1 :

Hint : 😰 Panic = fight-or-flight.

Correct Answers:

  • Sweating
  • Chest pain
  • Feelings of choking


Rationale :

Sweating

🔷 Sweating occurs during a panic attack because the sympathetic nervous system becomes highly activated.

🔷 This causes the body to release stress hormones such as epinephrine, leading to diaphoresis, trembling, palpitations, and a sense of danger.

🔷 The client may feel as though something life-threatening is happening even when there is no actual physical threat.

🔷 Sweating is an important sign because it reflects the body’s fight-or-flight response.

🔷 The nurse should remain calm, stay with the client, reduce stimulation, and encourage slow breathing.

Chest pain

🔷 Chest pain can accompany a panic attack because anxiety increases heart rate, muscle tension, and respiratory effort.

🔷 The client may describe chest tightness, pressure, or discomfort, which can intensify fear during the episode.

🔷 Chest pain during panic may feel similar to cardiac symptoms, so the nurse should still assess carefully and rule out urgent causes when needed.

🔷 Panic-related chest discomfort often occurs with palpitations, shortness of breath, dizziness, and fear of losing control.

🔷 Recognizing this symptom helps the nurse provide reassurance while maintaining appropriate safety assessment.

Feelings of choking

🔷 Feelings of choking are common during panic attacks because anxiety can cause throat tightness and altered breathing patterns.

🔷 The client may feel unable to breathe even when oxygen saturation is normal.

🔷 This sensation often occurs with hyperventilation, chest tightness, and fear of suffocation.

🔷 The nurse should use a calm voice, remain with the client, and coach slow, controlled breathing.

🔷 A low-stimulation environment helps reduce the intensity of the panic response.

Hypoventilation

🔷 Panic attacks are more commonly associated with hyperventilation, not hypoventilation.

🔷 Hyperventilation can cause dizziness, tingling, chest tightness, and a choking sensation.

Increased appetite

🔷 Increased appetite is not a typical acute symptom of a panic attack.

🔷 Panic attacks more commonly cause nausea, abdominal distress, dry mouth, or reduced appetite.


Distractor Analysis :

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2 :

Hint : 🧠 Made-up words.

Correct Answers:

  • Neologisms


Rationale :

💎 Neologisms are newly invented words or phrases that have meaning only to the client.

💎 The words “farfensnarf,” “credisfort,” and “zingast” are not standard words and represent abnormal word creation.

💎 This speech pattern is commonly seen in schizophrenia and reflects disorganized thought processes.

💎 The nurse should document the client’s exact words objectively without trying to assign false meaning to them.

💎 Therapeutic communication should focus on safety, emotional meaning, and gentle clarification when possible.

Echolalia

💎 Echolalia is the repetition of another person’s words or phrases.

💎 The client is creating new words rather than repeating what someone else said.

Flight of ideas

💎 Flight of ideas involves rapid movement from one topic to another with some loose connection.

💎 The main issue in this question is invented words, not rapid topic shifting.

Thought insertion

💎 Thought insertion is the belief that outside forces are placing thoughts into the client’s mind.

💎 This statement shows disorganized speech, not a delusion about thoughts being inserted.


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3 :

Hint : 🪞Appearance fixation.

Correct Answers:

  • Body dysmorphic disorder


Rationale :

🌟 Body dysmorphic disorder involves a persistent preoccupation with an imagined or exaggerated flaw in appearance.

🌟 The client has a normal healthy appearance but believes the face is extremely ugly.

🌟 This distorted perception causes distress and can lead to avoidance of social situations.

🌟 The statement “I look like Frankenstein” shows an unrealistic and excessive concern about appearance.

🌟 Nursing care includes therapeutic communication, assessment for anxiety or depression, and support for treatment such as cognitive behavioral therapy.

Malingering

🌟 Malingering involves intentionally exaggerating or producing symptoms for external gain.

🌟 This client’s belief appears sincere and distorted, not intentionally deceptive.

Persistent depression disorder

🌟 Persistent depressive disorder involves chronic depressed mood lasting at least 2 years in adults.

🌟 The main problem here is distorted body image, not long-term low mood.

Somatization

🌟 Somatization involves psychological distress expressed through physical symptoms.

🌟 This client is focused on perceived ugliness, not multiple physical complaints.


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4 :

Hint : 🧘DBT teaches balance.

Correct Answers:

  • Dialectical behavior therapy


Rationale :

🔶 Dialectical behavior therapy is one of the most effective treatments for borderline personality disorder.

🔶 It helps clients manage emotional extremes, impulsivity, unstable relationships, and self-destructive behaviors.

🔶 DBT teaches mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness.

🔶 These skills help the client replace intense, all-or-nothing reactions with more balanced responses.

🔶 DBT is especially useful because borderline personality disorder is strongly associated with emotional dysregulation and difficulty maintaining stable relationships.

Benzodiazepines

🔶 Benzodiazepines may reduce short-term anxiety but do not treat the core features of borderline personality disorder.

🔶 They can increase dependency risk and may worsen impulsivity in some clients.

Long-term inpatient hospitalization

🔶 Long-term hospitalization is not the preferred treatment for borderline personality disorder.

🔶 Structured therapy in an outpatient or controlled treatment setting is usually more beneficial.

Milieu therapy

🔶 Milieu therapy uses the treatment environment to encourage healthy behaviors.

🔶 It can support treatment but is not the most effective therapy for replacing emotional extremes in borderline personality disorder.


Distractor Analysis :

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5 :

Hint : 🤝 Helping relieves stress.

Correct Answers:

  • Altruism


Rationale :

🌿 Altruism is a mature defense mechanism in which a person copes with stress by helping others.

🌿 The client is experiencing constant family conflict but chooses to volunteer at a nursing home.

🌿 This allows the client to redirect emotional distress into a positive and meaningful activity.

🌿 Altruism benefits both the client and the people receiving help.

🌿 This is considered a healthy coping response because it reduces stress while promoting social connection and purpose.

Somatization

🌿 Somatization occurs when emotional distress is expressed as physical symptoms.

🌿 The client is not reporting physical symptoms related to family conflict.

Suppression

🌿 Suppression is the conscious decision to delay thinking about a stressful issue.

🌿 The client is not simply postponing thoughts but actively helping others.

Displacement

🌿 Displacement involves transferring emotions from one person or situation to a safer target.

🌿 The client is not redirecting anger or frustration onto another person or object.


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6 :

Hint : 💪 Sudden muscle spasm.

Correct Answers:

  • Acute dystonia


Rationale :

🟣 Acute dystonia is an extrapyramidal symptom involving sudden, sustained muscle contractions.

🟣 It can cause stiffening or spasms of the face, neck, back, arms, legs, jaw, tongue, or eyes.

🟣 High-potency first-generation antipsychotics have a higher risk of causing acute dystonic reactions.

🟣 This reaction often occurs shortly after starting the medication or after a dose increase.

🟣 The nurse should recognize this as urgent because laryngeal involvement can threaten breathing, and treatment may include benztropine or diphenhydramine as prescribed.

Pseudoparkinsonism

🟣 Pseudoparkinsonism causes tremor, rigidity, slowed movement, shuffling gait, and mask-like facial expression.

🟣 The question describes sudden stiffening of muscles, which is more consistent with acute dystonia.

Akathisia

🟣 Akathisia causes intense restlessness and an inability to sit still.

🟣 The client would likely pace, shift constantly, or report inner restlessness rather than muscle stiffening.

Tardive dyskinesia

🟣 Tardive dyskinesia causes involuntary repetitive movements, especially lip smacking, tongue movements, or facial grimacing.

🟣 It usually occurs after long-term antipsychotic therapy rather than shortly after medication administration.


Distractor Analysis :

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7 :

Hint : 💊Desired over available.

Correct Answers:

  • 30


Rationale :

🟡The prescribed dose is Lactulose 20 grams by mouth,

🟡The available dose is 10 grams/15 mL.

🟡Formula

📌Desired dose ÷ Available dose × Volume = Amount to administer.

📌20 g ÷ 10 g × 15 mL

✍️ 30 mL.


Distractor Analysis :

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8 :

Hint : ⏱️30 min = 0.5 hr.

Correct Answers:

  • 300


Rationale :

🔵The prescribed infusion is 150 mL of ceftriaxone sodium

🔵To infuse over 30 minutes.

🔵30 minutes must be converted to 0.5 hour.

🔵Formula

📌Volume ÷ Time in hours = mL/hour.

📌150 mL ÷ 0.5 hour

💎300 mL/hour.


Distractor Analysis :

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9 :

Hint : 🌤️ Mild improves focus.

Correct Answers:

  • Mild anxiety


Rationale :

✅ Mild anxiety is the level of anxiety associated with normal everyday stress.

✅ The client states that the anxiety helps them work more effectively, which is a key feature of mild anxiety.

✅ Mild anxiety can increase alertness, motivation, learning, and problem-solving ability.

✅ Minor behaviors such as nail biting may occur, but the client can still communicate and function effectively.

✅ This level of anxiety does not significantly impair perception or decision-making.

Severe anxiety

✅ Severe anxiety greatly narrows perception and interferes with problem-solving.

✅ The client would have difficulty functioning rather than working more effectively.

Moderate anxiety

✅ Moderate anxiety narrows the perceptual field and may reduce concentration.

✅ The client may need assistance to refocus, which is not described in this scenario.

Panic

✅ Panic is the most intense level of anxiety and can cause disorganized behavior or inability to process reality.

✅ The client’s symptoms are mild and manageable, not overwhelming or disabling.


Distractor Analysis :

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10 :

Hint : 🧊 Unconscious blocking.

Correct Answers:

  • Repression


Rationale :

♦️ Repression is considered the foundation of many unconscious defense mechanisms.

♦️ It involves unconsciously blocking painful, threatening, or unacceptable thoughts from awareness.

♦️ The person does not intentionally choose to forget the thought or memory.

♦️ Repressed emotions may still influence behavior even though the person is unaware of the original conflict.

♦️ Many other defense mechanisms develop from repression because the mind protects itself by keeping distressing material outside conscious awareness.

Suppression

♦️ Suppression is a conscious decision to delay thinking about stressful feelings or events.

♦️ It is not the foundation of unconscious defense mechanisms because the person is aware of the issue.

Sublimation

♦️ Sublimation redirects unacceptable impulses into socially acceptable activities.

♦️ It is a mature defense mechanism but not the basic foundation of unconscious defenses.

Altruism

♦️ Altruism involves managing stress by helping others.

♦️ It is a healthy mature defense mechanism, not the foundation of unconscious defense mechanisms.


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Total Questions: 10

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