1. 1. Question
The nursing diagnosis that would be most appropriate for a 22-year
old client who uses ritualistic behavior would be:
o A. Ineffective coping
o B. Impaired adjustment
o C. Personal identity disturbance
o D. Sensory/perceptual alterations
Incorrect
Correct Answer: A. Ineffective coping
Ineffective coping is the impairment of a person’s adaptive behaviors
and problem-solving abilities in meeting life’s demands; ritualistic
behavior fits under this category as a defining characteristic. During
the beginning of treatment, allow plenty of time for rituals. Do not be
judgmental or verbalize disapproval of the behavior. To deny the client
this activity can precipitate panic level of anxiety.
Option B: Gradually limit the amount of time allotted for
ritualistic behavior as the client becomes more involved in unit
activities. Anxiety is minimized when the client is able to replace
ritualistic behaviors with more adaptive ones. Encourage
independence and give positive reinforcement for independent
behaviors. Positive reinforcement enhances self-esteem and
encourages repetition of desired behaviors.
Option C: Personal identity disturbance is not a priority diagnosis
for the client. Assess client’s level of anxiety. Investigate the
types of situations that increase anxiety and result in ritualistic
behaviors. Helping the client recognize the precipitating factors is
the first step in teaching the client to interrupt the escalating
anxiety. Initially meet the client’s dependency needs as
necessary. Sudden and complete elimination of avenues for
dependency would create anxiety and will burden the client
more.
Option D: This nursing diagnosis is appropriate, but it is not the
priority. Encourage the recognition of situations that provoke
obsessive thoughts or ritualistic behaviors. Recognition of
precipitating factors is the first step in teaching the client to
interrupt escalation of anxiety. Provide positive reinforcement for
, non-ritualistic behaviors. Positive reinforcement enhances self-
esteem and encourages repetition of desired behaviors.
2. 2. Question
A psychiatrist prescribes an anti-obsessional agent for a client who is
using ritualistic behavior. A common anti-anxiety medication used for
this type of client would be:
A. fluvoxamine (Luvox)
B. benztropine (Cogentin)
C. amantadine (Symmetrel)
D. diphenhydramine (Benadryl)
Incorrect
Correct Answer: A. fluvoxamine (Luvox).
This drug blocks the uptake of serotonin. Fluvoxamine is used to treat
obsessive-compulsive disorder (bothersome thoughts that won’t go
away and the need to perform certain actions over and over) and
social anxiety disorder (extreme fear of interacting with others or
performing in front of others that interferes with normal life).
Fluvoxamine is in a class of medications called selective serotonin
reuptake inhibitors (SSRIs). It works by increasing the amount of
serotonin, a natural substance in the brain that helps maintain mental
balance.
Option B: Benztropine belongs to the synthetic class of
muscarinic receptor antagonists (anticholinergic drug). Thus, it
has a structure similar to that of diphenhydramine and atropine.
However, it is long-acting so that its administration can be with
less frequency than diphenhydramine. It also induces less CNS
stimulation effect compared to that of trihexyphenidyl, making it
a preferable drug of choice for geriatric patients. Moreover,
benztropine is FDA approved as adjunctive therapy of all forms of
parkinsonism.
Option C: Amantadine is now used mostly for Parkinson’s
disease. Clinical trials have shown that amantadine decreases
symptoms of bradykinesia, rigidity, and tremor. There is a
combined synergistic effect with added levodopa, which is
converted to dopamine by striatal enzymes in the CNS. There can
, be a transient benefit to the drug, so short-term therapy for
patients with the mild disease is best.
Option D: Diphenhydramine, which is available as an over-the-
counter medication, is a first-generation antihistamine that is
used in a variety of conditions to treat and prevent dystonias,
insomnia, pruritus, urticaria, vertigo, and motion sickness. It also
possesses local anesthetic properties for those patients who have
allergies to other, more commonly used local anesthetics;
however, this is an off-label use of the medication. An additional
off-label use is for the treatment of oral mucositis.
3. 3. Question
A 20-year old college student has been brought to the psychiatric
hospital by her parents. Her admitting diagnosis is borderline
personality disorder. When talking with the parents, which information
would the nurse expect to be included in the client’s history? Select
all that apply.
A. Impulsiveness
B. Lability of mood
C. Ritualistic behavior
D. Psychomotor retardation
E. Self-destructive behavior
Incorrect
Correct Answers: Answer: A, B, & E
Borderline personality disorder (BPD) is a serious psychological
condition that’s characterized by unstable moods and emotions,
relationships, and behavior. It’s one of several personality disorders
recognized by the American Psychiatric Association (APA). Personality
disorders are psychological conditions that begin in adolescence or
early adulthood, continue over many years, and, when left untreated,
can cause a great deal of distress. Thankfully, the right treatments
targeted for BPD can help significantly.
Option A: Impulsivity in at least two areas that are potentially
self-damaging, for example, spending, substance abuse, reckless
driving, sex, binge eating, etc. Note: Do not include suicidal or
, self-mutilating behavior covered in criterion 5. BPD is associated
with a tendency to engage in risky and impulsive behaviors, such
as going on shopping sprees, drinking excessive amounts of
alcohol or abusing drugs, engaging in promiscuous or risky sex,
or binge eating. Also, people with BPD are more prone to engage
in self-harming behaviors, such as cutting or burning and
attempting suicide.
Option B: Affective instability caused by a marked reactivity of
mood, for example, intense episodic dysphoria, anxiety, or
irritability, usually lasting a few hours and rarely more than a few
days. Emotional instability is a key feature of BPD. Individuals feel
like they’re on an emotional roller coaster with quick mood shifts
(i.e., going from feeling OK to feeling extremely down or blue
within a few minutes). Mood changes can last from minutes to
days and are often intense. Anger, anxiety, and overwhelming
emptiness are common as well.
Option C: Obsessive-compulsive disorder (OCD) is often a
disabling condition consisting of bothersome intrusive thoughts
that elicit a feeling of discomfort. To reduce the anxiety and
distress associated with these thoughts, the patient may employ
compulsions or rituals. These rituals may be personal and private,
or they may involve others to participate; the rituals are to
compensate for the ego-dystonic feelings of the obsessional
thoughts and can cause a significant decline in function.
Option D: Psychomotor retardation is a long established
component of depression that can have significant clinical and
therapeutic implications for treatment. Manifestations of
psychomotor retardation include slowed speech, decreased
movement, and impaired cognitive function. It is common in
patients with melancholic depression and those with psychotic
features.
Option E: Borderline personality disorder (BPD) is 1 of 4 cluster-
B disorders that include borderline, antisocial, narcissistic, and
histrionic. Borderline personality disorder (BPD) is characterized
by hypersensitivity to rejection and resulting instability of
interpersonal relationships, self-image, affect, and behavior.
Borderline personality disorder causes significant impairment and
distress and is associated with multiple medical and psychiatric
co-morbidities.
4. 4. Question
