TEST IV

All the questions in the quiz along with their answers are shown below. Your answers are
bolded. The correct answers have a green background while the incorrect ones have a red
background.
1. Following spinal injury, the nurse should encourage the client to drink fluids to avoid:

A) Urinary tract infection.

B) Fluid and electrolyte imbalance.

C) Dehydration.

D) Skin breakdown.

Clients in the early stage of spinal cord damage experience an atonic bladder, which is
characterized by the absence of muscle tone, an enlarged capacity, no feeling of
discomfort with distention, and overflow with a large residual. This leads to urinary stasis
and infection. High fluid intake limits urinary stasis and infection by diluting the urine
and increasing urinary output.
2. The client is transferred from the operating room to recovery room after an open-heart
surgery. The nurse assigned is taking the vital signs of the client. The nurse notified the
physician when the temperature of the client rises to 38.8 C or 102 F because elevated
temperatures:

A) May be a forerunner of hemorrhage.

B) Are related to diaphoresis and possible chilling.

C) May indicate cerebral edema.

D) Increase the cardiac output.

The temperature of 102 F (38.8C) or greater lead to an increased metabolism and

cardiac workload.
3. After radiation therapy for cancer of the prostate, the client experienced irritation in
the bladder. Which of the following sign of bladder irritability is correct?

A) Hematuria

B) Dysuria

C) Polyuria

D) Dribbling

Dysuria, nocturia, and urgency are all signs an irritable bladder after radiation therapy.
4. A client is diagnosed with a brain tumor in the occipital lobe. Which of the following
will the client most likely experience?

A) Visual hallucinations.

B) Receptive aphasia.

C) Hemiparesis.

D) Personality changes.

The occipital lobe is involve with visual interpretation.

5. A client with Addisons disease has a blood pressure of 65/60. The nurse understands
that decreased blood pressure of the client with Addisons disease involves a disturbance
in the production of:

A) Androgens

B) Glucocorticoids

C) Mineralocorticoids

D) Estrogen

Mineralocorticoids such as aldosterone cause the kidneys to retain sodium ions. With
sodium, water is also retained, elevating blood pressure. Absence of this hormone thus
causes hypotension.
6. The nurse is planning to teach the client about a spontaneous pneumothorax. The
nurse would base the teaching on the understanding that:

A) Inspired air will move from the lung into the pleural space.

B) There is greater negative pressure within the chest cavity.

C) The heart and great vessels shift to the affected side.

D) The other lung will collapse if not treated immediately.

As a person with a tear in the lung inhales, air moves through that opening into the
intrapleural and causes partial or complete collapse of the lungs.

7. During an assessment, the nurse recognizes that the client has an increased risk for
developing cancer of the tongue. Which of the following health history will be a
concern?

A) Heavy consumption of alcohol.

B) Frequent gum chewing.

C) Nail biting.

D) Poor dental habits.

Heavy alcohol ingestion predisposes an individual to the development of oral cancer.

8. The client in the orthopedic unit asks the nurse the reason behind why compact bone is
stronger than cancellous bone. Which of the following is the correct response of the
nurse?

A) Compact bone is stronger than cancellous bone because of its greater size.

B) Compact bone is stronger than cancellous bone because of its greater weight.

C) Compact bone is stronger than cancellous bone because of its greater volume.

D) Compact bone is stronger than cancellous bone because of its greater density.

The greater the density of compact bone makes it stronger than the cancellous bone.
Compact bone forms from cancellous bone by the addition of concentric rings of bones
substances to the marrow spaces of cancellous bone. The large marrow spaces are
reduced to haversian canals.
9. The nurse is reviewing the laboratory results of the client. In reviewing the results of
the RBC count, the nurse understands that the higher the red blood cell count, the :

A) Greater the blood viscosity.

B) Higher the blood pH.

C) Less it contributes to immunity.

D) Lower the hematocrit.

Viscosity, a measure of a fluids internal resistance to flow, is increased as the number of

red cells suspended in plasma.

10. The physician advised the client with Hemiparesis to use a cane. The client asks the
nurse why cane will be needed. The nurse explains to the client that cane is advised
specifically to:

A) Aid in controlling involuntary muscle movements.

B) Relieve pressure on weight-bearing joints.

C) Maintain balance and improve stability.

D) Prevent further injury to weakened muscles.

Hemiparesis creates instability. Using a cane provides a wider base of support and,
therefore greater stability.
11. The nurse is conducting a discharge teaching regarding the prevention of further
problems to a client who undergone surgery for carpal tunnel syndrome of the right
hand. Which of the following instruction will the nurse includes?

A) Learn to type using your left hand only.

B) Avoid typing in a long period of time.

C) Avoid carrying heavy things using the right hand.

D) Do manual stretching exercise during breaks.

Manual stretching exercises will assist in keeping the muscles and tendons supple and
pliable, reducing the traumatic consequences of repetitive activity.
12. A female client is admitted because of recurrent urinary tract infections. The client
asks the nurse why she is prone to this disease. The nurse states that the client is most
susceptible because of:

A) Continuity of the mucous membrane.

B) Inadequate fluid intake.

C) The length of the urethra.

D) Poor hygienic practices.

The length of the urethra is shorter in females than in males; therefore microorganisms
have a shorter distance to travel to reach the bladder. The proximity of the meatus to the
anus in females also increases this incidence.

13. A 55-year-old client is admitted with chest pain that radiates to the neck, jaw and
shoulders that occurs at rest, with high body temperature, weak with generalized sweating
and with decreased blood pressure. A myocardial infarction is diagnosed. The nurse
knows that the most accurate explanation for one of these presenting adaptations is:

A) Catecholamines released at the site of the infarction causes intermittent

localized pain.

B) Parasympathetic reflexes from the infarcted myocardium causes diaphoresis.

C) Constriction of central and peripheral blood vessels causes a decrease in blood

pressure.

D) Inflammation in the myocardium causes a rise in the systemic body

temperature.

Temperature may increase within the first 24 hours and persist as long as a week.
14. Following an amputation of a lower limb to a male client, the nurse provides an
instruction on how to prevent a hip flexion contracture. The nurse should instruct the
client to:.

A) Perform quadriceps muscle setting exercises twice a day.

B) Sit in a chair for 30 minutes three times a day.

C) Lie on the abdomen 30 minutes every four hours.

D) Turn from side to side every 2 hours.

The hips are in extension when the client is prone; this keeps the hips from flexing.
15. The physician scheduled the client with rheumatoid arthritis for the injection of
hydrocortisone into the knee joint. The client asks the nurse why there is a need for this
injection. The nurse explains that the most important reason for doing this is to:

A) Lubricate the joint.

B) Prevent ankylosis of the joint.

C) Reduce inflammation.

D) Provide physiotherapy.

Steroids have an anti-inflammatory effect that can reduce arthritic pannus formation.

16. The nurse is assigned to care for a 57-year-old female client who had a cataract
surgery an hour ago. The nurse should:

A) Advise the client to refrain from vigorous brushing of teeth and hair.

B) Instruct the client to avoid driving for 2 weeks.

C) Encourage eye exercises to strengthen the ocular musculature.

D) Teach the client coughing and deep-breathing techniques.

Activities such as rigorous brushing of hair and teeth cause increased intraocular pressure
and may lead to hemorrhage in the anterior chamber.
17. A client with AIDS develops bacterial pneumonia is admitted in the emergency
department. The clients arterial blood gases is drawn and the result is PaO2 80mmHg.
then arterial blood gases are drawn again and the level is reduced from 80 mmHg to 65
mmHg. The nurse should;

A) Have arterial blood gases performed again to check for accuracy.

B) Increase the oxygen flow rate.

C) Notify the physician.

D) Decrease the tension of oxygen in the plasma.

This decrease in PaO2 indicates respiratory failure; it warrants immediate medical

evaluation.
18. An 18-year-old college student is brought to the emergency department due to serious
motor vehicle accident. Right above-knee-amputation is done. Upon awakening from
surgery the client tells the nurse, What happened to me? I cannot remember anything?
Which of the following would be the appropriate initial nursing response?

A) You sound concerned; Youll probably remember more as you wake up.

B) Tell me what you think happened.

C) You were in a car accident this morning.

D) An amputation of your right leg was necessary because of an accident.

This is truthful and provides basic information that may prompt recollection of what
happened; it is a starting point.

19. A 38-year-old client with severe hypertension is hospitalized. The physician

prescribed a Captopril (Capoten) and Alprazolam (Xanax) for treatment. The client tells
the nurse that there is something wrong with the medication and nursing care. The nurse
recognizes this behavior is probably a manifestation of the clients:

A) Reaction to hypertensive medications.

B) Denial of illness.

C) Response to cerebral anoxia.

D) Fear of the health problem.

Clients adapting to illness frequently feel afraid and helpless and strike out at health team
members as a way of maintaining control or denying their fear.
20. Before discharge, the nurse scheduled the client who had a colostomy for colorectal
cancer for discharge instruction about resuming activities. The nurse should plan to help
the client understands that:

A) After surgery, changes in activities must be made to accommodate for the

physiologic changes caused by the operation.

B) Most sports activities, except for swimming, can be resumed based on the
clients overall physical condition.

C) With counseling and medical guidance, a near normal lifestyle, including

complete sexual function is possible.

D) Activities of daily living should be resumed as quickly as possible to avoid

depression and further dependency.

There are few physical restraints on activity postoperatively, but the client may have
emotional problems resulting from the body image changes.
21. A client is scheduled for bariatric surgery. Preoperative teaching is done. Which of
the following statement would alert the nurse that further teaching to the client is
necessary?

A) I will be limiting my intake to 600 to 800 calories a day once I start eating
again.

B) Im going to have a figure like a model in about a year.

C) I need to eat more high-protein foods.

D) I will be going to be out of bed and sitting in a chair the first day after
surgery..

clients need to be prepared emotionally for the body image changes that occur after
bariatric surgery. Clients generally experience excessive abdominal skin folds after
weight stabilizes, which may require a panniculectomy. Body image disturbance often
occurs in response to incorrectly estimating ones size; it is not uncommon for the client
to still feel fat no matter how much weight is lost.
22. The client who had transverse colostomy asks the nurse about the possible effect of
the surgery on future sexual relationship. What would be the best nursing response?

A) The surgery will temporarily decrease the clients sexual impulses.

B) Sexual relationships must be curtailed for several weeks.

C) The partner should be told about the surgery before any sexual activity.

D) The client will be able to resume normal sexual relationships.

Surgery on the bowel has no direct anatomic or physiologic effect on sexual performance.
However, the nurse should encourage verbalization.
23. A 75-year-old male client tells the nurse that his wife has osteoporosis and asks what
chances he had of getting also osteoporosis like his wife. Which of the following is the
correct response of the nurse?

A) This is only a problem for women.

B) You are not at risk because of your small frame.

C) You might think about having a bone density test,

D) Exercise is a good way to prevent this problem.

Osteoporosis is not restricted to women; it is a potential major health problem of all older
adults; estimates indicate that half of all women have at least one osteoporitic fracture
and the risk in men is estimated between 13% and 25%; a bone mineral density
measurement assesses the mass of bone per unit volume or how tightly the bone is
packed.
24. An older adult client with acute pain is admitted in the hospital. The nurse
understands that in managing acute pain of the client during the first 24 hours, the nurse
should ensure that:

A) Ordered PRN analgesics are administered on a scheduled basis.

B) Patient controlled analgesia is avoided in this population.

C) Pain medication is ordered via the intramuscular route.

D) An order for meperidine (Demerol) is secured for pain relief.

Around-the-clock administration of analgesics is recommended for acute pain in the older

adult population; this help to maintain a therapeutic blood level of pain medication.
25. A nurse is caring to an older adult with presbycusis. In formulating nursing care plan
for this client, the nurse should expect that hearing loss of the client that is caused by
aging to have:

A) Overgrowth of the epithelial auditory lining.

B) Copious, moist cerumen.

C) Difficulty hearing womens voices.

D) Tears in the tympanic membrane.

Generally, female voices have a higher pitch than male voices; older adults with
presbycusis (hearing loss caused by the aging process) have more difficulty hearing
higher-pitched sounds.
26. The nurse is reviewing the clients chart about the ordered medication. The nurse
must observe for signs of hyperkalemia when administering:

A) Furosemide (Lasix)

B) Hydrochlorothiazide (HydroDIURIL)

C) Metolazone (Zaroxolyn)

D) Spironolactone (Aldactone)

Aldactone is a potassium-sparing diuretic; hyperkalemia is an adverse effect.

27. The physician prescribed Albuterol (Proventil) to the client with severe asthma. After
the administration of the medication the nurse should monitor the client for:

A) Palpitation

B) Visual disturbance

C) Decreased pulse rate

D) Lethargy

Albuterols sympathomimetic effect causes cardiac stimulation that may cause

tachycardia and palpitation.
28. A client is receiving diltiazem (Cardizem). What should the nurse include in a
teaching plan aimed at reducing the side effects of this medication?

A) Take the drug with an antacid.

B) Lie down after meals.

C) Avoid dairy products in diet.

D) Change positions slowly.

Changing positions slowly will help prevent the side effect of orthostatic hypotension.
29. A client is receiving simvastatin (Zocor). The nurse is aware that this medication is
effective when there is decrease in:

A) The triglycerides

B) The INR

C) Chest pain

D) Blood pressure

Therapeutic effects of simvastatin include decreased serum triglyceries, LDL and

cholesterol.
30. A client is taking nitroglycerine tablets, the nurse should teach the client the
importance of:

A) Increasing the number of tablets if dizziness or hypertension occurs.

B) Limiting the number of tablets to 4 per day.

C) Making certain the medication is stored in a dark container.

D) Discontinuing the medication if a headache develops.

Nitroglycerine is sensitive to light and moisture ad must be stored in a dark, airtight

container.

31. The physician prescribes Ibuprofen (Motrin) and hydroxychloroquine sulfate

(Plaquenil) for a 58-year-old male client with arthritis. The nurse provides information
about toxicity of the hydroxychloroquine. The nurse can determine if the information is
clearly understood if the client states:

A) I will contact the physician immediately if I develop blurred vision.

B) I will contact the physician immediately if I develop urinary retention.

C) I will contact the physician immediately if I develop swallowing difficulty.

D) I will contact the physician immediately if I develop feelings of irritability.

Visual disturbance are a sign of toxicity because retinopathy can occur with this drug.
32. The client with an acute myocardial infarction is hospitalized for almost one week.
The client experiences nausea and loss of appetite. The nurse caring for the client
recognizes that these symptoms may indicate the:

A) Adverse effects of spironolactone (Aldactone)

B) Adverse effects of digoxin (Lanoxin)

C) Therapeutic effects of propranolol (Indiral)

D) Therapeutic effects of furosemide (Lasix)

Toxic levels of Lanoxin stimulate the medullary chemoreceptor trigger zone, resulting in
nausea and subsequent anorexia.
33. A client with a partial occlusion of the left common carotid artery is scheduled for
discharge. The client is still receiving Coumadin. The nurse provided a discharge
instruction to the client regarding adverse effects of Coumadin. The nurse should tell the
client to consult with the physician if:

A) Swelling of the ankles increases.

B) Blood appears in the urine.

C) Increased transient Ischemic attacks occur.

D) The ability to concentrate diminishes.

Warfarin derivatives cause an increase in the prothrombin time and INR, leading to an
increased risk for bleeding. Any abnormal or excessive bleeding must be reported,
because it may indicate toxic levels of the drug.

34. Levodopa is ordered for a client with Parkinsons disease. Before starting the
medication, the nurse should know that:

A) Levodopa is inadequately absorbed if given with meals.

B) Levodopa may cause the side effects of orthostatic hypotension.

C) Levodopa must be monitored by weekly laboratory tests.

D) Levodopa causes an initial euphoria followed by depression.

Levodopa is the metabolic precursor of dopamine. It reduces sympathetic outflow by

limiting vasoconstriction, which may result in orthostatic hypotension.
35. In making a diagnosis of myasthenia gravis Edrophonium HCI (Tensilon) is used.
The nurse knows that this drug will cause a temporary increase in:

A) Muscle strength

B) Symptoms

C) Blood pressure

D) Consciousness

Tensilon, an anticholinesterase drug, causes temporary relief of symptoms of myasthenia

gravis in client who have the disease and is therefore an effective diagnostic aid.
36. The nurse can determine the effectiveness of carbamazepine (Tegretol) in the
management of trigeminal neuralgia by monitoring the clients:

A) Seizure activity

B) Liver function

C) Cardiac output

D) Pain relief

Carbamazepine ( Tegretol) is administered to control pain by reducing the transmission of

nerve impulses in clients with trigeminal neuralgia.
37. Administration of potassium iodide solution is ordered to the client who will undergo
a subtotal thyroidectomy. The nurse understands that this medication is given to:

A) Ablate the cells of the thyroid gland that produce T4.

B) Decrease the total basal metabolic rate.

C) Decrease the size and vascularity of the thyroid.

D) Maintain function of the parathyroid gland.

Potassium iodide, which aids in decreasing the vascularity of the thyroid gland, decreases
the risk for hemorrhage.
38. A client with Addisons disease is scheduled for discharge. Before the discharge, the
physician prescribes hydrocortisone and fludrocortisone. The nurse expects the
hydrocortisone to:

A) Increase amounts of angiotensin II to raise the clients blood pressure.

B) Control excessive loss of potassium salts.

C) Prevent hypoglycemia and permit the client to respond to stress.

D) Decrease cardiac dysrhythmias and dyspnea.

Hydrocortisone is a glucocorticoid that has anti-inflammatory action and aids in

metabolism of carbohydrate, fat, and protein, causing elevation of blood glucose. Thus it
enables the body to adapt to stress.
39. A client with diabetes insipidus is taking Desmopressin acetate (DDAVP). To
determine if the drug is effective, the nurse should monitor the clients:

A) Arterial blood pH

B) Pulse rate

C) Serum glucose

D) Intake and output

DDAVP replaces the ADH, facilitating reabsorption of water and consequent return of
normal urine output and thirst.
40. A client with recurrent urinary tract infections is to be discharged. The client will be
taking nitrofurantoin (Macrobid) 50 mg po every evening at home. The nurse provides
discharge instructions to the client. Which of the following instructions will be correct?

A) Strain urine for crystals and stones

B) Increase fluid intake.

C) Stop the drug if the urinary output increases

D) Maintain the exact time schedule for drug taking.

To prevent crystal formation, the client should have sufficient intake to produce 1000 to
1500 mL of urine daily while taking this drug.
41. A client with cancer of the lung is receiving chemotherapy. The physician orders
antibiotic therapy for the client. The nurse understands that chemotherapy destroys
rapidly growing leukocytes in the:

A) Bone marrow

B) Liver

C) Lymph nodes

D) Blood

Prolonged chemotherapy may slow the production of leukocytes in bone marrow, thus
suppressing the activity of the immune system. Antibiotics may be required to help
counter infections that the body can no longer handle easily.
42. The physician reduced the clients Dexamethasone (Decadron) dosage gradually and
to continue a lower maintenance dosage. The client asks the nurse about the change of
dosage. The nurse explains to the client that the purpose of gradual dosage reduction is to
allow:

A) Return of cortisone production by the adrenal glands.

B) Production of antibodies by the immune system

C) Building of glycogen and protein stores in liver and muscle

D) Time to observe for return of increases intracranial pressure

Any hormone normally produced by the body must be withdrawn slowly to allow the
appropriate organ to adjust and resume production.
43. The nurse is assigned to care for a client with diarrhea. Excessive fluid loss is
expected. The nurse is aware that fluid deficit can most accurately be assessed by:

A) The presence of dry skin

B) A change in body weight

C) An altered general appearance

D) A decrease in blood pressure

Dehydration is most readily and accurately measured by serial assessment of body

weight; 1 L of fluid weighs 2.2 pounds.
44. Which of the following is the most important electrolyte of intracellular fluid?

A) Potassium

B) Sodium

C) Chloride

D) Calcium

The concentration of potassium is greater inside the cell and is important in establishing a
membrane potential, a critical factor in the cells ability to function.
45. Which of the following client has a high risk for developing hyperkalemia?

A) Crohns disease

B) End-Stage renal disease

C) Cushings syndrome

D) Chronic heart failure

The kidneys normally eliminate potassium from the body; hyperkalemia may necessitate
dialysis.
46. The nurse is reviewing the laboratory result of the client. The clients serum
potassium level is 5.8 mEq/L. Which of the following is the initial nursing action?

A) Call the cardiac arrest team to alert them

B) Call the laboratory and repeat the test

C) Take the clients vital signs and notify the physician

D) Obtain an ECG strip and have lidocaine available

Vital signs monitor cardiorespiratory status; hyperkalemia causes serious cardiac

dysrhythmias.

47. Potassium chloride, 20 mEq, is ordered and to be added in the IV solution of a client
in a diabetic ketoacidosis. The primary reason for administering this drug is:

A) Replacement of excessive losses

B) Treatment of hyperpnea

C) Prevention of flaccid paralysis

D) Treatment of cardiac dysrhythmias

Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the
cell, causing hypokalemia; therefore potassium, along with the replacement fluid, is
generally supplied.
48. A female client is brought to the emergency unit. The client is complaining of
abdominal cramps. On assessment, client is experiencing anorexia and weight is
reduced. The physicians diagnosis is colitis. Which of the following symptoms of fluid
and electrolyte imbalance should the nurse report immediately?

A) Skin rash, diarrhea, and diplopia

B) Development of tetaniy with muscles spasms

C) Extreme muscle weakness and tachycardia

D) Nausea, vomiting, and leg and stomach cramps.

Potassium, the major intracellular cation, functions with sodium and calcium to regulate
neuromuscular activity and contraction of muscle fibers, particularly the heart muscle. In
hypokalemia these symptoms develop.
49. The client is to receive an IV piggyback medication. When preparing the medication
the nurse should be aware that it is very important to:

A) Use strict sterile technique

B) Use exactly 100mL of fluid to mix the medication

C) Change the needle just before adding the medication

D) Rotate the bag after adding the medication

Because IV solutions enter the bodys internal environment, all solutions and medications
utilizing this route must be sterile to prevent the introduction of microbes.

50. The nurse is reviewing the laboratory result of the client. An arterial blood gas report
indicates the clients pH is 7.20, PCO2 35 mmHg and HCO3 is 19 mEq/L. The results
are consistent with:

A) Metabolic acidosis

B) Metabolic alkalosis

C) Respiratory acidosis

D) Respiratory alkalosis

A low pH and bicarbonate level are consistent with metabolic acidosis.

TEST V

All the questions in the quiz along with their answers are shown below. Your answers are
bolded. The correct answers have a green background while the incorrect ones have a red
background.
1. A 17-year-old client has a record of being absent in the class without permission, and
borrowing other peoples things without asking permission. The client denies stealing;
rationalizing instead that as long as no one was using the items, there is no problem to use
it by other people. It is important for the nurse to understand that psychodynamically, the
behavior of the client may be largely attributed to a development defect related to the:

A) Oedipal complex

B) Superego

C) Id

D) Ego

This shows a weak sense of moral consciousness. According to Freudian theory,

personality disorders stem from a weak superego.
2. A client tells the nurse, Yesterday, I was planning to kill myself. What is the best
nursing response to this cient?

A) What are you going to do this time?

B) Say nothing. Wait for the clients next comment

C) You seem upset. I am going to be here with you; perhaps you will want to talk
about it

D) Have you felt this way before?

The client needs to have his or her feelings acknowledged, with encouragement to discuss
feelings, and be reassured about the nurses presence.
3. In crisis intervention therapy, which of the following principle that the nurse will use to
plan her/his goals?

A) Crises are related to deep, underlying problems

B) Crises seldom occur in normal peoples lives

C) Crises may go on indefinitely.

D) Crises usually resolved in 4-6 weeks.

Part of the definition of a crisis is a time span of 4-6 weeks.

4. The nurse enters the room of the male client and found out that the client urinates on
the floor. The client hides when the nurse is about to talk to him. Which of the following
is the best nursing intervention?

A) Place restriction on the clients activities when his behavior occurs.

B) Ask the client to clean the soiled floor.

C) Take the client to the bathroom at regular intervals.

D) Limit fluid intake.

The client is most likely confused, rather than exhibiting acting-out, hostile behavior.
Frequent toileting will allow urination in an appropriate place.
5. A young lady with a diagnosis of schizophrenic reaction is admitted to the psychiatric
unit. In the past two months, the client has poor appetite, experienced difficulty in
sleeping, was mute for long periods of time, just stayed in her room, grinning and
pointing at things. What would be the initial nursing action on admitting the client to the
unit?

A) Assure the client that You will be well cared for.

B) Introduce the client to some of the other clients.

C) Ask Do you know where you are?

D) Take the client to the assigned room.

The client needs basic, simple orientation that directly relates to the here-and-now, and
does not require verbal interaction.
6. A 16-year-old girl was diagnosed with anorexia. What would be the first assessment of
the nurse?

A) What food she likes.

B) Her desired weight.

C) Her body image.

D) What causes her behavior.

Although all options may appear correct. A is the best because it focuses on a range of
possible positive reinforcers, a basis for an effective behavior modification program. It
can lead to concrete, specific nursing interventions right away and provides a
therapeutic use of control for the 16-year-old.
7. On an adolescent unit, a nurse caring to a client was informed that her clients closest
roommate dies at night. What would be the most appropriate nursing action?

A) Do not bring it up unless the client asks.

B) Tell the client that her roommate went home.

C) Tell the client, if asked, You should ask the doctor.

D) Tell the client that her closest roommate died.

The nurse needs to wait and see: do not jump the gun; do not assume that the client
wants to know now.
8. A woman gave birth to an unhealthy infant, and with some body defects. The nurse
should expect the womans initial reactions to include:

A) Depression

B) Withdrawal

C) Apathy

D) Anger

The woman is experiencing an actual loss and will probably exhibit many of the same
symptoms as a person who has lost someone to death.
9. A client in the psychiatric unit is shouting out loud and tells the nurse, Please, help
me. They are coming to get me. What would be the appropriate nursing response?

A) I wont let anyone get you.

B) Who are they?

C) I dont see anyone coming.

D) You look frightened.

This option is an example of pointing out reality- the nurses perception.

10. A client who is severely obese tells the nurse, My therapist told me that I eat a lot
because I didnt get any attention and love from my mother. What does the therapist
mean? What is the best nursing response?

A) What do you think is the connection between your not getting enough love
and overeating?

B) Tell me what you think the therapist means.

C) You need to ask your therapist.

D) We are here to deal with your diet, not with your psychological problems.

This response asks information that the nurse can use. If the client understands the
statement, the nurse can support the therapist when focusing on connection between food,
love, and mother. If the client does not understand the statement, the nurse can help get
clarification from the therapist.
11. After the discussion about the procedure the physician scheduled the client for
mastectomy. The client tells the nurse, If my breasts will be removed, Im afraid my
husband will not love me anymore and maybe he will never touch me. What should the
nurses response?

A) I doubt that he feels that way.

B) What makes you feel that way?

C) Have you discussed your feelings with your husband?

D) Ask the husband, in front of the wife, how he feels about this.

This option redirects the client to talk to her husband.

12. The child is brought to the hospital by the parents. During assessment of the nurse,
what parental behavior toward a child should alert the nurse to suspect child abuse?

A) Ignoring the child.

B) Flat affect.

C) Expressions of guilt.

D) Acting overly solicitous toward the child

This is an example of reaction formation, a coping mechanism.

13. A nurse is caring to a client with manic disorder in the psychiatric ward. On the
morning shift, the nurse is talking with the client who is now exhibiting a manic episode
with flight of ideas. The nurse primarily needs to:

A) Focus on the feelings conveyed rather than the thoughts expressed.

B) Speak loudly and rapidly to keep the clients attention, because the client is
easily distracted.

C) Allow the client to talk freely.

D) Encourage the client to complete one thought at a time.

Often the verbalized ideas are jumbled, but the underlying feelings are discernible and
must be acknowledged.
14. The nurse is caring to an autistic child. Which of the following play behavior would
the nurse expect to see in a child?

A) competitive play

B) nonverbal play

C) cooperative play

D) solitary play

Autistic children do best with solitary play because they typically do not interact with
others in a socially comprehensible and acceptable way.
15. The client is telling the nurse in the psychiatric ward, I hate them. Which of the
following is the most appropriate nursing response to the client?

A) Tell me about your hate.

B) I will stay with you as long as you feel this way.

C) For whom do you have these feelings?

D) I understand how you can feel this way.

The nurse is asking the client to clarify and further discuss feelings.
16. The mother visits her son with major depression in the psychiatric unit. After the
conversation of the client and the mother, the nurse asks the mother how it is talking to
her son. The mother tells the nurse that it was a stressful time. During an interview with

the client, the client says, we had a marvelous visit. Which of the following coping
mechanism can be described to the statement of the client?

A) Identification.

B) Rationalization.

C) Denial.

D) Compensation.

Denial is the act of avoiding disagreeable realities by ignoring them.

17. A male client is quiet when the physician told him that he has stage IV cancer and has
4 months to live. The nurse determines that this reaction may be an example of:

A) Indifference

B) Denial

C) Resignation

D) Anger

Reactions when told of a life-threatening illness stem from Kbler-Ross ideas on death
and dying. Denial is a typical grief response, and usually is a first reaction.
18. A nurse is caring to a female client with five young children. The family member told
the client that her ex-husband has died 2 days ago. The reaction of the client is stunned
silence, followed by anger that the ex-husband left no insurance money for their young
children. The nurse should understand that:

A) The children and the injustice done to them by their fathers death are the
womans main concern.

B) To explain the womans reaction, the nurse needs more information about the
relationship and breakup.

C) The woman is not reacting normally to the news.

D) The woman is experiencing a normal bereavement reaction.

Shock and anger are commonly the primary initial reactions.

19. A client who is manic comes to the outpatient department. The nurse is assigning an
activity for the client. What activity is best for the nurse to encourage for a client in a
manic phase?

A) Solitary activity, such as walking with the nurse, to decrease stimulation.

B) Competitive activity, such as bingo, to increase the clients self-esteem.

C) Group activity, such as basketball, to decrease isolation.

D) Intellectual activity, such as scrabble, to increase concentration.

This option avoids external stimuli, yet channels the excess motor activity that is often
part of the manic phase.
20. The nurse is about to administer Imipramine HCI (Tofranil) to the client, the client
says, Why should I take this? The doctor started me on this 10days ago; it didnt help
me at all. Which of the following is the best nursing response:

A) What were you expecting to happen?

B) It usually takes 2-3 weeks to be effective.

C) Do you want to refuse this medication? You have the right.

D) Thats a long time wait when you feel so depressed.

The patient needs a brief, factual answer.

21. Which of the following drugs the nurse should choose to administer to a client to
prevent pseudoparkinsonism?

A) Isocarboxazid (Marplan)

B) Chlorpromazine HCI (Thorazine)

C) Trihexyphenidyl HCI (Artane)

D) Trifluoperazine HCI (Stelazine)

Trihexyphenidyl HCI (Artane) is often used to counteract side effect of

pseudoparkinsonism, which often accompanies the use of phenothiazine, such as
chlorpromazine HCI (Thorazine or Trifluoperazine HCI (Stelazine).
22. The nurse is caring to an 80-year-old client with dementia? What is the most
important psychosocial need for this client?

A) Focus on the there-and-then rather the here-and-now.

B) Limit in the number of visitors, to minimize confusion.

C) Variety in their daily life, to decrease depression.

D) A structured environment, to minimize regressive behaviors.

Persons with dementia needs sameness, consistency, structure, routine, and predictability.
23. A client tells the nurse, I dont want to eat any meals offered in this hospital because
the food is poisoned. The nurse is aware that the client is expressing an example of:

A) Delusion.

B) Hallucination.

C) Negativism.

D) Illusion.

This is a false belief developed in response to an emotional need.

24. A client is admitted in the hospital. On assessment, the nurse found out that the client
had several suicidal attempts. Which of the following is the most important nursing
action?

A) Ignore the client as long as he or she is talking about suicide, because suicide
attempt is unlikely.

B) Administer medication.

C) Relax vigilance when the client seems to be recovering from depression.

D) Maintain constant awareness of the clients whereabouts.

The client must be constantly observed.

25. The nurse suspects that the client is suffering from depression. During assessment,
what are the most characteristic signs and symptoms of depression the nurse would note?

A) Constipation, increased appetite.

B) Anorexia, insomnia.

C) Diarrhea, anger.

D) Verbosity, increased social interaction.

The appetite is diminished and sleeping is affected to a client with depression.

26. The client in the psychiatric unit states that, The goodas are coming! I must be
ready. In response to this neologism, the nurses initial response is to:

A) Acknowledge that the word has some special meaning for the client.

B) Try to interpret what the client means.

C) Divert the clients attention to an aspect of reality.

D) State that what the client is saying has not been understood and then divert
attention to something that is really bound.

It is important to acknowledge a statement, even if it is not understood.

27. A male client diagnosed with depression tells the nurse, I dont want to look weak
and I dont even cry because my wife and my kids cant bear it. The nurse understands
that this is an example of:

A) Repression.

B) Suppression.

C) Undoing.

D) Rationalization.

Rationalization is the process of constructing plausible reasons for ones responses.

28. A female client tells the nurse that she is afraid to go out from her room because she
thinks that the other client might kill her. The nurse is aware that this behavior is related
to:

A) Hallucination.

B) Ideas of reference.

C) Delusion of persecution.

D) Illusion.

The client has ideas that someone is out to kill her.

29. A female client is taking Imipramine HCI (Tofranil) for almost 1 week and shows
less awareness of the physical body. What problem would the nurse be most concerned?

A) Nausea.

B) Gait disturbances.

C) Bowel movements.

D) Voiding.

A serious side effect of Imipramine HCI (Tofranil) is urinary retention (voiding

problems)
30. A 6-year-old client dies in the nursing unit. The parents want to see the child. What
is the most appropriate nursing action?

A) Give the parents time alone with the body.

B) Ask the physician for permission.

C) Complete the postmortem care and quietly accompany the family to the childs
room.

D) Suggest the parents to wait until the funeral service to say good-bye.

This allows the parents/family to grieve over the loss of the child, by going through the
steps of leave taking.
31. A 20-year-old female client is diagnosed with anxiety disorder. The physician
prescribed Flouxetine (Prozac). What is the most important side effects should a nurse be
concerned?

A) Tremor, drowsiness.

B) Seizures, suicidal tendencies.

C) Visual disturbance, headache.

D) Excessive diaphoresis, diarrhea.

Assess for suicidal tendencies, especially during early therapy. There is an increased risk
of seizures in debilitated client and those with a history of seizures.
32. A nurse is assigned to activate a client who is withdrawn, hears voices and
negativistic. What would be the best nursing approach?

A) Mention that the voices would want the client to participate.

B) Demand that the client must join a group activity.

C) Give the client a long explanation of the benefits of activity.

D) Tell the client that the nurse needs a partner for an activity.

The nurse helps to activate by doing something with the client.

33. A nurse is going to give a rectal suppository as a preoperative medication to a 4-yearold boy. The boy is very anxious and frightened. Which of the following statement by the
nurse would be most appropriate to gain the childs cooperation?

A) Be a big kid! Everyones waiting for you.

B) Lie still now and Ill let you have one of your presents before you even have
your operation.

C) Take a nice, big, deep breath and then let me hear you count to five.

D) You look so scared. Want to know a secret? This wont hurt a bit!

Preschool children commonly experience fears and fantasies regarding invasive

procedures. The nurse should attempts to momentarily distract the child with a simple
task that can be easily accomplished while the child remains in the side-lying position.
The suppository can be slipped into place while the child is counting, and then the nurse
can praise the child for cooperating, while holding the buttocks together to prevent
expulsion of the suppository.
34. A depressed client is on an MAO inhibitor? What should the nurse watch out for?

A) Hypertensive crisis.

B) Diet restrictions.

C) Taking medication with meals.

D) Exposure to sunlight.

This is the more inclusive answer, although diet restrictions (answer1) are important,
their purpose is to prevent hypertensive crisis (answer 2).
35. A 16-year-old girl is admitted for treatment of a fracture. The client shares to the
nurse caring to her that her step-father has made sexual advances to her. She got the

chance to tell it to her mother but refuses to believe. What is the most therapeutic action
of the nurse would be:

A) Tell the client to work it out with her father.

B) Tell the client to discuss it with her mother.

C) Ask the father about it.

D) Ask the mother what she thinks.

This comes closest to beginning to focus on family-centered approach to intervene in the

conspiracy of silence. This is therefore the best among the options.
36. A client with a diagnosis of paranoid disorder is admitted in the psychiatric hospital.
The client tells the nurse, the FBI is following me. These people are plotting against
me. With this statement the nurse will need to:

A) Acknowledge that this is the clients belief but not the nurses belief.

B) Ask how that makes the client feel.

C) Show the client that no one is behind.

D) Use logic to help the client doubt this belief.

The nurse should neither challenge nor use logic to dispel an irrational belief.
37. A nurse is completing the routine physical examination to a healthy 16-year-old male
client. The client shares to the nurse that he feels like killing his girlfriend because he
found out that her girlfriend had another boyfriend. He then laughs, and asks the nurse to
keep this a secret just between the two of them. The nurse reviews his chart and notes
that there is no previously history of violence or psychiatric illness. Which of the
following would be the best action of the nurse to take at this time?

A) Suggest the teen meet with a counselor to discuss his feelings about his
girlfriend.

B) Tell the teen that his feelings are normal, and recommend that he find another
girlfriend to take his mind off the problem.

C) Recall the teenage boys often say things they really do not mean and ignore the
comment.

D) Regard the comment seriously and notify the teens primary health care
provider and parents

Any threat to the safety of oneself or other should always be taken seriously and never
disregarded by the nurse.
38. Which of the following person will be at highest risk for suicide?

A) A student at exam time

B) A married woman, age 40, with 6 children.

C) A person who is an alcoholic.

D) A person who made a previous suicide attempt.

The likelihood of multiple contributing factors may make this person at higher risk for
suicide. Some factors that may exist are physical illness related to alcoholism, emotional
factors ( anxiety, guilt, remorse), social isolation due to impaired relationships and
economic problems related to employment.
39. A male client is repetitively doing the handwashing every time he touches things. It is
important for a nurse to understand that the clients behavior is probably an attempt to:

A) Seek attention from the staff.

B) Control unacceptable impulses or feelings.

C) Do what the voices the patient hears tell him or her to do.

D) Punish himself or herself for guilt feeling.

A ritual, such as compulsive handwashing, is an attempt to allay anxiety caused by

unconscious impulses that are frightening.
40. In a mental health settings, the basic goal of nursing is to:

A) Advance the science of psychiatry by initiating research and gathering data for
current statistics on emotional illness.

B) Plan activity programs for clients.

C) Understand various types of family therapy and psychological tests and how to
interpret them.

D) Maintain a therapeutic environment.

This is the most neutral answer by process of elimination.

41. A 3-year-old boy is brought to the emergency department. After an hour, the boy dies
of respiratory failure. The mother of the boy becomes upset, shouting and abusive,
saying to the nurse, If it had been your son, they would have done more to save it.
What should the nurse say or do?

A) Touch her and tell her exactly what was done for her baby.

B) Allow the mother to continue her present behavior while sitting quietly with
her.

C) No, all clients are given the same good care.

D) Yes, youre probably right. Your son did not get better care.

This option allows a normal grief response (anger).

42. The nurse is interacting to a client with an antisocial personality disorder. What
would be the most therapeutic approach of the nurse to an antisocial behavior?

A) Gratify the clients inner needs.

B) Give the client opportunities to test reality.

C) Provide external controls.

D) Reinforce the clients self-concept.

Personality disorders stem from a weak superego, implying a lack of adequate controls.
43. A 55-year-old male client tells the nurse that he needs his glasses and hearing aid with
him in the recovery room after the surgery, or he will be upset for not granting his
request. What is the appropriate nursing response?

A) Do you get upset and confused often?

B) You wont need your glasses or hearing aid. The nurses will take care of you.

C) I understand. You will be able to cooperate best if you know what is going on,
so I will find out how I can arrange to have your glasses and hearing aid available
to you in the recovery room.

D) I understand you might be more cooperative if you have your aid and glasses,
but that is just not possible. Rules, you know.

The client will be easier to care for if he has his hearing aid and glasses.

44. The male client had fight with his roommates in the psychiatric unit. The client
agitated client is placed in isolation for seclusion. The nurse knows it is essential that:

A) A staff member has frequent contacts with the client.

B) Restraints are applied.

C) The client is allowed to come out after 4 hours.

D) All the furniture is removed form the isolation room.

Frequent contacts at times of stress are important, especially when a client is isolated.
45. A medical representative comes to the hospital unit for the promotion of a new
product. A female client, admitted for hysterical behavior, is found embracing him.
What should the nurse say?

A) Have you considered birth control?

B) This isnt the purpose of either of you being here.

C) I see youve made a new friend.

D) Think about what you are doing.

This response is aimed at redirecting the inappropriate behavior.

46. A client with dementia is for discharge. The nurse is providing a discharge instruction
to the family member regarding safety measures at home. What suggestion can the nurse
make to the family members?

A) Avoid stairs without banisters.

B) Use restraints while the client is in bed to keep him or her from wandering off
during the night.

C) Use restraints while the client is sitting in a chair to keep him or her from
wandering off during the day.

D) Provide a night-light and a big clock.

This option is best to decrease confusion and disorientation to place and time.
47. A 30-year-old married woman comes to the hospital for treatment of fractures. The
woman tells the nurse that she was physically abused by her husband. The woman

receives a call from her husband telling her to get home and things will be different. He
felt sorry of what he did. What can the nurse advise her?

A) Do you think so?

B) Its not likely.

C) What will be different?

D) I hope so, for your sake.

This option helps the woman to think through and elaborate on her own thoughts and
prognosis.
48. A female client was diagnosed with breast cancer. It is found to be stage IV, and a
modified mastectomy is performed. After the procedure, what behaviors could the nurse
expects the client to display?

A) Denial of the possibility of carcinoma.

B) Signs of grief reaction.

C) Relief that the operation is over.

D) Signs of deep depression.

It is mostly likely that grief would be expressed because of object loss.

49. A client is withdrawn and does not want to interact to anybody even to the nurse.
What is the best initial nursing approach to encourage communication with this client?

A) Use simple questions that call for a response.

B) Encourage discussion of feelings.

C) Look through a photo album together.

D) Bring up neutral topics.

Neutral, nonthreatening topics are best in attempting to encourage a response.

50. Which of the following nursing approach is most important in a client with
depression?

A) Deemphasizing preoccupation with elimination, nourishment, and sleep.

B) Protecting against harm to others.

C) Providing motor outlets for aggressive, hostile feelings.

D) Reducing interpersonal contacts.

It is important to externalize the anger away from self.