NCLEX RN Practice Question # 487-491

A client is admitted to a mental health unit for treatment of psychotic behavior. The client is at the locked exit door and is shouting, “Let me out. There’s nothing wrong with me. I don’t belong here.” A nurse analyzes this behavior as:

1. Denial
2. Projection
3. Regression
4. Rationalization

What is Paranoid Disorders?

Description
Paranoid disorder is a concrete, pervasive delusional system characterized by persecutory and grandiose beliefs.
The client exhibits suspiciousness and mistrust of others.
The client often is viewed by others as hostile, stubborn, and defensive.

Behaviors

Suspicious and mistrustful
Emotionally distant
Distortion of reality
Poor insight and poor judgments
Hypervigilance
Low self-esteem
Highly sensitive, difficulty in admitting own error, and taking pride in being correct
Hypercritical and intolerant of others
Hostile, aggressive, and quarrelsome
Evasive
Concrete thinking
Delusions
Delusions serve a purpose in establishing identity and self-esteem.
The client may have grandiose and persecutory delusions.
Process of delusion includes denial, projection, and rationalization.
As trust in others increases, the need for delusions decreases.

Types of paranoid disorders

Paranoid personality disorder (see later)
    Suspicious
    Nonpsychotic
    No hallucinations or delusions
    No symptoms of schizophrenia
Paranoia-induced state
    Abrupt onset in response to stress; subsides when stress decreases
    No hallucinations, but experiences paranoid delusions
    May be sensitive and suspicious before the development of delusions

A community health nurse visits a client at home. The client states, “I haven’t slept at all the last couple of nights.” Which response by the nurse illustrates a therapeutic communication technique for this client?

1. “Go on.”
2. “Sleeping?”
3. “You’re having difficulty sleeping?”
4. “Sometimes, I have trouble sleeping too.”

Therapeutic and Communication Techniques

Clarifying and validating
Encouraging formulation of a plan of action
Focusing and refocusing
Listening
Maintaining neutral responses
Maintaining silence
Providing acknowledgment and feedback
Providing information and presenting reality
Providing nonverbal encouragement
Reflecting
Restating
Sharing perceptions

Which of the following individuals is least likely at risk for the development of Kaposi’s sarcoma?

1. A kidney transplant client
2. A male with a history of same-gender partners
3. A client receiving antineoplastic medications
4. An individual working in an environment in which he or she is exposed to asbestos

Kaposi’s sarcoma (NCLEX Review)

Description:

Skin lesions that occur primarily in individuals with a compromised immune system

Assessment

Kaposi’s sarcoma is a slow-growing tumor that appears as raised, oblong, purplish, reddish-brown lesions; may be tender or nontender.
Organ involvement includes the lymph nodes, airways or lungs, or any part of the gastrointestinal tract from the mouth to anus.

Interventions

Maintain standard precautions.
Provide protective isolation if the immune system is depressed.
Prepare the client for radiation therapy or chemotherapy as prescribed.
Administer immunotherapy, as prescribed, to stabilize the immune system.

The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi’s sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which of the following?

1. Swelling in the genital area
2. Swelling in the lower extremities
3. Punch biopsy of the cutaneous lesions
4. Appearance of reddish-blue lesions noted on the skin

Acquired Immunodeficiency Syndrome (AIDS) NCLEX Review

Description

AIDS is a disorder caused by human immunodeficiency virus (HIV) and characterized by generalized dysfunction of the immune system
HIV infects CD4þ T cells; a gradual decrease in CD4þ T cell count occurs and this results in a progressive immunodeficiency; the risk for opportunistic infections is present.
HIV is transmitted through blood, semen, vaginal secretions, and breast milk; the incubation period is months to years.
Horizontal transmission occurs through intimate sexual contact or parenteral exposure to blood or body fluids that contain the virus.
Vertical (perinatal) transmission occurs from an HIV-infected pregnant woman to her fetus
The most common opportunistic infection that occurs in children infected with HIV is Pneumocystis jiroveci pneumonia (formerly known as Pneumocystis carinii pneumonia); P. jiroveci pneumonia most frequently occurs between the ages of 3 and 6 months, when HIV status may be indeterminate. An infant or child infected with HIV is at risk for developing a life-threatening opportunistic infection. Monitor the infant or child closely for signs of infection and report these signs immediately if they occur.

Diagnostic tests:

Before testing, counseling should be provided to parents; issues that should be addressed include the causes of HIV, reasons for testing, implications of positive test results, confidentiality issues, and beneficial effects of early intervention 

The client is diagnosed with stage I Lyme disease. The nurse assesses the client for which characteristic of this stage?

1. Arthralgias
2. Flu-like symptoms
3. Enlarged and inflamed joints
4. Signs of neurological disorders

Lyme Disease ( NCLEX Review)

Description

Lyme disease is an infection caused by the spirochete Borrelia burgdorferi, acquired from a tick bite (ticks live in wooded areas and survive by attaching to a host).
Infection with the spirochete stimulates inflammatory cytokines and autoimmune mechanisms.

Assessment

The typical ring-shaped rash of Lyme disease does not occur in all clients. Many clients never develop a rash. Additionally, if a rash does occur, it can occur anywhere on the body, not only at the site of the bite.

Interventions

Gently remove the tick with tweezers, wash the skin with antiseptic, and dispose of the tick by flushing it down the toilet; the tick may also be placed in a sealed jar so that the health care provider can inspect it and determine its type.
Perform a blood test 4 to 6 weeks after a bite to detect the presence of the disease (testing before this time is not reliable).
Instruct the client in the administration of antibiotics as prescribed; these are initiated immediately (even before the blood testing results are known).
Instruct the client to avoid areas that contain ticks, such as wooded grassy areas, especially in the summer months.
Instruct the client to wear long-sleeved tops, long pants, closed shoes, and hats while outside.
Instruct the client to spray the body with tick repellent before going outside.
Instruct the client to examine the body when returning inside for the presence of ticks.