NR-326 Mental Health Nursing - Set 4 - Part 2

Correct Answer: Fever, drenching sweats and marked tachycardia

Delirium tremens is delirium plus autonomic storm. Fever, soaking diaphoresis and a racing pulse mark the instability that drives its mortality, so this combination calls for immediate provider notification and intensive monitoring. Option a is incorrect because tremor appears in the earliest hours of withdrawal and persists through the course. On its own it carries none of the cardiovascular danger that defines this emergency. Option b is incorrect because vomiting is a familiar early withdrawal symptom that the protocol already covers, and it is scored routinely. Fluid loss matters, yet it does not by itself announce autonomic collapse. Option c is incorrect because headache belongs to the minor withdrawal picture and responds to supportive care. Discomfort of this kind never carries the weight of a rising temperature paired with an unstable heart rate.

Correct Answer: Addiction, marked by loss of control

Compulsive use that continues despite lost work and a threatened relationship, together with running out early, marks loss of control. Those behavioral features define addiction rather than any purely physiologic change. Option a is incorrect because tolerance alone means a given amount produces less effect over time, a receptor level change. It says nothing about lost jobs, damaged relationships or the inability to stop. Option c is incorrect because physical dependence shows itself only as withdrawal when the drug is stopped, and a client with cancer pain has it without any addiction. This scenario turns on behavior instead. Option d is incorrect because withdrawal is the predictable syndrome that follows cutting back, and avoiding it does not explain job loss or a partner's ultimatum. The pattern described is far broader than symptom relief.

Correct Answer: A generalized tonic clonic withdrawal seizure

Withdrawal seizures cluster between eight and forty eight hours after the last drink, peaking near the first day. This client sits squarely in that window, so seizure precautions and protocol dosing belong in the plan. Option a is incorrect because Korsakoff syndrome develops slowly out of repeated untreated thiamine deficiency and shows as permanent memory loss with confabulation. It is not an acute event of the second hospital day. Option b is incorrect because delirium tremens typically appears two to four days after the last drink, later than this client's timeline. Watching for it remains necessary, but it is not the risk of the coming hours. Option d is incorrect because Wernicke encephalopathy comes from acute thiamine depletion and presents with confusion, eye movement abnormality and ataxia. Thiamine given before any glucose prevents it, so the seizure window remains the pressing concern.

Correct Answer: An experienced member who guides a newer member

A sponsor is a fellow member further along in recovery who offers guidance, availability between meetings, and help working through the steps. The relationship is peer to peer and rests on anonymity. Option a is incorrect because twelve step fellowships are peer led and free, with no professional staff and no assignments from a treatment team. Anyone may attend an open meeting without a referral. Option c is incorrect because attendance records would breach the anonymity the fellowship is built on. Groups keep no rosters, and members use first names only so that identity stays inside the room. Option d is incorrect because relatives have their own fellowships, such as Al-Anon and Alateen, rather than a place beside the member. The sponsor role belongs to someone with personal recovery experience.

Correct Answer: Possible substance impairment with diversion of medication

Unexplained absences from the unit, rising wastage entries, and clients whose pain goes unrelieved form the classic cluster that suggests a nurse is using and diverting controlled substances. The pattern, not any single sign, raises the concern. Option b is incorrect because poor time management would show up as late charting and missed breaks, not as medication records that fail to match what clients actually received. Workload alone does not leave pain untreated this way. Option c is incorrect because calling this ordinary workflow ignores a documented safety problem. Wastage irregularities paired with clients in pain are red flags in every nurse practice act, and dismissing them leaves clients at risk. Option d is incorrect because a protocol gap would leave pain untreated across the whole unit and every shift. Here the reports cluster around one nurse's assignment while that nurse is repeatedly off the floor.

Correct Answer: Name the reaction in report and review the plan

Countertransference becomes useful only when it is spoken aloud. Saying in report that she feels uniquely special, then auditing her practice against the written care plan, interrupts splitting before care becomes uneven. Option a is incorrect because the extra time is the problem, not the treatment. A solo exception hands the client a different answer from every nurse and teaches that limits shift depending on who is working. Option b is incorrect because reassignment may follow later, yet it skips the step that matters. Moving a nurse without telling the team what happened leaves the dynamic invisible and ready to repeat with whoever takes over. Option c is incorrect because an abrupt withdrawal of contact reads as rejection to someone whose central fear is abandonment. Swinging from over involvement to refusal repeats the pattern rather than correcting it.

Correct Answer: The absence of regular compensatory behavior

Binge eating disorder is defined by binges that are not followed by regular compensatory behavior. That single absence separates it from bulimia nervosa, where the compensatory pattern is a required criterion. Option b is incorrect because concern about shape and weight runs through both conditions and through anorexia nervosa as well. A shared feature can never serve as the point of separation. Option c is incorrect because weight varies widely in binge eating disorder and sits in the normal range in most clients with bulimia. The number on the scale settles nothing diagnostically here. Option d is incorrect because guilt and disgust after eating already appear in the description given. Marked distress is required for the diagnosis, yet it belongs to both binge patterns and distinguishes neither.

Correct Answer: The first is schizoid, the second is avoidant

The discriminator is desire for closeness. Schizoid clients neither want nor enjoy relationships, while avoidant clients want them badly and stay away only because they expect rejection and feel inadequate. Option a is incorrect because grouping both under schizoid ignores the second client's stated longing for company. Wanting closeness while fearing humiliation is the avoidant core, and it responds to graded exposure rather than to being left alone. Option c is incorrect because the labels are reversed. Indifference to company with no distress about it belongs to schizoid personality disorder, and hypersensitivity to negative evaluation belongs to the avoidant client described second. Option d is incorrect because avoidant personality disorder requires a wish for relationships plus a view of the self as inept. The first client reports contentment in solitude, so that self-critical, longing element is missing.

Correct Answer: Reddened conjunctivae with a rapid pulse

Cannabis intoxication brings conjunctival injection, dry mouth, increased appetite, altered time sense and tachycardia, along with impaired coordination and short term memory. Care is supportive, with reassurance in a calm setting. Option a is incorrect because narrowed pupils with depressed respirations point to an opioid. Cannabis does not suppress the brainstem drive to breathe, which is why it almost never causes a fatal overdose. Option b is incorrect because gooseflesh and cramping belong to opioid withdrawal, a state of sympathetic arousal. This student looks intoxicated and relaxed, and nothing in the history suggests a substance has been stopped. Option d is incorrect because nystagmus in both directions with rigidity and startling strength suggests phencyclidine. That client is dangerous to himself and staff, a very different problem from this relaxed and hungry student.

Correct Answer: It prevents withdrawal seizures and delirium tremens

Benzodiazepines occupy the same receptor complex alcohol acted on, calming the hyperexcitable brain of withdrawal. That substitution prevents seizures and delirium tremens and lowers mortality, which is why dosing follows a protocol rather than a whim. Option a is incorrect because no sedative repairs hepatic injury. Liver disease from years of drinking is managed with abstinence and nutrition, and it actually changes which agent in this class the provider selects. Option b is incorrect because thiamine is a separate vitamin given parenterally to prevent Wernicke encephalopathy. Both are ordered for this client, yet one corrects a deficiency while the other quiets an overexcited nervous system. Option c is incorrect because craving control after discharge is a long term treatment goal handled by other medications, not by a withdrawal sedative. Continuing a benzodiazepine past the acute phase would create a second dependence.

Correct Answer: Lower the bed and ready suction and oxygen

Seizure precautions come first for anyone with prior withdrawal seizures: bed low, rails padded, suction and oxygen ready at the bedside. Setting this up before symptoms build protects the airway when a seizure comes. Option a is incorrect because nothing is ever placed in the mouth of a seizing client. Forcing an object between the teeth risks broken teeth, soft tissue injury and airway obstruction from the object itself. Option c is incorrect because a dark room invites shadows that the withdrawing client misreads as figures or insects. Adequate lighting with reduced noise is what lowers misperception, and visitors are not the problem here. Option d is incorrect because restraints raise agitation, body temperature and the risk of muscle breakdown in a withdrawing client. They are a last resort, while one to one observation keeps the client far safer.

Correct Answer: The rigidity is ego-syntonic and feels correct to him

Obsessive compulsive personality disorder is ego-syntonic, so the client experiences perfectionism and control as the right way to work and locates the fault in others rather than in himself. Option b is incorrect because intrusive unwanted rituals performed to neutralize anxiety define obsessive compulsive disorder, an ego-dystonic condition. This client reports no such distress and defends his standard as reasonable. Option c is incorrect because true obsessions are absent in the personality disorder, leaving nothing for exposure and response prevention to target. Psychotherapy aimed at flexibility, with time limits on tasks, fits this client better. Option d is incorrect because personality pathology is stable from early adulthood rather than newly acquired. A recent shift in how someone functions should prompt a search for a medical illness or a new life stressor.

Correct Answer: Cluster B with narcissistic personality disorder

Grandiosity, a need for admiration and absent empathy place narcissistic personality disorder in cluster B. The rage at a limit reflects fragile self-esteem, since a limit says that he is not exempt. Option a is incorrect because paranoid clients fear harm and read malice into neutral acts rather than demanding recognition. Contempt for peers and a hunger for status are not the same as suspicion. Option b is incorrect because obsessive compulsive personality disorder centers on perfectionism, orderliness and control of detail. That client would follow the posted schedule rigidly, not rage at being asked to keep it. Option d is incorrect because antisocial behavior turns on violating others' rights, deceit and indifference to harm done. This client seeks admiration and status; there is no report of exploitation, lying or a criminal history.

Correct Answer: Medication treatment substantially lowers the risk of death

Medication for opioid use disorder is the standard of care because it cuts mortality sharply, blunts craving, and keeps people in treatment. Taking a prescribed medication under supervision is not the same as addiction. Option a is incorrect because agreeing with the substitution claim repeats a myth the nurse is meant to correct. Addiction means compulsive use despite harm, while this client takes a monitored prescription that restores function. Option b is incorrect because medication is not a last resort held in reserve. It is offered as first line care alongside counseling, and delaying it leaves the client exposed to overdose during that wait. Option c is incorrect because tolerance falls once treatment stops, and a return to use at that point carries a sharply raised risk of fatal overdose. Early discontinuation worsens outcomes rather than improving them.

Correct Answer: The serum phosphorus level

Phosphate shifts into the cells once feeding restarts, so the serum phosphorus falls first and falls fastest. Tracking it catches refeeding syndrome before arrhythmia, heart failure or respiratory failure develops. Option b is incorrect because albumin reflects long standing protein status and changes over weeks, far too slowly to warn anyone. It stays flat while the electrolyte shifts of early refeeding are already dangerous. Option c is incorrect because a white cell count tracks marrow suppression and infection risk, which starvation does produce, yet it has no bearing on the intracellular ion movement that makes early feeding lethal. Option d is incorrect because uric acid belongs to gout and renal stone workups. Nothing about it signals the insulin driven fall in phosphate, potassium and magnesium that defines the refeeding emergency.

Correct Answer: "It sounds like this is a painful morning for you."

Naming the feeling without debating the accuracy of the perception keeps the alliance intact. Arguing about size never corrects the distortion, so the nurse stays with the distress the client is describing. Option a is incorrect because contradicting the client about her body invites a fight nobody wins. The distortion is a symptom, and telling her she is wrong reliably damages the working relationship. Option c is incorrect because reasoning from the scale treats a perceptual disturbance as a factual error. Evidence does not shift this belief, and the client hears only that her experience is dismissed. Option d is incorrect because comparing her to everyone else minimizes a symptom that is driving a life threatening illness. Ordinary body dissatisfaction and a distorted body image are not the same thing.

Correct Answer: Set a start date and identify concrete resources

He is in preparation, intending to act very soon. The matched work is practical: pick a date, line up a treatment referral and supports, and think through the barriers he is likely to meet. Option a is incorrect because questioning whether a problem exists drags him backward into ground he has already covered. He has stated a decision, and treating it as doubtful risks losing the opening he offered. Option b is incorrect because handing over a leaflet is what you offer someone who does not yet see a problem. A client ready to act needs a plan and a referral, not more background reading. Option d is incorrect because praise alone leaves him with intention and no structure. Motivation fades quickly without a date, a contact, and a way to handle the first obstacle, and the moment passes.

Correct Answer: Dilated pupils with gooseflesh and diarrhea

Opioid withdrawal mirrors the drug it follows. Expect widened pupils, piloerection, cramping and diarrhea alongside the yawning, tearing and runny nose already present, with tachycardia and restlessness completing the flu like picture. Option a is incorrect because narrowed pupils with depressed breathing describe the intoxicated client, not the withdrawing one. Pupil size is the quickest way to tell those two states apart at the bedside. Option b is incorrect because withdrawal drives sweating and restlessness rather than dry skin and sleepiness. A client in this state paces, cannot settle and describes the worst influenza of his life. Option c is incorrect because pulse and pressure rise during opioid withdrawal as sympathetic activity climbs. A slow heart with falling pressure would suggest bleeding, sepsis or a depressant on board instead.

Correct Answer: Preventing and detecting refeeding syndrome

The first days carry the electrolyte danger, so monitoring for refeeding syndrome outranks every other goal. Weight, body image and family work all matter, yet none of them kills the client this week. Option b is incorrect because pushing for rapid gain in the opening days is what precipitates the dangerous electrolyte shift. Restoration matters over weeks, and it proceeds only as the laboratory results allow. Option c is incorrect because a starved brain cannot do cognitive work, so body image therapy is postponed until nutrition improves. Beginning it now would achieve nothing while the physical crisis continues. Option d is incorrect because family assessment is part of the overall plan rather than the acute safety focus. Scheduling interviews does not protect a heart that is about to lose its phosphate.

Correct Answer: Bring the requests to the team and restate the plan

Targeted flattery followed by requests that grow is the classic pattern, and the new staff member is tested first. Disclosing the requests to the team and returning to the written plan stops the drift. Option a is incorrect because boundary erosion almost always begins with a small kindness. Each granted favor sets up a larger one, and contraband entering the unit through a student endangers everyone living on it. Option b is incorrect because avoidance teaches the student nothing and leaves the same approach available to the next person. The learning happens when the request is named openly and answered from a shared plan. Option c is incorrect because a private justification hands him an argument and puts a novice alone in a negotiation. Explanations invite debate, and the client will simply move on to whoever seems easiest next.