ودالشمال12 PDF

‫‪PSYCHIATRIC‬‬ ‫‪1012‬‬ ‫ودالشمال‬
‫ودالشمال‬
‫‪PSYCHIATRIC‬‬
‫صناعة النجاح وتجاوز الفشل‬
‫ألف مبروك لكل الناجحين وبالتوفيق للممتحنين‬
‫قروب طور ذاتك ‪ ..‬مناقشة امتحانات البرومتريك والبيرسون فيو للتمريض‬ ‫‪Page 1‬‬
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PSYCHIATRIC 1012 ‫ودالشمال‬
Correct
1. Mental health is defined as:
A. The ability to distinguish what is real from what is not.

B. A state of well-being where a person can realize his own
abilities can cope with normal stresses of life and work

productively
C. Is the promotion of mental health, prevention of mental disorders, nursing
care of patients during illness and rehabilitation
D. Absence of mental illness
Feedback
A state of well-being where a person can realize his own abilities can cope with
normal stresses of life and work productively.
Mental health is a state of emotional and psychosocial well being. A mentally
healthy individual is self aware and self directive, has the ability to solve
problems, can cope with crisis without assistance beyond the support of family
and friends fulfill the capacity to love and work and sets goals and realistic
limits. A. This describes the ego function reality testing. C. This is the
definition of Mental Health and Psychiatric Nursing. D. Mental health is not
just the absence of mentalillness.
Correct
2. Liza says, "Give me 10 minutes to recall the name of our college professor
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who failed many students in our anatomy class." She is operating on her:
A. Subconscious
B. Conscious
C. Unconscious
D. Ego
Feedback
Subconscious
Subconscious refers to the materials that are partly remembered partly
forgotten but these can be recalled spontaneously and voluntarily. B. This
functions when one is awake. One is aware of his thoughts, feelings actions
and what is going on in the environment. C. The largest potion of the mind
that contains the memories of one’s past particularly the unpleasant. It is
difficult to recall the unconscious content. D. The conscious self that deals
and tests reality.
Correct
3. Which of the following describes the role of a technician?
A. Administers medications to a schizophrenic patient.
B. The nurse feeds and bathes a catatonic client

C. Coordinates diverse aspects of care rendered to the patient
D. Disseminates information about alcohol and its effects.
Feedback
Administers medications to a schizophrenic patient.
Administration of medications and treatments, assessment, documentation are
the activities of the nurse as a technician. B. Activities as a parent surrogate.
C. Refers to the ward manager role. D. Role as a teacher.
Correct
4. Primary level of prevention is exemplified by:
A. Helping the client resume self care.

B. Ensuring the safety of a suicidal client in the institution.
C. Teaching the client stress management techniques
D. Case finding and surveillance in the community
Feedback
Teaching the client stress management techniques
Primary level of prevention refers to the promotion of mental health and
prevention of mental illness. This can be achieved by rendering health
teachings such as modifying ones responses to stress. A. This is tertiary level of
prevention that deals with rehabilitation. B and D. Secondary level of
prevention which involves reduction of actualillness through early detection
and treatment of illness.
Correct
5. Which comment about a 3 year old child if made by the parent may indicate
child abuse?
A. “Once my child is toilet trained, I can still expect her to have some"
B. “When I tell my child to do something once, I don’t expect to
have to tell"
C. “My child is expected to try to do things such as, dress and feed.”
D. “My 3 year old loves to say NO.”
Feedback
“When I tell my child to do something once, I don’t expect to have to tell"
Abusive parents tend to have unrealistic expectations on the child. A,B and C
are realistic expectations on a 3 year old.
Correct
6. Situation: In a home visit done by the nurse, she suspects that the wife and her
child are victims of abuse.Which of the following is the most appropriate for
the nurse to ask?
A. “Are you being threatened or hurt by your partner?
B. “Are you frightened of you partner”

C. “Is something bothering you?”
D. “What happens when you and your partner argue?”
Feedback
“Are you being threatened or hurt by your partner?
The nurse validates her observation by asking simple, direct question. This also
shows empathy. B, C, and D are indirect questions which may not lead to the
discussion of abuse.
Correct
7. The wife admits that she is a victim of abuse and opens up about her persistent
distaste for sex. This sexual disorder is:
A. Sexual desire disorder
B. Sexual arousal Disorder

C. Orgasm Disorder
D. Sexual Pain Disorder
Feedback
Sexual desire disorder Has little or no sexual desire or has distaste for sex. B.
Failure to maintain the physiologic requirements for sexual intercourse. C.
Persistent and recurrent inability to achieve an orgasm. D. Also called
dyspareunia. Individuals with this disorder suffer genital pain before, during
and after sexual intercourse.
Correct
8. What would be the best approach for a wife who is still living with her abusive
husband?
A. “Here’s the number of a crisis center that you can call for help .”
B. “Its best to leave your husband.”
C. “Did you discuss this with your family?”
D. “ Why do you allow yourself to be treated this way”
Feedback
“Here’s the number of a crisis center that you can call for help .”
Protection is a priority concern in abuse. Help the victim to develop a plan to
ensure safety. B. Do not give advice to leave the abuser. Making decisions for
the victim further erodes her esteem. However discuss options available. C. The
victim tends to isolate from friends and family. D. This is judgmental. Avoid in
anyway implying that she is at fault.
Correct
9. The primary nursing intervention for a victim of child abuse is:
A. Assess the scope of the problem

B. Analyze the family dynamics
C. Ensure the safety of the victim
D. Teach the victim coping skills
Feedback
Ensure the safety of the victim
The priority consideration is the safety of the victim. Attend to the
physical injuries to ensure the physiologic safety and integrity of the
child. Reporting suspected case of abuse may deter recurrence of abuse.
A,B and D may be addressed later.
Correct
10. The superego is that part of the psyche that:
A. Uses defensive function for protection.

B. Is impulsive and without morals.
C. Determines the circumstances before making decisions.
D. The censoring portion of the mind.
Feedback
The censoring portion of the mind.The critical censoring portion of one’s
personality; the conscience. A. This refers to the ego function that protects itself
from anything that threatens it.. B. The Id is composed of the untamed,
primitive drives and impulses. C. This refers to the ego that acts as the
moderator of the struggle between the id and the superego.
Correct
11. A 26-year-old male reports losing his sight in both eyes. He's diagnosed as
having a conversion disorder and is admitted to the psychiatric unit. Which
nursing intervention would be most appropriate for this client?
A. Not focusing on his blindness
B. Providing self-care for him

C. Telling him that his blindness isn't real
D. Teaching eye exercises to strengthen his eyes
Feedback
Focusing on the client's blindness can positively reinforce the blindness and
further promote the use of maladaptive behaviors to obtain secondary gains.
The client should be encouraged to participate in his own self-care as much as
possible to avoid fostering dependency. To promote self-esteem, give positive
reinforcement for what the client can do. Blindness and other physical
symptoms in a conversion disorder aren't under the client's control and are real
to him. Eye exercises won't resolve the client's blindness because no organic
pathology is causing the symptoms.
Correct
12. The nurse is caring for a client, a Vietnam veteran, who exhibits signs
and symptoms of posttraumatic stress disorder. Signs and symptoms of
posttraumatic stress disorder include:
A. Hyper alertness and sleep disturbances.
B. Memory loss of traumatic event and somatic distress.

C. Feelings of hostility and violent behavior.
D. Sudden behavioral changes and anorexia.
Feedback
Signs and symptoms of posttraumatic stress disorder include
hyperalertness, sleep disturbances, exaggerated startle, survival guilt,
and memory impairment. Also, the client relives the traumatic event
through dreams and recollections. Hostility, violent behavior, and
anorexia aren't usual signs or symptoms of posttraumatic stress disorder.

Correct
13. A client is admitted with a diagnosis of schizotypal personality
disorder. Which signs would this client exhibit during social
situations?
A. Aggressive behavior
B. Paranoid thoughts
C. Emotional affect
D. Independence needs
Feedback
Clients with schizotypal personality disorder experience excessive
social anxiety that can lead to paranoid thoughts. Aggressive behavior
is uncommon, although these clients may experience agitation with
anxiety. Their behavior is emotionally cold with a flattened affect,
regardless of the situation. These clients demonstrate a reduced
capacity for close or dependent relationships.
Correct
14. The nurse is caring for a client who is suicidal. When accompanying
the client to the bathroom, the nurse should:
A. Give him privacy in the bathroom.

B. Allow him to shave.
C. Open the window and allow him to get some fresh air.
D. Observe him.
Feedback
The nurse has a responsibility to observe continuously the acutely
suicidal client & not provide privacy. The nurse should watch for
clues, such as communicating suicidal thoughts, threats, and messages;
hoarding medications; and talking about death. By accompanying the
client to the bathroom, the nurse will naturally prevent hanging or
other injury. The nurse will check the client's area and fix dangerous
conditions, such as exposed pipes and windows without safety glass.
The nurse will also remove potentially dangerous objects, such as
belts, razors, suspenders, glass, and knives.
Correct
15. A client with paranoid type schizophrenia becomes angry and tells the
nurse to leave him alone. The nurse should
A. Tell him that she'll leave for now but will return soon.
B. Ask him if it's okay if she sits quietly with him.

C. Ask him why he wants to be left alone
D. Tell him that she won't let anything happen to him
Feedback
If the client tells the nurse to leave, the nurse should leave but let the
client know that she'll return so that he doesn't feel abandoned. Not
heeding the client's request can agitate him further. Also, challenging
the client isn't therapeutic and may increase his anger. False
reassurance isn't warranted in this situation.
Correct
16. The nurse is caring for an adolescent female who reports amenorrhea,
weight loss, and depression. Which additional assessment finding
would suggest that the woman has an eating disorder?
A. Wearing tight-fitting clothing

B. Increased blood pressure
C. Oily skin
D. Excessive and ritualized exercise
Feedback
A client with an eating disorder will normally exercise to excess in an
effort to burn as many calories as possible. The client will usually wear
loose-fitting clothing to hide what she considers to be a fat body. Skin
and nails become dry and brittle, and blood pressure and body
temperature drop from excessive weight loss.
Correct
17. A high school student is referred to the school nurse for suspected
substance abuse. Following the nurse's assessment and interventions,
what would be the most desirable outcome?
A. The student discusses conflicts over drug use.

B. The student accepts a referral to a substance abuse
counselor.
C. The student agrees to inform his parents of the problem.
D. The student reports increased comfort with making choices.
Feedback
All of the outcomes stated are desirable; however, the best outcome is
that the student would agree to seek the assistance of a professional
substance abuse counselor.
Correct
18. A client with bipolar disorder is being treated with lithium for the first
time. The nurse should observe the client for which common adverse
effect of lithium?
A. Sexual dysfunction
B. Constipation
C. Polyuria
D. Seizures
Feedback
Polyuria commonly occurs early in the treatment with lithium and
could result in fluid volume deficit. Sexual dysfunction isn't a common
adverse effect of lithium; it's more common with sedatives and
tricyclic antidepressants. Diarrhea, not constipation, occurs with

lithium. Constipation can occur with other psychiatric drugs, such as
antipsychotic drugs. Seizures may be a later sign of lithium toxicity.
Correct
19. The nurse is caring for a client diagnosed with bulimia. The most
appropriate initial goal for a client diagnosed with bulimia is to:
A. Avoid shopping for large amounts of food.

B. Control eating impulses.
C. Identify anxiety-causing situations.
D. Eat only three meals per day.
Feedback
Bulimic behavior is generally a maladaptive coping response to stress
and underlying issues. The client must identify anxiety-causing
situations that stimulate the bulimic behavior and then learn new ways
of coping with the anxiety. Controlling shopping for large amounts of
food isn't a goal early in treatment. Managing eating impulses and
replacing them with adaptive coping mechanisms can be integrated
into the care plan after initially addressing stress and underlying issues.
Eating three meals per day isn't a realistic goal early in treatment.
Correct
20. A 24-year-old client is experiencing an acute schizophrenic episode.
He has vivid hallucinations that are making him agitated. The nurse's
best response at this time would be to:
A. Take the client's vital signs

B. Explore the content of the hallucinations.
C. Tell him his fear is unrealistic.

D. Engage the client in reality-oriented activities
Feedback
Exploring the content of the hallucinations will help the nurse
understand the client's perspective on the situation. The client shouldn't
be touched, such as in taking vital signs, without telling him exactly
what's going to happen. Debating with the client about his emotions
isn't therapeutic. When the client is calm, engage him in reality-based
activities.
Correct
21. In teaching a client about Alcoholics Anonymous, the nurse states that
Alcoholics Anonymous has helped in the rehabilitation of many
alcoholics, probably because many people find it easier to change their
behavior when they:
A. Have the support of rehabilitated alcoholics
B. Know that rehabilitated alcoholics will sympathize with them

C. Can depend on rehabilitated alcoholics to help them identify
personal problems related to alcoholism
D. Realize that rehabilitated alcoholics will help them develop defense
mechanisms to cope with their alcoholism.
Feedback
Membership in Alcoholics Anonymous is voluntary. Its rehabilitated
members are available to support alcoholics, and the understanding
and influence of these rehabilitated members often helps alcoholics
change their behavior. The role of rehabilitated members does not
include sympathizing with others abusing alcohol. The role of
rehabilitated members does not include helping others abusing alcohol
to identify personal problems. The role of rehabilitated members does
not include helping others abusing alcohol to develop defense
mechanisms to cope with alcoholism.
Correct
22. The nurse will conduct a psycho educational group for family
members about depression. Which of the following topics would be of
little help to the family members?
A. Managing the depressed client at home.
B. Drug classifications
C. Support and self-help groups.
D. Education about depression
Feedback
Focusing on antidepressant medications would be helpful, but the topic
of drug classifications is too general. A topic such as managing the

depressed client at home will help family members learn positive
techniques for managing day-to-day problems and will promote family
cohesiveness. A topic such as receiving support from self-help groups
is helpful to family members to reduce feelings of isolation and
powerlessness. Educating the family about the illness dispels myths,
enlists family cooperation, and promotes adaptive coping skills.
Correct
23. A client is a Vietnam War veteran with a diagnosis of posttraumatic
stress disorder. He has a history of nightmares, depression,
hopelessness, and alcohol abuse. Which option offers the client the
most lasting relief of his symptoms?
A. The opportunity to verbalize memories of trauma to a
sympathetic listener
B. Family support
C. Prescribed medications taken as ordered
D. Alcoholics Anonymous (AA) meetings
Feedback
Although it's difficult, clients with posttraumatic stress disorder can
obtain the most lasting relief if they verbalize memories of the trauma
to a sympathetic listener. Family members are commonly frightened
by the information and can't be consistently supportive.
Antidepressants may help but these drugs can mask feelings and can't
provide lasting relief. Treatment for alcohol abuse, including AA

meetings, must be considered when planning care but alone doesn't
provide lasting relief.
Correct
24. The nurse is caring for a client with a phobia who is being treated for the
condition. The client is introduced to short periods of exposure to the
phobic object while in a relaxed state. The nurse understands that this
form of behavior modification can best be described as:
A. Milieu therapy
B. Aversion therapy
C. Self-control therapy
D. Systematic desensitization
Feedback
Systematic desensitization is a form of therapy used when the client is
introduced to short periods of exposure to the phobic
object while in a relaxed state. Gradually exposure is increased until the
anxiety about or fear of the object or situation has ceased.
Options 1, 2, and 3 are incorrect.
Test-Taking Strategy: Use the process of elimination. Focus on the
strategic words introduced to short periods of exposure. This will direct
you to the correct option. If you had difficulty with this question, review
systematic desensitization.
Correct
25. The client with a diagnosis of anorexia nervosa, who is in a state of

starvation, is in a two-bed room. A newly admitted client will be assigned
to this client's room. Which of the following clients would be an
appropriate choice as this client's roommate?
A. A client with pneumonia

B. A client receiving diagnostic tests
C. A client who thrives on managing others

D. A client who could benefit from the client's assistance at Mealtime
Feedback
The client undergoing diagnostic tests is an acceptable roommate. The
client with anorexia nervosa is most likely experiencing hematological
complications, such as leukopenia. Having a roommate with pneumonia
would place the client with anorexia nervosa at risk for infection. The
client with anorexia nervosa should not be put in a situation in which the
client can focus on the nutritional needs of others or being managed by
others because this may contribute to sublimation and suppression of
personal hunger.
Correct
26. A hospitalized client is started on phenelzine sulfate (Nardil) for the
treatment of depression. The nurse instructs the client to avoid
consuming which foods while taking this medication? Select all that
apply.
A. Figs
B. Yogurt
C. Crackers
D. Aged cheese
E. Tossed salad
F. Oatmeal cookies
Feedback
Phenelzine sulfate (Nardil) is a monoamine oxidase inhibitor. The client
should avoid taking in foods that are high in tyramine. Use of these foods
could trigger a potentially fatal hypertensive crisis. Foods to avoid
include yogurt, aged cheeses, smoked or processed meats, red wines, and
fruits such as avocados, raisins, or figs.
Test-Taking Strategy: Recall that phenelzine sulfate is a monoamine
oxidase inhibitor and that foods high in tyramine needed to be avoided.
Next, from the food items listed in the question, identify the food that
contains tyramine. Review the food items to avoid with monoamine
oxidase inhibitors if you had difficulty with this question
Correct
27. A nurse enters a client's room, and the client is demanding release from
the hospital. The nurse reviews the client's record and notes that the client
was admitted 2 days ago for treatment of an anxiety disorder and that the
admission was a voluntary admission. Which of the following actions will
the nurse take?
A. Contact the physician.
B. Call the client's family.

C. Persuade the client to stay a few more days.
D. Tell the client that discharge is not possible at this time.
Feedback
Generally, the client seeks voluntary admission. Voluntary clients have
the right to demand and obtain release. If the client is a minor, the release
may be contingent on the consent of the parent(s) or guardian. The nurse
needs to be familiar with the state and facility policies and procedures.
Many states require that the client submit a written release notice to the
facility staff members, who reevaluate the client's condition for possible
conversion to involuntary status, according to criteria established by laws.
The best nursing action is to contact the physician. Test-Taking Strategy:
Use the process of elimination. Noting the type of hospital admission will
assist in eliminating option 4. To “persuade” a client to stay in the hospital
is inappropriate. Option 2 should be eliminated simply based on the
subjects of client rights and confidentiality. Review the various types of
hospital admission and discharge processes if you had difficulty with this
question.
Correct
28. The nurse assesses a client with the admitting diagnosis of bipolar
affective disorder, mania. The symptom presented by the client that
requires the nurse's immediate intervention is the client's:
A. Outlandish behaviors and inappropriate dress

B. Nonstop physical activity and poor nutritional intake
C. Grandiose delusions of being a royal descendent of King Arthur

D. Constant, incessant talking that includes sexual innuendoes and
teasing the staff
Feedback
Mania is a mood characterized by excitement, euphoria, hyperactivity,
excessive energy, decreased need for sleep, and impaired ability to
concentrate or complete a single train of thought. Mania is a period when
the mood is predominantly elevated, expansive, or irritable. All options
reflect a client's possible symptomatology. Option 2, however, clearly
presents a problem
that compromises physiological integrity and needs to be addressed
immediately.
Test-Taking Strategy: Note the strategic word immediate and use
Maslow's Hierarchy of Needs theory to assist you in answering the
question. Option 2 is the only option that reflects a physiological need.
Review care of the client with mania if you had difficulty
with this question.
Correct
29. The nurse is conducting a group therapy session, and a client with a manic
disorder is monopolizing the group. The appropriate nursing action is
which of the following?
A. Ask the client to leave.

B. Refer the client to another group.
C. Tell the client to stop monopolizing
D. Thank the client for the contribution and tell him or her to
allow others a chance to contribute
Feedback
If a client is monopolizing the group, the nurse must be direct and
decisive. The best action is to thank the client and suggest that the client
stop talking and try listening to others. Although
option 3 may be a direct response, option 4 is a more specific and direct
statement. Options 1 and 2 are inappropriate.
Test-Taking Strategy: Use the process of elimination. Eliminate options 1
and 2 first because they are comparative or alike. Use therapeutic
communication techniques to assist in directing you to option 4. If you
had difficulty with this question, review therapeutic communication
techniques for the client with a manic disorder.
Correct
30. The spouse of a client admitted to the mental health unit for
alcohol withdrawal says to the nurse, "I should get out of this bad
situation." The most helpful response by the nurse would be:
A. “Why don't you tell your husband about this?”

B. “What do you find difficult about this situation?”
C. “This is not the best time to make that decision.”

D. “I agree with you. You should get out of this situation.”
Feedback
The most helpful response is one that encourages the client to solve
problems. Giving advice implies that the nurse knows what is best and
also can foster dependency. The nurse should not agree with the client,
nor should the nurse request that the client provide explanations.
Test-Taking Strategy: Use therapeutic communication techniques.
Eliminate option 1 because of the word why, which should be avoided in
communication. Eliminate option 4 because the nurse is agreeing with
the client. Eliminate option 3 because this option places the client's
feelings on hold. Option 2 is the only option that addresses the client's
feelings. Review therapeutic communication techniques if you had
difficulty with this question.
Correct
31. An 18-year-old woman is admitted to an inpatient mental health unit with
the diagnosis of anorexia nervosa. A cognitive behavioral approach is
used as part of her treatment plan. The nurse understands that the purpose
of this approach is to:
A. Provide a supportive environment.

B. Examine intrapsychic conflicts and past issues.
C. Emphasize social interaction with clients who withdraw.
D. Help the client identify and examine dysfunctional
thoughts and beliefs.
Feedback
Cognitive behavioral therapy is used to help the client identify and
examine dysfunctional thoughts and to identify and examine values and
beliefs that maintain these thoughts. Options 1, 2, and 3 are incorrect.
Test-Taking Strategy: Use the process of elimination and note the
strategic words cognitive behavioral. Focusing on these words should
direct you to option 4. If you are unfamiliar with this type of therapy and
its purpose, review this content.
Correct
32. A nurse is preparing to care for a dying client, and several family
members are at the client's bedside. Select the therapeutic techniques that
the nurse will use when communicating with the family. Select all that
apply.
A. Discourage reminiscing.
B. Make the decisions for the family.
C. Encourage expression of feelings, concerns, and fears.
D. Explain everything that is happening to all family members.

E. Extend touch and hold the client's or family member's
hand if appropriate.
F. Be honest and truthful and let the client and family know
that you will not abandon them.
Feedback
The nurse must determine whether there is a spokesperson for the family
and how much the client and family want to know. The nurse needs to
allow the family and client the opportunity for
informed choices and assist with the decision-making process if
asked. The nurse should encourage expression of feelings, concerns, and
fears, as well as reminiscing. The nurse needs to be honest and truthful
and let the client and family know that they will not be abandoned.
Extend touch and hold the client's or family member's hand, if
appropriate.
Test-Taking Strategy: Recalling therapeutic communication techniques
and client and family rights will assist you in answering
this question. Review these techniques and care of the dying client if you
had difficulty with this question.
Correct
33. The depressed client verbalizes feelings of low self-esteem and self-
worth typified by statements such as "I'm such a failure. I can't do
anything right." The best nursing response would be to:
A. Tell the client that this is not true, that we all have a purpose in
life.
B. Identify recent behaviors or accomplishments that
demonstrate the client's skills.
C. Reassure the client that you know how the client is feeling and that
things will get better.

D. Remain with the client and sit in silence; this will encourage the client
to verbalize feelings.
Feedback
Feelings of low self-esteem and worthlessness are common symptoms of
the depressed client. An effective plan of care to enhance the client's
personal self-esteem is to provide experiences for the client that are
challenging but that will not be met with failure. Reminders of the client's
past accomplishments or personal successes are ways to interrupt the
client's negative self-talk and distorted cognitive view of self. Silence may
be interpreted as agreement. Options 1 and 3 give advice and devalue the
client's feelings.
Test-Taking Strategy: Use the process of elimination and therapeutic
communication techniques. Focus on the client's diagnosis. You can
eliminate options 1 and 3 easily. From the remaining options, focusing on
the client's diagnosis will direct you to option 2. Review care of the client
with depression if you had difficulty with this question.
Correct
34. A client is admitted to the hospital with a diagnosis of major depression,
severe, single episode. The nurse assesses the client and identifies a
nursing diagnosis of nutrition: less than body requirements, imbalanced
related to poor nutritional intake. The appropriate nursing intervention
related to this diagnosis is:
A. Weigh the client three times per week before breakfast.

B. Explain to the client the importance of a good nutritional intake.
C. Schedule brief nursing interactions with the client during
several meals in which small portions are offered.

D. Report the nutritional concern to the psychiatrist and obtain a
nutritional consultation as soon as possible.
Feedback
Change in appetite is one of the major symptoms of depression. Other
symptoms include a depressed mood, increased fatigue, feelings of
worthlessness, diminished ability to think, or indecisiveness and
psychomotor agitation or retardation. Option 2 is incorrect because the
client is experiencing poor concentration; thus, even if the client does
understand the rationale, the client still may not be able to complete
tasks. Weighing the client does not address how to increase nutritional
intake. Reporting to the psychiatrist and the nutritionist is to some
degree correct but does not present a method to increase food intake.
Test-Taking Strategy: Use the process of elimination, focusing on the
subject, poor nutritional status. Option 3 is the only option that addresses
the imbalanced nutrition concretely and designs a method in which the
client feasibly will increase the nutritional intake.
Review care of the client with depression if you had difficulty with this
question.
Correct
35. The nurse is discharging a client with a history of command
hallucinations to harm self or others. The nurse provides instructions to

the client about interventions for hallucinations and anxiety and
determines that the client understands the instructions if the client states:
A. “My medications won't make me anxious.”

B. “I'll go to support group and talk so that I don't hurt anyone.”
C. “I won't get anxious or hear things if I get enough sleep and eat well.”
D. “I can call my therapist when I'm hallucinating so that I
can talk about my feelings and plans and not hurt

anyone.”
Feedback
The risk for impulsive and aggressive behavior may increase if a client is
receiving command hallucinations to harm self or others. The nurse
should ask the client whether he or she has intentions to hurt himself or
herself or others. Talking about auditory hallucinations can interfere with
subvocal muscular
activity associated with a hallucination. Options 1, 2, and 3 will aid in
wellness but are not specific interventions for hallucinations, if they occur.
Test-Taking Strategy: Use the process of elimination. Options 1, 2, and 3
are interventions that a client can carry out to aid wellness. Option 4 is a
specific agreement to seek help and evidences self-responsible
commitment and control over one's own behavior. Review teaching points
for a client with a history of hallucinations
if you had difficulty with this question.
Correct
36. The nurse is performing an assessment on a client with dementia. Which
data gathered during the assessment indicate a manifestation associated
with dementia?
A. Confabulation
B. Improvement in sleeping
C. Absence of sundown syndrome
D. Presence of personal hygienic care
Feedback
The clinical picture of dementia varies from the development of mild
cognitive defects to severe, life-threatening alterations in neurological
functioning. For the client to use confabulation or the fabrication of
events or experiences to fill in memory gaps is not unusual. Often, lack
of inhibitions on the part of the client may constitute the first indication
of anything being “wrong” to the client's significant others (the client
may undress in front of others or demonstrate slovenly table manners but
was formerly well mannered). As the dementia progresses, the client will
have episodes of wandering or sundowning.
Test-Taking Strategy: Use the process of elimination and focus on the
client's diagnosis. Noting the subject, a manifestation, will direct you to
option 1. If you had difficulty with this question, review the
manifestations associated with dementia.
Correct
37. A client with a diagnosis of major depression, recurrent, with psychotic

features, is admitted to the mental health unit. To create a safe
environment for the client, the nurse most importantly devises a plan of
care that deals specifically with the client's:
A. Self-care deficit.
B. Imbalanced nutrition.
C. Deficient knowledge.
D. Disturbed thought processes.
Feedback
Major depression, recurrent, with psychotic features, alerts the nurse that
in addition to the criteria that designates the diagnosis of major
depression, one also must deal with the client's psychosis. Psychosis is
defined as a state in which a person's mental capacity to recognize reality
and to communicate and relate to
others is impaired, thus interfering with the person's ability to deal with
the demands of life. Disturbed thought processes generally indicate a state
of increased anxiety in which hallucinations and delusions prevail.
Although all the nursing diagnoses may be appropriate because the client
is experiencing psychosis, option 4 is the correct option.
Test-Taking Strategy: Use the process of elimination. All the nursing
diagnoses listed may be appropriate for a client diagnosed with major
depression. The strategic words leading to the correct option are psychotic
features, in which the client often suffers with disturbed thought
processes, such as hallucinations and delusions. Review appropriate

nursing diagnoses for major depression and psychotic features if you had
Correct
38. The nurse develops a nursing diagnosis of self-care deficit for an older
client with dementia. Which of the following is an appropriate goal for
this client?
A. The client will function at the highest level of

independence possible.
B. The client will complete all activities of daily living independently
within a 1-hour time frame.
C. The client will be admitted to a long-term care facility to have
activities of daily living needs met.
D. The nursing staff will attend to all the client's activities of daily living
needs during the hospital stay.
Feedback
All clients, regardless of age, need to be encouraged to perform at the
highest level of independence possible. Independence contributes to the
client's sense of control and sense of well-being. Option 3 is incorrect
because what the self-care deficit entails is not known. To assume that
the client requires long-term care based on so little information would be
erroneous. Options 2 and 4 are close-ended statements.
and 4 first because of the close-ended word all. From the remaining
options, select option 1 because it is the umbrella option. Review care of
the client with dementia if you had difficulty with
this question.
Correct
39. The nurse is working with a client who has sought counseling after trying
to rescue a neighbor involved in a house fire. In spite of the client's
efforts, the neighbor died. Which action does the nurse engage in with the
client during the working phase of the nurse-client relationship?
A. Exploring the client's ability to function

B. Exploring the client's potential for self-harm
C. Inquiring about the client's perception or appraisal of the neighbor's
death
D. Inquiring about and examining the client's feelings that
may block adaptive coping
Feedback
The client must first deal with feelings and negative responses before the
client can work through the meaning of the crisis. Option 4 pertains
directly to the client's feelings. Options 1 and 2 do not directly address the
client's feelings. Option 3 is more of an assessment question.
Test-Taking Strategy: Focus on the subject of the question, the working
phase of the nurse-client relationship. Think about the interventions that
occur in this phase. Using the process of elimination, focus on this subject
and on the option that focuses on the feelings of the client. This will direct
you to option 4. Review the phases of the nurse-client relationship if you
Correct
40. A female client with anorexia nervosa is a member of a predischarge
support group. The client verbalizes that she would like to buy some new
clothes, but her finances are limited. Group members have brought some
used clothes to the client to replace the client's old clothes. The client
believes that the new clothes were much too tight and has reduced her
calorie intake to 800 calories daily. The nurse analyzes this behavior as:
A. Normal behavior
B. Evidence of the client's disturbed body image
C. Regression as the client is moving toward the community

D. Indicative of the client's ambivalence about hospital discharge
Feedback
Disturbed body image is a concern with clients with anorexia nervosa.
Although the client may struggle with
ambivalence and show regressed behavior, the client's coping pattern
relates to the basic issue of disturbed body image. The nurse should
address this need in the support group.
Test-Taking Strategy: Use the process of elimination, focusing on the
information provided in the question, which is related directly to an
altered body image. This should direct you to the correct option. Review
the needs of the client with anorexia nervosa if you had difficulty with
this question.
Correct
41. During the termination phase of the nurse-client relationship, the clinic
nurse observes that the client has made several sarcastic remarks and has
an angry affect. The most appropriate interpretation of the behavior is that
the client:
A. Needs to be admitted to the hospital.

B. Needs to be referred to the psychiatrist as soon as possible.
C. Requires further treatment and is not ready to be discharged.
D. Is displaying typical behaviors that can occur during
termination.
Feedback
In the termination phase of a relationship, it is normal for a client to
demonstrate a number of regressive behaviors that can be disturbing to the
nurse. Typical behaviors include return of symptoms, anger, withdrawal,
and minimizing the relationship. The anger that the client is experiencing
is a normal behavior during the termination phase and does not
necessarily indicate the need for hospitalization or treatment.
Test-Taking Strategy: Note the strategic words termination phase. This
alone may assist in directing you to option 4. Additionally,
note that options 1, 2, and 3 are comparable. These options address the
need for further supervised treatment. If you are unfamiliar with the client
behaviors associated with the termination phase, review this content.

Correct
42. A client who is delusional says to the nurse, "The federal guards were
sent to kill me." The nurse's best response is:
A. “I don't believe this is true.”

B. “The guards are not out to kill you.”
C. “What makes you think the guards were sent to hurt you?”
D. “I don't know anything about the guards. Do you feel
afraid that people are trying to hurt you?”
Feedback
For the nurse to empathize with the client's experience is most
therapeutic. Disagreeing with delusions may make the client more
defensive, and the client may cling to the delusions even
more. Encouraging discussion regarding the delusion is
inappropriate.
Test-Taking Strategy: Use therapeutic communication techniques.
Eliminate options 1 and 2 because they are comparative or alike and are
statements that disagree with the client. Option 3 encourages discussion
regarding the delusion. Review communication techniques with the client
experiencing delusions if you had
Correct
43. A client who has just been sexually assaulted is quiet and calm. The nurse
analyzes this behavior as indicating which defense mechanism?
A. Denial
B. Projection
C. Rationalization
D. Intellectualization
Feedback
Denial is refusal to admit to a painful reality and may be a response by a
victim of sexual abuse. Projection is transferring one's internal feelings,
thoughts, and unacceptable ideas and traits to someone else.
Rationalization is justifying the unacceptable attributes about oneself.
Intellectualization is the excessive use of abstract thinking or
generalizations to decrease painful thinking. Test-Taking Strategy: Use
the process of elimination and note the strategic words calm and quiet.
These behaviors indicate denial in a sexually abused victim. If you had
difficulty with this question,
review content related to the sexually abused victim and defense
mechanisms.
Correct
44. A client with a diagnosis of major depression who has attempted suicide
says to the nurse, "I should have died. I've always been a failure. Nothing
ever goes right for me." The therapeutic response to the client is:
A. “I don't see you as a failure.”
B. “You have everything to live for.”

C. “Feeling like this is all part of being ill.”
D. “You've been feeling like a failure for a while?”
Feedback
Responding to the feelings expressed by a client is an effective
therapeutic communication technique. The correct option is an example
of the use of restating. Options 1, 2, and 3 block communication because
they minimize the client's experience and do not facilitate exploration of
the client's expressed feelings. Test-Taking Strategy: Use the process of
elimination and therapeutic communication techniques to direct you to
the option that directly addresses the client's feelings and concerns. Also,
option 4 is the only option stated in the form of a question and is open-
ended; thus, it will encourage the verbalization of feelings. Review
therapeutic communication techniques if you had difficulty with this
question.
Correct
45. The 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?
A. “Go on.”
B. “Sleeping?”
C. “You're having difficulty sleeping?”
D. “Sometimes, I have trouble sleeping too.”
Feedback
Option 3 uses the therapeutic communication technique of restatement.
Although restatement is a technique that has a prompting component to it,
it repeats the client's major theme,
which assists the nurse to obtain a more specific perception of the problem
from the client. Options 1, 2, and 4 are not therapeutic responses.
Test-Taking Strategy: Use the process of elimination. Option 1 is a
general lead and allows the client to direct the discussion. Option 2 uses
reflection, which simply repeats the client's last words to prompt further
discussion. Option 4 focuses on the nurse's problem. Option 3 will provide
the perception of the problem from the
client's perspective. Review therapeutic communication techniques if you
Correct
46. When planning the discharge of a client with chronic anxiety, the nurse
directs the goals at promoting a safe environment at home. The
appropriate maintenance goal should focus on which of the following?
A. Ignoring feelings of anxiety

B. Identifying anxiety-producing situations
C. Continued contact with a crisis counselor

D. Eliminating all anxiety from daily situations
Feedback
Recognizing situations that produce anxiety allows the client to prepare

to cope with anxiety or avoid a specific stimulus. Counselors will not be
available for all anxiety-producing
situations, and this option does not encourage the development of
internal strengths. Ignoring feelings will not resolve anxiety. Elimination
of all anxiety from life is impossible.
Test-Taking Strategy: Use the process of elimination. Eliminate option 4
first because of the word all. Eliminate option 1 next, because feelings
should not be ignored. From the remaining options, select option 2
because this option is more client-centered and helps prepare the client to
deal with anxiety should it occur. Review home care planning for the
client with chronic anxiety if you had
Correct
47. All treatment team members are seen as equally important in helping
clients meet their treatment goals. This type of therapy approach is:
A. Milieu therapy
B. Interpersonal therapy
C. Behavior modification
D. Rational emotive therapy
Feedback
All treatment team members are viewed as significant and valuable to the
client's successful treatment outcomes in milieu therapy. Behavior
modification is based on rewards and punishment. Rational emotive

therapy deals with the correction of distorted
thinking. Interpersonal therapy on the other hand is based on a one-to-one
or group therapy approach in which the therapist-client relationship is
often used as a way for the client to examine other relationships in his or
her life.
Test-Taking Strategy: Focus on the subject. Note the relationship between
the words helping clients to meet their treatment goals and option 1.
Review the types of therapy noted in the options if you had difficulty with
this question.
Correct
48. A home health nurse is talking to the spouse of a client taking
an antidepressant. The spouse says, "Now that my husband is
responding to the antidepressant, the suicidal risk is over and you can
stop making these home visits." After analyzing this statement, which
of the following is the appropriate nursing response?
A. “I need to continue with my visits. Your comment reflects a lack of

knowledge that this disease runs in families.”
B. “I agree with you. Clients who want to kill themselves are only
suicidal for a limited time. No one can feel self-destructive forever.”
C. “I agree with you. The suicidal threats were really attention seeking.
Continuing to visit would reinforce your husband's use of
manipulation.”
D. “I need to continue with my visits. Most suicides occur
within 3 months after improvement begins because the

client now has the energy to carry out the suicidal
intentions.”
Feedback
Most suicides occur within 3 months after the beginning of the
improvement, when the client has the energy to carry out the suicidal
intentions. Options 1, 2, and 3 are incorrect because they fail to address
safety and involve giving false information. Test-Taking Strategy: Use
the process of elimination and knowledge regarding the facts about
suicide to answer the question. Recalling that a critical time for a suicidal
client is when the client has energy will direct you to option 4. Review
the concepts related
to suicide and therapeutic communication techniques if you had
Correct
49. The supervisor reprimands the nurse in charge of the nursing unit because
the charge nurse has not adhered to the unit budget. Later that afternoon,
the charge nurse accuses the nursing staff of wasting supplies. This
behavior is an example of:
A. Denial
B. Repression
C. Suppression
D. Displacement
Feedback
Ego defense mechanisms are operations outside of a person's awareness
that the ego calls into play to protect against anxiety. Displacement is the
discharging of pent-up feelings on persons less threatening than those who
initially aroused the emotion. Denial is the blocking out of painful or
anxiety-inducing events or feelings. Repression is unconsciously keeping
unacceptable feelings out of awareness. Suppression is consciously
keeping unacceptable feelings and thoughts out of awareness. Test-Taking
Strategy: Use the process of elimination. Read the behavior identified in
the question to assist you in determining the type of ego defense
mechanism or behavior used. Remember that displacement is the
discharging of pent-up feelings on persons less threatening than those who
initially aroused the emotion. If you had difficulty with this question,
review defense mechanisms
Correct
50. The manic client announces to everyone in the dayroom that a stripper is
coming to perform this evening. When the nurse firmly states that this
will not happen, the manic client becomes verbally abusive and threatens
physical violence to the nurse. Based on the analysis of this situation, the
nurse determines that the appropriate action would be to:
A. Orient the client to time, person, and place.

B. Tell the client that the behavior is not appropriate.
C. Escort the manic client to her room, with assistance.
D. Tell the client that smoking privileges are revoked for 24 hours.
Feedback
The client is at risk for injury to self and others and therefore should be
escorted out of the dayroom. Antipsychotic medications are useful to
manage the manic client. Hyperactive and agitated behavior usually
responds to haloperidol (Haldol). Option 4 may increase the agitation
that already exists in this client. Orientation will not halt the behavior.
Telling the client that the behavior is not appropriate already has been
attempted by the nurse. Test-Taking Strategy: Use the process of
elimination and Maslow's Hierarchy of Needs theory to answer the
question. Look for the option that promotes safety of the client, other
clients, and staff. If you had difficulty with this question, review the
appropriate interventions when dealing with a manic client.
Correct
51. The nurse is caring for a client with anorexia nervosa. The nurse is
monitoring the behavior of the client and understands that the client with
anorexia nervosa manages anxiety by:
A. Engaging in immoral acts

B. Always reinforcing self-approval
C. Observing rigid rules and regulations
D. Having the need always to make the right decision
Feedback
Clients with anorexia nervosa have the desire to please others. Their need
to be correct or perfect interferes with rational decision-making processes.
These clients are moralistic. Rules and rituals help the clients manage
their anxiety.
subject, managing anxiety. Eliminate options 2 and 4 because of the close-
ended word always. Option 1 is not characteristic of the client with
anorexia. Review the characteristics associated with this disorder if you
Correct
52. Select the appropriate interventions for caring for the client in alcohol
withdrawal. Select all that apply.
A. Monitor vital signs.
B. Maintain an NPO status.

C. Provide a safe environment
D. Address hallucinations therapeutically.
E. Provide stimulation in the environment

F. Provide reality orientation as appropriate.
Feedback
When the client is experiencing withdrawal from alcohol, the priority for
care is to prevent the client from harming himself or herself or others.

The nurse would provide a low stimulating environment to maintain the
client in as calm a state as possible. The nurse would monitor the vital
signs closely and report abnormal findings. The nurse would reorient the
client to reality frequently and would address hallucinations
therapeutically. Adequate nutritional and fluid intake need to be
maintained.
Test-Taking Strategy: Use therapeutic communication techniques to
assist in selecting the correct interventions. Also, recalling the
characteristics associated with alcohol withdrawal will assist in
answering correctly.
Review these interventions if you had difficulty with this question.
Correct
53. Select the characteristics of the termination stage of group development.
Select all that apply.
A. The group evaluates the experience.
B. The real work of the group is accomplished.

C. Group interaction involves superficial conversation.
D. Group members become acquainted with each other.
E. Some structuring of group norms, roles, and responsibilities take place.
F. The group explores members' feelings about the group
and the impending separation.
Feedback
The stages of group development include the initial stage, the working
stage, and the termination stage. During the initial stage, the group
members become acquainted with each other and some structuring of
group norms, roles, and responsibilities take place. During the initial
stage, group interaction involves superficial conversation During the
working stage, the real work of the group is accomplished. During the
termination stage. the group evaluates the experience and explores
members' feelings about the group and the impending separation.
Test-Taking Strategy: Focus on the subject, the termination stage.
Reading each item presented and recalling the stages of group
development will assist in answering this question. Review these stages if
you had difficulty with this question.
Correct
54. The nurse is caring for a client who is scheduled for electroconvulsive
therapy. The nurse notes that an informed consent has not been obtained
for the procedure. On review of the record, the nurse notes that the
admission was an involuntary hospitalization. Based on this information,
the nurse determines:
A. That the physician will provide the informed consent

B. That an informed consent does not need to be obtained
C. That an informed consent should be obtained from the family
D. That an informed consent needs to be obtained from the
client
Feedback
Clients who are admitted involuntarily do not lose their right to informed
consent. Clients must be considered legally competent until they have
been declared incompetent through a legal proceeding. The informed
consent needs to be obtained from the client.
Test-Taking Strategy: Knowledge regarding the hospital admission
processes and client's rights is necessary to answer this question. If you
had difficulty with this question, focus on the subject of client rights to
direct you to option 4. Review client rights if you had difficulty with this
question.
Correct
55. The nurse employed in a mental health unit is assigned to care for a client
admitted to the unit 2 days ago. On review of the client's record, the nurse
notes that the admission was a voluntary admission. Based on this type of
admission, the nurse anticipates which of the following?
A. The client will resist treatment measures.

B. The client will be angry and will refuse care.
C. The client's family will resist treatment measures.
D. The client will participate in the planning of the care and
treatment plan
Feedback
Generally, the client seeks voluntary admission. A voluntary admission

permits a client to make a written application for admission. If the client
seeks voluntary admission, the most likely expectation is that the client
will participate in the treatment program. Options 1, 2, and 3 are not
characteristics of this type of admission.
Test-Taking Strategy: Use the process of admission. Note the strategic
words voluntary admission. This should direct you to option 4.
Additionally, note that options 1, 2, and 3 are comparative or alike.
Review the various types of hospital admission processes if you had
Correct
56. A client with major depression is considering cognitive therapy.
The client asks the nurse, "How does this treatment work?" The nurse
responds and tells the client that:
A. “This type of treatment will help you relax and develop new
coping skills.”
B. “This type of treatment helps you confront your fears by gradually
exposing you to them.”
C. “This type of treatment helps you examine how your past life has
contributed to your problems.”
D. This type of treatment helps you examine how your
thoughts and feelings contribute to your difficulties.”
Feedback
Cognitive therapy frequently is used for clients with depression. This

type of therapy is based on exploring the client's subjective experience.
Cognitive therapy includes examining the client's thoughts and feelings
about situations and how these thoughts and feelings contribute to and
perpetuate the client's difficulties and mood.
Test-Taking Strategy: Focusing on the word cognitive will assist you in
selecting the correct option. Look for a similar word used in the
question and repeated in one of the options. Note the relationship of the
word cognitive in the question and thoughts in option 4. Review this
form of therapy if you had difficulty with this question.
Correct
57. The client is unwilling to go out of the house for fear of
"doing something crazy in public." Because of this fear, the client
remains homebound, except when accompanied outside by the spouse.
Based on this data, the nurse determines that the client is experiencing:
A. Agoraphobia
B. Social phobia
C. Claustrophobia
D. Hypochondriasis
Feedback
Agoraphobia is a fear of open spaces and the fear of being trapped in a
situation from which there may not be an escape. Agoraphobia includes
the possibility of experiencing a sense of helplessness or embarrassment
if an attack occurs. Avoidance of such situations usually results in

reduction of social and professional interactions. Social phobia focuses
more on specific situations, such as the fear of speaking, performing, or
eating in public. Claustrophobia is a fear of closed places. Clients with
hypochondriacal symptoms focus their anxiety on physical complaints
and are preoccupied with their health.
Test-Taking Strategy: Use the process of elimination. Focusing on the
strategic words remains homebound will direct you to option 1. If you
had difficulty with this question, review phobia types and associated
client behaviors.
Correct
58. The nurse is providing care to a client admitted to the hospital with a
diagnosis of acute anxiety disorder. While conversing with the client, the
client says to the nurse, "I have a secret that I want to tell you. You won't
tell anyone about it, will you?" The appropriate nursing response is which
of the following?
A. “No, I won't tell anyone.”

B. “I cannot promise to keep a secret.”
C. “If you tell me the secret, I will tell it to your doctor.”

D. “If you tell me the secret, I will need to document it in your record.”
Feedback
The nurse should never promise to keep a secret. Secrets are appropriate
in a social relationship but not in a therapeutic one.
The nurse needs to be honest with the client and tell the client that a
promise cannot be made to keep the secret. Options 1, 3, and 4 are
inappropriate responses.
Test-Taking Strategy: Use the process of elimination. Option 1 can be
eliminated easily because it is inappropriate. Options 3 and 4 are not only
inappropriate but are also somewhat threatening and may even block
further communication. Review therapeutic communication techniques
and the nurse-client relationship if you had difficulty with this question.
Correct
59. A nurse is conducting a group therapy session. During the session, a
client with mania consistently talks and dominates the group session, and
her behavior is disrupting group interactions. The nurse would initially:
A. Ask the client to leave the group session.

B. Ask another nurse to escort the client out of the group session.
C. Tell the client that she will not be able to attend any future group
sessions.
D. Tell the client that she needs to allow other clients in the
group time to talk.
Feedback
Manic clients may be talkative and can dominate group meetings or
therapy sessions by their excessive talking. If this occurs, the nurse
initially would set limits on the client's behavior. Initially, asking the
client to leave the session or asking another person to escort the client out
of the session is inappropriate. This may agitate the client and further
escalate the client's behavior. Option 2 is also an inappropriate initial
action because it violates the client's right to receive treatment and is a
threatening action. Test-Taking Strategy: Use the process of elimination
and note the strategic word initially. Eliminate options 1 and 2 first
because they are comparative or alike. Next, eliminate option 3 because it
violates the client's right to receive treatment and is a threatening action.
Remember that setting firm limits with the client initially is best. Review
care of a client with mania if you had difficulty with this question.
Correct
60. The nurse observes that a client is pacing, agitated, and presenting
aggressive gestures. The client's speech pattern is rapid, and affect is
belligerent. Based on these observations, the nurse's immediate priority of
care is to:
A. Provide safety for the client and other clients on the unit.
B. Provide the clients on the unit with a sense of comfort and safety.
C. Assist the staff in caring for the client in a controlled environment.
D. Offer the client a less stimulated area to calm down and gain control.
Feedback
Safety of the client and other clients is the priority. Option 1 is the only
option that addresses the client and other
clients' safety needs. Option 2 addresses other clients' needs. Option 3 is
not client-centered. Option 4 addresses the client's needs. Test-Taking
Strategy: Note the strategic words immediate priority and use Maslow's
hierarchy of needs theory to prioritize. Note the words agitated,
aggressive, and belligerent. Safety is the strategic subject. Option 1 is the
umbrella option and addresses the safety of all. Review nursing
interventions to provide safety to clients if you had difficulty with this
question.
Correct
61. The nurse is caring for a male client diagnosed with catatonic stupor. The
client is lying on the bed with his body pulled into a fetal position. The
appropriate nursing intervention is which of the following?
A. Ask direct questions to encourage talking.

B. Leave the client alone and intermittently check on him.
C. Sit beside the client in silence with occasional open-ended
questions.
D. Take the client into the dayroom with other clients so that they can
help watch him.
Feedback
Clients who are withdrawn may be immobile and mute and may require
consistent, repeated approaches. Communication with withdrawn clients
requires much patience from the nurse. Interventions include the
establishment of interpersonal contact. The nurse facilitates
communication with the client by sitting in silence, asking open-ended
questions, and pausing to provide opportunities for the client to respond.
Test-Taking Strategy: Eliminate option 2 because the client would not be

left alone. Option 4 relies on other clients to care for this client, which is
an inappropriate expectation. Asking direct questions of this client is not
therapeutic. Option 3 provides for client supervision and communication
as appropriate. Review care of the client with catatonic stupor if this
question was difficult.
Correct
62. A nurse employed in a mental health unit of a hospital is the leader of a
group psychotherapy session. The nurse's role in the termination stage of
group development is to:
A. Encourage problem-solving.
B. Encourage accomplishment of the group's work.
C. Acknowledge the contributions of each group member.
D. Encourage members to become acquainted with one another.
Feedback
In the termination stage, the group leader's task is to acknowledge the
contributions of each member and the experience of the group as a whole.
In this stage, the group members prepare for separation and assist each
other to prepare for the future. Options 1 and 2 identify the tasks of the
working stage. Option 4 identifies the orientation stage.
and 2 first because they are comparative or alike. From the remaining
options, note the relationship between the words termination stage in the
question and option 3. Review the stages of group development if you had
Correct
63. Laboratory work is prescribed for a client who has been experiencing
delusions. When the nurse approaches the client to obtain a specimen of
the client's blood, the client begins to shout "You're all vampires. Let me
out of here!" The appropriate nursing response is which of
the following?
A. “What makes you think that I am a vampire?”

B. “I'll leave and come back later for your blood.”
C. “I am not going to hurt you; I am going to help you.”
D. “It must be frightening to think that others want to hurt
you.”
Feedback
Option 4 helps the client focus on the emotion underlying the delusion
but does not argue with it. Option 1 places the client in a position that
requires a response. Option 2 avoids the client. Option 3 is an attempt to
convince the client to believe another thought. This response may cause
the client to hold the delusion more strongly.
Test-Taking Strategy: Use the process of elimination and therapeutic
communication techniques to answer the question. Option 4 is the only
option that recognizes the client's needs and focuses on the client's
feelings. Review therapeutic communication techniques if you had

Correct
64. A male client with delirium becomes disoriented and confused in his
room at night. The best initial nursing intervention is to:
A. Move the client next to the nurse's station.

B. Use an indirect light source and turn off the television.
C. Keep the television and a soft light on during the night.

D. Play soft music during the night, and maintain a well-lit room.
Feedback
Provision of a consistent daily routine and a low stimulating environment
is important when the client is disorientated. Noise, including radio and
television, may add to the confusion and disorientation. Moving the client
next to the nurses' station is not the initial action.
Test-Taking Strategy: Use the process of elimination and note the
strategic word initial in the question. Eliminate options 3 and 4 first
because they are comparative or alike. Focusing on the strategic word will
direct you easily to option 2. Review measures related to the client who is
disoriented and confused if you had difficulty with this question.
Correct
65. A client begins to experience extrapyramidal side effects from an
antipsychotic medication. The nurse anticipates that the physician will
prescribe which of the following to treat this condition?
A. Haloperidol (Haldol)
B. Benztropine (Cogentin)
C. Prochlorperazine (Compazine)
D. Chlorpromazine (Thorazine)
Feedback
Benztropine (Cogentin) is an anticholinergic medication used to treat
drug-induced extrapyramidal reactions, except tardive dyskinesia.
Options 1, 3, and 4 are antipsychotic medications. Antipsychotic
medications can cause extrapyramidal reactions Test-Taking Strategy:
Focus on the medications in the options. Recalling the classifications of
each will direct you to option 2. Remember that benztropine (Cogentin)
is an anticholinergic medication. Review the side effects and
extrapyramidal reactions of antipsychotic medications if you had
Correct
66. A client admitted to the mental health unit is experiencing disturbed
thought processes and believes that the food is being poisoned. Which
communication technique does the nurse plan to use to encourage the
client to eat?
A. Using open-ended questions and silence
B. Focusing on self-disclosure regarding food preferences

C. Identifying the reasons that the client may not want to eat
D. Offering opinions about the necessity of adequate nutrition
Feedback
Open-ended questions and silence are strategies used to encourage clients
to discuss their problems. Options 3 and 4 are not helpful to the client
because they do not encourage the client to express feelings. The nurse
should not offer opinions and should encourage the client to identify the
reasons for the behavior. Option
2 is not a client-centered intervention.
and 4 first because they do not support client expression of feelings.
Eliminate option 2 next because it is not a client-centered response.
Focusing on the client's feelings will direct you to option 1. Review
therapeutic communication techniques if you had difficulty with this
question.
Correct
67. The nurse is caring for a female client who was admitted to the mental
health unit recently for anorexia nervosa. The nurse enters the client's
room and notes that the client is engaged in rigorous push-ups. Which
nursing action is appropriate?
A. Interrupt the client and weigh her immediately.

B. Interrupt the client and offer to take her for a walk.
C. Allow the client to complete her exercise program.

D. Tell the client that she is not allowed to exercise rigorously.
Feedback
Clients with anorexia nervosa frequently are preoccupied with rigorous
exercise and push themselves beyond normal limits to work off caloric
intake. The nurse must provide for appropriate exercise and place limits
on rigorous activities. Options 1, 3, and 4 are inappropriate nursing
actions.
client's diagnosis. Also, focus on the need for the nurse to set firm limits
with clients who have this disorder. If you had difficulty with this
question, review interventions for the client with anorexia nervosa.
Correct
68. The client with schizophrenia has been started on medication therapy with
clozapine (Clozaril). The nurse assesses the results of which laboratory
study to monitor for adverse effects from this medication?
A. Platelet count
B. Blood glucose level
C. White blood cell count
D. Liver function studies
Feedback
The client taking clozapine (Clozaril) may experience agranulocytosis,
which is monitored by reviewing the results of the white blood cell count.
Treatment is interrupted if the white blood cell count drops below
3000/mm3. Agranulocytosis could be fatal if undetected and untreated.

The other options are not related specifically to the use of this medication.
Test-Taking Strategy: Use the process of elimination. Recalling that this
medication causes agranulocytosis will direct you to option 3. Review the
adverse effects of this medication if you had
difficulty with this question
Correct
69. A client with an eating disorder is planning to attend group meetings
with Overeaters Anonymous, and the nurse describes this group to the
client. The nurse determines that the client needs additional information
if the client states which of the following about this self-help group?
A. “The leader is a nurse or psychiatrist.”
B. “The members provide support to each other.”

C. “People who have a similar problem are able to help others.”
D. “It is designed to serve people who have a common problem.”
Feedback
The sponsor of a self-help group is an experienced member of the group.
A nurse or psychiatrist may be asked by the group to serve as a resource
but would not be the leader of the group. Options 2, 3, and 4 are
characteristics of a self-help group. Test-Taking Strategy: Use the
process of elimination and focus on the subject, self-help group. Note the
strategic words needs
additional information in the question. Note that options 2, 3, and 4 are

comparative or alike. This should direct you easily to option 1, the
correct option. Review the characteristics of a self-help group if you had
Correct
70. The home health nurse visits a client at home and determines that the
client is dependent on drugs. Which of the following assessment questions
would assist the nurse to provide appropriate nursing care?
A. “Why did you get started on these drugs?”

B. “How much do you use and what effect does it have on
you?”
C. “How long did you think you could take these drugs without someone
finding out?”
D. The nurse does not ask any questions for fear that the client is in denial
and will throw the nurse out of the home.
Feedback
Whenever the nurse carries out an assessment for a client who is
dependent on drugs, it is best for the nurse to attempt to elicit information
by being nonjudgmental and direct. Option 1 is incorrect because it is
judgmental and off focus and reflects the nurse's bias. Option 3 is
incorrect because it is judgmental, insensitive, and aggressive, which is
nontherapeutic. Option 4 is incorrect because it indicates passivity on the
nurse's part and uses rationalization to avoid the therapeutic nursing
intervention. Test-Taking Strategy: Use the process of elimination and

therapeutic communication techniques to answer the question. Also, focus
on the subject, provide appropriate nursing care. Review assessment of a
client who is a substance abuser if you had difficulty with this question.
Correct
71. The client says to the nurse, "I'm going to die, and I wish my
family would stop hoping for a cure! I get so angry when they carry on
like this. After all, I'm the one who's dying." The therapeutic response
by the nurse is:
A. “Have you shared your feelings with your family?”

B. “I think we should talk more about your anger with your family.”
C. “You're feeling angry that your family continues to hope
for you to be cured?”

D. “Well, it sounds like you're being pretty pessimistic. After all, years
ago, people died of pneumonia.”
Feedback
Restating is the therapeutic communication technique in which the nurse
repeats what the client says to show understanding and to review what
was said. Option 3 uses the therapeutic technique of restating. In option
1, the nurse is attempting to assess the client's ability to discuss feelings
openly with family members.
In option 2, the nurse attempts to use focusing, but the attempt to discuss
central issues is premature. In option 4, the nurse makes a judgment and
is nontherapeutic in the one-to-one relationship. Test-Taking Strategy:

Use therapeutic communication techniques to answer the question.
Option 3 is the only option that identifies the use of a therapeutic
technique and focuses on the client's feelings. Review these techniques if
you had difficulty with this question.
Correct
72. The nurse employed in a mental health clinic is greeted by a neighbor in a
local grocery store. The neighborsays to the nurse, "How is Carol doing? She
is my best friend and is seen at your clinic every week." The appropriate
nursing response is which of the following?
A. “I cannot discuss any client situation with you.”
B. “If you want to know about Carol, you need to ask her yourself.”
C. “I'm not suppose to discuss this, but because you are my neighbor, I can
tell you that she is doing great!”
D. “I'm not suppose to discuss this, but because you are my neighbor, I can
tell you that she really has some problems!”
Feedback
A nurse is required to maintain confidentiality regarding the client and the
client's care. Confidentiality is basic to the therapeutic relationship and is a
client's right. The most appropriate response to the neighbor is option 1.
Option 2 is a rather blunt statement and does not acknowledge the issue that
the nurse cannot reveal if the named person is or was a client. Options 3 and 4
identify statements that do not maintain client confidentiality.
Option 1 is the most direct and correct.

Test-Taking Strategy: Focus on the subject of the question, maintaining
confidentiality. This should assist you easily in eliminating options 3 and 4.
From the remaining options, select option 1 over option 2 because it is the
most direct and correct. Option 2 is a rather blunt and rude statement. Review
confidentiality issues if you had difficulty with this question.
Correct
73. A 39 year old mother with obsessive-compulsive disorder has become
immobilized by her elaborate hand washing and walking rituals. Nurse
Trish recognizes that the basis of O.C. disorder is often:
A. Problems with being too conscientious

B. Problems with anger and remorse
C. Feelings of guilt and inadequacy
D. Feeling of unworthiness and hopelessness
Feedback
Ritualistic behavior seen in this disorder is aimed at controlling guilt and
inadequacy by maintaining an absolute set pattern of behavior.
Correct
74. Nurse Tina is caring for a client with depression who has not responded to
antidepressant medication. The nurse anticipates that what treatment
procedure may be prescribed?
A. Neuroleptic medication
B. Short term seclusion
C. Psychosurgery
D. Electroconvulsive therapy
Feedback
Electroconvulsive therapy is an effective treatment for depression that has
not responded to medication..
Correct
75. Nurse Perry is aware that language development in autistic child
resembles:
A. Scanning speech
B. Speech lag
C. Shuttering
D. Echolalia
Feedback
The autistic child repeat sounds or words spoken by others.
Correct
76. Nurse Monette recognizes that the focus of environmental (MILIEU)
therapy is to:
A. Manipulate the environment to bring about positive
changes in behavior
B. Allow the client’s freedom to determine whether or not they will be
involved in activities
C. Role play life events to meet individual needs
D. Use natural remedies rather than drugs to control behavior
Feedback
Environmental (MILIEU) therapy aims at having everything in the
client’s surrounding area toward helping the client.
Correct
77. To establish open and trusting relationship with a female client who has
been hospitalized with severe anxiety, the nurse in charge should?
A. Encourage the staff to have frequent interaction with the client

B. Share an activity with the client
C. Give client feedback about behavior
D. Respect client’s need for personal space
Feedback
Moving to a client’s personal space increases the feeling of threat, which
increases anxiety.
Correct
78. Nurse Monet is caring for a female client who has suicidal tendency.
When accompanying the client to the restroom, Nurse Monet should…
A. Give her privacy

B. Allow her to urinate
C. Open the window and allow her to get some fresh air
D. Observe her
Feedback
The Nurse has a responsibility to observe continuously the acutely
suicidal client. The Nurse should watch for clues, such as communicating
suicidal thoughts, and messages; hoarding medications and talking about
death.
Correct
79. Nurse Trish would expect a child with a diagnosis of reactive attachment
disorder to:
A. Have more positive relation with the father than the mother
B. Cling to mother & cry on separation
C. Be able to develop only superficial relation with the others
D. Have been physically abuse
Feedback
Children who have experienced attachment difficulties with primary
caregiver are not able to trust others and therefore relate superficially
Correct
80. A male client is diagnosed with schizotypal personality disorder. Which
signs would this client exhibit during social situation?
A. Paranoid thoughts
B. Emotional affect
C. Independence need
D. Aggressive behavior
Feedback
Clients with schizotypal personality disorder experience excessive social
anxiety that can lead to paranoid thoughts.
Correct
81. Mario is complaining to other clients about not being allowed by staff to
keep food in his room. Which of the following interventions would be
most appropriate?
A. Allowing a snack to be kept in his room

B. Reprimanding the client
C. Ignoring the clients behavior
D. Setting limits on the behavior
Feedback
The nurse needs to set limits in the client’s manipulative behavior to help
the client control dysfunctional behavior. A consistent approach by the

staff is necessary to decrease manipulation.
Correct
82. Nurse Claire is caring for a client diagnosed with bulimia. The most
appropriate initial goal for a client diagnosed with bulimia is?
A. Encourage to avoid foods

B. Identify anxiety causing situations
C. Eat only three meals a day

D. Avoid shopping plenty of groceries
Feedback
Bulimia disorder generally is a maladaptive coping response to stress and
underlying issues. The client should identify anxiety causing situation that
stimulate the bulimic behavior and then learn new ways of coping with the
anxiety.
Correct
83. A male client who is experiencing disordered thinking about food being
poisoned is admitted to the mental health unit. The nurse uses which
communication technique to encourage the client to eat dinner?
A. Focusing on self-disclosure of own food preference

B. Using open ended question and silence
C. Offering opinion about the need to eat

D. Verbalizing reasons that the client may not choose to eat
Feedback
Open ended questions and silence are strategies used to encourage clients to
discuss their problem in descriptive manner.
Correct
84. Marco approached Nurse Trish asking for advice on how to deal with his
alcohol addiction. Nurse Trish should tell the client that the only effective
treatment for alcoholism is:
A. Psychotherapy
B. Alcoholics anonymous (A.A.)
C. Total abstinence
D. Aversion Therapy
Feedback
Total abstinence is the only effective treatment for alcoholism.
Correct
85. When working with a male client suffering phobia about black cats, Nurse
Trish should anticipate that a problem for this client would be?
A. Anxiety when discussing phobia
B. Anger toward the feared object
C. Denying that the phobia exist

D. Distortion of reality when completing daily routines
Feedback
Discussion of the feared object triggers an emotional response to the object.
Correct
86. Which of the following activities would Nurse Trish recommend to the client
who becomes very anxious when thoughts of suicide occur?
A. Using exercise bicycle
B. Meditating
C. Watching TV
D. Reading comics
Feedback
Using exercise bicycle is appropriate for the client who becomes very anxious
when thoughts of suicidal occur.
Correct
87. Which of the following liquids would nurse Leng administer to a female
client who is intoxicated with phencyclidine (PCP) to hasten excretion of the
chemical?
A. Shake
B. B. Tea
C. Cranberry Juice
D. Grape juice
Feedback
An acid environment aids in the excretion of PCP. The nurse will definitely
give the client with PCP intoxication cranberry juice to acidify the urine to a
ph of 5.5 & accelerate excretion.
Correct
88. When developing a plan of care for a female client with acute stress disorder who
lost her sister in a car accident. Which of the following would the nurse expect to
initiate?
A. Facilitating progressive review of the accident and its

consequences
B. Postponing discussion of the accident until the client brings it up
C. Telling the client to avoid details of the accident
D. Helping the client to evaluate her sister’s behavior
Feedback
The nurse would facilitate progressive review of the accident and its consequence
to help the client integrate feelings & memories and to begin the grieving
process.
Correct
89. Jose is diagnosed withamphetamine psychosis and was admitted in the
emergency room.Nurse Ronald would most likely prepare to administer which of
the following medication?
A. Librium
B. Valium
C. Ativan
D. Haldol
Feedback
The nurse would prepare to administer an antipsychotic medication such as
Haldol to a client experiencing amphetamine psychosis to decrease agitation &
psychotic symptoms, including delusions, hallucinations & cognitive impairment.
Correct
90. When assessing a male client for suicidal risk, which of the following methods of
suicide would the nurse identify as most lethal?
A. Wrist cutting
B. Head banging
C. Use of gun
D. Aspirin overdose
Feedback
A crucial factor is determining the lethality of a method is the amount of time that
occurs between initiating the method & the delivery of the lethal impact of the
method.
Correct
91. The nursing assistant tells nurse Ronald that the client is not in the dining room
for lunch. Nurse Ronald would direct the nursing assistant to do which of the
following?
A. Tell the client he’ll need to wait until supper to eat if he misses lunch
B. Invite the client to lunch and accompany him to the dining room
C. Inform the client that he has 10 minutes to get to the dining room for lunch
D. Take the client a lunch tray and let the client eat in his room
Feedback
The nurse instructs the nursing assistant to invite the client to lunch & accompany
him to the dinning room to decrease manipulation, secondary gain, dependency
and reinforcement of negative behavior while maintaining the client’s worth.
Correct
92. When taking a health history from a female client who has a moderate level of
cognitive impairment due to dementia, the nurse would expect to note the presence
of:
A. Accentuated premorbid traits
B. Enhance intelligence
C. Increased inhibitions
D. Hyper vigilance
Feedback
A moderate level of cognitive impairment due to dementia is characterized by
increasing dependence on environment & social structure and by increasing
psychologic rigidity with accentuated previous traits & behaviors.
Correct
93. The primary nursing diagnosis for a female client with a medical diagnosis of
major depression would be:
A. Situational low self-esteem related to altered role

B. Powerlessness related to the loss of idealized self
C. Spiritual distress related to depression
D. Impaired verbal communication related to depression
Feedback
Depressed clients demonstrate decreased communication because of lack of
psychic or physical energy.
Correct
94. Nurse John recognizes that paranoid delusions usually are related to the defense
mechanism of:
A. Projection
B. Identification
C. Repression
D. Regression
Feedback
Projection is a mechanism in which inner thoughts and feelings are projected onto
the environment, seeming to come from outside the self rather than from within.
Correct
95. Nurse Tony should first discuss terminating the nurse-client relationship with a
client during the:
A. Termination phase when discharge plans are being made.

B. Working phase when the client shows some progress.
C. Orientation phase when a contract is established.
D. Working phase when the client brings it up.
Feedback
When the nurse and client agree to work together, a contract should be established,
the length of the relationship should be discussed in terms of its ultimate termination.
Correct
96. The initial nursing intervention for the significant-others during shock phase of a
grief reaction should be focused on:
A. Presenting full reality of the loss of the individuals
B. Directing the individual’s activities at this time

C. Staying with the individuals involved
D. Mobilizing the individual’s support system
Feedback
This provides support until the individuals coping mechanisms and personal support
systems can be immobilized.
Correct
97. Tina with a histrionic personality disorder is melodramatic and responds to others
and situations in an exaggerated manner. Nurse Trish would recommend which of the
following activities for Tina?
A. Baking class
B. Role playing
C. Scrap book making

D. Music group
Feedback
The nurse would use role-playing to teach the client appropriate responses to others
and in various situations. This client dramatizes events, drawn attention to self, and is
unaware of and does not deal with feelings. The nurse works to help the client clarify
true feelings & learn to express them appropriately.
Correct
98. Grace is exhibiting withdrawn patterns of behavior. Nurse Johnny is aware that this
type of behavior eventually produces feeling of:
A. Repression
B. Loneliness
C. Anger
D. Paranoia
Feedback
The withdrawn pattern of behavior presents the individual from reaching out to others
for sharing the isolation produces feeling of loneliness.
Correct
99. A male client who is experiencing disordered thinking about food
being poisoned is admitted to the mental health unit. The nurse uses
which communication technique to encourage the client to eat
dinner?
A. Focusing on self-disclosure of own food preference

B. Using open ended question and silence
C. Offering opinion about the need to eat

D. Verbalizing reasons that the client may not choose to eat
Feedback
Open ended questions and silence are strategies used to encourage
clients to discuss their problem in descriptive manner.
Correct
100. Mario is admitted to the emergency room with drug-included anxiety
related to over ingestion of prescribed antipsychotic medication. The
most important piece of information the nurse in charge should obtain
initially is the:
A. Length of time on the med.

B. Name of the ingested medication & the amount ingested
C. Reason for the suicide attempt

D. Name of the nearest relative & their phone number
Feedback
In an emergency, lives saving facts are obtained first. The name and
the amount of medication ingested are of outmost important in treating
this potentially life threatening situation.
Correct
101. A characteristic that would suggest to Nurse Anne that an adolescent
may have bulimia would be:
A. Frequent regurgitation & re-swallowing of food

B. Previous history of gastritis
C. Badly stained teeth
D. Positive body image
Feedback
Dental enamel erosion occurs from repeated self-induced vomiting.
Correct
102. A 23 year old client has been admitted with a diagnosis of
schizophrenia says to the nurse “Yes, its march, March is little
woman”. That’s literal you know”. These statement illustrate:
A. Neologisms
B. Echolalia
C. Flight of ideas
D. Loosening of association
Feedback
Loose associations are thoughts that are presented without the logical
connections usually necessary for the listening to interpret the
message.
Correct
103. Nurse Monette recognizes that the focus of environmental (MILIEU)
therapy is to:
A. Manipulate the environment to bring about positive
changes in behavior
B. Allow the client’s freedom to determine whether or not they will
be involved in activities
C. Role play life events to meet individual needs
D. Use natural remedies rather than drugs to control behavior
Feedback
Environmental (MILIEU) therapy aims at having everything in the
client’s surrounding area toward helping the client.
Correct
104. Nurse Tina is caring for a client with delirium and states that “look at
the spiders on the wall”. What should the nurse respond to the client?
A. “You’re having hallucination, there are no spiders in this room at

all”
B. “I can see the spiders on the wall, but they are not going to hurt
you”
C. “Would you like me to kill the spiders”
D. “I know you are frightened, but I do not see spiders on
the wall”
Feedback
When hallucination is present, the nurse should reinforce reality with
the client.
Correct
105. Marco approached Nurse Trish asking for advice on how to deal with
his alcohol addiction. Nurse Trish should tell the client that the only
effective treatment for alcoholism is:
A. Psychotherapy
B. Alcoholics anonymous (A.A.)
C. Total abstinence
D. Aversion Therapy
Feedback
Correct
106. Which of the following would Nurse Hazel expect to assess for a
client who is exhibiting late signs of heroin withdrawal?
A. Yawning & diaphoresis

B. Restlessness & Irritability
C. Constipation & steatorrhea
D. Vomiting and Diarrhea
Feedback
Vomiting and diarrhea are usually the late signs of heroin withdrawal,
along with muscle spasm, fever, nausea, repetitive, abdominal cramps
and backache.
Correct
107. A neuromuscular blocking agent is administered to a client before
ECT therapy. The Nurse should carefully observe the client for?
A. Respiratory difficulties
B. Nausea and vomiting

C. Dizziness
D. Seizures
Feedback
Neuromuscular Blocker, such as SUCCINYLCHOLINE (Anectine)
produces respiratory depression because it inhibits contractions of
respiratory muscles.
Correct
108. When planning the discharge of a client with chronic anxiety, Nurse
Chris evaluates achievement of the discharge maintenance goals.
Which goal would be most appropriately having been included in the
plan of care requiring evaluation?
A. The client eliminates all anxiety from daily situations

B. The client ignores feelings of anxiety
C. The client identifies anxiety producing situations
D. The client maintains contact with a crisis counselor
Feedback
Recognizing situations that produce anxiety allows the client to
prepare to cope with anxiety or avoid specific stimulus.
Correct
109. Nurse Perry is aware that language development in autistic child
resembles:
A. Scanning speech
B. Speech lag
C. Shuttering
D. Echolalia
Feedback
The autistic child repeat sounds or words spoken by others.
Correct
110. Nurse Maureen is developing a plan of care for a female client with
anorexia nervosa. Which action should the nurse include in the plan?
A. Provide privacy during meals

B. Set-up a strict eating plan for the client
C. Encourage client to exercise to reduce anxiety

D. Restrict visits with the family
Feedback
Establishing a consistent eating plan and monitoring client’s weight
are important to this disorder.
Correct
111. Nurse Joey is aware that the signs & symptoms that would be most
specific for diagnosis anorexia are?
A. Excessive weight loss, amenorrhea & abdominal
distension
B. Slow pulse, 10% weight loss & alopecia
C. Compulsive behavior, excessive fears & nausea
D. Excessive activity, memory lapses & an increased pulse
Feedback
These are the major signs of anorexia nervosa. Weight loss is
excessive (15% of expected weight).
Correct
112. Kris periodically has acute panic attacks. These attacks are
unpredictable and have no apparent association with a specific object or
situation. During an acute panic attack, Kris may experience:
A. Heightened concentration
B. Decreased perceptual field
C. Decreased cardiac rate

D. Decreased respiratory rate
Feedback
Panic is the most severe level of anxiety. During panic attack, the client
experiences a decrease in the perceptual field, becoming more focused
on self, less aware of surroundings and unable to process information
from the environment. The decreased perceptual field contributes to
impaired attention and inability to concentrate.
Correct
113. Which of the following best explains why tricyclic antidepressants are used
with caution in elderly patients?
A. Central Nervous System effects

B. Cardiovascular system effects
C. Gastrointestinal system effects

D. Serotonin syndrome effects
Feedback
The TCAs affect norepinephrine as well as other neurotransmitters, and thus
have significant cardiovascular side effects. Therefore, they are used with
caution in elderly clients who may have increased risk factors for cardiac
problems because of their age and other medical conditions. The remaining
side effects would apply to any client taking a TCA and are not particular to
an elderly person.
Correct
114. PROPRANOLOL (Inderal) is used in the mental health setting to manage
which of the following conditions?
A. Antipsychotic – induced akathisia and anxiety
B. Obsessive – compulsive disorder (OCD) to reduce ritualistic behavior

C. Delusions for clients suffering from schizophrenia
D. The manic phase of bipolar illness as a mood stabilizer
Feedback
Propranolol is a potent beta adrenergic blocker and producing a sedating
effect, therefore it is used to treat antipsychotic induced akathisia and
anxiety.
Correct
115. A nurse who explains that a client’s psychotic behavior is unconsciously
motivated understands that the client’s disordered behavior arises from
which of the following?
A. Abnormal thinking
B. Altered neurotransmitters
C. Internal needs
D. Response to stimuli
Feedback
The concept that behavior is motivated and has meaning comes from the
psychodynamic framework. According to this perspective, behavior arises
from internal wishes or needs. Much of what motivates behavior comes
from the unconscious. The remaining responses do not address the internal
forces thought to motivate behavior.
Correct
116. A client with dysthymic disorder reports to a nurse that his life is hopeless
and will never improve in the future. How can the nurse best respond using
a cognitive approach?
A. Agree with the client’s painful feelings

B. Challenge the accuracy of the client’s belief
C. Deny that the situation is hopeless

D. Present a cheerful attitude
Feedback
Use of cognitive techniques allows the nurse to help the client recognize
that this negative beliefs may be distortions and that, by changing his
thinking, he can adopt more positive beliefs that are realistic and hopeful.
Agreeing with the client’s feelings and presenting a cheerful attitude are not
consistent with a cognitive approach and would not be helpful in this
situation. Denying the client’s feelings is belittling and may convey that the
nurse does not understand the depth of the client’s distress.
Correct
117. Which of the following statements should be included when teaching
clients about monoamine oxidase inhibitor (MAOI) antidepressants?
A. Don’t take aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs)

B. Have blood levels screened weekly for leucopenia
C. Avoid strenuous activity because of the cardiac effects of the drug
D. Don’t take prescribed or over the counter medications
without consulting the physician
Feedback
MAOI antidepressants when combined with a number of drugs can cause
life-threatening hypertensive crisis. It’s imperative that a client checks with
his physician and pharmacist before taking any other medications.
Correct
118. Discharge instructions for a male client receiving tricyclic antidepressants
include which of the following information?
A. Restrict fluids and sodium intake

B. Don’t consume alcohol
C. Discontinue if dry mouth and blurred vision occur

D. Restrict fluid and sodium intake
Feedback
Drinking alcohol can potentiate the sedating action of tricyclic
antidepressants. Dry mouth and blurred vision are normal adverse effects of
tricyclic antidepressants.
Correct
119. Before helping a male client who has been sexually assaulted, nurse Maureen
should recognize that the rapist is motivated by feelings of:
A. Hostility
B. Inadequacy
C. Incompetence
D. Passion
Feedback
Rapists are believed to harbor and act out hostile feelings toward all women
through the act of rape.
Correct
120. Which activity would be most appropriate for a severely withdrawn client?
A. Art activity with a staff member
B. Board game with a small group of clients

C. Team sport in the gym
D. Watching TV in the dayroom
Feedback
The best approach with a withdrawn client is to initiate brief, nondemanding
activities on a one-to-one basis. This approach gives the nurse an opportunity to
establish a trusting relationship with the client. A board game with a group
clients or playing a team sport in the gym may overwhelm a severely
withdrawn client. Watching TV is a solitary activity that will reinforce the
client’s withdrawal from others.
Correct
121. The nurse describes a client as anxious. Which of the following statement about
anxiety is true?
A. Anxiety is usually pathological

B. Anxiety is directly observable
C. Anxiety is usually harmful
D. Anxiety is a response to a threat
Feedback
Anxiety is a response to a threat arising from internal or external stimuli.
Correct
122. Which medication can control the extra pyramidal effects associated with
antipsychotic agents?
A. Clorazepate (Tranxene)
B. Amantadine (Symmetrel)
C. Doxepin (Sinequan)
D. Perphenazine (Trilafon)
Feedback
Amantadine is an anticholinergic drug used to relive drug-induced extra
pyramidal adverse effects such as muscle weakness, involuntary muscle
movements, pseudoparkinsonism and tar dive dyskinesia.
Correct
123. Francis who is addicted to cocaine withdraws from the drug. Nurse Ron
should expect to observe:
A. Hyperactivity
B. Depression
C. Suspicion
D. Delirium
Feedback
There is no set of symptoms associated with cocaine withdrawal, only the
depression that follows the high caused by the drug.
Correct
124. When performing a physicalexamination on a female anxious client,
nurse Nelli would expect to find which of the following effects produced
by the parasympathetic system?
A. Muscle tension
B. Hyperactive bowel sounds
C. Decreased urine output

D. Constipation
Feedback
The parasympathetic nervous system would produce incomplete G.I.
motility resulting in hyperactive bowel sounds, possibly leading to
diarrhea.
Correct
125. A client refuses to remain on psychotropic medications after discharge
from an inpatient psychiatric unit. Which information should the
community health nurse assess first during the initial follow-up with this
client?
A. Income level and living arrangements

B. Involvement of family and support systems
C. Reason for inpatient admission
D. Reason for refusal to take medications
Feedback
The first are for assessment would be the client’s reason for refusing
medication. The client may not understand the purpose for the medication,
may be experiencing distressing side effects, or may be concerned about
the cost of medicine. In any case, the nurse cannot provide appropriate
intervention before assessing the client’s problem with the medication.
The patient’s income level, living arrangements, and involvement of
family and support systems are relevant issues following determination of
the client’s reason for refusing medication. The nurse providing follow-up
care would have access to the client’s medical record and should already
know the reason for inpatient admission.
Correct
126. Before helping a male client who has been sexually assaulted, nurse
Maureen should recognize that the rapist is motivated by feelings of:
A. Hostility
B. Inadequacy
C. Incompetence
D. Passion
Feedback
Rapists are believed to harbor and act out hostile feelings toward all
women through the act of rape.
Correct
127. Andy is admitted to the psychiatric unit with a diagnosis of borderline
personality disorder. Nurse Hilary should expects the assessment to
reveal:
A. Coldness, detachment and lack of tender feelings

B. Somatic symptoms
C. Inability to function as responsible parent
D. Unpredictable behavior and intense interpersonal
relationships
Feedback
A client with borderline personality displays a pervasive pattern of
unpredictable behavior, mood and self image. Interpersonal relationships
may be
intense and unstable and behavior may be inappropriate and impulsive.
Correct
128. Nurse John is aware that the therapy that has the highest success rate for
people with phobias would be:
A. Psychotherapy aimed at rearranging maladaptive thought process

B. Psychoanalytical exploration of repressed conflicts of an earlier
development phase
C. Systematic desensitization using relaxation technique
D. Insight therapy to determine the origin of the anxiety and fear
Feedback
The most successful therapy for people with phobias involves behavior
modification techniques using desensitization.

Correct
129. Which nursing diagnosis is most appropriate for a client with anorexia
nervosa who expresses feelings of guilt about not meeting family
expectations?
A. Anxiety
B. Disturbed body image
C. Defensive coping
D. Powerlessness
Feedback
The client with anorexia typically feels powerless, with a sense of having
little control over any aspect of life besides eating behavior. Often, parental
expectations and standards are quite high and lead to the clients’ sense of
guilt over not measuring up.
Correct
130. Kris periodically has acute panic attacks. These attacks are unpredictable
and have no apparent association with a specific object or situation. During
an acute panic attack, Kris may experience:
A. Heightened concentration
B. Decreased perceptual field
C. Decreased cardiac rate
D. Decreased respiratory rate
Feedback
Panic is the most severe level of anxiety. During panic attack, the client
experiences a decrease in the perceptual field, becoming more focused on
self,
less aware of surroundings and unable to process information from the
environment. The decreased perceptual field contributes to impaired
attention
andinability to concentrate.
Correct
131. Initial interventions for Marco with acute anxiety include all except which
of the following?
A. Touching the client in an attempt to comfort him
B. Approaching the client in calm, confident manner

C. Encouraging the client to verbalize feelings and concerns
D. Providing the client with a safe, quiet and private place
Feedback
The emergency nurse must establish rapport and trust with the anxious
client before using therapeutic touch. Touching an anxious client may
actually
increase anxiety.
Correct
132. Which activity would be most appropriate for a severely withdrawn client?
A. Art activity with a staff member
B. Board game with a small group of clients

C. Team sport in the gym
D. Watching TV in the dayroom
Feedback
The best approach with a withdrawn client is to initiate brief, nondemanding
activities on a one-to-one basis. This approach gives the nurse an opportunity
to establish a trusting relationship with the client. A board game with a group
clients or playing a team sport in the gym may overwhelm a severely
withdrawn client. Watching TV is a solitary activity that will reinforce the
client’s withdrawal from others.
Correct
133. Nurse John is aware that a serious effect of inhaling cocaine is?
A. Deterioration of nasal septum
B. Acute fluid and electrolyte imbalances

C. Extra pyramidal tract symptoms
D. Esophageal varices
Feedback
Cocaine is a chemical that when inhaled, causes destruction of the mucous

membranes of the nose.
Correct
134. The nurse understands that the therapeutic effects of typical antipsychotic
medications are associated with which neurotransmitter change?
A. Decreased dopamine level
B. Increased acetylcholine level

C. Stabilization of serotonin
D. Stimulation of GABA
Feedback
Excess dopamine is thought to be the chemical cause for psychotic thinking.
The typical antipsychotics act to block dopamine receptors and therefore
decrease the amount of neurotransmitter at the synapses. The typical
antipsychotics do not increase acetylcholine, stabilize serotonin, stimulate
GABA.
Correct
135. Tony with agoraphobia has been symptom-free for 4 months. Classicsigns and
symptoms of phobia include:
A. Severe anxiety and fear
B. Withdrawal and failure to distinguish reality from fantasy

C. Depression and weight loss
D. Insomnia and inability to concentrate
Feedback
Phobias cause severe anxiety (such as panic attack) that is out of proportion to
the threat of the feared object or situation. Physical signs and
symptoms of phobias include profuse sweating, poor motor control, tachycardia
and elevated B.P.
Correct
136. Nursing preparation for a client undergoing electroconvulsive therapy (ECT)
resemble those used for:
A. General anesthesia
B. Cardiac stress testing

C. Neurologic examination
D. Physical therapy
Feedback
The nurse should prepare a client for ECT in a manner similar to that for general
anesthesia.
Correct
137. A decision is made to not hospitalize a client with obsessive-compulsive
disorder. Of the following abilities the client has demonstrated, the one that
probably most influenced the decision not to hospitalize him is his ability to:
A. Hold a job.
B. Relate to his peers.
C. Perform activities of daily living.
D. Behave in an outwardly normal
Feedback
If a client can do ADLs , there is no reason for that client to be hospitalized.
Correct
138. Which of the following client statements about clozapine (Clozaril) indicates that
the client needs additional teaching?
A. "I need to have my blood checked once every several months while I’m taking
this drug."
B. "I need to sit on the side of the bed for a while when I wake up in the
morning."
C. "The sleepiness I feel will decrease as my body adjusts to clozapine."
D. "I need to call my doctor whenever I notice that I have a fever
or sore throat."
Feedback
Clozapine causes AGRANULOCYTOSIS and bone marrow depression. Early s/s
includes fever and sore throat. The medication is to be withheld this time or the
patient might develop severe infection leading to death.

Correct
139. A client was hospitalized with major depression with suicidal ideation for 1
week. He is taking venlafaxine (Effexor), 75 mg three times a day, and is
planning to return to work. The nurse asks the client if he is experiencing
thoughts of self-harm. The client responds, "I hardly think about it anymore and
wouldn't do anything to hurt myself." The nurse judges:
A. The client to be decompensating and in need of being readmitted to the

hospital.
B. The client to need an adjustment or increase in his dose of antidepressant.
C. The depression to be improving and the suicidal ideation to be
lessening.
D. The presence of suicidal ideation to warrant a telephone call to the client's
physician
Feedback
too obvious, no need to rationalize.
Correct
140. After 3 days of taking haloperidol, the client shows an inability to sit still, is
restless and fidgety, and paces around the unit. Of the following extrapyramidal
adverse reactions, the client is showing signs of:
A. Dystonia
B. Akathisia
C. Parkinsonism
D. Tardive dyskinesia.
Feedback
The client shows sign of motor restlessness, which is specific for Akathisia or
MAKATI SYA.
Correct
141. Which of the following drugs needs a WBC level checked regularl?
A. Lithane
B. Clozaril
C. Tofranil
D. Diazepam
Feedback
Clozapine is a dreaded aypical antipsychotic because it causes severe bone
marrow depression, agranulocytosis, infection and sore throat. WBC count is
important to assess if the clients immune function is severely impaired. The first
presenting sign of agranulocytosis is SORE THROAT.
Correct
142. The nurse judges correctly that a client is experiencing an adverse effect from
amitriptyline hydrochloride (Elavil) when the client demonstrates:
A. An elevated blood glucose level.

B. Insomnia
C. Hypertension
D. Urinary retention.
Feedback
Elavil is an TC antidepressant. It should not cause insomnia. Hypertension are
specific of MAOI anti depressants when tyramine is ingested. Due to the
anticholinergic s/e of TCAs, Urinary retention is an adverse effect.
Correct
143. After the nurse has taught the client who is being discharged on lithium
(Eskalith) about the drug, which of the following client statements would indicate
that the teaching has been successful?
A. "I need to restrict eating any foods that contain salt."

B. "If I forget a dose, I can double the dose the next time I take it."
C. "I'll call my doctor right away for any vomiting, severe hand
tremors, or muscle weakness."

D. "I should increase my fluid”
Feedback
This is a sign of light lithium toxicity. Increasing fluid intake will cause dilutional
decrease of lithium level. Restriction of sodium will cause dilutional increase in
lithium level.
Correct
144. A client is admitted to the hospital. Twelve hours later the nurse observes hand
tremors, hyperexicitability, tachycardia, diaphoresis and hypertension. The nurse
suspects alcohol withdrawal. The nurse should ask the client:
A. At what time was your last drink taken?
B. Why didn’t you tell us you’re a drinker?

C. Do you drink beer or hard liquor?
D. How long have you been drinking?
Feedback
This question will give the nurse idea WHEN will the withdrawal occur.
Withdrawal occurs 5 to 10 hours after the last intake of alcohol. This is a crucial
and mortality is very high during this period. Client will undergo delirium
tremens, seizures and DEATH if not recognize earlier by the nurse. B is very
judgmental, C is non specific, whether it is a beer or a wine It is still alcohol and
has the same effects. D is a valuable question to determine the chronic effects of
alcohol ingestion but asking letter A can broaden the line between life and death.
Correct
145. A 16 year old child is hospitalized, according to Erik Erikson, what is an
appropriate intervention?
A. Tell the friends to visit the child
B. Encourage patient to help child learn lessons missed
C. Call the priest to intervene

D. Tell the child’s girlfriend to visit the child.
Feedback
The child is 16 years old, In the stage of IDENTITY VS. ROLE CONFUSION.
The most significant persons in this group are the PEERS. B refers to children in
the school age while C refers to the young adulthood stage of INTIMACY VS.
ISOLATION. The child is not dying and the situation did not even talk about the
child’s belief therefore, calling the priest is unnecessary.
Correct
146. 60 year old post CVA patient is taking TPA for his disease, the nurse understands
that this is an example of what level of prevention?
A. Primary
B. Secondary
C. Tertiary
D. Nota
Feedback
The client already had stroke, TPA stands for TRANSPLASMINOGEN
ACTIVATOR which are thrombolytics, dissolving clots formed in the vessels of
the brain. We are just preventing COMPLICATIONS here.
Correct
147. The client is taking risperidone (Risperdal) to treat the positive and negative
symptoms of schizophrenia. Which of the following negative symptoms will

improve?
A. Abnormal thought form.

B. Hallucinations and delusions.
C. Bizarre behaviour.
D. Asocial behaviour and anergia.
Feedback
A,B and C are all positive symptoms of schizophrenia. Negative symptoms
includes anhedonia, anergia, associative looseness and Asocial behavior.
Correct
148. Preparing the client for the termination phase begins:
A. Pre orientation
B. Orientation
C. Working
D. Termination
Feedback
Telling the client that there is a TERMINATION PHASE should be in the
ORIENTATION PHASE, however, in preparing the client for the
TERMINATION, it should be done in the working phase.
The nurse will start to lessen the number of meetings to prevent development of
transference or counter transference.

Correct
149. The patient complaint of vomiting, diarrhea and restlessness after taking lithane.
The nurse’s initial intervention is:
A. Recognize that this is a sign of toxicity and withhold the next
medication.
B. Notify the physician.
C. Check V/S to validate patient’s concerns.
D. Recognize that this is a normal side effects of lithium and still continue the
drug.
Feedback
The nurse should recognize that this is an early s/s of lithium toxicity. Taking the
clients vital signs will not confirm diarrhea,
vomiting or restlessness. Notifying the physician is unnecessary at this point and
the physician will likely to withhold the medication.
Correct
150. The nurse in the substance abuse unit is trying to encourage a client to attend
Alcoholics Anonymous meetings. When the client asks the nurse what he must
do to become a member, the nurse should
respond:
A. "You must first stop drinking."

B. "Your physician must refer you to this program."
C. "Admit you're powerless over alcohol and that you need help."
D. "You must bring along a friend who will support you."
Feedback
Rationale: The first of the "Twelve Steps of Alcoholics Anonymous" is admitting
that an individual is powerless over alcohol and that life has become
unmanageable. Although Alcoholics Anonymous promotes total abstinence, a
client will still be accepted if he drinks. A physician referral isn't necessary to
join. New members are assigned a support person who may be called upon when
the client has the urge to drink.
Correct
151. A client with anorexia nervosa describes herself as "a whale." However, the
nurse's assessment reveals that the client is 5′ 8" (1.7 m) tall and weighs only 90
lb (40.8 kg). Considering the client's unrealistic body image, which intervention
should be included in the plan of care?
A. Asking the client to compare her figure with magazine photographs of women
her age
B. Assigning the client to group therapy in which participants provide realistic
feedback about her weight
C. Confronting the client about her actual appearance during one-on-one
sessions, scheduled during each shift
D. Telling the client of the nurse's concern for her health and desire
to help her make decisions to keep her healthy
Feedback
Rationale: A client with anorexia nervosa has an unrealistic body image that
causes consumption of little or no food. Therefore, the client needs assistance
with making decisions about health. Instead of protecting the client's health,
options A, B, and C may serve to make the client defensive and more entrenched
in her unrealistic body image.
Correct
152. In the emergency department, a client with facial lacerations states that her
husband beat her with a shoe. After the health care team repairs her lacerations,
she waits to be seen by the crisis intake
nurse, who will evaluate the continued threat of violence. Suddenly the client's
husband arrives, shouting that he wants to "finish the job." What is the first
priority of the health care worker who witnesses this scene?
A. Remaining with the client and staying calm

B. Calling a security guard and another staff member for
assistance
C. Telling the client's husband that he must leave at once
D. Determining why the husband feels so angry
Feedback
Rationale: The health care worker who witnesses this scene must take precautions
to ensure personal as well as client safety, but shouldn't attempt to manage a
physically aggressive person alone. Therefore, the first priority is to call a
security guard and another staff member. After doing this, the health care worker
should inform the husband what is expected, speaking in concise statements and
maintaining a firm but calm demeanor. This approach makes it clear that the
health care worker is in control and may diffuse the situation until the security
guard arrives. Telling the husband to leave would probably be
ineffective because of his agitated and irrational state. Exploring his anger doesn't
take precedence over safeguarding the client and staff.
Correct
153. A client with disorganized type schizophrenia has been hospitalized for the past 2
years on a unit for chronic mentally ill clients. The client's behavior is labile and
fluctuates from childishness
and incoherence to loud yelling to slow but appropriate interaction. The client
needs assistance with all activities of daily living. Which behavior is
characteristic of disorganized type schizophrenia?
A. Extreme social impairment
B. Suspicious delusions
C. Waxy flexibility
D. Elevated affect
Feedback
Rationale: Disorganized type schizophrenia (formerly called hebephrenia) is
characterized by extreme social impairment, marked inappropriate affect,

silliness, grimacing, posturing, and fragmented delusions and hallucinations. A
client with a paranoid disorder typically exhibits suspicious delusions, such as a
belief that evil forces are after him. Waxy flexibility, a condition in which the
client's limbs remain fixed in uncomfortable positions for long periods,
characterizes
catatonic schizophrenia. Elevated affect is associated withschizoaffective
disorder
Correct
154. A client is admitted for an overdose of amphetamines. When assessing this client,
the nurse should expect to see:
A. Tension and irritability.
B. Slow pulse.
C. Hypotension
D. Constipation.
Feedback
Rationale: An amphetamine is a nervous system stimulant that is subject to abuse
because of its ability to produce wakefulness and euphoria. An overdose
increases tension and irritability. Options B and C are incorrect because
amphetamines stimulate norepinephrine, which increases the heart rate and blood
flow. Diarrhea is a common adverse effect, so option D is incorrect.
Correct
155. After completing chemical detoxification and a 12-step program to treat crack
addiction, a client is being prepared for discharge. Which remark by the client
indicates a realistic view of the future?
A. "I'm never going to use crack again."

B. "I know what I have to do. I have to limit my crack use."
C. "I'm going to take 1 day at a time. I'm not making any
promises."
D. "I will substitue crack for something else"
Feedback
Rationale: Twelve-step programs focus on recovery 1 day at a time.Such
programs discourage people from claiming that they will never again use a
substance, because relapse is common. The belief that one may use a limited
amount of an abused substance indicates denial. Substituting one abused
substance for another predisposes the client to cross-addiction.
Correct
156. The nurse is caring for a client being treated for alcoholism. Before initiating
therapy with disulfiram (Antabuse), the nurse teaches the client that he must read
labels carefully on which of the following
products?
A. Carbonated beverages
B. Aftershave lotion
C. Toothpaste
D. Cheese
Feedback
Rationale: Disulfiram may be given to clients with chronic alcohol abuse who
wish to curb impulse drinking. Disulfiram works by blocking the oxidation of
alcohol, inhibiting the conversion of acetaldehyde to acetate. As acetaldehyde
builds up in the blood, the client experiences noxious and uncomfortable
symptoms. Even alcohol rubbed onto the skin can produce a reaction. The client
receiving disulfiram must be taught to read ingredient labels carefully to avoid
products containing alcohol such as aftershave lotions. Carbonated beverages,
toothpaste, and cheese don't contain alcohol and don't need to be avoided by the
client.
Correct
157. Which of the following drugs may be abused because of tolerance and
physiologic dependence.
A. Lithium (Lithobid) and divalproex (Depakote).

B. Verapamil (Calan) and chlorpromazine (Thorazine)
C. Alprazolam (Xanax) and phenobarbital (Luminal)
D. Clozapine (Clozaril) and amitriptyline (Elavil)
Feedback
Rationale: Both benzodiazepines, such as alprazolam, and barbiturates, such as
phenobarbital, are addictive, controlled substances. All the other drugs listed
aren't addictive substances.

Correct
158. A client is hospitalized with fractures of the right femur and right humerus
sustained in a motorcycle accident. Police suspect the client was intoxicated at
the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2%
(200 mg/dl). The client later admits to drinking heavily for years. During
hospitalization, the client periodically complains of tingling and numbness in the
hands and feet. The nurse realizes that these symptoms probably result from:
A. Acetate accumulation.
B. Thiamine deficiency.
C. Triglyceride buildup.
D. A below-normal serum potassium level
Feedback
Rationale: Numbness and tingling in the hands and feet are symptoms of
peripheral polyneuritis, which results from inadequate intake of vitamin B1
(thiamine) secondary to prolonged and excessive alcohol intake. Treatment
includes reducing alcohol intake, correcting nutritional deficiencies through diet
and vitamin supplements, and preventing such residual disabilities as foot and
wrist drop. Acetate accumulation, triglyceride buildup, and a below-normal
serum
potassium level are unrelated to the client's symptoms.
Correct
159. A dystonic reaction can be caused by which of the following medications?
A. Diazepam (Valium)
B. Haloperidol (Haldol)
C. Amitriptyline (Elavil)
D. Clonazepam (Klonopin)
Feedback
Rationale: Haloperidol is a phenothiazine and is capable of causing dystonic
reactions. Diazepam and clonazepam are benzodiazepines, and amitriptyline is a
tricyclic antidepressant. Benzodiazepines don't cause dystonic reactions;
however, they can cause drowsiness, lethargy, and hypotension. Tricyclic
antidepressants rarely cause severe dystonic reactions; however, they can cause a
decreased level of consciousness, tachycardia, dry mouth, and dilated pupils.
Correct
160. The nurse is caring for a client with bulimia. Strict management of dietary intake
is necessary. Which intervention is also important?
A. Fill out the client's menu and make sure she eats at least half of what is on her
tray.
B. Let the client eat her meals in private. Then engage her in social activities for
at least 2 hours after each meal.
C. Let the client choose her own food. If she eats everything she
orders, then stay with her for 1 hour after each meal.
D. Let the client eat food brought in by the family if she chooses, but she should
keep a strict calorie count.
Feedback
Rationale: Allowing the client to select her own food from the menu will help her
feel some sense of control. She must then eat 100% of what she selected.
Remaining with the client for at least 1 hour after eating will prevent purging.
Bulimic clients should only be allowed to eat food provided by the dietary
department.
Correct
161. A client who's at high risk for suicide needs close supervision. To best ensure the
client's safety, the nurse should:
A. Check the client frequently at irregular intervals throughout the
night
B. Assure the client that the nurse will hold in confidence anything the client says
C. Repeatedly discuss previous suicide attempts with the client
D. Disregard decreased communication by the client because this is common in
suicidal clients
Feedback
Rationale: Checking the client frequently but at irregular intervals prevents the
client from predicting when observation will take place and altering behavior in a
misleading way at these times. Option B may encourage the client to try to
manipulate the nurse or seek attention for having a secret suicide plan. Option C
may reinforce suicidal ideas. Decreased communication is a sign of withdrawal

that may indicate the client has decided to commit suicide; the nurse
shouldn't disregard it (option D )
Correct
162. While pacing in the hall, a client with paranoid schizophrenia runs to the nurse
and says, "Why are you poisoning me? I know you work for central thought
control! You can keep my thoughts. Give me back my soul!" How should the
nurse respond during the early stage of the therapeutic process?
A. "I'm a nurse. I'm not poisoning you. It's against the nursing code of ethics."
B. "I'm a nurse, and you're a client in the hospital. I'm not going to
harm you."
C. "I'm not poisoning you. And how could I possibly steal your soul?"
D. "I sense anger. Are you feeling angry today?"
Feedback
Rationale: The nurse should directly orient a delusional client to reality,
especially to place and person. Options A and C may encourage further delusions
by denying poisoning and offering information related to the delusion. Validating
the client's feelings, as in option D, occurs during a later stage in the therapeutic
process.
Correct
163. 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 client’s 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.
Feedback
Often the verbalized ideas are jumbled, but the underlying feelings are
discernible and must be acknowledged.
Correct
164. 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.
Feedback
This is the more inclusive answer, although diet restrictions (answer1) are
important, their purpose is to prevent hypertensive crisis (answer 2).
Correct
165. A 20-year-old female client is diagnosed with anxiety disorder. The
physician prescribed Fluoxetine (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.
Feedback
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.
Correct
166. 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.
Feedback
The appetite is diminished and sleeping is affected to a client with depression.
Correct
167. 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.
Feedback
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.
Correct
168. 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.
Feedback
The client needs basic, simple orientation that directly relates to the here-and-
now, and does not require verbal interaction.
Correct
169. On an adolescent unit, a nurse caring to a client was informed that her client’s
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.
Feedback
The nurse needs to wait and see: do not “jump the gun”; do not assume that the
client wants to know now.

Correct
170. 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. “It’s not likely.”
C. “What will be different?”
D. “I hope so, for your sake.”
Feedback
This option helps the woman to think through and elaborate on her own thoughts
and prognosis.
Correct
171. 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.
Feedback
It is mostly likely that grief would be expressed because of object loss.
Correct
172. 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.
Feedback
The nurse helps to activate by doing something with the client.
Correct
173. 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
Feedback
Autistic children do best with solitary play because they typically do not interact
with others in a socially comprehensible and acceptable way.
Correct
174. 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 client’s inner needs.

B. Give the client opportunities to test reality.
C. Provide external controls.
D. Reinforce the client’s self-concept.
Feedback
Personality disorders stem from a weak superego, implying a lack of adequate
controls.
Correct
175. 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.
Feedback
This option is best to decrease confusion and disorientation to place and time.
Correct
176. 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 won’t 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.”
Feedback
The client will be easier to care for if he has his hearing aid and glasses.
Correct
177. A male client is repetitively doing the handwashing every time he touches things.
It is important for a nurse to understand that the client’s 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.
Feedback
A ritual, such as compulsive handwashing, is an attempt to allay anxiety caused
by unconscious impulses that are frightening.
Correct
178. 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.
Feedback
This is the most neutral answer by process of elimination.
Correct
179. 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.
Feedback
The client has ideas that someone is out to kill her.
Correct
180. 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.
Feedback
It is important to externalize the anger away from self.
Correct
181. 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.
Feedback
Neutral, nonthreatening topics are best in attempting to encourage a response.
Correct
182. 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 father’s death are the
woman’s main concern.
B. To explain the woman’s 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.
Feedback
Shock and anger are commonly the primary initial reactions.

Correct
183. 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 client’s self-esteem.
C. Group activity, such as basketball, to decrease isolation.
D. Intellectual activity, such as scrabble, to increase concentration.
Feedback
This option avoids external stimuli, yet channels the excess motor activity that is
often part of the manic phase.
Correct
184. 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 client’s belief but not the nurse’s
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.
Feedback
The nurse should neither challenge nor use logic to dispel an irrational belief.
Correct
185. A 17-year-old client has a record of being absent in the class without permission,
and “borrowing” other people’s 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
Feedback
This shows a weak sense of moral consciousness. According to Freudian theory,
personality disorders stem from a weak superego.
Correct
186. 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.
Feedback
A serious side effect of Imipramine HCI (Tofranil) is urinary retention (voiding
problems)
Correct
187. 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.
Feedback
Frequent contacts at times of stress are important, especially when a client is
isolated.
Correct
188. 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)
Feedback
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).
Correct
189. The client in the psychiatric unit states that, “The goodas are coming! I must be
ready.” In response to this neologism, the nurse’s 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 client’s 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.
Feedback
It is important to acknowledge a statement, even if it is not understood.
Correct
190. A client tells the nurse, “I don’t 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.
Feedback
This is a false belief developed in response to an emotional need.
Correct
191. 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, you’re probably right. Your son did not get better care.”
Feedback
This option allows a normal grief response (anger).
Correct
192. A male client diagnosed with depression tells the nurse, “I don’t want to look
weak and I don’t even cry because my wife and my kids can’t bear it.” The nurse
understands that this is an example of:
A. Repression.
B. Suppression.
C. Undoing.
D. Rationalization.
Feedback
Rationalization is the process of constructing plausible reasons for one’s
responses.
Correct
193. A client who is severely obese tells the nurse, “My therapist told me that I eat a
lot because I didn’t 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.”
Feedback
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 thestatement,
the nurse can help get clarification from the therapist.
Correct
194. 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 client’s 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?”
Feedback
The client needs to have his or her feelings acknowledged, with encouragement to
discuss feelings, and be reassured about the nurse’s presence.
Correct
195. A woman gave birth to an unhealthy infant, and with some body defects. The nurse
should expect the woman’s initial reactions to include:
A. Depression
B. Withdrawal
C. Apathy
D. Anger
Feedback
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.
Correct
196. 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 client’s 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.
Feedback
The client is most likely confused, rather than exhibiting acting-out, hostile
behavior. Frequent toileting will allow urination in an appropriate place.
Correct
197. 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.
Feedback
Persons with dementia needs sameness, consistency, structure, routine, and
predictability.
Correct
198. 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 won’t let anyone get you.”

B. “Who are they?”
C. “I don’t see anyone coming.”
D. “You look frightened.”
Feedback
This option is an example of pointing out reality- the nurse’s perception.
Correct
199. 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 people’s lives
C. Crises may go on indefinitely.
D. Crises usually resolved in 4-6 weeks.
Feedback
Part of the definition of a crisis is a time span of 4-6 weeks.
Correct
200. 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.
Feedback
Although all options may appear correct. Knowing what food she likes 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.
Correct
201. 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 child’s
room.
D. Suggest the parents to wait until the funeral service to say “good-bye.”
Feedback
This allows the parents/family to grieve over the loss of the child, by going through
the steps of leave taking.
Correct
202. A nurse is going to give a rectal suppository as a preoperative medication to a 4-
year-old boy. The boy is very anxious and frightened. Which of the following
statement by the nurse would be most appropriate to gain the child’s cooperation?
A. “Be a big kid! Everyone’s waiting for you.”

B. “Lie still now and I’ll 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 won’t hurt a bit!”
Feedback
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.
Correct
203. 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 didn’t
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. “That’s a long time wait when you feel so depressed.”
Feedback
The patient needs a brief, factual answer.
Correct
204. 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
Feedback
Reactions when told of a life-threatening illness stem from Kübler-Ross’ ideas on
death and dying. Denial is a typical grief response, and usually is a first reaction.
Correct
205. 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 teen’s primary
health care provider and parents
Feedback
Any threat to the safety of oneself or other should always be taken seriously and
never disregarded by the nurse.
Correct
206. 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.”
Feedback
The nurse is asking the client to clarify and further discuss feelings.
Correct
207. 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.
Feedback
Denial is the act of avoiding disagreeable realities by ignoring them.
Correct
208. 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 isn’t the purpose of either of you being here.”
C. “I see you’ve made a new friend.”

D. “Think about what you are doing.”
Feedback
This response is aimed at redirecting the inappropriate behavior.
Correct
209. 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.
Feedback
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.
Correct
210. After the discussion about the procedure the physician scheduled the client for
mastectomy. The client tells the nurse, “If my breasts will be removed, I’m afraid
my husband will not love me anymore and maybe he will never touch me.” What
should the nurse’s 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.
Feedback
This option redirects the client to talk to her husband.
Correct
211. 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 client’s whereabouts.
Feedback
The client must be constantly observed.
Correct
212. 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
Feedback
This is an example of reaction formation, a coping mechanism.
Correct
213. The nurse is developing a plan of care for a client with anorexia nervosa.
Which action should the nurse include in the plan?
A. Restrict visits with the family until the client begins to eat.
B. Provide privacy during meals.
C. Set up a strict eating plan for the client.
D. Encourage the client to exercise, which will reduce her anxiety.
Feedback
Rationale: Establishing a consistent eating plan and monitoring the client's
weight are important for this disorder. The family should be included in the
client's care. The client should be monitored during meals — not given
privacy. Exercise must be limited and supervised.
Correct
214. A client is admitted to the psychiatric unit with a diagnosis of borderline
personality disorder. The nurse expects the assessment to
reveal:
A. Unpredictable behavior and intense interpersonal

relationships.
B. Inability to function as a responsible parent.
C. Somatic symptoms.
D. Coldness, detachment, and lack of tender feelings.
Feedback
Rationale: A client with borderline personality disorder displays a pervasive
pattern of unpredictable behavior, mood, and self-image. Interpersonal
relationships may be intense and unstable and behavior may be inappropriate
and impulsive. Although the client's impaired ability to form relationships may
affect parenting skills, inability to function as a responsible parent is more
typical of antisocial personality disorder. Somatic symptoms characterize
avoidant personality disorder. Coldness, detachment, and lack of tender feelings
typify schizoid and schizotypal personality disorders.
Correct
215. After completing chemical detoxification and a 12-step program to treat crack
addiction, a client is being prepared for discharge. Which remark by the client
indicates a realistic view of the future?
A. "I'm never going to use crack again."

B. "I know what I have to do. I have to limit my crack use."
C. "I'm going to take 1 day at a time. I'm not making any
promises."
D. "I will substitue crack for something else"
Feedback
Rationale: Twelve-step programs focus on recovery 1 day at a time.Such
programs discourage people from claiming that they will never again use a
substance, because relapse is common. The belief that one may use a limited
amount of an abused substance indicates denial. Substituting one abused
substance for another predisposes the client to cross-addiction.
Correct
216. The nurse is assessing a 15-year-old female who's being admitted for treatment
of anorexia nervosa. Which clinical manifestation is the nurse most likely to
find?
A. Tachycardia
B. Warm, flushed extremities
C. Parotid gland tenderness
D. Coarse hair growth
Feedback
Rationale: Frequent vomiting causes tenderness and swelling of the parotid
glands. The reduced metabolism that occurs with severe weight loss produces
bradycardia and cold extremities. Soft, downlike hair (called lanugo) may cover
the extremities, shoulders, and face of an anorexic client.
Correct
217. Tourette syndrome is characterized by the presence of multiple motor and
vocal tics. A vocal tic that involves repeating one's own sounds or words is
known as:
A. Echolalia
B. Palilalia
C. Apraxia
D. Aphonia
Feedback
Rationale: Palilalia is defined as the repetition of sounds and words. Echolalia
is the act of repeating the words of others. Apraxia is the inability to carry out
motor activities, and aphonia is the inability to speak
Correct
218. A client is admitted to the substance abuse unit for alcohol detoxification.
Which of the following medications is the nurse most likely to administer to
reduce the symptoms of alcohol withdrawal?
A. Naloxone (Narcan)
C. Magnesium sulfate
D. Chlordiazepoxide (Librium)
Feedback
Rationale: Chlordiazepoxide (Librium) and other tranquilizers help reduce the
symptoms of alcohol withdrawal. Haloperidol (Haldol) may be given to treat
clients with psychosis, severe agitation, or delirium. Naloxone (Narcan) is
administered for narcotic overdose. Magnesium sulfate and other
anticonvulsant medications are only administered to treat seizures if they occur
during withdrawal.
Correct
219. A dystonic reaction can be caused by which of the following medications?
A. Diazepam (Valium)
C. Amitriptyline (Elavil)
D. Clonazepam (Klonopin)
Feedback
Rationale: Haloperidol is a phenothiazine and is capable of causing dystonic
reactions. Diazepam and clonazepam are benzodiazepines, and amitriptyline is
a tricyclic antidepressant. Benzodiazepines don't cause dystonic reactions;
however, they can cause drowsiness, lethargy, and hypotension. Tricyclic
antidepressants rarely cause severe dystonic reactions; however, they can
cause a decreased level of consciousness, tachycardia, dry mouth, and dilated
pupils.
Correct
220. Clonidine (Catapres) can be used to treat conditions other than hypertension.
For which of the following conditions might the drug be administered?
A. Phencyclidine (PCP) intoxication

B. Alcohol withdrawal
C. Opiate withdrawal
D. Cocaine withdrawal
Feedback
Rationale: Clonidine is used as adjunctive therapy in opiate withdrawal.
Benzodiazepines, such as chlordiazepoxide (Librium), and neuropleptic agents,
such as haloperidol, are used to treat alcohol withdrawal. Benzodiazepines and
neuropleptic agents are typically used to treat PCP intoxication.
Antidepressants and medications with dopaminergic activity in the brain, such
as fluoxotine (Prozac), are used to treat cocaine withdrawal.
Correct
221. Flumazenil (Romazicon) has been ordered for a client who has overdosed on
oxazepam (Serax). Before administering the medication, the nurse should be
prepared for which common adverse effect?
A. Seizures
B. Shivering
C. Anxiety
D. Chest pain
Feedback
Seizures are the most common serious adverse effect of using flumazenil to
reverse benzodiazepine overdose. The effect is magnified if the client has a
combined tricyclic antidepressant and benzodiazepine overdose. Less common
adverse effects include shivering, anxiety, and chest pain.
Correct
222. When planning care for a client who has ingested phencyclidine (PCP), which
of the following is the highest priority?
A. Client's physical needs

B. Client's safety needs
C. Client's psychosocial needs

D. Client's medical needs
Feedback
Rationale: The highest priority for a client who has ingested PCP is meeting
safety needs of the client as well as the staff. Drug effects are unpredictable and
prolonged, and the client may lose control easily. After safety needs have been
met, the client's physical, psychosocial, and medical needs can be met.
Correct
223. Victims of domestic violence should be assessed for what important
information?
A. Reasons they stay in the abusive relationship (for example, lack of financial
autonomy and isolation)
B. Readiness to leave the perpetrator and knowledge of resources
C. Use of drugs or alcohol

D. History of previous victimization
Feedback
Rationale: Victims of domestic violence must be assessed for their readiness to
leave the perpetrator and their knowledge of the resources available to them.
Nurses can then provide the victims with information and options to enable them
to leave when they are ready. The reasons they stay in the relationship are
complex and can be explored at a later time. The use of drugs or alcohol is
irrelevant. There is no evidence to suggest that previous victimization results in
a
person's seeking or causing abusive relationships.
Correct
224. One of the goals for a client with anorexia nervosa is that the client will
demonstrate increased individual coping by responding to stress in constructive
ways. Which of the following actions is the best
indicator that the client is working toward meeting the goal?
A. The client drinks 4 L of fluid per day.

B. The client paces around the unit most of the day
C. The client keeps a journal and discusses it with the nurse.
D. The client talks almost constantly with friends by telephone
Feedback
Rationale: The client is moving toward meeting the goal because recording and
discussing feelings is a constructive way to manage stress. Although physical
activity can reduce stress, the anorexic client is more likely to use pacing to burn
calories and lose weight. Although talks with friends can decrease stress, constant
talking is more likely a way of avoiding dealing with problems. Increased fluid
intake may be an attempt by the client to curb her appetite and artificially increase
her weight.
Correct
225. For a client with anorexia nervosa, the nurse plans to include the parents in therapy
sessions along with the client. What fact should the nurse remember to be typical
of parents of clients with anorexia
nervosa?
A. They tend to overprotect their children.
B. They usually have a history of substance abuse.

C. They maintain emotional distance from their children
D. They alternate between loving and rejecting their children
Feedback
Rationale: Clients with anorexia nervosa typically come from a family with parents
who are controlling and overprotective. These clients use eating to gain control of
an aspect of their lives. The characteristics described in options B, C, and D aren't
typical of parents of children with anorexia
Correct
226. Which of the following signs should the nurse expect in a client with
known amphetamine overdose?
A. Hypotension
B. Tachycardia
C. Hot, dry skin

D. Constricted pupils
Feedback
Rationale: Amphetamines are central nervous system stimulants. They
cause sympathetic stimulation, including hypertension, tachycardia,
vasoconstriction, and hyperthermia. Hot, dry skin is seen with
anticholinergic agents such as jimsonweed. Pupils will be dilated, not
constricted.
Correct
227. An unemployed woman, age 24, seeks help because she feels depressed
and abandoned and doesn't know what to do with her life. She says she
has quit her last five jobs because her coworkers didn't like her and didn't
train her adequately. Last week, her boyfriend broke up with her after she
drove his car into a tree after an argument. The client's initial diagnosis is
borderline personality disorder. Which nursing observations support this
diagnosis?
A. Flat affect, social withdrawal, and unusual dress

B. Suspiciousness, hypervigilance, and emotional coldness
C. Lack of self-esteem, strong dependency needs, and
impulsive behavior
D. Insensitivity to others, sexual acting out, and violence
Feedback
Borderline personality disorder is characterized by lack of self-esteem,
strong dependency needs, and impulsive behavior. Instability in
interpersonal relationships, mood, and poor self-image
also is common. Typically, the client can't tolerate being alone and
expresses feelings of emptiness or boredom. Flat affect, social withdrawal,
and unusual dress are characteristic of schizoid personality disorder.
Suspiciousness, hypervigilance, and emotional coldness are seen in
paranoid personality disorders. In antisocial personality disorder, clients
are usually insensitive to others and act out sexually; they may also be
violent
Correct
228. An 16-year-old boy is admitted to the facility after acting out his
aggressions inappropriately at school. Predisposing factors to the
expression of aggression include:
A. Violence on television.
B. Passive parents.
C. An internal locus of control.
D. A single-parent family
Feedback
Rationale: Violence on television has been correlated with an increase in
aggressive behavior. Passive parents contribute to acting-out behaviors but
not specifically to violence. An internal locus of control leads to a positive
sense of self-esteem and isn't related to violence or aggression. There is no
direct correlation between single-parent families and violence.
Correct
229. In group therapy, a client who has used I.V. heroin every day for the past 14
years says, "I don't have a drug problem. I can quit whenever I want. I've
done it before." Which defense mechanism is the client using?
A. Denial
B. Obsession
C. Compensation
D. Rationalization
Feedback
Rationale: A client who states that he or she doesn't have a drug problem
and can quit using drugs at any time — despite evidence to the contrary —
is denying the drug addiction. Obsession isn't a defense mechanism. In
compensation, the client emphasizes positive attributes to compensate for
negative ones. In rationalization, the client justifies behaviors by faulty
logic.
Correct
230. A client is admitted to the inpatient adolescent unit after being arrested for
attempting to sell cocaine to an undercover police officer. The nurse plans

to write a behavioral contract. To best promote compliance, the contract
should be written:
A. Abstractly
B. By the client alone.
C. Jointly by the client and nurse.
D. Jointly by the physician and nurse.
Feedback
Rationale: A contract written jointly by the client and nurse most
successfully promotes cooperation and consistent behavior. The most
effective contract — and the type least likely to allow for manipulation and
misinterpretation — states the behavioral terms as concretely as possible. A
contract written solely by the client may not be agreeable to staff members;
one written by the physician and nurse may not be agreeable to the client.
Correct
231. A client is admitted to the psychiatric clinic for treatment of anorexia
nervosa. To promote the client's physical health, the nurse should plan to:
A. Severely restrict the client's physical activities.

B. Weigh the client daily, after the evening meal.
C. Monitor vital signs, serum electrolyte levels, and acid-base
balance.
D. Instruct the client to keep an accurate record of food and fluid intake.
Feedback
Rationale: An anorexic client who requires hospitalization is in poor physical
condition from starvation and may die as a result of arrhythmias,
hypothermia, malnutrition, infection, or cardiac abnormalities secondary to
electrolyte imbalances. Therefore, monitoring the client's vital signs, serum
electrolyte level, and acid base balance is crucial. Option A may worsen
anxiety. Option B is incorrect because a weight obtained after breakfast is
more accurate than one obtained after the evening meal. Option D would
reward the client with attention for not eating and reinforce the control issues
that are central to the underlying psychological problem; also, the client may
record food and fluid intake inaccurately.
Correct
232. A 15-year-old client is brought to the clinic by her mother. Her mother
expresses concern about her daughter's weight loss and constant dieting. The
nurse conducts a health history interview. Which of the following comments
indicates that the client may be suffering from anorexia nervosa?
A. "I like the way I look. I just need to keep my weight down because I'm a
cheerleader."
B. "I don't like the food my mother cooks. I eat plenty of fast food when I'm
out with my friends."
C. "I just can't seem to get down to the weight I want to be. I'm
so fat compared to other girls."
D. "I do diet around my periods; otherwise, I just get so bloated."
Feedback
Rationale: Low self-esteem is the highest risk factor for anorexia nervosa.
Constant dieting to get down to a "desirable weight" is characteristic of the
disorder. Feeling inadequate when compared to
peers indicates poor self-esteem. Most clients with anorexia nervosa don't like
the way they look, and their self-perception may be distorted. A girl with
cachexia may perceive herself to be overweight
when she looks in the mirror. Preferring fast food over healthy food is common
in this age-group. Because of the absence of body fat necessary for proper
hormone production, amenorrhea is common in a client with anorexia nervosa.
Correct
233. The nurse is caring for a client who she believes has been abusing opiates.
Assessment findings in a client abusing opiates such as morphine include:
A. Dilated pupils and slurred speech.

B. Rapid speech and agitation.
C. Dilated pupils and agitation.
D. Euphoria and constricted pupils.
Feedback
Rationale: Assessment findings in a client abusing opiates include agitation,
slurred speech, euphoria, and constricted pupils.
Correct
234. Which of the following medical conditions is commonly found in clients with
bulimia nervosa?
A. Allergies
B. Cancer
C. Diabetes mellitus
D. Hepatitis A
Feedback
Rationale: Bulimia nervosa can lead to many complications, including diabetes,
heart disease, and hypertension. The eating disorder isn't typically associated
with allergies, cancer, or hepatitis A.
Correct
235. Which is the drug of choice for treating Tourette syndrome?
A. Fluoxetine (Prozac)
B. Fluvoxamine (Luvox)
C. Haloperidol (Haldol)
D. Paroxetine (Paxil)
Feedback
Rationale: Haloperidol is the drug of choice for treating Tourette syndrome.
Prozac, Luvox, and Paxil are antidepressants and aren't used to treat Tourette
syndrome
Correct
236. A client voluntarily admits himself to the substance abuse unit. He confesses
that he drinks 1 qt or more of vodka each day and uses cocaine occasionally.
Later that afternoon, he begins to show signs of alcohol withdrawal. What are
some early signs of this condition?
A. Vomiting, diarrhea, and bradycardia

B. Dehydration, temperature above 101° F (38.3° C), and pruritus
C. Hypertension, diaphoresis, and seizures
D. Diaphoresis, tremors, and nervousness
Feedback
Rationale: Alcohol withdrawal syndrome includes alcohol withdrawal,
alcoholic hallucinosis, and alcohol withdrawal delirium (formerly delirium
tremens). Signs of alcohol withdrawal include diaphoresis,
tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and
pulse rate, sleep disturbance, and irritability. Although diarrhea may be an early
sign of alcohol withdrawal, tachycardia — not bradycardia — is associated
with alcohol withdrawal. Dehydration and an elevated temperature may be
expected, but a temperature above 101° F indicates an infection rather than
alcohol withdrawal. Pruritus rarely occurs in alcohol withdrawal. If withdrawal
symptoms remain untreated, seizures may arise later.
Correct
237. Which assessment finding is most consistent with early alcohol withdrawal?
A. Heart rate of 120 to 140 beats/minute
B. Heart rate of 50 to 60 beats/minute

C. Blood pressure of 100/70 mm Hg
D. Blood pressure of 140/80 mm Hg
Feedback
Rationale: Tachycardia, a heart rate of 120 to 140 beats/minute, is a common
sign of alcohol withdrawal. Blood pressure may be labile throughout
withdrawal, fluctuating at different stages. Hypertension typically occurs in
early withdrawal. Hypotension, although rare during the early withdrawal
stages, may occur in later stages. Hypotension is associated with cardiovascular
collapse and most commonly occurs in clients who don't receive treatment. The
nurse should monitor the client's vital signs carefully throughout the entire
alcohol withdrawal process.
Correct
238. A client is brought to the psychiatric clinic by family members, who tell the
admitting nurse that the client repeatedly drives while intoxicated despite their
pleas to stop. During an interview with the nurse, which statement by the client
most strongly supports a diagnosis of psychoactive substance abuse?
A. "I'm not addicted to alcohol. In fact, I can drink more than I used to without
being affected."
B. "I only spend half of my paycheck at the bar."
C. "I just drink to relax after work."
D. "I know I've been arrested three times for drinking and
driving, but the police are just trying to hassle me."
Feedback
Rationale: According to the Diagnostic and Statistical Manual of Mental
Disorders, 4th edition, diagnostic criteria for psychoactive substance abuse
include a maladaptive pattern of such use, indicated either by continued use
despite knowledge of having a persistent or recurrent social, occupational,
psychological, or physical problem caused or exacerbated by substance abuse
or recurrent use in dangerous situations (for example, while driving). For this
client, psychoactive substance dependence must be ruled out; criteria for this
disorder include a need for increasing amounts of the substance to achieve
intoxication (option A), increased time and money spent on the substance
(option B), inability to fulfill role obligations (option C), and typical
withdrawal symptoms.
Correct
239. A client with paranoid personality disorder is admitted to a psychiatric
facility. Which remark by the nurse would best establish rapport and
encourage the client to confide in the nurse?
A. "I get upset once in a while, too."
B. "I know just how you feel. I'd feel the same way in your situation."
C. "I worry, too, when I think people are talking about me."
D. "At times, it's normal not to trust anyone."
Feedback
Rationale: Sharing a benign, nonthreatening, personal fact or feeling helps
the nurse establish rapport and encourages the client to confide in the nurse.
The nurse can't know how the client feels. Telling the client otherwise, as in
option B, would justify the suspicions of a paranoid client; furthermore, the
client relies on the nurse to interpret reality. Option C is incorrect because it
focuses on the nurse's feelings, not the client's. Option D wouldn't help
establish rapport or encourage the client to confide in the nurse
Correct
240. A 26-year-old client is admitted to the psychiatric unit with acute onset of
schizophrenia. His physician prescribes the phenothiazine chlorpromazine
(Thorazine), 100 mg by mouth four times per day. Before administering the
drug, the nurse reviews the client's medication history. Concomitant use of
which drug is likely to increase the risk of extrapyramidal effects?
A. Guanethidine (Ismelin)
B. Droperidol (Inapsine)
C. Lithium carbonate (Lithonate)

D. Alcohol
Feedback
Rationale: When administered with any phenothiazine, droperidol may
increase the risk of extrapyramidal effects. The other options are incorrect
Correct
241. Which information is most important for the nurse to include in a teaching plan
for a schizophrenic client taking clozapine (Clozaril)?
A. Monthly blood tests will be necessary.

B. Report a sore throat or fever to the physician immediately.
C. Blood pressure must be monitored for hypertension.

D. Stop the medication when symptoms subside.
Feedback
Rationale: A sore throat and fever are indications of an infection caused by
agranulocytosis, a potentially life-threatening complication of clozapine.
Because of the risk of agranulocytosis, white blood cell (WBC) counts are
necessary weekly, not monthly. If the WBC count drops below 3,000/µl, the
medication must be stopped. Hypotension may occur in clients taking this
medication. Warn the client to stand up slowly to avoid dizziness from
orthostatic hypotension. The medication should be continued, even when
symptoms have been controlled. If the medication must be stopped, it should be
slowly tapered over 1 to 2 weeks and only under the supervision of a physician.
Correct
242. A client with a history of medication noncompliance is receiving outpatient
treatment for chronic undifferentiated schizophrenia. The physician is most
likely to prescribe which medication for this client?
A. Chlorpromazine (Thorazine)
B. Imipramine (Tofranil)
C. Lithium carbonate (Lithane)
D. Fluphenazine decanoate (Prolixin Decanoate)
Feedback
Rationale: Fluphenazine decanoate is a long-acting antipsychotic agent given
by injection. Because it has a 4-week duration of action, it's commonly
prescribed for outpatients with a history of medication noncompliance.
Chlorpromazine, also an antipsychotic agent, must be administered daily to
maintain adequate plasma levels, which necessitates compliance with the
dosage schedule. Imipramine, a tricyclic antidepressant, and lithium carbonate,
a mood stabilizer, are rarely used to treat clients with chronic schizophrenia.
Correct
243. A client is admitted to the psychiatric unit with a tentative diagnosis of psychosis.
Her physician prescribes the phenothiazine thioridazine (Mellaril) 50 mg by
mouth three times per day. Phenothiazines differ from central nervous system
(CNS) depressants in their sedative effects by producing:
A. Deeper sleep than CNS depressants.

B. Greater sedation than CNS depressants.
C. A calming effect from which the client is easily aroused.
D. More prolonged sedative effects, making the client more difficult to arouse.
Feedback
Rationale: Shortly after phenothiazine administration, a quieting and calming
effect occurs, but the client is easily aroused, alert, and responsive and has good
motor coordination.
Correct
244. A client is admitted with a diagnosis of delusions of grandeur. This diagnosis
reflects a belief that one is:
A. Highly important or famous
B. Being persecuted.
C. Connected to events unrelated to oneself.
D. Responsible for the evil in the world.
Feedback
Rationale: A delusion of grandeur is a false belief that one is highly important or
famous. A delusion of persecution is a false belief that one is being persecuted. A
delusion of reference is a false belief that one is connected to events unrelated to
oneself or a belief that one is responsible for the evil in the world.
Correct
245. When teaching the family of a client with schizophrenia, the nurse should
provide which information?
A. Relapse can be prevented if the client takes the medication.

B. Support is available to help family members meet their own
needs.
C. Improvement should occur if the client has a stimulating environment.
D. Stressful family situations can precipitate a relapse in the client.
Feedback
Rationale: Because family members of a client with schizophrenia face difficult
situations and great stress, the nurse should inform them of support services that
can help them cope with such problems. The nurse should also teach them that
medication can't prevent relapses and that environmental stimuli may precipitate
symptoms. Although stress can trigger symptoms, the nurse shouldn't make the
family feel responsible for relapses (as in option D).
Correct
246. Important teaching for a client receiving risperidone (Risperdal) would include
advising the client to:
A. double the dose if missed to maintain a therapeutic level.

B. Be sure to take the drug with a meal because it's very irritating to the stomach.
C. Discontinue the drug if the client reports weight gain.
D. Notify the physician if the client notices an increase in bruising.
Feedback
Rationale: Bruising may indicate blood dyscrasias, so notifying the physician
about increased bruising is very important. Don't double the dose. This drug
doesn't irritate the stomach, and weight gain isn't a problem.
Correct
247. A client is admitted to the psychiatric hospital with a diagnosis of catatonic
schizophrenia. During the physical examination, the client's arm remains
outstretched after the nurse obtains the pulse and blood pressure, and the nurse
must reposition the arm. This client is exhibiting:
A. Suggestibility.
B. Negativity.
C. Waxy flexibility.
D. Retardation
Feedback
Rationale: Waxy flexibility, the ability to assume and maintain awkward or
uncomfortable positions for long periods, is characteristic of catatonic
schizophrenia. Clients commonly remain in these awkward positions until
someone repositions them. Clients with dependency problems may demonstrate
suggestibility, a response pattern in which one easily agrees to the ideas and
suggestions of others rather than making independent judgments. Negativity (for
example, resistance to being moved or being asked to cooperate) and retardation
(slowed movement) also occur in catatonic clients.
Correct
248. Drug therapy with thioridazine (Mellaril) shouldn't exceed a daily dose of 800
mg to prevent which adverse reaction?
A. Hypertension
B. Respiratory arrest
C. Tourette syndrome
D. Retinal pigmentation
Feedback
Rationale: Retinal pigmentation may occur if the thioridazine dosage exceeds 800
mg per day. The other options don't occur as a result of exceeding this dose.
Correct
249. A client tells the nurse that people from Mars are going to invade the earth.
Which response by the nurse would be most therapeutic?
A. "That must be frightening to you. Can you tell me how you feel
about it?"
B. "There are no people living on Mars."
C. "What do you mean when you say they're going to invade the earth?"
D. "I know you believe the earth is going to be invaded, but I don't believe that."
Feedback
Rationale: This response addresses the client's underlying fears without feeding
the delusion. Refuting the client's delusion, as in option B, would increase
anxiety and reinforce the delusion. Asking the client to elaborate on the delusion,
as in option C, would also reinforce it. Voicing disbelief about the delusion, as in
option D, wouldn't help the client deal with underlying fears
Correct
250. A client with a diagnosis of paranoid schizophrenia comments tothe nurse,

"How do I know what is really in those pills?" Which of the following is the
best response?
A. Say, "You know it's your medicine."

B. Allow him to open the individual wrappers of the medication.
C. Say, "Don't worry about what is in the pills. It's what is ordered."
D. Ignore the comment because it's probably a joke.
Feedback
Rationale: Option B is correct because allowing a paranoid client to open his
medication can help reduce suspiciousness. Option A is incorrect because the
client doesn't know that it's his medication and he's obviously suspicious.
Telling the client not to worry or ignoring the comment isn't supportive and
doesn't offer reassurance.
Correct
251. A client receiving fluphenazine decanoate (Prolixin Decanoate) therapy
develops pseudoparkinsonism. The physician is likely to prescribe which drug
to control this extrapyramidal effect?
A. Phenytoin (Dilantin)
B. Amantadine (Symmetrel)
C. Benztropine (Cogentin)
D. Diphenhydramine (Benadryl)
Feedback
Rationale: An antiparkinsonian agent, such as amantadine, may be used to
control pseudoparkinsonism; diphenhydramine or benztropine may be used to
control other extrapyramidal effects. Phenytoin is used to treat seizure activity.
Correct
252. The nurse is providing care to a client with a catatonic type of schizophrenia
who exhibits extreme negativism. To help the client meet his basic needs, the
nurse should:
A. Ask the client which activity he would prefer to do first.

B. Negotiate a time when the client will perform activities.
C. Tell the client specifically and concisely what needs to be
done.
D. Prepare the client ahead of time for the activity.
Feedback
Rationale: The client needs to be informed of the activity and when it will be
done. Giving the client choices isn't desirable because he can be manipulative
or refuse to do anything. Negotiating and preparing the client ahead of time
also isn't therapeutic with this type of client because he may not want to
perform the activity.
Correct
253. A client, age 36, with paranoid schizophrenia believes the room is bugged by
the Central Intelligence Agency and that his roommate is a foreign spy. The
client has never had a romantic relationship, has no contact with family
members, and hasn't been employed in the last 14 years. Based on Erikson's
theories, the nurse should recognize that this client is in which stage of
psychosocial development?
A. Autonomy versus shame and doubt

B. Generativity versus stagnation
C. Integrity versus despair
D. Trust versus mistrust
Feedback
Rationale: This client's paranoid ideation indicates difficulty trusting others.
The stage of autonomy versus shame and doubt deals with separation,
cooperation, and self-control. Generativity versus stagnation is the normal
stage for this client's chronologic age. Integrity versus despair is the stage for
accepting the positive and negative aspects of one's life, which would be
difficult or impossible for this client.
Correct
254. Every day for the past 2 weeks, a client with schizophrenia stands up
during group therapy and screams, "Get out of here right now! The
elevator bombs are going to explode in 3 minutes!" The next time this
happens, how should the nurse respond?
A. "Why do you think there is a bomb in the elevator?"

B. "That is the same thing you said in yesterday's session."
C. "I know you think there are bombs in the elevator, but
there aren't."
D. "If you have something to say, you must do it according to our group
rules."
Feedback
Rationale: Option C is the most therapeutic response because it orients the
client to reality. Options A and B are condescending. Option D sounds
punitive and could embarrass the client.
Correct
255. A client tells the nurse that people from Mars are going to invade the
earth. Which response by the nurse would be most therapeutic?
A. "That must be frightening to you. Can you tell me how
you feel about it?"

B. "There are no people living on Mars."
C. "What do you mean when you say they're going to invade the earth?"
D. "I know you believe the earth is going to be invaded, but I don't believe
that."
Feedback
Rationale: This response addresses the client's underlying fears without
feeding the delusion. Refuting the client's delusion, as in option B, would

increase anxiety and reinforce the delusion. Asking the client to elaborate
on the delusion, as in option C, would also reinforce it. Voicing disbelief
about the delusion, as in option D, wouldn't help the client deal with
underlying fears
Correct
256. A client is admitted with a diagnosis of delusions of grandeur. This
diagnosis reflects a belief that one is:
A. Highly important or famous
B. Being persecuted.
C. Connected to events unrelated to oneself.
D. Responsible for the evil in the world.
Feedback
Rationale: A delusion of grandeur is a false belief that one is highly
important or famous. A delusion of persecution is a false belief that one is
being persecuted. A delusion of reference is a false belief that one is
connected to events unrelated to oneself or a belief that one is responsible
for the evil in the world.
Correct
257. The nurse is caring for a client with schizophrenia. Which of the
following outcomes is the least desirable?
A. The client spends more time by himself.
B. The client doesn't engage in delusional thinking.

C. The client doesn't harm himself or others.
D. The client demonstrates the ability to meet his own self-care needs.
Feedback
The client with schizophrenia is commonly socially isolated and
withdrawn; therefore, having the client spend more time by himself
wouldn't be a desirable outcome. Rather, a desirable outcome would
specify that the client spend more time with other clients and staff on the
unit. Delusions are false personal beliefs. Reducing or eliminating
delusional thinking using talking therapy and antipsychotic medications
would be a desirable outcome. Protecting the client and others from harm
is a desirable client outcome achieved by close observation, removing any
dangerous objects, and administering medications. Because the client with
schizophrenia may have difficulty meeting his or her own self-care needs,
fostering the ability to perform self-care independently is a desirable client
outcome.
Correct
258. The nurse is teaching a psychiatric client about her prescribed drugs,
chlorpromazine and benztropine. Why is benztropine administered?
A. To reduce psychotic symptoms

B. To reduce extrapyramidal symptoms
C. To control nausea and vomiting
D. To relieve anxiety
Feedback
Rationale: Benztropine is an anticholinergic medication, administered to
reduce the extrapyramidal adverse effects of chlorpromazine and other
antipsychotic medications. Benztropine doesn't reduce psychotic symptoms,
relieve anxiety, or control nausea and vomiting.
Correct
259. Propranolol (Inderal) is used in the mental health setting to manage which
of the following conditions?
A. Antipsychotic-induced akathisia and anxiety
B. The manic phase of bipolar illness as a mood stabilizer

C. Delusions for clients suffering from schizophrenia
D. Obsessive-compulsive disorder (OCD) to reduce ritualistic behavior
Feedback
Rationale: Propranolol is a potent beta-adrenergic blocker and produces a
sedating effect; therefore, it's used to treat antipsychotic induced akathisia
and anxiety. Lithium (Lithobid) is used to stabilize clients with bipolar
illness. Antipsychotics are used to treat delusions. Some antidepressants
have been effective in treating OCD.
Correct
260. A client with paranoid schizophrenia is admitted to the psychiatric unit of a
hospital. Nursing assessment should include careful observation of the client's:
A. Thinking, perceiving, and decision-making skills.
B. Verbal and nonverbal communication processes

C. Affect and behavior.
D. Psychomotor activity.
Feedback
Rationale: Nursing assessment of a psychotic client should include careful
inquiry about and observation of the client's thinking, perceiving, symbolizing,
and decision-making skills and abilities. Assessment of such a client typically
reveals alterations in thought content and process, perception, affect, and
psychomotor behavior; changes in personality, coping, and sense of self; lack
of self-motivation; presence of psychosocial stressors; and degeneration of
adaptive functioning. Although assessing communication processes, affect,
behavior, and psychomotor activity would reveal important information about
the client's condition, the nurse should concentrate on determining whether the
client is hallucinating by assessing thought processes and decision-making
ability.
Correct
261. The etiology of schizophrenia is best described by:
A. Genetics due to a faulty dopamine receptor.

B. Environmental factors and poor parenting.
C. Structural and neurobiological factors.

D. A combination of biological, psychological, and environmental factors.
Feedback
Rationale: A reliable genetic marker hasn't been determined for schizophrenia.
However, studies of twins and adopted siblings have strongly implicated a
genetic predisposition. Since the mid-19th century, excessive dopamine activity
in the brain has also been suggested as a causal factor. Communication and the
family system have been studied as contributing factors in the development of
schizophrenia. Therefore, a combination of biological, psychological,
and environmental factors are thought to cause schizophrenia.
Correct
262. A client with schizophrenia who receives fluphenazine (Prolixin) develops
pseudoparkinsonism and akinesia. What drug would the nurse administer to
minimize extrapyramidal symptoms?
A. Benztropine (Cogentin)
B. Dantrolene (Dantrium)
C. Clonazepam (Klonopin)
D. Diazepam (Valium)
Feedback
Rationale: Benztropine is an anticholinergic drug administered to reduce
extrapyramidal adverse effects in the client taking antipsychotic drugs. It works
by restoring the equilibrium between the neurotransmitters acetylcholine and

dopamine in the central nervous system (CNS). Dantrolene, a hydantoin drug
that reduces the catabolic processes, is administered to alleviate the symptoms
of neuroleptic malignant syndrome, a potentially fatal adverse effect of
antipsychotic drugs. Clonazepam, a benzodiazepine drug that depresses the
CNS, is administered to control seizure activity. Diazepam, a benzodiazepine
drug, is administered to reduce anxiety.
Correct
263. Which information is most important for the nurse to include in a teaching plan
for a schizophrenic client taking clozapine (Clozaril)?
A. Monthly blood tests will be necessary.

B. Report a sore throat or fever to the physician immediately.
C. Blood pressure must be monitored for hypertension.

D. Stop the medication when symptoms subside.
Feedback
Rationale: A sore throat and fever are indications of an infection caused by
agranulocytosis, a potentially life-threatening complication of clozapine.
Because of the risk of agranulocytosis, white blood cell (WBC) counts are
necessary weekly, not monthly. If the WBC count drops below 3,000/µl, the
medication must be stopped. Hypotension may occur in clients taking this
medication. Warn the client to stand up slowly to avoid dizziness from
orthostatic hypotension. The medication should be continued, even when
symptoms have been controlled. If the medication must be stopped, it should be
slowly tapered over 1 to 2 weeks and only under the supervision of a physician.
Correct
264. Which of the following is one of the advantages of the newer antipsychotic
medication risperidone (Risperdal)?
A. The absence of anticholinergic effects

B. A lower incidence of extrapyramidal effects
C. Photosensitivity and sedation

D. No incidence of neuroleptic malignant syndrome
Feedback
Rationale: Risperdal has a lower incidence of extrapyramidal effects than the
typical antipsychotics. Risperdal does produce anticholinergic effects and
neuroleptic malignant syndrome can occur. Photosensitivity isn't an advantage.
Correct
265. A client is admitted to the psychiatric unit of a local hospital with chronic
undifferentiated schizophrenia. During the next several days, the client is
seen laughing, yelling, and talking to herself. This behavior is characteristic
of:
A. A client is admitted to the psychiatric unit of a local hospital with chronic

undifferentiated schizophrenia. During the next several days, the client is
seen laughing, yelling, and talking to herself. This behavior is
characteristic of:
B. Looseness of association.
C. Illusion.
D. Hallucination
Feedback
Auditory hallucination, in which one hears voices when no external stimuli
exist, is common in schizophrenic clients. Such behaviors as laughing,
yelling, and talking to oneself suggest such a hallucination. Delusions, also
common in schizophrenia, are false beliefs or ideas that arise without external
stimuli. Clients with schizophrenia may exhibit looseness of association, a
pattern of thinking and communicating in which ideas aren't clearly linked to
one another. Illusion is a less severe perceptual disturbance in which the
client misinterprets actual external stimuli. Illusions are rarely associated with
schizophrenia.
Correct
266. A client who's taking antipsychotic medication develops a very high
temperature, severe muscle rigidity, tachycardia, and rapid deterioration in
mental status. The nurse suspects what complication of antipsychotic
therapy?
A. Agranulocytosis
B. Extrapyramidal effects
C. Anticholinergic effects
D. Neuroleptic malignant syndrome (NMS)
Feedback
A rare but potentially fatal condition of antipsychotic medication is called
NMS. It generally starts with an elevated temperature and severe
extrapyramidal effects. Agranulocytosis is a blood disorder. Anticholinergic
effects include blurred vision, drowsiness, and dry mouth. Symptoms of
extrapyramidal effects include tremors, restlessness, muscle spasms, and
pseudoparkinsonism.
Correct
267. For several years, a client with chronic schizophrenia has received 10 mg of
fluphenazine hydrochloride (Prolixin) by mouth four times per day. Now the
client has a temperature of 102° F (38.9° C), a heart rate of 120 beats/minute, a
respiratory rate of 20 breaths/minute, and a blood pressure of 210/140 mm Hg.
Because the client also is confused and incontinent, the nurse suspects
malignant neuroleptic syndrome. What steps should the nurse take?
A. Give the next dose of fluphenazine, call the physician, and monitor vital
signs.
B. Withhold the next dose of fluphenazine, call the physician, and monitor
vital signs.
C. Give the next dose of fluphenazine and restrict the client to the room to
decrease stimulatio
D. Withhold the next dose of fluphenazine, administer an antipyretic agent, and
increase the client's fluid intake.
Feedback
Malignant neuroleptic syndrome is a dangerous adverse effect of neuroleptic
drugs such as fluphenazine. The nurse should withhold the next dose, notify the
physician, and continue to monitor vital signs. Although an antipyretic agent
may be used to reduce fever, increased fluid intake is contraindicated because it
may increase the client's fluid volume further, raising blood pressure even
higher.
Correct
268. A psychotic client reports to the evening nurse that the day nurse put something
suspicious in his water with his medication. The nurse replies, "You're worried
about your medication?" The nurse's communication is:
A. An example of presenting reality.

B. Reinforcing the client's delusions.
C. Focusing on emotional content.
D. A nontherapeutic technique called mind reading.
Feedback
The nurse should help the client focus on the emotional content rather than
delusional material. Presenting reality isn't helpful because it can lead to
confrontation and disengagement. Agreeing with the client and supporting his
beliefs are reinforcing delusions. Mind reading isn't therapeutic.
Correct
269. Which of the following groups of characteristics would the nurse expect to see
in the client with schizophrenia?
A. Loose associations, grandiose delusions, and auditory

hallucinations
B. Periods of hyperactivity and irritability alternating with depression
C. Delusions of jealousy and persecution, paranoia, and mistrust
D. Sadness, apathy, feelings of worthlessness, anorexia, and weight loss
Feedback
Loose associations, grandiose delusions, and auditory hallucinations are all
characteristic of the classic schizophrenic client. These clients aren't able to
care for their physical appearance. They frequently hear voices telling them to
do something either to themselves or to others. Additionally, they verbally
ramble from one topic to the next. Periods of hyperactivity and irritability
alternating with depression are characteristic of bipolar or manic disease.
Delusions of jealousy and persecution, paranoia, and mistrust are characteristics
of paranoid disorders. Sadness, apathy, feelings of worthlessness, anorexia, and
weight loss are characteristics of depression.
Correct
270. A client has a history of chronic undifferentiated schizophrenia. Because she
has a history of noncompliance with antipsychotic therapy, she'll receive
fluphenazine decanoate (Prolixin Decanoate) injections every 4 weeks. Before
discharge, what should the nurse include in her teaching plan?
A. Asking the physician for droperidol (Inapsine) to control any extrapyramidal

symptoms that occur
B. Sitting up for a few minutes before standing to minimize
orthostatic hypotension
C. Notifying the physician if her thoughts don't normalize within 1 week
D. Expecting symptoms of tardive dyskinesia to occur and to be transient
Feedback
The nurse should teach the client how to manage common adverse reactions,
such as orthostatic hypotension and anticholinergic effects. Antipsychotic
effects of the drug may take several weeks to appear. Droperidol increases the
risk of extrapyramidal effects when given in conjunction with phenothiazines
such as fluphenazine. Tardive dyskinesia is a possible adverse reaction and
should be reported immediately
Correct
271. The nurse is caring for a client with schizophrenia who experiences auditory
hallucinations. The client appears to be listening to someone who isn't visible.
He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing
intervention is the most appropriate?
A. Approach the client and touch him to get his attention

B. Encourage the client to go to his room where he'll experience fewer
distractions.
C. Acknowledge that the client is hearing voices but make it clear
that the nurse doesn't hear these voices.

D. Ask the client to describe what the voices are saying
Feedback
By acknowledging that the client hears voices, the nurse conveys acceptance of
the client. By letting the client know that the nurse doesn't hear the voices, the
nurse avoids reinforcing the hallucination. The nurse shouldn't touch the client
with schizophrenia without advance warning. The hallucinating client may
believe that the touch is a threat or act of aggression and respond violently.
Being alone in his room encourages the client to withdraw and may promote
more hallucinations. The nurse should provide an activity to distract the client.
By asking the client what the voices are saying, the nurse is reinforcing the
hallucination. The nurse should focus on the client's feelings, rather than the
content of the hallucination.
Correct
272. Benztropine (Cogentin) is used to treat the extrapyramidal effects induced by
antipsychotics. This drug exerts its effect by
A. Decreasing the anxiety causing muscle rigidity.

B. Blocking the cholinergic activity in the central nervous system
(CNS).
C. Increasing the level of acetylcholine in the CNS
D. Increasing norepinephrine in the CNS.
Feedback
Option B is the action of Cogentin. Anxiety doesn't cause extrapyramidal
effects. Overactivity of acetylcholine and lower levels of dopamine are the
causes of extrapyramidal effects. Benztropine doesn't increase norepinephrine
in the CNS.
Correct
273. The nurse formulates a nursing diagnosis of Impaired social interaction related
to disorganized thinking for a client with schizotypal personality disorder.
Based on this nursing diagnosis, which nursing intervention takes highest
priority?
A. Helping the client to participate in social interactions

B. Establishing a one-on-one relationship with the client
C. Exploring the effects of the client's behavior on social interactions

D. Developing a schedule for the client's participation in social interactions
Feedback
By establishing a one-on-one relationship, the nurse helps the client learn how
to interact with people in new situations. The other options are appropriate but
should take place only after the nurse-client relationship is established.
Correct
274. A client with borderline personality disorder becomes angry when he is told
that today's psychotherapy session with the nurse will be delayed 30 minutes
because of an emergency. When the session finally begins, the client expresses
anger. Which response by the nurse would be most helpful in dealing with the
client's anger?
A. "If it had been your emergency, I would have made the other client wait."
B. "I know it's frustrating to wait. I'm sorry this happened."
C. "You had to wait. Can we talk about how this is making you
feel right now?"

D. "I really care about you and I'll never let this happen again."
Feedback
This response may diffuse the client's anger by helping to maintain a
therapeutic relationship and addressing the client's feelings. Option A wouldn't
address the client's anger. Option B is incorrect because the client with a
borderline personality disorder blames others for things that happen, so
apologizing reinforces the client's misconceptions. The nurse can't promise that
a delay will never occur again, as in option D, because such matters are outside
the nurse's control.
Correct
275. A client receiving haloperidol (Haldol) complains of a stiff jaw and difficulty
swallowing. The nurse's first action is to:
A. Reassure the client and administer as needed lorazepam (Ativan) I.M.

B. Administer as needed dose of benztropine (Cogentin) I.M. as
ordered.
C. Administer as needed dose of benztropine (Cogentin) by mouth as ordered.
D. Administer as needed dose of haloperidol (Haldol) by mouth.
Feedback
The client is most likely suffering from muscle rigidity due to haloperidol. I.M.
benztropine should be administered to prevent asphyxia or aspiration.
Lorazepam treats anxiety, not extrapyramidal effects. Another dose of
haloperidol would increase the severity of the reaction.
Correct
276. Situation: An old woman was brought for evaluation due to the hospital for
evaluation due to increasing forgetfulness and limitations in daily function.
She tearfully tells the nurse “I can’t take it when she accuses me of stealing
her things.” Which response by the nurse will be most therapeutic?
A. ”Don’t take it personally. Your mother does not mean it.”

B. “Have you tried discussing this with your mother?”
C. “This must be difficult for you and your mother.”
D. “Next time ask your mother where her things were last seen.”
Feedback
This reflecting the feeling of the daughter that shows empathy. A and D.
Giving advise does not encourage verbalization. B. This response does not
encourage verbalization of feelings.
Correct
277. Situation : The nurse assigned in the detoxification unit attends to various
patients with substance-related disorders.
A client is admitted with needle tracts on his arm, stuporous and with pin
point pupil will likely be managed with:
A. Naltrexone (Revia)
B. Narcan (Naloxone)
C. Disulfiram (Antabuse)
D. Methadone (Dolophine)
Feedback
Narcan is a narcotic antagonist used to manage the CNS depression due to
overdose with heroin. A. This is an opiate receptor blocker used to relieve the
craving for heroine C. Disulfiram is used as a deterrent in the use of alcohol.
D. Methadone is used as a substitute in the withdrawal from heroine
Correct
278. The client with anorexia nervosa is improving if:
A. She eats meals in the dining room.

B. Weight gain
C. She attends ward activities.

D. She has a more realistic self concept.
Feedback
Weight gain is the best indication of the client’s improvement. The goal is
for the client to gain 1-2 pounds per week. (A)The client may purge after
eating. (C) Attending an activity does not indicate improvement in
nutritional state. (D) Body image is a factor in anorexia nervosa but it is not
an indicator for improvement.
Correct
279. Situation: A 20 year old college student is admitted to the medical ward
because of sudden onset of paralysis of both legs. Extensive examination
revealed no physical basis for the complaint. The nurse plans intervention
based on which correct statement about conversion disorder?
A. The symptoms are conscious effort to control anxiety

B. The client will experience high level of anxiety in response to the
paralysis.
C. The conversion symptom has symbolic meaning to the client
D. A confrontational approach will be beneficial for the client.
Feedback
the client uses body symptoms to relieve anxiety. A. The condition occurs
unconsciously. B. The client is not distressed by the lost or altered body
function. D. The client should not be confronted by the underlying cause of
his condition because this can aggravate the client’s anxiety.
Correct
280. Situation : The nurse assigned in the detoxification unit attends to various
patients with substance-related disorders

The client admitted for alcohol detoxification develops increased tremors,
irritability, hypertension and fever. The nurse should be alert for
impending:
A. Delirium tremens
B. Korsakoff’s syndrome
C. Esophageal varices
D. Wernicke’s syndrome
Feedback
Delirium Tremens is the most extreme central nervous system irritability
due to withdrawal from alcohol B. This refers to an amnestic syndrome
associated with chronic alcoholism due to a deficiency in Vit. B C. This is a
complication of liver cirrhosis which may be secondary to alcoholism . D.
This is a complication of alcoholism characterized by irregularities of eye
movements and lack of coordination.
Correct
281. Situation: An old woman was brought for evaluation due to the hospital for
evaluation due to increasing forgetfulness and limitations in daily function.
She says to the nurse who offers her breakfast, “Oh no, I will wait for my
husband. We will eat together” The therapeutic response by the nurse is:
A. “Your husband is dead. Let me serve you your breakfast.”
B. “I’ve told you several times that he is dead. It’s time to eat.”
C. “You’re going to have to wait a long time.”
D. “What made you say that your husband is alive?
Feedback
The client should be reoriented to reality and be focused on the here and
now.. B. This is not a helpful approach because of the short term memory of
the client. C. This indicates a pompous response. D. The cognitive limitation
of the client makes the client incapable of giving explanation
Correct
282. Situation: A 35 year old male has intense fear of riding an elevator. He
claims “ As if I will die inside.” This has affected his studies The client is
suffering from:
A. Agoraphobia
B. Social phobia
C. Claustrophobia
D. Xenophobia
Feedback
Claustrophobia is fear of closed space. A. Agoraphobia is fear of open space
or being a situation where escape is difficult. B. Social phobia is fear of
performing in the presence of others in a way that will be humiliating or
embarrassing. D. Xenophobia is fear of strangers.
Correct
283. The personality type of Ryan is:
A. Masochistic
B. Conforming
C. Dependent
D. Perfectionist
Feedback
A client with dependent personality is predisposed to develop asthma. A. The
conforming non-assertive client is predisposed to develop hypertension
because of the tendency to repress rage. C. The perfectionist and compulsive
tend to develop migraine. D. The masochistic, self sacrificing type are prone
to develop rheumatoid arthritis.
Correct
284. Which of the following interventions should be prioritized in the care of the
suicidal client?
A. Remove all potentially harmful items from the client’s room.
B. Allow the client to express feelings of hopelessness.

C. Note the client’s capabilities to increase self esteem.
D. Set a “no suicide” contract with the client.
Feedback
Accessibility of the means of suicide increases the lethality. Allowing patient

to express feelings and setting a no suicide contract are interventions for
suicidal client but blocking the means of suicide is priority. Increasing self
esteem is an intervention for depressed clients bur not specifically for suicide.
Correct
285. Which is the highest priority in the post ECT care?
A. Observe for confusion

B. Monitor respiratory status
C. Reorient to time, place and person

D. Document the client’s response to the treatment
Feedback
A side effect of ECT which is life threatening is respiratory arrest. A and C.
Confusion and disorientation are side effects of ECT but these are not the
highest priority.
Correct
286. The following medications will likely be prescribed for the client EXCEPT:
A. Prozac
B. Tofranil
C. Parnate
D. Zyprexa
Feedback
This is an antipsychotic. A. This is a SSRI antidepressant. B. This
antidepressant belongs to the Tricyclic group. C. This is a MAOI
antidepressant.
Correct
287. The nurse exemplifies awareness of the rights of a client whose anger is
escalating by:
A. Taking a directive role in verbalizing feelings
B. Using an authoritarian, confrontational approach

C. Putting the client in a seclusion room
D. Applying mechanical restraints
Feedback
The client has the right to be free from unnecessary restraints. Verbalization
of feelings or “talking down” in a non-threatening environment is helpful to
relieve the client’s anger. B. This is a threatening approach. C and D.
Seclusion and application restraints are done only when less restrictive
measures have failed to contain the client’s anger.
Correct
288. The client is arrogant and manipulative. In ensuring a therapeutic milieu, the
nurse does one of the following:
A. Agree on a consistent approach among the staff assigned to
the client.
B. Suggest that the client take a leading role in the social activities
C. Provide the client with extra time for one on one sessions
D. Allow the client to negotiate the plan of care
Feedback
A consistent firm approach is appropriate. This is a therapeutic way of to
handle attempts of exploiting the weakness in others or create conflicts
among the staff. Bargaining should not be allowed. B. This is not therapeutic
because the client tends to control and dominate others. C. Limits are set for
interaction time. D. Allowing the client to negotiate may reinforce
manipulative behavior.
Correct
289. A client on Lithium has diarrhea and vomiting. What should the nurse do
first:
A. Recognize this as a drug interaction

B. Give the client Cogentin
C. Reassure the client that these are common side effects of lithium therapy
D. Hold the next dose and obtain an order for a stat serum
lithium level
Feedback
Diarrhea and vomiting are manifestations of Lithium toxicity. The next dose
of lithium should be withheld and test is done to validate the observation. A.

The manifestations are not due to drug interaction. B. Cogentin is used to
manage the extra pyramidal symptom side effects of antipsychotics. C. The
common side effects of Lithium are fine hand tremors, nausea, polyuria and
polydipsia.
Correct
290. Situation: An 18 year old female was sexually attacked while on her way
home from work. She is brought to the hospital by her mother.
Rape is an example of which type of crisis:
A. Situational
B. Adventitious
C. Developmental
D. Internal
Feedback
Adventitious
Adventitious crisis is a crisis involving a traumatic event. It is not part of
everyday life. A. Situational crisis is from an external source that upset ones
psychological equilibrium C and D. Are the same. They are transitional or
developmental periods in life
Correct
291. During the initial care of rape victims the following are to be considered
EXCEPT:
A. Assure privacy.
B. Touch the client to show acceptance and empathy
C. Accompany the client in the examination room.

D. Maintain a non-judgmental approach.
Feedback
Touch the client to show acceptance and empathy
The client finds touch intrusive and therefore should be avoided. A. Privacy is
one of the rights of a victim of rape. C. The client is anxious. Accompanying
the client in a quiet room ensures safety and offers emotional support. D.
Guilt feeling is common among rape victims. They should not be blamed.
Correct
292. The nurse acts as a patient advocate when she does one of the following:
A. She encourages the client to express her feeling regarding her experience.
B. She assesses the client for injuries.
C. She postpones the physical assessment until the client is calm
D. Explains to the client that her reactions are normal
Feedback
She postpones the physical assessment until the client is calm
The nurse acts as a patient advocate as she protects the client from
psychological harm A. The nurse acts a a counselor B. The nurse acts as a
technician D. This exemplifies the role of a teacher

Correct
293. Crisis intervention carried out to the client has this primary goal:
A. Assist the client to express her feelings

B. Help her identify her resources
C. Support her adaptive coping skills
D. Help her return to her pre-rape level of function
Feedback
Help her return to her pre-rape level of function
The goal of crisis intervention to help the client return to her level of function
prior to the crisis. A,B and C are interventions or strategies to attain the goal
Correct
294. Five months after the incident the client complains of difficulty to
concentrate, poor appetite, inability to sleep and guilt. She is likely suffering
from:
A. Adjustment disorder
B. Somatoform Disorder
C. Generalized Anxiety Disorder
D. Post traumatic disorder
Feedback
Post traumatic disorder. Post traumatic stress disorder is characterized by

flashback, irritability, and difficulty falling asleep and concentrating
following an extremely traumatic event. This lasts for more that one month
A. Adjustment disorder is the maladaptive reaction to stressful events
characterized by anxiety, depression and work or social impairments. This
occurs within 3 months after the event B. Somatoform disorders are anxiety
related disorders characterized by presence of physical symptoms without
demonstrable organic basis C. Generalized anxiety disorder is characterized
by chronic, excessive anxiety for at least 6 months
Correct
295. Situation: A 29 year old client newly diagnosed with breast cancer is pacing,
with rapid speech headache and inability to focus with what the doctor was
saying.
The nurse assesses the level of anxiety as:
A. Mild
B. Moderate
C. Severe
D. Panic
Feedback
Severe
The client’s manifestations indicate severe anxiety. A Mild anxiety is
manifested by slight muscle tension, slight fidgeting, alertness, ability to
concentrate and capable of problem solving. B. Moderate muscle tension,
increased vital signs, periodic slow pacing, increased rate of speech and
difficulty in concentrating are noted in moderate anxiety. D. Panic level of
anxiety is characterized immobilization, incoherence, feeling of being
overwhelmed and disorganization
Correct
296. Anxiety is caused by:
A. An objective threat
B. A subjectively perceived threat
C. Hostility turned to the self

D. Masked depression
Feedback
a subjectively perceived threat Anxiety is caused by a subjectively perceived
threat A. Fear is caused by an objective threat C. A depressed client
internalizes hostility D. Mania is due to masked depression
Correct
297. It would be most helpful for the nurse to deal with a client with severe anxiety
by:
A. Give specific instructions using speak in concise statements.
B. Ask the client to identify the cause of her anxiety.

C. Explain in detail the plan of care developed
D. Urge the client to focus on what the nurse is saying
Feedback
Give specific instructions using speak in concise statements.
The client has narrowed perceptual field. Lengthy explanations cannot be
followed by the client. B. The client will not be able to identify the cause of
anxiety C and D. The client has difficulty concentrating and will not be able to
focus.
Correct
298. Which of the following medications will likely be ordered for the client?"
A. Prozac
B. Valium
C. Risperdal
D. Lithium
Feedback
Valium
Antianxiety A. Antidepressant C. Antipsychotic D. Antimanic
Correct
299. Which of the following is included in the health teachings among clients
receiving Valium?:
A. Avoid foods rich in tyramine.

B. Take the medication after meals.
C. It is safe to stop it anytime after long term use.

D. Double up the dose if the client forgets her medication.
Feedback
Take the medication after meals. Antianxiety medications cause G.I. upset so it
should be taken after meals. A. This is specific for antidepressant MAOI.
Taking tyramine rich food can cause hypertensive crisis. C. Valium causes
dependency. In which case, the medication should be gradually withdrawn to
prevent the occurrence of convulsion. D The dose of Valium should not be
doubled if the previous dose was not taken. It can intensify the CNS depressant
effects.
Correct
300. A client is experiencing an anxiety attack. The most appropriate nursing
intervention should include?
A. Turing on the television

B. Leaving the client alone
C. Staying with the client and speaking in short sentences
D. Ask the client to play with other clients
Feedback
C. Appropriate nursing interventions for an anxiety attack include using short
sentences, staying with the client, decreasing stimuli, remaining calm and
medicating as needed.
Correct
301. A nursing care plan for a male client with bipolar I disorder should include:
A. Providing a structured environment
B. Designing activities that will require the client to maintain contact with
reality
C. Engaging the client in conversing about current affairs
D. Touching the client to provide assurance
Feedback
A. Structure tends to decrease agitation and anxiety and increases the client's
feeling of security.
Correct
302. To further assess a clent's suicidal potential. Nurse Katrina should be
especially alert to the client expression of:
A. Frustration and fear of death

B. Anger and resentment
C. Anxiety and loneliness
D. Helplessness and hopelessness
Feedback
D. The expression of these feelings may indicate that this client is unable to
continue the struggle of life.

Correct
303. Conney with borderline personality disorder who is to be discharged soon
threatens to "do something" to herself if discharged. Which of the following
actions by the nurse would be most important?
A. Ask a family member to stay with the client at home temporarily

B. Discuss the meaning of the client's statement with her
C. Request an immediate extension for the client

D. Ignore the clients statement because it's a sign of manipulation
Feedback
B. Any suicidal statement must be assessed by the nurse. The nurse should
discuss the client's statement with her to determine its meaning in terms of
suicide.
Correct
304. Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis and
hyperactivity. Blood pressure is 190/87 mmhg and pulse is 92 bpm. Which of
the medications would the nurse expect to administer?
A. Naloxone (Narcan)
B. Benzlropine (Cogentin)
C. Lorazepam (Ativan)
D. Haloperidol (Haldol)
Feedback
C. The nurse would most likely administer benzodiazepine, such as lorazepan
(ativan) to the client who is experiencing symptoms: The client's experiences
symptoms of withdrawal because of the rebound phenomenon when the
sedation of the CNS from alcohol begins to decrease.
Correct
305. Mario is admitted to the emergency room with drug-induced anxiety related
to over ingestion of prescribed antipsychotic medication. The most important
piece of information the nurse in charge should obtain initially is the
A. Length of time on med.

B. Name of the ingested medication and the amount ingested
C. Reason for the suicide attempt

D. Name of the nearest relative and their phone number
Feedback
B. In an emergency, life saving facts are obtained first. The name and the
amount of medication ingested are the most important facts to obtain.
Correct
306. Which of the following foods would the nurse Trish eliminate from the diet of
a client in alcohol withdrawal?
A. Milk
B. Orange Juice
C. Caffeine free Soda
D. Regular Coffee
Feedback
Regular coffee contains caffeine which acts as a psychomoter stimulant and
leads to feelings of anxiety and agitation. Serving coffee to the client may add
to tremors or wakefulness.
Correct
307. Nurse Monette is aware that extremely depressed clients seem to do best in
setting where they have:
A. Multiple stimuli
B. Routine activities
C. Minimal decision making

D. Varied activities
Feedback
B. Depression usually is both emotional and physical. A simple daily routine is
the best, least stressful and least anxiety producing.
Correct
308. Marco approached Nurse Trisha asking for advice on how to deal with his
alcohol addiction. Nurse Trisha should tell the client that the only effective
treatment for alcoholism is:
A. Psychotherapy
B. Alcoholics Anonymous (A.A.)
C. Total Abstinence
D. Aversion Therapy
Feedback
Correct
309. Nurse Benjie is communicating with a male client with substance induced
persisting dementia; the client cannot remember facts and fills in the gaps with
imaginary information. Nurse Benji is aware that this is typical of?
A. Flight if ideas
B. Associative looseness
C. Confabulation
D. Concretism
Feedback
C. Confabulation or the filling in of memory caps with imaginary facts is a
defense mechanism used by people experiencing memory deficits.
Correct
310. A 32 year old male graduate student, who has become increasingly withdrawn
and neglectful of his work and hygiene, is brought to the psychiatric hospital by
his parents. After detailed assessment, a diagnosis of schizophrenia is made. It

is unlikely that the client will demonstrate:
A. Low self esteem

B. Concrete thinking
C. Effective self boundaries
D. Weak ego
Feedback
C. A person with this disorder would not have adequate self-boundaries.
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‫‪PSYCHIATRIC‬‬ ‫‪1012‬‬ ‫ودالشمال‬

A. The ability to distinguish what is real from what is not.

abilities can cope with normal stresses of life and work

A. Administers medications to a schizophrenic patient.

B. The nurse feeds and bathes a catatonic client

A. Helping the client resume self care.

D. Case finding and surveillance in the community

A. “Are you being threatened or hurt by your partner?

B. “Are you frightened of you partner”

A. Sexual desire disorder

B. Sexual arousal Disorder

D. “ Why do you allow yourself to be treated this way”

A. Assess the scope of the problem

D. Teach the victim coping skills

10. The superego is that part of the psyche that:

A. Uses defensive function for protection.

A. Not focusing on his blindness

B. Providing self-care for him

A. Hyper alertness and sleep disturbances.

B. Memory loss of traumatic event and somatic distress.

anorexia aren't usual signs or symptoms of posttraumatic stress disorder.

A. Give him privacy in the bathroom.

B. Ask him if it's okay if she sits quietly with him.

A. Wearing tight-fitting clothing

A. The student discusses conflicts over drug use.

tricyclic antidepressants. Diarrhea, not constipation, occurs with

A. Avoid shopping for large amounts of food.

D. Eat only three meals per day.

A. Take the client's vital signs

C. Tell him his fear is unrealistic.

A. Have the support of rehabilitated alcoholics

B. Know that rehabilitated alcoholics will sympathize with them

mechanisms to cope with their alcoholism.

A. Managing the depressed client at home.

of drug classifications is too general. A topic such as managing the

A. The opportunity to verbalize memories of trauma to a

provide lasting relief. Treatment for alcohol abuse, including AA

25. The client with a diagnosis of anorexia nervosa, who is in a state of

A. A client with pneumonia

C. A client who thrives on managing others

A. Contact the physician.

B. Call the client's family.

A. Outlandish behaviors and inappropriate dress

C. Grandiose delusions of being a royal descendent of King Arthur

A. Ask the client to leave.

allow others a chance to contribute

A. “Why don't you tell your husband about this?”

C. “This is not the best time to make that decision.”

A. Provide a supportive environment.

thoughts and beliefs.

D. Explain everything that is happening to all family members.

that you will not abandon them.

things will get better.

A. Weigh the client three times per week before breakfast.

several meals in which small portions are offered.

hallucinations to harm self or others. The nurse provides instructions to

A. “My medications won't make me anxious.”

can talk about my feelings and plans and not hurt

37. A client with a diagnosis of major depression, recurrent, with psychotic

processes, such as hallucinations and delusions. Review appropriate

A. The client will function at the highest level of

A. Exploring the client's ability to function

may block adaptive coping