Nursing Elites

1. When assessing a patient with schizophrenia who exhibits flat affect and social withdrawal, these symptoms are classified as:

• A. Positive symptoms
• B. Negative symptoms
• C. Cognitive symptoms
• D. Mood symptoms

Correct answer: B

Rationale: Flat affect and social withdrawal are characteristic of negative symptoms in schizophrenia. Negative symptoms involve disruptions to normal emotions and behaviors, such as reduced emotional expression (flat affect) and social withdrawal. These symptoms reflect a decrease or absence of normal functions. Positive symptoms, on the other hand, involve the presence of abnormal behaviors or experiences, such as hallucinations and delusions, which are added to a person’s experiences. Cognitive symptoms relate to difficulties with thinking, memory, and processing information, impacting cognition. Mood symptoms involve disturbances in mood regulation, which is distinct from the flat affect seen in negative symptoms.

2. A client has been diagnosed with borderline personality disorder. Which behavior is characteristic of this disorder?

• A. Excessive need for attention
• B. Instability in relationships
• C. Fear of abandonment
• D. Lack of interest in activities

Correct answer: B

Rationale: The correct answer is B: Instability in relationships. Individuals with borderline personality disorder often exhibit instability in their relationships, characterized by intense and unstable interpersonal connections, oscillating between idealization and devaluation. This pattern can lead to frequent conflicts, dramatic emotional shifts, and difficulties maintaining stable relationships. Choices A, C, and D are incorrect. While individuals with borderline personality disorder may also have an excessive need for attention, fear of abandonment, or lack of interest in activities, the hallmark feature defining this disorder is the instability in relationships.

3. Which of the following interventions should not be included in the care plan for a client with major depressive disorder?

• A. Encourage participation in activities
• B. Promote adequate nutrition and hydration
• C. Discourage verbalization of feelings
• D. Monitor for suicidal ideation

Correct answer: C

Rationale: Interventions for a client with major depressive disorder should focus on promoting activities, adequate nutrition, hydration, and monitoring for suicidal ideation. Verbalizing feelings is a crucial part of therapy for clients with depression as it helps in processing emotions and seeking support. Therefore, discouraging verbalization of feelings is not appropriate and goes against therapeutic principles.

4. Kyle, a patient with schizophrenia, began taking the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay, he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select one that does not apply.

• A. Hold his medication and contact his prescriber.
• B. Wipe him with a washcloth wet with cold water or alcohol.
• C. Administer a medication such as benztropine IM to correct this dystonic reaction.
• D. Reassure him that although there is no treatment for his tardive dyskinesia, it will pass.

Correct answer: C

Rationale: The patient's symptoms, including stiffness, diaphoresis, inability to respond verbally, and vital sign abnormalities, are indicative of neuroleptic malignant syndrome (NMS), a serious and potentially life-threatening side effect of antipsychotic medications. Administering a medication such as benztropine intramuscularly is the priority to address the dystonic reaction associated with NMS. This intervention can help alleviate symptoms and prevent further complications. Holding the medication and contacting the prescriber may be necessary but addressing the acute symptoms takes precedence. Wiping the patient with a cold washcloth or alcohol would not address the underlying medical emergency. Reassuring the patient about tardive dyskinesia is irrelevant and not the immediate concern in this scenario.

5. A client is diagnosed with somatic symptom disorder. Which of the following behaviors should the nurse expect?

• A. Excessive worry about physical symptoms
• B. Fear of gaining weight
• C. Frequent visits to healthcare providers
• D. Persistent depressive mood

Correct answer: C

Rationale: Individuals with somatic symptom disorder often exhibit frequent visits to healthcare providers due to their excessive worry about physical symptoms. They seek reassurance and explanations for their perceived medical issues, even when there is no organic basis for their complaints. This behavior is a characteristic feature of somatic symptom disorder and distinguishes it from other conditions. Choices A, B, and D are incorrect. Excessive worry about physical symptoms may occur but it is not the primary behavior associated with this disorder. Fear of gaining weight is more characteristic of eating disorders, and persistent depressive mood is more indicative of mood disorders rather than somatic symptom disorder.

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