probably talking about work,

Rationale: Hallucination and asocial behaviors are

the nurse is reinforcing reality to encounter the

typical symptoms of undifferentiated schizophrenia.

client’s

Preoccupation

with

persecutory

delusions

Additionally, this response voices doubt in the

hallucinations

are

associated

with

client’s paranoid interpretation. Telling the client not

schizophrenia. Grossly disorganized behaviors and

to pay attention to the men fails to address the

speech are associated with disorganized type of

client’s

schizophrenia. Immobility and waxy flexibility are

illusion

(misinterpretation

misinterpretation

and

of

reality).

misperceptions.

Closing the drapes so that the client doesn’t see the men

ignores

the

client’s

misperception

and

paranoid

associated with catatonic type of schizophrenia.

and

MAD : Maladaptive Disorders | BSN 002

Bilings)

misinterpretation. (NCLEX-RN Examination 8th Edition by Diane M. Bilings) (NCLEX-RN Examination 8th Edition by Diane M. Bilings) 36. C Rationale:

34. C Rationale;

Patients

with

antisocial

personality

disorder typically show no remorse and justify their Clients

may

act

on

command

actions as being right for them, despite being

hallucinations and harm themselves or others.

socially unacceptable. 1. Such a person would have

Therefore, the staff needs to know when the client is

difficulties with interactions. 2. This person behaves

hearing such commands, to ensure safety first.

bizarrely and has few interactions with others. 4.

Telling the client the voices are real but nurse

This person has intense, angry relationships, is

doesn’t hear them would be an appropriate response

impulsive, and may self-mutilate.

later in the client’s hospitalization when the client’s

7

(Reference: www.evolve.elsevier.com)

result. Options 2, 3, and 4 are not the most frequent causes of postretirement adjustment disorder.

37: A Rationale: Controlling the impulse to self-mutilate or

(Reference: www.evolve.elsevier.com)

self-destruct would be indicative of improved ability would impulsively act out the urge. Option 2 is not a

40. C

desired outcome. Option 3 does not suggest

Rationale: Cultural practices dealing with grief and

improved management of feelings. Option 4 is not a

loss differ. Failure to incorporate the significance of

desired outcome.

cultural practices into the treatment plan may impede resolution of the patient's grieving. 1. Talking about the loss helps the patient come to terms with

(Reference: www.evolve.elsevier.com)

it. 2. Empathy is a helpful response. 4. Obtaining help from qualified persons to assist with grief resolution is valuable if the patient approves of their

38. C

involvement.

Rationale: This question will give the nurse data about the patient's feelings about entering treatment. Generally, patients who are willing to become

(Reference: www.evolve.elsevier.com)

involved derive greater benefits. 1. The question will not alter the patient's level of anxiety. 2. The goal of nursing assessment is to gather specific data. 4.

MAD : Maladaptive Disorders | BSN 002

to tolerate distressing thoughts. Ordinarily the patient

41. D

This question is not designed to gather this

Rationale: This response is calm, matter-of-fact and

information.

firm. The nurse is not permitting the patient to be manipulative, nor is she setting up a situation in which a power struggle is likely to arise. Option 1

(Reference: www.evolve.elsevier.com)

praises the patient for her behavior. Option 2 is manipulative on the part of the nurse. Option 3 suggests the patient will not be weighed according to

39. A

schedule.

Rationale: Identity and purpose are often associated with one's job. When one retires, loss of identity and purpose often occur, which requires adaptation. If

(Reference: www.evolve.elsevier.com)

adaptation does not occur, adjustment disorder may 42. A

8

Rationale:

Change

comes

slowly

even

when

appropriate goals are set with the patient. When goals are unattainable, staff become discouraged or

(Reference: www.evolve.elsevier.com)

frustrated with lack of progress. Regarding option 2, when a nurse adopts the behaviors used by an antisocial patient, it is not related to lack of progress toward goals. Regarding option 3, the antisocial patient is usually uncaring about the opinions of others. Regarding option 4, antisocial patients act out feelings, instead of turning them inward.

45. Answer: C Rationale: Reducing stimulation is calming and will allow the patient to focus his or her limited intellectual skills on regaining control. 1. Behavioral can easily be misinterpreted as a threat. 4. Patients

(Reference: www.evolve.elsevier.com)

need increased personal space during catastrophic reactions 43. B Rationale: The nurse who is aware of his or her

(Reference: www.evolve.elsevier.com)

personal feelings and views about sexual issues can assist a patient with a sexual disorder. Lack of clarity

46. C

about one's feelings and views clouds the nurse's

Rationale: Repetition of words or phrases that are

focus. 1. Previous experience may prove to be

similarly in sound and in no other way (rhyming) is

helpful, but is not the most important qualification. 3.

one altered thought and language pattern in

Thinking that all types of sexual dysfunction can be

schizophrenia. Clang association often take the form

corrected

the

of rhyming. Loosened associations occur when

prognosis for most sexual dysfunction disorders is

individual speaks with frequent changes of subject,

poor shows lack of information.

and the content is obliquely related. Echolalia is the

is

unrealistic.

4.

Thinking

that

MAD : Maladaptive Disorders | BSN 002

responses to the patient should be positive. 2. Touch

involuntary parrot like repetition of words spoken by others. Word salad is the use of words with no (Reference: www.evolve.elsevier.com)

apparent meaning attached to them or to their relationship to one another. Reference: Saunders Q & A Review for the NCLEX-

44. D Rationale: This question asks directly about the

RN Examination by Linda Anne Silvestri, 2006, Elsevier Inc 47. B

coping skills used in the past. After this lead-in the

Rationale: By definition, an ego defense mechanism

nurse can question further to find out how effective

are operations outside of a person's awareness that

the coping skills were. This option is the only

the ego calls into play to protect against anxiety.

question that relates specifically to adequacy of

Denial is the defense mechanism that blocks out

coping skills.

painful or anxiety inducing events or feelings. In this case, the client cannot deal the upcoming surgery

9

for

cancer

Psychosis

and and

therefore delusions

denies are

the not

illness.

Reference: Saunders Q & A Review for the NCLEX-

defense

RN Examination by Linda Anne Silvestri, 2006,

mechanism. Displacement is the discharging of

Elsevier Inc

pent-up feelings on persons less dangerous than

50. B

those initially around the feelings.

Rationale: The client in manic state often has inadequate food and fluid intake as a result of

Reference: Saunders Q & A Review for the NCLEX-

the run” are best because the client is too active to

RN Examination by Linda Anne Silvestri, 2006,

sit at meals and use utensils. Additionally, clients in

Elsevier Inc

manic state should not have caffeine containing products. Reference: Saunders Q & A Review for the NCLEXRN Examination by Linda Anne Silvestri, 2006,

48. A

Elsevier Inc. Rationale:

A

client

experiencing

paranoia

is

distrustful and suspicious of others. The health care team needs to establish rapport with the client.

51. B

Laughing or whispering in front of the client would

Rationale:

increase the client's paranoia. Options 2,3 and 4 ask

condition in which patient talks continuously and

the client to trust on multitude levels. These options

then switch to unrelated topic. Loose association is

are too intrusive for a client who is paranoid

somewhat similar to more obvious and completely

Reference: Saunders Q & A Review for the NCLEX-

unrelated. A, C, D are all alteration in perception. A

RN Examination by Linda Anne Silvestri, 2006,

refers to a person thinking that everyone is talking

Elsevier Inc

about him. C and D are all sensory alterations. The

49. A

difference is that, in hallucination, there is no need

Rationale: Exercising 23 to 4 hours everyday is

for a stimulus. In illusion, a stimulus (a phone cord)

excessive physical activity and unrealistic fir 16 year

is mistakenly identified by the client as something

old. The nurse needs to further assess this

else (snake).

flight of ideas: flight of ideas is a

MAD : Maladaptive Disorders | BSN 002

physical agitation. Foods that the client can eat “on

statement immediately to find out why the client feels the need to exercise this much to maintain her figure. Although it's unfortunate that her best friend had this disease this is not considered a major threat

52. A

to the client's physical well-being. A weight that

Rationale: I understand and that’s God’s voice are

exceeds 15% below the ideal weight is significant

real to you, but I don’t hear anything. I will stay with

with anorexia nervosa. It is not considered abnormal

you: the nurse should first ACKNOWLEDGE that the

to check weight every day. Many clients with

voices are reality the patient and then PRESENT

anorexia nervosa check their weight close to 20

REALITY by telling the patient that you do not hear

times a day.

anything. The third part of the nursing intervention in hallucination is LESSENING THE SIMULI by either

1 0

staying with the patient or REMOVING the patient

client with paranoid schizophrenia is at risk for

from a highly stimulating place. Telling the client that

violence toward himself or others. The other options

the voices are part of his illness is not therapeutic.

are also appropriate nursing diagnoses but should

People with schizophrenia think that they are ill.

be addressed after the safety of the client and those

Letter C and D disregards the client’s concerns and

around him is established.

therefore, not therapeutic. 53. C

http://www.scribd.com/doc/6389830/109-Questionsand-Rationale-on-Psychotic-Disorders

suicidal ideation to be lessening: too obvious, no need to rationalize. 57. B Rationale: Option B is the action of Cogentin.

54. D

Anxiety

doesn't

cause

extrapyramidal

effects.

Rationale: “I need to call my doctor whenever I

Overactivity of acetylcholine and lower levels of

notice that I have a fever or sore throat.”: clozapine

dopamine are the causes of extrapyramidal effects.

causes AGRANULOCYTOSIS and bone marrow

Benztropine doesn't increase norepinephrine in the

depression. Early s/s includes fever and sore throat.

CNS.

The medication is to be withheld this time or the patient might develop severe infection leading to death.

http://www.scribd.com/doc/6389830/109-Questions-

MAD : Maladaptive Disorders | BSN 002

Rationale: the depression to be improving and the

and-Rationale-on-Psychotic-Disorders 55. C. Rationale:

Schizophrenia:

when

disorders

of

58. C

perception and thoughts came in. the only diagnosis

Rationale: By acknowledging that the client hears

doctor

of

voices, the nurse conveys acceptance of the client.

schizophrenia. A, B and D can occur in normal

By letting the client know that the nurse doesn't hear

individuals

the

can

make

is

without

among

altering

the their

choices

perceptions.

voices,

the

nurse

avoids

reinforcing

the

Schizophrenia is characterized by disorders of

hallucination. The nurse shouldn't touch the client

thoughts, hallucinations, delusions, illusion and

with schizophrenia without advance warning. The

disorganization.

hallucinating client may believe that the touch is a threat or act of aggression and respond violently. Being alone in his room encourages the client to

56. A Rationale:

withdraw and may promote more hallucinations. The Because

of

such

factors

as

suspiciousness, anxiety, and hallucinations, the

nurse should provide an activity to distract the client. By asking the client what the voices are saying, the

1 1

nurse is reinforcing the hallucination. The nurse should focus on the client's feelings, rather than the content of the hallucination.

61. D Rationale: The client’s energy level is so high that a complete night’s sleep probably is impossible. The

http://www.scribd.com/doc/6389830/109-Questions-

nurse should use any “down” time to promote rest.

and-Rationale-on-Psychotic-Disorders

The client’s sleep pattern, including a bedtime routine, can be repatterned when the client’s come

59. C

A). During the manic phase, the client’s energy level is so high that enforcing seclusion during the night

Rationale: Nihilistic delusions are false ideas about

isn’t likely to promote sleep (Option B). The nurse

the self, others, or the world. Somatic delusions

should encourage the client to sleep or rest at any

involve a false belief about the functioning of the

time to prevent physical exhaustion (Option D)

body. Body dysmorphic disorder is characterized by a belief that the body is deformed or defective in a specific way. Apraxia is the inability to carry out motor activities.

62. A Rationale: A depressed client is at great risk for committing

suicide

and

needs

continuous

http://www.scribd.com/doc/6389830/109-Questions-

observation. This client must not be left alone

and-Rationale-on-Psychotic-Disorders

(Option B and D). The nurse must not relinquish

MAD : Maladaptive Disorders | BSN 002

down from the manic phase of the disorder (Option

responsibilities to another client (Option C).

60. C 63. B Rationale: The client's signs and symptoms suggest

Rationale: The nurse must not reinforce the client’s

neuroleptic malignant syndrome, a life-threatening

hallucinations. Telling the client to listen to the

reaction to neuroleptic medication that requires

voices would reinforce the hallucinations (Option A).

immediate treatment. Tardive dyskinesia causes

The nurse shouldn’t say things that may not be true

involuntary movements of the tongue, mouth, facial

(Option C). The voices are real to the client, telling

muscles, and arm and leg muscles. Dystonia is

him that he doesn’t hear them isn’t therapeutic

characterized by cramps and rigidity of the tongue,

(Option D).

face, neck, and back muscles. Akathisia causes restlessness, anxiety, and jitteriness.

http://www.scribd.com/doc/6389830/109-Questionsand-Rationale-on-Psychotic-Disorders

64. A

Rationale: This response orients the client to reality and provides the structure the client’s needs to solve

1 2

the immediate problem. The client is too anxious and

Rationale: Disturbed thought process related to

regressed to engage in the problem solving required

paranoia is the client’s problem, and the plan of care

by options B and C. Option D is insane because the

must

client is unable to provide self care as a result of

experiencing

severe anxiety that interferes with problem solving

suspicious of others. The members of the health

and prevents awareness of the reality.

cafe team need to establish a rapport and trust with

address

this

paranoia

problem. and

is

The

client

distrustful

is and

the client. Therefore laughing or whispering in front of the client would be counterproductive. 68. B Rationale: Clients with anorexia nervosa commonly

Rationale: Mania is a mood characterized by

communicate on a superficial level and avoid

excitement,

expressing feelings. Identifying feelings and learning

energy, decreased need for sleep, and impaired

to express them are initial steps in decreasing

ability to concentrate or complete a single train of

isolation. Clients with anorexia nervosa are usually

thought. Mania is a period when the mood is

able to discuss abstract and concrete issues.

predominantly elevated, expansive or irritable. All

Confrontation

effective

options reflect a client’s possible symptomatology.

communication strategy as it may cause the client to

Option B, however, clearly presents a problem that

withdraw and become more depressed.

compromises a physiological integrity and need to

usually

isn’t

an

euphoria,

hyperactivity,

excessive

be addressed immediately. (Source: Springhouse Review for NCLEX-RN 5th

69. C

edition; Page 624)

Rationale: The client taking clozapine (Clozaril) may

MAD : Maladaptive Disorders | BSN 002

65. C

experience agranulocytosis, which is monitored by reviewing the result of the white blood count.

66. A Rationale: Denial is refusal to admit a painful reality, which is treated as if it does not exist. In projection, a person

unconsciously

rejects

emotionally

unacceptable features and attributes them to other persons, objects, or situations. In regression, the client returns to earlier, more comforting, although less mature, way of behaving. Rationalization is justifying illogical or unreasonable ideas, actions or feelings by developing acceptable explanations that the teller and the listener. 67. B

Treatment is interrupted if the white blood count drops below 3000/mm3. Agranulocytosis can be fatal if undetected and untreated. The other options are not related specifically to the use of this medication. 70. B Rationale: Clients with anorexia nervosa frequently are preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide appropriate exercise and place limits on rigorous activities.

1 3

(Reference: Saunders’ Comprehensive Review

76. A

NCLEX-RN Examination 4TH ed by Linda Anne

Rationale: Clients with panic disorder tend to be

Silvestri, MSN, RN, Canada 2008.)

socially withdrawn. Going to the mall is a sign of working on avoidance behaviors. Hyperventilation is a

71. C

key

symptom of panic

disorder.

Teaching

Rationale: The development of physical symptoms

with panic disorder. The client taking medications for

without a physical cause is an anxiety-reducing

panic disorder, such as trycyclic antidepressants and

mechanism.

benzodiazepines, must be weaned off these drugs. Most clients with panic disorder with agoraphobia don’t have nutritional problems.

72. B 77. D Rationale: Mediating frustration within the real world is an ego function and requires ego strength.

Rationale: The client must be aware of the connection between sources of anxiety and the symptoms of a panic attack. Role-playing a panic attack isn’t useful for the client. Later in treatment, the client can develop an exercise program as part

73. B Rationale: Slips of the tongue also called Freudian slip are material from the unconscious that slips out in unguarded moments.

of the overall plan to handle stress. Learning to identify cognitive distortions is a useful strategy to teach the client after he’s begun to work on identifying sources of anxiety.

MAD : Maladaptive Disorders | BSN 002

breathing control is a major intervention for clients

78. D 74. A

Rationale: Stopping antianxiety dugs such as

Rationale: Talking in the third person reflect poor ego boundaries and dissociation from the real self.

withdrawal symptoms. Stopping a benzodiazepine doesn’t tend to cause depression, increase cognitive

75. C Rationale:

benzodiazepines can cause the client to have

abilities, or decrease sleeping difficulties. The

superego

incorporates

all

experiences and learning from external environment (society, family etc.) into the external environment.

79. A Rationale: Use of lithium during pregnancy results in congenital

defects,

especially

cardiac

defects.

Thyroids problems don’t occur in the first trimester of the pregnancy. In lithium toxicity, a condition called (Reference: Mosby's Comprehensive Review of Nursing for NCLEX-RNR Examination Book, 2009, by Saxton)

nontoxic goiter ma occur. An adverse effect of lithium is polyuria, not urine retention. The rate of spontaneous abortion is no greater than for nonusers.

1 4

importance. Never try to force recall of information 80. A,B,D

the client is not prepared to know. Reduction of anxiety

Rationale: A client with an impulse control disorder

helps

avoid

the

emergence

of

subpersonalities.

who displays violent, aggressive, and assaultive behavior generally functions well in other areas of 84. B

of proportion wit the stressor. Such a client

Rationale: Telling the client who complains of seeing

commonly has a history of parental alcoholism and a

UFOs that “I can tell that what you’re seeing

chaotic family life, and often verbalizes sincere

frightens you; how can I help to make you more

remorse and guilt for the aggressive behavior.

comfortable?” validates the client’s feelings without agreeing with or challenging the client’s irrational

(Reference: Lippincott Wiliams & Wilkins. NCLEX-

beliefs.

RN Question and Answer p. 374)

81. D

85. C Rationale: A client with a bipolar disorder and a

Rationale: Although the precise mechanism of

superimposed seasonal affective depression needs

inheritance is unknown, developing a social phobia

to be careful about the time of day that the

is 11% more likely if a family member has the

phototherapy is utilized. Because of circardian

disorder.

rhythms, it has been found that bipolar clients with seasonal depression do best if they utilize the

MAD : Maladaptive Disorders | BSN 002

his life. The degree of aggressiveness is typically out

phototherapy treatment in the later afternoon. If the 82. C Rationale: Malingering is characterized by the client’s deliberate attempt to gain attention. The clinical manifestations are not confirmed by lab tests. The client will bring the clinical manifestations to the attention of others for secondary gain. The client does not withdraw but becomes demanding of health care providers and others.

phototherapy is manifestations

used

may

in

result.

the morning, manic Exploring

appetite,

energy level, feelings of self-worth, and how much money the client is spending may all be important interventions, but determining the time of the day the client is using phototherapy allows the nurse to obtain the information that may be causing the dramatic change and elevation in mood. (Reference: Complete Review for NCLEX-RN by Donna Gauwitz, Thomson Asian Edition, NSNA

83. A

(2007))

Rationale: One-to-on supervision and making a suicide contract with a client who has a dissociative disorder are priorities to meet the safety needs of the client under distress. Confidentiality is of the utmost

86. A

1 5

Rationale: Mild anxiety motivates one to action, such

physical and emotional dependence on the parents.

as learning or making changes. Higher levels of

The major task during infancy is the development of

anxiety tends to blur the individual's perceptions and

trust. School age deals with the task of industry and

interfere with functioning.

developing skills for working in and relating to the world. Preschool age deals with developing a sense of initiative.

87. D Rationale: The client's early arrival indicates an indicates that the client has been told what to expect.

92. C Rationale: The child resolves oedipal conflicts by learning to identify with the parent of the same sex and accomplishes this by mimicking the role of his parent.

88. D Rationale: Anxiety is a human response,causing both physical and emotional changes that everyone experiences when faced with stressful situations.

Oral

stage

is

the

earliest

stage

of

development and operates solely on the pleasure principle, largely id oriented; this stage is concerned with the development of trust. Genital stage is when the interest shifts from the anal region to the genital region and questions about sexuality arise during this stage. Latency stage is when there is increasing

89. C

sex-role development; this stage is concerned with

Rationale: The individual using sublimation attempts

peer group identification.

to fulfill desires by selecting a socially acceptable

MAD : Maladaptive Disorders | BSN 002

expected degree of anxiety; the quiet waiting

activity rather than one that is socially unacceptable. 93. B Rationale: Values and beliefs from parents and

90. B Rationale: Toddlers struggle to identify their own

society are expressed through the child’s play world.

needs. Too early and too strict toilet training results

These values become part of the child’s system

in

and

through the process of internalization (introjection).

physical abilities are in conflict with parental

Projection- if this happens, children will learn to

demands. Toddlers are faced with giving up these

blame others for their own faults. Competition

needs or risking parental disapproval.

happens in the later stage. Independence is

ambivalence

because

toddler's

needs

influenced by the environment and others in it rather (Reference: Mosby’s Review of Nursing for NCLEX-

than play.

RN Examination) 91. C Rationale: The toddler is learning autonomy, but

94. C

because of the nature of development, there is still

1 6

Rationale: the child realizes that the parent of the

report them to the physician. The client should be

same sex cannot be bested in a struggle for the

instructed to monitor his lithium levels on a regular

affection of the parent of the opposite sex. The role

basis to avoid toxicity. The nurse should explain that

and the behaviour of the same-sex parent are

7 to 21 days may pass before the client notes a

therefore assumed by the child to attract the parent

change in his mood. Lithium doesn’t have addictive

of the opposite sex. Rejects the parent of the same

properties. Tyramine is a potential concern for

sex – this is a conflict, not a resolution. Introjects

clients taking monoamine-oxidase inhibitors.

a greater conflict and leaves a fragmented self.

97. B,C,E

Identifies with the parent of the opposite sex- this is

Rationale: Neuroleptic malignant syndrome is a life-

in conflict with heterosexual drives.

threatening

adverse

effect

of

antipsychotic

medications such as Haldol. It’s associated with a rapid increase in temperature. The most common extrapyramidal adverse effect, akathisia, is a form of

95. B

psychomotor restlessness that can often be relieved Rationale: Children 2 to 7 years old have difficulty

b pacing. Haldol and the anticholinergic medications

distinguishing reality from fantasy; this presents the

that are provided to alleviate it extrapyramidal effects

greatest challenge to the nurse. Sensorimotor stage-

can result in a dry mouth. Providing the client with

children from birth to 1 year of age focus on “in the

hard candy to suck on can help alleviate this

moment” thinking; preoperative preparation most

problem. Haldol isn’t given subcutaneously and

likely will not be recalled. Formal operational stage-

doesn’t affect blood suga levels. Urticaria is not

children 12 to 16 years of age can think in the

usually associated with Haldol administration.

abstract and have the ability to solve the complex problems; children in this stage usually do not pose difficulties

in

preoperative

teaching.

98. C

Concrete

Rationale: The preoccupation in hypochondriasis is

operational stage- children 7 to 11 years of age have

related to bodily functions or physical sensations.

the ability to comprehend and visualize a series of

Repeated physical examinations, diagnostic tests,

events and can think about the past and present;

and reassurance from the physician don’t allay the

this stage provides less of a challenge to absorb

concerns about bodily disease. There’s a belief that

preoperative teachings.

a health care professional has poor insight if he sees

(Reference: Mosby’s Review of Nursing for NCLEXRN Examination)

MAD : Maladaptive Disorders | BSN 002

behaviours of both parents – doing this gives rise to

the concern about having a serious illness as excessive or unreasonable. The other responses aren’t valid.

96. B,E,F Rationale: Client education should cover the signs and symptoms of drug toxicity as well as the need to

99. D Rationale:

Sleep

deprivation

can

lead

to

hallucinations and delusions. Uninterrupted sleep is an important nursing consideration in planning care.

1 7

All other data are expected and shouldn’t cause sleep deprivation.

104. B

100. C The

amount

of

time

focused

on

discussing physical symptoms should be decreased.

Rationale: Any behavioural therapy or learning of

Lack of positive reinforcement may help her to stop

new methods of coping with situations requires

the maladaptive behavior. However, avoiding the

modification of approach and attitudes; hence

statement all together demeans the client and

personality is always capable of change.

doesn’t address the underlying problem. Asking the client

to

further

explain

emphasizes

physical

symptoms and prevents the client from attending

105. B

group therapy. All physical complaints need to be evaluated for physiological causes by the physician. Rationale:

Attributing

unacceptable

feelings

or

(Reference: Lippincott Wiliams & Wilkins. NCLEX-

attributes to others is the mechanism known as

RN Question and Answer p. 307)

projection, the data demonstrate use of this defense mechanism.

101. C Rationale:

By developing skills in one area, the

individual compensates or makes up for a real or imagined deficiency, thereby maintaining a positive

(Reference: Mosby’s Review of Nursing for NCLEXRN Examination)

MAD : Maladaptive Disorders | BSN 002

Rationale:

self-image. 106. A Rationale: Splitting is the compartmentalization of

102. D

opposite-affect states and failure to integrate the

Rationale: Fears and anxieties about themselves

positive and negative aspects of self or others.

and their possessions are common in older adults because of a decreased self-concept and an altered

107. C

body image; these changes result in a decreased

Rationale:

ability to cope.

wrong are expressed in the superego, which acts to

Conscience and a sense of right and

counterbalance

the

id’s

desire

for

immediate

gratification. 103. A Rationale:

Use of denial involves failure to

acknowledge the reality of a situation.

108. D Rationale: The mature personality does not respond to the immediate gratification, demands of the id or

1 8

the oppressive control of the superego because the

114. D

ego is strong to maintain a balance between them.

Rationale: when the individual experiences a threat to self-esteem, anxiety increases and defense

Rationale: Repression is a coping mechanism in which unacceptable feelings are kept out of conscious awareness; later, under stress anxiety, thoughts or feelings surface and come into one’s conscious awareness. 110. D

mechanisms are used to protect the self. 115. A Rationale: this client is using the cognitive distortions of overgeneralization and pessimism. Negative events are magnified and become the focus while the contrary positive experiences are minimized and ignored. By focusing on the negative, the depressive mood is reinforced. (Reference: Mosby’s Review of Nursing for NCLEX-

Rationale: Intellectualization occurs when a painful

RN Examination)

emotion is avoided by means of a rational explanation that removes the event from any personal significance.

116. B

(Reference: Mosby’s Review of Nursing for NCLEXRN Examination)

Rationale: system

stimulants.

stimulation 111. C Rationale: This is the age of Freud’s phallic stage

Amphetamines including

are

They

central

nervous

cause

sympathetic

hypertension,

tachycardia,

vasoconstriction, and hyperthermia. Hot, dry skin is seen

with

anticholinergic

agents

such

as

MAD : Maladaptive Disorders | BSN 002

109. A

jimsonweed. Pupils will be dilated not constricted.

and Erikson’s stage of initiative versus guilt.

117. A 112. C

Rationale: anxiety is a normal reaction to the

Rationale: Children view their own worth by the

termination of the nurse-client relationship. The

response received from their parents. This sense of

nurse should help the client explore his feelings

worth sets the basic ego strengths and is vital to the

about the end of the therapeutic relationship. While

formation of the personality.

anger about the termination may be a healthy

113. D Rationale: when acting-out against the primary source of anxiety creates even further anxiety or danger, the individual may use displacement to express feelings on a safer person or object.

response, banging the table, shouting and other forms of acting out aren’t appropriate behaviour. Withdrawal

isn’t

a

healthy

response

to

the

termination of a relationship. By rationalizing the termination, the client avoids expressing his feelings and emotions.

1 9

118. A

121. B

Rationale: The client’s memory of a traumatic

Rationale: Flight of ideas is the shifting of a topic

childhood incident and her current signs and

from one subject to another in a somewhat related

symptoms (nightmares, flashbacks, and related

way while looseness of association is the shifting of

fears) suggests that she has PTSD with delayed

a topic from one subject to another in a completely

onset. The client doesn’t occasionally lose track of

unrelated way

movements

and

actions,

as

in

multiple

personality disorder. Her anxiety isn’t primary but results from severe emotional trauma. Although she

122. C

experiences flashbacks, these aren’t psychotic Rationale: elevated temperature, elevated blood

episodes, as in schizophrenia.

pressure

and

diaphoresis

are

indicative

of

Neuroleptic malignant syndrome, which is a medical emergency.

119. B Rationale: the nurse must question this order immediately. Thioridazine (Mellaril) has and absolute

123. A

dosage ceiling of 800 mg / day. Any dosage above this level places the client at high risk for toxic

Rationale: Disorganization is the phase of s crisis

pigmentary retinopathy, which can’t be reversed. As

situation characterized by feelings of great anxiety

written, the order allows for administering more than

and inability to perform activities of daily living.

MAD : Maladaptive Disorders | BSN 002

her

the maximum 800 mg / day; it should be corrected immediately,

before

the

client’s

health

is

jeopardized.

124. C Rationale: Patients who are narcissistic feels that they are special and they demand special attention

120. B

from others.

Rationale: Diarrhea is the most common physiologic response to stress and anxiety. The other options could also be related to stress and anxiety but they don’t occur as frequently or as commonly as diarrhea

125. C Rationale:

Catatonic

schizophrenia

is

usually

manifested by stuporous withdrawal, hallucinations, delusions, waxy flexibilities and catatonic rigidity.

(Reference: Mosby’s Review of Nursing for NCLEXRN Examination)

2 0

(Reference: The ABC’s of Psychiatric Nursing: Core Concepts for the Nurse Licensure Exam by Ray A. Gapuz)

Concepts for the Nurse Licensure Exam by Ray A.

126. D

Gapuz) Giving

broad

opening

provides

an

opportunity for a patient to choose the topic of conversation, hence it is appropriate to use when initiating interaction.

131. C Rationale: Tardive dyskinesia is usually manifested by lip smacking and tongue twitching. Oculogyric crisis is usually manifested by upward rolling of the

127. A

eyeballs.

Rationale: Aged cheese, cheddar cheese and Swiss cheese are high in tyramine and are therefore to be avoided. Cottage cheese and cream cheese are allowed.

132. C Rationale:

Initial

therapeutic

effects

of

antidepressants occur after 2-3 weeks while full therapeutic effects occur after 3-4 weeks. 128. B Rationale: The therapeutic use of self requires self awareness initially, therefore the nurse has to deal with her feelings first.

133. C

MAD : Maladaptive Disorders | BSN 002

Rationale:

(Reference: The ABC’s of Psychiatric Nursing: Core

Rationale: Projection is attributing to others one’s unconscious wishes/fear. Usually it is seen in paranoid patients.

129. A Rationale: The ritual preformed by the obsessivecompulsive patient is their way of expressing fears and tensions.

134. D Rationale: Interacting with parents with autistic thinking requires thorough analysis of speech patterns, the meanings of their expressions and the

130. A Rationale: Depressed patients usually turn their hostile feelings towards themselves. Providing an

relationship of these to their covert needs. This situation usually poses great difficulty on the part of the nurse.

outlet for theses aggressive feelings will make the patient feel less guilty.

135. A

2 1

Rationale: At the height of depression, patients usually have difficulty conceptualizing activities. The patient’s plan to organize child care indicates that his

139. D

ability to conceptualize is working. This indicates

Rationale: Responding to the feelings expressed by

recovery from depression.

a client is an effective therapeutic communication technique. The correct option is an example of the use of restating.

(Reference: The ABC’s of Psychiatric Nursing: Core Gapuz)

140. C Rationale:

Option

C

uses

the

therapeutic

communication technique of restatement. Although

136. D

restatement is a technique that has a prompting

Rationale: The client must first deal with feelings and

component to it, it repeats the client’s major theme,

negative responses before the client can work

which assists the nurse to obtain a more specific

through the meaning of the crisis.

perception of the problem from the client.

137. A

(Reference:

Silvestri,

“Comprehensive

Review

th

Rationale: Denial is refusal to admit to a painful

NCLEX-RN Examamination, 4 ed”, 2008)

reality and may be a response by a victim of sexual abuse. Projection is transferring one’s internal feelings, thoughts, and unacceptable ideas and traits

141. C

to someone else. Rationalization is justifying the

Rationale: When the nurse and client agree to work

unacceptable

oneself.

together, a contract should be established, the

Intellectualization is the excessive use of abstract

length of the relationship should be discussed in

thinking or generalizations to decrease painful

terms of its ultimate termination.

attributes

about

MAD : Maladaptive Disorders | BSN 002

Concepts for the Nurse Licensure Exam by Ray A.

thinking.

142. B 138. D Rationale: The nurse should initiate brief, frequent Rationale: In the termination phase, the relationship

contacts throughout the day to let the client know

comes to a close. Ending treatment sometimes may

that he is important to the nurse. This will positively

be traumatic for clients who have come to value the

affect the client’s self-esteem.

relationship and the help. Because loss is an issue, any unresolved feelings related to loss may resurface during this phase.

2 2

143. D

Rationale: The client preoccupied with delusions of

Rationale: The statement “I don’t think about killing myself as much as I used to.” Indicates a lessening of suicidal ideation and improvement in the client’s condition.

the persecution, grandeur, ideas of reference, and auditory hallucinations is predisposed to suicidal and violent behavior. Option A is not applicable, as this would reinforce the client’s delusions of persecution. Option B and D should be eliminated since this is another area of concern, but safety must be first addressed.

Rationale:

The

drug

of

choice

for

a

client

experiencing extra pyramidal side effects from haloperidol

(Haldol)

is

benztropine

mesylate

(cogentin) because of its anti cholinergic properties.

148. C Rationale:

Client

with

paranoid

schizophrenia

frequently seclude themselves from others because of their suspiciousness, which results in their reluctance to trust people. Option A should be

145. D Rationale: An aloof, detached, withdrawn posture is a means of protecting the self by withdrawing and maintaining a safe, emotional distance.

eliminated because fear of being alone is not the appropriate nursing diagnosis. Option B is also eliminated since this response has to do with suspiciousness and persecutory feelings but it is incorrect because it is an example of circular nursing. Option D is also eliminated as for impaired

(Reference: NCLEX Review: Psychiatric Nursing Practice Test Part 2)

146. C Rationale: This would distract the client by offering alternate activity. Option A should be eliminated never ask “why” question. The client is unable to explain this behavior. Option B is also eliminated because this response is threatening and implies misbehavior by the client. Option D is also eliminated because this does not distract the client from the behavior and leaves her in the room alone to continue washing her hands.

social skills is not also the appropriate nursing

MAD : Maladaptive Disorders | BSN 002

144. C

diagnosis.

149. C Rationale:

Clients

who

are

diagnosed

with

schizophrenic disorders have difficulty handling complex

information,

communication

so

simple.

it

is

Option

best A

to

should

keep be

eliminated because the mood of the staff is not significant. Option B is also eliminated since the client deals best with simple direct sentences. Option D is also eliminated as client in general do not have trouble with violent behaviors.

147. C

2 3

Rationale:

Rationale: Major aspects of the pre-ECT stage are: obtaining lab and diagnostic data, getting an informed consent, and reinforcing client and family education. Option B is not applicable. Option C it should be eliminated because the client is NPO after midnight. Option D is also eliminated since this is important,

but

not

necessarily

the

nurse’s

responsibility.

Restating

is

the

therapeutic

communication technique in which the nurse repeats what the client says to show understanding and to review what was said. Option 3 uses the therapeutic technique of restating. Option 1, the nurse is attempting to assess the client’s ability to discuss feelings openly with family members. In option 2, the nurse attempts to use focusing, but the attempt to discuss central issues is premature. In option 4, the nurse makes a judgment and is nontherapeutic in the one-to-one relationship.

(Reference:

Meyer,

J.

(2003)

“The

Princeton

th

Review, cracking the NCLEX-RN”, 7 edition, New York: Random House Inc.)

154. D Rationale: Clients who are admitted involuntarily do not lose their right to informed consent. Clients must

151. D

be considered legally competent until they have been

declared

incompetent

through

a

legal

Rationale: Option d helps the client focus on the

proceeding. The informed consent needs to be

emotion underlying the delusion but does not argue

obtained from the client.

with it. Option 1 places the client in a position that requires a response. Option 2 avoids the client. Option3 is an attempt to convince the client to believe another thought. This response may cause the client to hold the delusion more strongly.

MAD : Maladaptive Disorders | BSN 002

150. A

155. D Rationale: False imprisonment is an act with the intent to confine a person to a specific area. A nurse can be charged with false imprisonment if the nurse

152. D

prohibits a client from leaving the hospital if the client has been admitted voluntarily and if no agency or

Rationale: The client must first deal with feelings and

legal policies exist for detaining the client. However,

negative responses before the client can work

if the client has been admitted involuntarily or had

through the meaning of the crisis. Option 4 pertains

agreed to an evaluation before discharge, the

directly to the client’s feelings. Option 1 and 2 do not

nurse’s actions are reasonable.

directly address the client’s feelings. Option 3 is more of an assessment question. (Reference: The ABC’s of Psychiatric Nursing: Core Concepts for the Nurse Licensure Exam by Ray A. 153. C

Gapuz)

2 4

156. C Rationale: Antiseptic mouthwash often contains

(Reference: NCLEX Review: Psychiatric Nursing Practice Test Part 2)

alcohol & should be kept in locked area, unless labeling clearly indicates that the product does not contain alcohol.

161. B Rationale: A is a characteristic of a borderline

157. D Rationale: Monitoring of vital signs provides the best information about the client’s overall physiologic

disorder.

Client

with

antisocial

personality disorder do not experience disordered thoughts. Poor judgment is a result of not paying to the legality of their actions

status during alcohol withdrawal & the physiologic response to the medication used.

162. D Rationale: Avoidant is characterized by a pervasive

158. D Rationale: Barbiturates are CNS depressants; the nurse would be especially alert for the possibility of respiratory failure. Respiratory failure is the most likely cause of death from barbiturate over dose.

pattern of social discomfort. Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of. Antisocial is characterized by a pervasive pattern of disregard for and violation of the rights of others. Clients with

MAD : Maladaptive Disorders | BSN 002

personality

passive-aggressive personality disorder express resistance

through

procrastination,

FORGETFULNESS, and stubbornness 159. A Rationale: The nurse would facilitate progressive review of the accident and its consequence to help the client integrate feelings & memories and to begin the grieving process.

163. A Rationale: A is a verbal communication because it consists of words a person uses to speak to one or more listeners. B is an observation which means watching the speaker’s nonverbal customs. Nodding

160. A Rationale: A moderate level of cognitive impairment

of head is a body language which is also a nonverbal communication.

due to dementia is characterized by increasing dependence on environment & social structure and by increasing psychologic rigidity with accentuated previous traits & behaviors.

164. D

2 5

Rationale: Introjection is accepting another person’s

Instead, the nurse makes assumptions that may

attributes, beliefs, and values as one’s own.

seem like accusations

Displacement

is

ventilation

of

intense

feeling

towards persons less threatening. Undoing is exhibiting acceptable behavior to make up for or negate

unacceptable

behavior.

Projection

167. B

is

unconsciously blaming of unacceptable inclinations

Rationale:

Clients

older

than

18

years

old,

or thoughts on an external object.

diagnosed with a conduct disorder before 17 years, as well as problems with the criminal justice system, may have antisocial personality disorder. The

165. A Rationale:

behaviors Antisocial

personality

disorder

is

are not associated with borderline,

narcissistic and histrionic personality disorder.

characterized by a pervasive pattern of disregard for and violation of the rights of others and with the central

characteristics

of

deceit

and

168. C

MANIPULATION. Rationale: The first immediate intervention is to ensure ongoing observation of the client. Therefore, (Reference: Videbeck, “Psychiatric Mental Health Nursing”)

the

nurse

should

arrange

for

an

unlicensed

assistance to sit with the client. The nurse should avoid

restraints,

which

increases

anxiety,

fearfulness, and risk for injury and strangulation. 166. B

MAD : Maladaptive Disorders | BSN 002

possessing a history of fighting, lying and stealing,

Administering haloperidol and moving the client to a room near the nurse’s station are possible options;

Rationale: Confrontation is the skill of caringly

however, the nurse should first use one-to one

pointing out discrepancies between what a client

observation.

says and does. In this case, the client displayed developing trust in the nurse, but then seemed to engage in avoidance. The nurse uses a three-part formula, called a perception check, increasing communication without accusing the client or making assumptions about his behaviors. The first option follows the formula for assertive statements, which this scenario does not call for at this time. Telling the client feelings for his wife does not describe, offer possible interpretations of, or ask for feedback about the confusing behavior. With the last statement, the nurse neither describes nor interprets the behavior.

169. C Rationale: Stimulant medication ids the most helpful intervention for improving attention span and ability to focus. Parents should use negative consequences for specific undesirable actions, such as aggression or temper tantrums. Inability to focus is the symptom of the disorder most amenable to medication. Reward-based programs help shape behaviors; however, the inability to focus associated with ADHD or ADD improves most dramatically with medication.

2 6

Social skills training will help the child improve relationships, but will not affect attention span.

173. A Rationale: The client with mania is seldom sitting long enough to eat and burns many calories for

Rationale: Controlled breathing techniques can dampen

sympathetic

arousal

and

correct

hyperventilation during a panic attack. In addition, regular practice may help prevent panic attacks. A therapist uses Desensitization for clients with phobias. Nothing suggests the need for lifestyle

energy. Answer B is incorrect because the client should be treated the same as other clients. Small meals are not a correct option for this client. Allowing her into the kitchen gives her privileges that other clients do not have and should not be allowed, so answer D is incorrect.

changes. Panic attacks usually have no identifiable trigger. Problem solving techniques are more beneficial for clients with Generalized Anxiety

174. C

disorder who tend to catastrophize about decision-

Rationale: The nurse would most likely administer

making.

benzodiazepine, such as Lorazepam (Ativan) to the client who is experiencing symptoms: tremors, diaphoresis

171. A Rationale: If the client is a threat to the staff and to other clients the nurse should call for help and

and

hyperactivity.

The

client

experiences symptoms of withdrawal because of the rebound phenomenon when the sedation of the CNS from alcohol begins to decrease.

MAD : Maladaptive Disorders | BSN 002

170. D

prepare to administer a medication such as Haldol to sedate him. Answer B is incorrect because simply telling the client to calm down will not work. Answer

175. C

C is incorrect because telling the client that if he

Rationale: Clients who are withdrawn may be

continues he will be punished is a threat and may

immobile and mute, and require consistent, repeated

further anger him. Answer D is incorrect because if

interventions. Communication with withdrawn clients

the client is left alone he might harm himself.

requires much patience from the nurse. The nurse facilitates communication with the client by sitting in silence, asking open-ended question and pausing to

172. C

provide opportunities for the client to respond.

Rationale: The client who is confused might forget that he ate earlier. Don’t argue with the client. Simply get him something to eat that will satisfy him until lunch. Answers A and D are incorrect because the

(Reference: NCLEX-RN Exam Practice Question Exam Cram By Rinehart & Associates)

nurse is dismissing the client. Answer B is validating the delusion.

2 7

176. C

(Reference: The ABC’s of Psychiatric Nursing: Core

Rationale: Providing assistance during recovery period falls under rehabilitation, which is a tertiary

Concepts for the Nurse Licensure Exam by Ray A. Gapuz)

level of prevention strategy. 181. D Rationale:

177. A

Initial

therapeutic

effects

of

antidepressants occur after 2-3 weeks while full therapeutic effects occur after 3-4 weeks.

placed in a normal (3gms), high fluid diet (3L) or high sodium (6-10 gms), high fluid diet. This is done to

182. B

facilitate excretion of lithium from the body.

Rationale: Respiratory depression can occur after electro-convulsive therapy due to the muscular relaxation

effect

of

Anectine,

so

assess

for

respiration

178. B Rationale: Rationalization is justifying one’s actions

183. D

which are based on other motives. It is usually seen

Rationale: Identifying alternate coping skills facilitate

among alcoholics.

rehabilitation of the patient. Alcoholic patients usually cope with problems by drinking alcohol. 184. C

179. B Rationale: Preventing the patient from using the bathroom for 2 hours after eating prevents the patient from inducing vomiting.

MAD : Maladaptive Disorders | BSN 002

Rationale: A patient who is taking lithium must be

Rationale: Leaving a light on the patient’s room will decrease visual hallucinations, which frequently occur in alcohol withdrawal syndromes 185. A Rationale: When a depressed patient suddenly

180. D

becomes cheerful, it means that the patient is

Rationale: Before the administration of antabuse, the patient must be free of alcohol for atleast 12 hours tp prevent

antabuse

manifested

by

reaction

severe

which

nausea

and

is

usually vomiting,

respiratory depression and orthostatic hypotension.

recovering from depression and is n danger of committing suicide. (Reference: “The ABC’s of Psychiatric Nursing: Core Concepts for Nurse Licensure Exam” by Ray A. Gapuz)

186 .D Rationale:

The

suicidal

client

has

difficulty

expressing anger toward others. The depressed

2 8

suicidal client frequently expresses feelings of low

Rationale: The client who is confused might forget

self-worth, feelings of remorse and guilt, and a

that he ate earlier. Don’t argue with the client. Simply

dependence on others; therefore, answers A, B, and

get him something to eat that will satisfy him until

C are incorrect.

lunch. Answers A and D are incorrect because the nurse is dismissing the client. Answer B is validating

187.C A history of cruelty to people and

animals, truancy, setting fires, and lack of guilt or

(Reference:

remorse are associated with a diagnosis of conduct

exam-reviewer)

http://nursingcrib.com/nursing-board-

disorder in children, which becomes a diagnosis of antisocial personality disorder in adults. Answer A is

191. B.

incorrect

antisocial

Rationale: For the client with bulimia, binges involve

hold consistent

a lost of control that results in thoughts of self

because

personality disorder

the does

client not

with

employment. Answer B is incorrect because the IQ

depreciation.

is usually higher than average. Answer D is incorrect because of a lack of guilt or remorse for wrong-

192. D

doing.

Rationale: When working with a client who is withdrawn and speaks little, answers briefly, and looks at the floor, the nurse should focus on the

188. D Rationale: Leaving a nightlight on during the evening

simplest type of behaviour. (i.e. behaviour requiring the least effort for the client.)

and night shifts helps the client remain oriented to the environment and fosters independence. Answers A and B will not decrease the client’s confusion. Answer C will increase the likelihood of confusion in an elderly client.

MAD : Maladaptive Disorders | BSN 002

Rationale:

the delusion.

193. B Rationale: To promote a therapeutic relationship with a suspicious client, it is best to spend brief intervals with the client each day to develop trust, respect and rapport.

189.A Rationale: If the client is a threat to the staff and to other clients the nurse should call for help and prepare to administer a medication such as Haldol to sedate him. Answer B is incorrect because simply telling the client to calm down will not work. Answer

194. D. Rationale: When the client feels unworthiness, she reflects low self esteem. Presenting another set of facts in a manner that is accepting of the client but avoids a power struggle is helpful.

C is incorrect because telling the client that if he continues he will be punished is a threat and may further anger him. Answer D is incorrect because if the client is left alone he might harm himself.

195. D. Rationale: The nurse sets limit on an unacceptable or threatening behaviour to help the client regain control and preserve his self esteem.

190.C

2 9

(Reference: Lippincott’s Review for NCLEX- RN

Rationale:

Confusion,

disorientation,

behavioral

examination 8th Edition.)

changes, and alterations in judgment are early signs of dementia. Answers A, C, and D do not relate to

196. B – protective gear helps prevent infections that

the question; therefore, they are incorrect.

may gain entry through

197.

A

Rationale: schizophrenia has a multifocal origin and its cause may include a genetic component. Support is needed for both patients and caregivers.

203.

A

Rationale: The child with mental retardation should not be overprotected but need protection from injury and the teasing of other children. B,C, and D Children with mental retardation have learning difficulty. They should be taught with patience and repetition, start from simple to complex, use visuals

198.

B

and compliment them for motivation. Realistic

Rationale: a suicide attempt is a serious and self-

expectations should be set and optimize their

destructive behavior that demands searching for

capability.

weapons and harmful materials to increase safety.

199.

D

Rationale: delirium tremens occur as acute alcohol withdrawal progresses. It include symptoms such as clouding of sensorium, hallucinations, seizures, and autonomic hyperactivity.

200. B Rationale: cognitive symptoms include inflated selfesteem and grandiosity

204.

B

Rationale: Altered parenting role refers to the inability to create an environment that promotes optimum growth and development of the child. This is reflected in the parent’s inability to care for the

MAD : Maladaptive Disorders | BSN 002

openings in the skin, the eyes, and the mouth

child. A. This refers to lack of choices or inability to mobilize one’s resources. C. Refers to change in family relationship and function. D. Ineffective coping is the inability to form valid appraisal of the stressor or inability to use available resources

201. A 205.

B

Rationale: Participating in reality orientation is the

Rationale: These are manifestations of autistic

most appropriate activity for the client who is

disorder. A. These manifestations are noted in

confused. Answers B, C, and D are incorrect

Oppositional Defiant Disorder, a disruptive disorder

because they are not suitable activities for a client

among children. C. These are manifestations of

who is confused.

Attention

Deficit

Disorder

D.

These

are

the

manifestations of Conduct Disorder 202. B

(Reference:

http://nursingcrib.com/nursing-board-

exam-reviewer)

3 0

206. B

compromises physiological integrity and needs to be

Rationale: Projection is the process of attributing

addressed immediately.

one’s own thoughts about one’s self to others. 207.A

Rationale: For the nurse to empathize with the

Rationale: This allows the agitated, angry client time

client‘s experience is most therapeutic. Disagreeing

to regain self-control, telling the client that the nurse

with delusions may make the client more defensive,

will return will decrease possible guilt feelings and

and the client may cling to the delusions even more.

implies to the client that the nurse cares enough to

Encouraging discussion regarding the delusion is

return.

inappropriate.

208.C

213. C

Rationale: planning

All

behavior

intervention,

has

the

meaning;

nurse

must

before

Rationale: A conversion disorder is the alteration or

try

loss of a physical function that cannot be explained

to

understand what the behavior means to the client.

by any known pathophysiological mechanism. A conversion disorder is thought to be an expression

209.D Rationale:

of a psychological need or conflict. In this situation, When

acceptance

is

reached

the

the client witnessed an accident that was so

individual is beginning to withdraw; communication is

psychologically painful that the client became blind.

simple, concise, and most often nonverbal.

A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity,

210.B

memory, or consciousness. Psychosis is a state in

Rationale: Intellectually the person knows the

which the person’s mental capacity to recognize

compulsive acts are senseless but is unable to stop

reality, communicate, and relate to others is

doing them because they control anxiety.

impaired, thus interfering width the person’s ability to

MAD : Maladaptive Disorders | BSN 002

212. D

deal with life’s demands. Repression is a coping (Reference: Mosby’s Review Questions for the

mechanism in which unacceptable feelings are kept

NCLEX-RN® Examination, 6th Edition)

out of awareness.

211. B

214. A

Rationale: Mania is a mood characterized by

Rationale: If a client with severe anxiety is left alone,

excitement,

excessive

the client may feel abandoned and become

energy, decreased need for sleep, and impaired

overwhelmed. Placing the client in a quiet room is

ability to concentrate for complete a single train of

also important, but the nurse must stay with the

thought. Mania is a period when the mood is

client. Teaching the client deep breathing or

predominantly elevated, expansive, or irritable. All

relaxation is not possible until the anxiety decreases.

options reflect a client’s possible symptomatolgy.

Encouraging the client to discuss concerns and

Option B, however, clearly presents a problem that

feelings would not take place until the anxiety has

euphoria,

hyperactivity,

decreased.

3 1

statements neither reinforce the risk of violently 215. B

acting out or nor define limits for future behavior.

Rationale: Solitary activities that require a short

Restraining a patient is unpleasant for all concerned,

attention span with mild physical exertion are the

but disclosing this information to the patient without

most appropriate activities for a client who is

addressing the dangerousness of his behavior and

exhibiting aggressive behavior. Writing (journaling),

reinforcing what is expected of him is insufficient.

minimize stimuli and provide a constructive release

218. C

for tension. Competitive games should be avoided

Rationale: paralanguage is the use of vocal effects,

because they can stimulate aggression and increase

such as tone and tempo, to convey a message.

psychomotor activity.

Appearance is to the way people look. Kinetics involves body language or movement. Proxemics is

(Reference:

Silvestri,

Linda

Anne,

Saunders

Comprehensive Review NCLEX RN EXAMINATION

the use of spatial relationships (distance between people) during interaction to communicate learning.

4th ed., © 2008 Canada: Saunders.) 219. A 216. B

Rationale: The priority nursing diagnostic category is

Rationale: Rationalization is the offering of a socially

Anxiety, severe to panic-level, as evidenced by J.'s

acceptable or logical reason for doing, feeling, or

extreme withdrawal and attempt to protect himself

behaving in a way that might not be otherwise

from

acceptable. Reaction formation is the development

immediately to reduce his anxiety and to protect the

of attitudes or behaviors that are opposite of what

patient and others from possible injury. Impaired

one actually feels or wants to do. Denial is avoiding

verbal

reality by ignoring unpleasant events. Regression is

noncommunicativeness. Altered thought processes,

a return to behaviors that reflect an earlier

as evidenced by an inability to understand the

developmental level

situation, and Dressing and grooming self-care

the

environment.

communication,

The

nurse

as

must

evidenced

act

MAD : Maladaptive Disorders | BSN 002

walks with staff, and finger painting are activities that

by

deficit, as evidenced by a disheveled appearance, 217. C

are all appropriate nursing diagnostic categories but

Rationale: the most therapeutic response to J.'s

are not the priority in this situation.

apology should incorporate a realistic statement acknowledging, in a nonpunitive but serious manner,

220. D

the possible consequences of his violent behavior.

Rationale: J.'s statement combines truth (the ozone

The nurse should also set clear limits by describing

layer is being destroyed), some exaggeration that

the expected behavior and the consequences the

may be delusional (the earth is doomed), and some

patient will face if he again loses control. Violent

projection of his own fears (the nurse should get

behavior is dangerous to both the patient and others

away). By choosing to respond to the underlying

and should not be excused or made light by saying

message about J.'s fear of being destroyed, the

"I know you didn't mean to hurt us..." or "Let's see

nurse attempts to help him identify and express his

how well you control yourself from now on." Such

feelings in a more direct and appropriate manner.

3 2

Reflecting doubt about delusional statements can

Rationale: Response A indicates improvement in the

help the patient see that the nurse does not share

concrete

his belief. However, such reflection should not be

improvement in the core problem of poor attention

stated judgmentally ("You are Overacting"). Pursuing

span and difficulty completing a task. Responses C

a discussion about the ozone layer or ignoring his

and D indicate improvement in the core problem of

comments

being

completely

are

nontherapeutic

approaches because they do not acknowledge his

thinking.

able

to

Response

distinguish

B

indicates

background

from

foreground information.

fear. (Reference: http://www.blogcatalog.com/blog/nclex-

Rationale: Dissociation involves the separating of

and-local-board-prc-sample-exam)

any group of mental or behavioral processes from the rest of consciousness. In isolation, there is a

221. B

splitting off the emotional and thought components

Rationale: Identifying symptoms that trigger a

of the emotional and thought components of a

relapse allows the client and family to take

situation. Regression involves a retreat to behavior

preventive action. Responses A,C, and D indicate

characteristic of an earlier developmental period due

that the client has learned strategies for coping with

to stress.

hallucinations. (Reference: Hoyson, Patricia McLean & Kimberly A. 222. A

Serroka, NCLEX-RN Review 2008, Jones and

Rationale: Negative symptoms of psychosis involve

Bartlett Publichers Sudbury, Massachusetts; pages

a diminution or loss of normal functioning. They

334-335 and 365-336)

MAD : Maladaptive Disorders | BSN 002

225. D

include affective flattening, alogia (restricted thought and speech), avolution/apathy (lack of behavior

226. A

initiation),and

to

Rationale: Narcolepsy involves brief periods of deep

experience pleasure or maintain social contacts?.

sleep and an irresistible desire to sleep. It is usually

Positive symptoms of psychosis involve an excess

associated with cataplexy and sleep paralysis.

or distortion of normal functioning. These include

Primary hypersomnia involves prolonged sleep that

psychotic disorders of thinking (delusions) and

interferes with functioning. Primary insomnia is

disorganization of speech (illogicality) and behavior.

difficulty falling to sleep. Sleep apnea is an absence

anhedonia/asociality

(inability

of breathing usually related to upper airway collapse. 223. B Rationale: Assessment (identification) comes before implementation. Responses controlling the physical effects of anxiety, beginning breathing exercises,

227. C

and

Rationale:

using

problem-solving

are

implementation

activities that are appropriate longer-term goals.

Many

clients

in

withdrawal

are

dehydrated. Fluid up to 3000ml per day should be encouraged. The peak time of DTs after the last

224. A

drink is 24-48 hours. Antabuse blocks an enzyme

3 3

that

metabolizes

highly

toxic

acetaldehyde,

(Reference: Hoyson, Patricia McLean & Kimberly A.

producing nausea and hypotension. Naltrexone

Serroka, NCLEX-RN Review 2008, Jones and

(ReVia, Trexan) blocks the craving for alcohol.

Bartlett Publichers Sudbury, Massachusetts; pages

Alcohol interferes with the absorption of the B

334-335 and 365-336)

vitamins. Thus, they should be supplemented. 228. C

Rationale: Depressed clients see the future as a

Rationale: Religious objections are usually upheld by

blank and have given up all hope where the anxious

the courts. When ruling against psychiatric clients’

client has not. All other symptoms are shared by

rights to refuse treatment, courts look for benefits of

clients experiencing the two conditions. Both also

treatment outweighing risks and side effects that are

experience

not

changes,

permanent.

In

the

case

of

involuntary

commitment of a competent client, a hearing is held

difficulty and

concentrating,

nonspecific

cardio

appetite pulmonary

complaints.

before an independent psychiatrist where the client has a right to legal counsel.

232. B Rationale:

This

assurance

is

a

limit-setting

229. C

intervention and promotes a sense of safety to the

Rationale: Advocacy is acting in support of a client’s

client. The intervention of discontinuing external

right. Clients have a right to understand and

limits as soon as the client is able to self-regulate

participate

decision-making.

empowers the client to use self-control. The

Encouraging client feedback, explaining unit rules

intervention of all staff consistently enforcing limits

and policies, and making sure clients understand

promotes behavior shaping. Accepting the client

expectations for participation are strategies for

while rejecting inappropriate behavior protects self-

working with the client in a therapeutic environment.

esteem.

in

treatment

MAD : Maladaptive Disorders | BSN 002

231. D

Explaining unit rules and policies relates to safety, while encouraging client feedback relates to self-

233. A

understanding. Clarifying expectations for a client’s

Rationale: Demonstrating less impulsive behavior is

participation relates to structure.

an appropriate goal for Cluster B PDs including borderline

PD

(impulsive

and

unpredictable

230. B

behavior), histrionic PD (dramatic and reactive

Rationale: Treatment for severe depression begins

behavior),

with a mood stabilizer and an antidepressant. If

importance),

psychosis is present in the manic client, treatment

behavior in conflict with the society). Identifying

begins with a mood stabilizer and an atypical

behaviors that maximize social interactions and

antipsychotic. Diuretics have no role in treatment of

participating in activity groups are appropriate goals

mania or depression. If a diuretic is given in

for cluster A PDs, which include the odd-eccentric

combination with lithium, blood lithium levels will

disorders

increase along with the potential for lithium toxicity.

schizotypal PD. Making decisions independently is

narcissistic and

PD

anti-social

of paranoid

PD,

(grandiose PD

self-

(manipulative

schizoid PD, and

an appropriate goal for cluster C PDs, which

3 4

includes anxious and fearful disorders such as avoidant

PD,

dependent

PD,

and

obsessive-

compulsive PD. 234. C Rationale: All of the responses represent deviations in adult partners’ coalition. In the schismatic pattern, children are forced to join one or the other camp of undercut each other as a defense against closeness. In the disengaged coalition, adult members are oblivious to the effects of their actions on others. In the enmeshed pattern, there is one over-controlling adult with high intensity interactions between the partners. In the skew pattern, one mate is severely dysfunctional and the other is passive with regard to the dysfunction. 235. A Rationale: This response acknowledges the need for the false belief while not encouraging it or arguing with the client, clearly states what is expected, and

MAD : Maladaptive Disorders | BSN 002

warring parents. The adult partners belittle and

offers self. Empathy is a process which people feel with one another. Reflection is repeating the client’s verbal

or

nonverbal

message.

The

client

is

demonstrating manipulative behavior. (Reference: Hoyson, Patricia McLean & Kimberly A. Serroka, NCLEX-RN Review 2008, Jones and Bartlett Publichers Sudbury, Massachusetts; pages 334-335 and 365-336)

3 5