Post by Nursing Board 101 on Aug 18, 2010 14:06:46 GMT -5
1. Thiamine has been prescribed for an alcoholic patient. The rationale for administration of this medication is the prevention of:
a. Alcoholic dementia
b. Huntington’s disease
c. Wernicke-korsakoff syndrome
d. Alcohol withdrawal syndrome
Ans: C - Chronic thiamine deficiency of alcoholism leads to the degenerative encephalopathy known as wernicke-korsakoff syndrome
2. When caring for a patient with organic brain disorder, the nurse evaluates outcomes by:
a. The emotional and financial support of a family
b. The elimination of antipsychotic medications
c. Maintenance of optimal level functioning
d. How safety the patient performs ADLs
Ans: C- This patient must be evaluated daily for activities that will help him achieve the highest level of functioning possible.
3. The patient is experiencing a fixed, false vbelief that cannot be corrected by logical reasoning. This is a/an:
a. Delusion
b. Hallucination
c. Illusion
d. Symbolism
Ans: A- A delusion is a false belief, and it is almost impossible for the patient to change that belief once it is in belief system.
4. A patient complains that he cannot get rid of the idea that harm is looming all around him. The thought comes, unbidden, and upsets him. This repeated, unbidden thought is a/an:
a. Obsession
b. Compulsion
c. Delusion
d. Illusion
Ans: A- an obsession is a repeated thought that the patient has little or nio control over. The anxiety that the obsessive thought causes usually leads to compulsive behavior.
5. An acutely patient is screaming, “I’m dead; I’m dying; my body is greeting stiff.” The nurse attempts to refocus on reality by stating to the patient:
a. “You are very upset. Let me help you”
b. “That’s hard to believe
c. “Why do you keep saying that?”
d. “You’re not dead. Your heart is still beating.”
Ans: A- This response reorients the patient to reality and offers assistance.
6. In planning care for the patient with a personally disorder, the nurse realizes that this patient will most likely.
a. Not need long-term therapy
b. Will not require medication
c. Require anti-anxiety medication
d. Resist any change in behavior
Ans: D- Persons who suffer from a personality disorder seldom see the need to change, causing much resistance to therapy.
7. To understand the meaning of the cleaning rituals the nurse must realize:
a. The patient cannot help herself
b. The patient cannot change
c. Rituals relieve intense anxiety
d. Medications cannot help
Ans: C- The level of intensity is so high the person must relieve it through some kind of physical activity.
8. The nursing assessment indicates the patient is creating new words. This is documented as:
a. Cryptic language
b. Magical thinking
c. Loose associations
d. Neologisms
Ans: D- Neologisms are expressed when a patient is experiencing serious disturbances of thought processes
9. You have been working with a nine-year-old client, and his parents, to help him stop sucking his thumb. Each time he sucks his thumb, you note it on the chart, and he does not get to have his next dessert. When he no longer sucks most thumbs, you evaluate his thumb-sucking behavior as most likely.
a. Reinforced
b. Faded
c. Extinguished
d. Generalized
Ans: C- Behavior is extinguished when the child realizes that the does not want to consequences of the of the behavior to continue.
10. Shaping of behavior occurs when:
a. Reinforcement is directed toward a desired is achieved
b. Behavior is separated in situations similar to the originally reinforced situation
c. The client changes behavior
d. Learning of appropriate behavior is achieved
Ans: A- Reinforcement ids directed toward a desired response
11. A patient has been given a diagnosis of Neuroleptic Malignant Syndrome (NMS). What would the movement plan include?
a. Monitor temperature and blood pressure
b. Administer neulroeptic medications
c. Encourage mild activity
d. Increase antipsychotic medication
Ans: A- Monitor temperature and blood pressure unexplained tachycardia, unstable blood pressure, tachypnea, muscle rigidity, cyanotic skin mottling, and rapidly rising body temperature at the onset; however, the signs are quite subtle and may resemble a cold or flu.
12. In providing supportive therapy to the depressed patient, the nurse is aware that depression is often caused by the repression of:
a. Anxiety
b. Anger
c. Fear
d. Grief
Ans: B- One of the most common causes anger is repressed anger and the inability to ventilate anger.
13. One morning, the patient says to the nurse.” I do love my mother, but sometimes I wish she would just go ahead and die.” This statement reflects feelings of:
a. Conversion
b. Ambivalence
c. Anxiety
d. Conflict
Ans: B- The love-hate relationship is a classic sign of ambivalence
14. A priority nursing intervention initially with this patient is to:
a. Help her substitute feeling for her mother
b. Encourage her to find other interests
c. Develop a trusting relationship with her
d. Tell her to forget the past
Ans: C- A therapeutic relationship that involves a basic trust in one another is essential before other therapy can occur.
15. A patient with Organic Brain Syndrome (OBS) is confused at night. The plan of care should include:
a. Keep the room well lighted
b. Keep sensory stimulation to a minimum
c. Offer a sedative at about 10 p.m
d. Always use physical restraints
Ans: B- This patient needs minimal stimulation and a quite environment as a Milieu therapy.
16. When a patient freely expresses his feelings, thoughts, anxieties and gets a sense of emotional relief. This experience is termed:
a. Revelation
b. Déjà vu
c. Catharsis
d. Projection
Ans: C- The patient may experience a catharsis in many ways, but most often through psychotherapy.
17. A suspicious patient says, “Its not for us to talk in the hospital. They are everything.” The nurse responds:
a. “Don’t worry about it. It is safe here.”
b. “Don’t be silly. We could see the recorders if they were here.”
c. “Who told you that you are being recorded?”
d. “You appear to be stressed. Let’s take a walk.”
Ans: D- The statement shows support, but does not feed into the patient’s paranoia
18. A patient is staying in his room very quite and withdrawn. The nurse approaches the patient and say:
a. “I’ve noticed that you have been very quiet.”
b. “Get out and join the others.”
c. You are suicidal today, aren’t you?”
d. “The doctor won’t like you staying secluded.”
Ans: A- The statement reflect the nurse’s assessment of the patient’s behavior and shows concern to which the patient can respond.
19. A patient speaks in a whisper. The nurse replies:
a. “I cannot hear you. Please speak more loudly.”
b. “Are you saying something?”
c. “Why aren’t you talking right?”
d. “Are you afraid someone is listening?”
Ans: A- This statement is the most supportive to which the patient might respond.
20. A patient complains,” My sister always hated me. She was jealous.” The nurse respond:
a. “Your sister was jealous?”
b. “Tell me about on e of the times she was jealous.”
c. “Why was she so hate full and jealous?”
d. “Mother are often jealous and teach their daughters.”
Ans: B- This reply takes a broad, generalized statement and asks for specific incident that can be addressed in therapy
21. While teaching the patient the nurse explains the purpose of antipsychotic drugs. These medications have been proven to be effective in:
a. Curing symptoms
b. Controlling symptoms
c. Preventing psychosis
d. Curing mental illness
Ans: B- The primary purpose of antipsychotic medication is to control symptoms so that the patient can begin functioning and participate in therapy:
22. The nursing interventions most effective in working with substances patient are:
a. Firm and Directive
b. Instillation of values
c. Helpful and advisory
d. Subjective and non-judgmental
Ans: A- The patient suffering with a addictive behaviors requires firm, directive, limit-setting in a structured environment.
23. The nurse promptive reports which symptom when the patient is taking psychotic medications?
a. Mild rash
b. Dry mouth
c. Sore throat
d. Photosensitivity
Ans: C- Sore throat and other flu-like symptoms, are often the first signs of neuroleptic malignant syndrome and should be reported immediately
24. A very angry patient is threatening to leave the hospital AMA. What action should be taken?
a. Let him check out of the hospital
b. Inform him of the consequences of leaving AMA
c. Tell him that no one is allowed to leave the hospital
d. Put the patient in restraints until the physician comes
Ans: B- The patient must be informed of the consequences of his behavior. Knowing there will be repercussions may make him changes his mind.
25. A 79-year-old patient spends a lot of time just talking about the past. What action is appropriate regarding their behavior?
a. Get him involved with others his age
b. Tell him he should talk about current events
c. Reorient him to present and ignore past
d. Listen attentively and encourage talking
Ans: D- Talking about the past can be quite therapeutic as the person grows older. Some units have “reminiscence therapy” based on this theory.
26. A patient is masturbating in his room. There is no one present. The nurse should:
a. Ask the patient to stop at once
b. Sternly criticize the patient’s behavior
c. Threaten to tell the doctor if he doesn’t stop
d. Quietly leave, allow the behavior
Ans: D-Masturbating under most circumstances is considered normal behavior.
27. A patient states, “I am a bird, you know, rat, cat, no one knows. He, That it.” This is an example of:
a. Word salad
b. Associate looseness
c. Flight of ideas
d. Cognitive distortion
Ans: A- This is classic sign of disturbance of thought processes, and this patient should be re-oriented
28. The best response to a patient who is verbalizing words that cannot be understood is:
a. “You are not making sense.”
b. “Go on says what you really mean.”
c. “Say that so I can understand.”
d. “Please repeat yourself.”
Ans: A-This statement is a caring way to re-orient the person to reality.
29. Maslow see the individual being capable of reaching a peak capacity of fulfilling his human potential and of being satisfied with this no matter what it is. Maslow called this peak experience:
a. Homeostesis
b. Alarm reaction
c. Existentialism
d. Self-actualization
Ans: D-The top level of Maslow’s hierarchy of need is self-actualization
30. In attempting to control a patient who is suffering panic, the nursing priority is:
a. Provide safety
b. Hold the patient
c. Describe crisis in detail
d. Demonstrate ADLs frequently
Ans: A-The patient who is in state of panic is out of control, and safety is the priority consideration.
31. The patient states, “ I want to talk about elusive bombardment.” The nurse respond:
a. “You don’t know what you are talking about.”
b. “Just what is elusive bombardment.”
c. “Tell me more about this.”
d. “Where did you study that?”
Ans: B- The nurse’s response should be one that will begin to reorient the patient to reality. This statement should be the opening to make the patient aware that there is no bombardment.
32. The nurse-therapies utilizing cognitive therapy in working with a 35-year-old woman diagnosed with depression. The focus of his approach to therapy is to:
a. Learn to intellectualize feelings
b. Learn to focus on thought, not feeling
c. Replace concrete thinking with abstract
d. Replace irrational, negative thinking
Ans: D- Cognitive therapy focuses on a resolving cognitive thinking or the making of assumptions without knowing the facts. Cognitive therapy helps to resolve these distortions through positive thinking and restructuring
33. A patient is constantly complaining with a variety of vague aches and pains. A physical exam shows no reason for her symptoms. The nurse:
a. Explains that she is not all
b. Encourage her to talk
c. Gives her sympathy
d. Tells her she is psychotic
Ans: B- The patient who has psychosomatic complains will benefit from verbalizing her anxieties.
34. During a family therapy session, the family is complaining about excessive bickering at mealtimes. The nurse instructs them to engage in bickering for the minutes at the beginning of each meal. This therapeutic techniques is:
a. Self- disclosure
b. Paradoxical intervention
c. Friendly confrontation
d. Family collaboration
Ans: B- This intervention is sometimes used when the therapist wants the family to become aware of the absurdity of their actions
35. The nurse is teaching new parents about parenting skills. She explains that a child’s mental health is best promoted by:
a. Material goods
b. Parents who stay together
c. Unconditional love
d. Strict discipline
Ans: C- From birth, the child needs the unconditional love of significant to feel secure and to learn to trust.
36. After several meetings, then nurse realizes that she has not been able to establish a therapeutic relationship with the patient. What action should be a priority in this situation?
a. Refer the patient to another nurse or another unit
b. Do a self-assessment on interactions with the patient
c. Limit the amount of time with this particular patient
d. Ask the unit manager to change nursing assignment
Ans: B- The nurse should assess why she is not able to implement the therapeutic Use of self-establishing a therapeutic relationship with this patient. The nurse should carefully monitor for transference or countertransference issues.
37. For patient in group therapy, the goal is:
a. Exchanging information and ideas
b. Developing insight by relating to others
c. Learning that everyone has problems
d. Identifying with other group members
e. All of the above
Ans: E- The instillation of hope, the imparting of information, altruism, the development of social skills, and corrective emotional experience are therapeutic factors of group therapy that contribute to positive outcomes.
38. A 76-year-old man is sobbing and is quite agitated following the death of his wife from cancer just 6 hours ago. He is not following anyone to talk with or comfort him. He repeats, “I can’t go on without her. I don’t know what I am going to do.” The nurse includes in the plan of care:
a. Nutritional needs
b. Sleep and rest
c. Calling family members
d. Suicide precautions
Ans: D- The threat of the impulsive act of committing suicide when the man is distraught with grief must be considered in this plan of care.
39. A 19-year-old female has been diagnosed with bulimia and is hospitalized. The nurse enters the room when the patient’s mothers is visiting and asks the patient a question. The mother interrupts as her daughter begins to answer, and the mother answers for her. The nurse should respond by saying:
a. To the mother: “ Thank you. I think you are correct.”
b. To the patient: “I would like for you to answer.”
c. To the patient: “ Do you always let your mother speak for you?”
d. To the patient: “ Do you agree with what your mother is saying?”
Ans: B-This reply speaks directly to the patient, and elicits a direct response from the patient while indirectly implying to the mother not to answer.
40. The priority in working with a patient with a thought disorder is:
a. Get him to understand what you’ve saying
b. Get him to do his ADLs
c. Reorient him to reality
d. Administer antipsychotic medications
Ans: C- The person with a thought disorder is not in touch with reality and must be reorient before any other communication takes place.
41. The nurse is taking a history on a female patient with migraine headaches. It is noted that the husband appears more attentive when the patient is complaining of headache pain. This attention may be assessed as a:
a. Coping mechanism
b. Caring behavior
c. Secondary gain
d. Positive reinforcement
Ans: C- A patient who experience chronic pain may experience a benefit related to having the pain. This benefit, whether it is negative or positive, is called a secondary gain.
42. The family is being taught the safety issues in taking care of the Alzheimer’s patient at home. I initiating the discharge planning, the nurse cautions:
a. Medications should be avoided
b. That nursing care is very expensive
c. Self-care can be accomplished eventually
d. Burn-out among family members is common
Ans: D- Family members, in the g\beginning, often do not realize the demands in keeping the Alzheimer’s patient in a safe environment.
43. Frustrated parents of a 5-year-old boy are being taught new parenting skills. The man problem is that he throws temper tantrums when he does not get his way. When the parents reward him for handling his frustration in ways other than throwing a tantrum, this concept is called:
a. Negative reinforcement
b. Positive reinforcement
c. Parental modeling
d. Cognitive reinforcement
Ans: B- Reinforcement is a significant concept of behavioral theory, which states that when a behavior is rewarded, or reinforced, in some way (whether negative or positive) it is likely to be repeated.
44. The nurse-therapist is utilizing cognitive therapy in working with 35-year-old woman diagnosed with depression. The focus of this approach to therapy is to:
a. Learn to intellectualize feelings
b. Learn to focus on thoughts, not feeling
c. Replace concrete thinking with abstract
d. Replace irrational, negative thinking
Ans: D- Cognitive therapy focuses on a resolving a cognitive distortion, which is irrational, negative thinking or the making of assumptions without knowing the facts. Cognitive therapy helps to resolve these distortions through positive thinking and restructuring
45. The function of encouraging communication and facilitating group interaction is accomplished by the:
a. Contributor
b. Hamonizer
c. Gate-keeper
d. Standard keeper
Ans: C- Several different labels are put on the roles that group members assume in group therapy. The gate-keeper assumes the role of regulating who will interact, or participate, ion the group therapy process.
46. The nurse is assessing a patient’s nonverbal behavior. Which is a priority in interpreting this behavior?
a. Consider the usual meaning of the behavior
b. Consider the patient’s cultural background
c. Validate any perceptions with patient
d. Consult best reference on nonverbal behavior
Ans: C- It is always best to clarify, and not interpret, any behavior the patient is exhibiting, whether it be verbal or nonverbal behavior.
47. The nurse finds a female patient crying in her room. The patient asks the nurse to leave. As the nurse lightly touches her shoulder, the nurse states, “ I would like to stay with you for a while.” The rationale for this action is:
a. To show sympathy and understanding
b. To show the patient how to help herself
c. Convey empathy and a willingness to listen
d. Find out what the patient is crying about
Ans: C-The best way for the nurse to comfort this patient is to provide a supportive atmosphere. With a light touch and an empathetic voice, this support is conveyed.
48. A young adolescent patient is to be discharged in two days. He has been prescribed Haldol for hallucinations, and will be given a prescription when he goes home. Patient teaching regarding Haldol should begin:
a. The day of discharge
b. With the discharge summary
c. Before the medication is administered
d. Whenever the patient can come to the hospital
Ans: C- Patient teaching regarding medication, especially psychotropic medications, should begin even before administration. Depending upon the state laws, the patient and /or significant others may be asked to sign an informed consent regarding the medication’s actions and side effects.
49. The patient diagnosed with schizophrenia exhibits an inappropriate affect and shows no interest in communicating with others. This is a part of the schizophrenia process called:
a. Paranoia
b. Delusions
c. Loosening
d. Ambivalence
Ans: D- One of the most obvious characteristic of schizophrenia is social withdrawal and indifference toward others
50. The nurse is explaining why the family of the schizophrenia patient should participate in therapy. The focus of therapy is:
a. Communication and interaction
b. Explanation of medications
c. Finding the identified patient
d. Establishing boundaries
Ans: A- The therapy will focus on communicating support to the patient and changing negative interactions.
51. An alcoholic patient asks. “Is there any medication to help me get over this alcoholism?” Which drug may be prescribed?
a. Xanax
b. Librium
c. Antabuse
d. Catapres
Ans: C- Antabuse is a medications often used in conjunction with behavior modification to stop drinking. If the alcoholic drinks while taking this medication, he will become very ill and will probably require emergency care.
52. In taking with the manipulative patient, the nurse realizes that she must set firm limits. This is particularly necessary because she realizes what this patient is attempting is to:
a. Help
b. Control
c. Gain acceptance
d. Be appreciated
Ans: B- The manipulative person always to control, and the nurse must be alert assertive in controlling this patient.
53. The nurse is providing patient to the patient who has just diagnosed with major depression and prescribed amitriptyline (Elavil) 50 mg hs. The patient is instructed that medication will take effect.
a. Immediately
b. In about 36 hours
c. In 14-21 days
d. In about a month
Ans: C- The depressed patient will begin to feel therapeutic effect of Elavil in 2-3 weeks. However, the patient should be instructed that the sedative effects will take effect immediately
54. In giving a patient information regarding psychotropic medications, the nurse stresses that the primary purpose of these medications is to:
a. Cure most psychosis
b. Modify learned behavior
c. Provide missing chemicals
d. Decrease psychotic symptoms
Ans: D- The greatest benefit of psychotropic medications is controlling the symptoms enough for the patient to participate in therapy
55. The patient asks the nurse, “What is this therapy for anyway. I just don’t understand it.” The best reply is:
a. “It keeps you from being put on medications.”
b. It helps you to change other in the family.”
c. “The purpose of therapy is to help you change.”
d. NO one but professionals can really understand it.”
Ans: C- When a person goes into therapy she is , in effect, saying, “I’m not happy with the way things are going.” The primary purpose is to facilitate the change that the person decides to make.
56. Blood levels are drawn on the patient who has been taking Lithium for about six months. The present level is 2.1 mEq/L. The nurse evaluate this level as:
a. Therapeutic
b. Below therapeutic
c. Potentially dangerous
d. Fatally toxic
Ans: D- The therapeutic level for Lithium is 0.8 to 1.8 mEq/L. Lithium has a narrow therapeutic range and blood levels can become toxic very quickly.
57. A manipulative alcoholic patients asks the nurse to go out with him when he gets out of the hospital. She discusses her role and the importance of a therapeutic relationship with him. Which techniques is she implementing?
a. Defining professionalism
b. Telling him no politely
c. Quietly reprimanding him
d. Defining boundaries
Ans: D-In a therapeutic relationship, it is important to set limits by establishing boundaries. When the patient attempts to overstep boundaries, the nurse must redefine the limits.
58. While discussing his recent divorce, the nurse states to the patient,” I notice you become anxious when we start talking out your ex-wife.” What communication techniques is being implement?
a. Confronting behavior
b. Initiating awareness
c. Initiating change
d. Making an observation
Ans: D- The nurse is stating was she assesses. The purpose is to get to patient to confirm the behavior and discuss it.
59. The new patient states,” I just don’t understand this therapy business. What does it do anyway?” The nurse explains that the focus of the therapeutic process is:
a. Identifying significant others as support system
b. Therapist telling patient what he needs to do
c. Recognizing needs and discovering ways to change
d. Discovering goals in life
Ans: C- Therapy often focuses on what the patient states his needs or problems are, and ideally, he will gain insight and make necessary changes to get these needs filled.
60. In working with a difficult patient, the nurse recognizes that transference is most likely to occur in which stages of therapy?
a. Initial
b. Working
c. Termination
d. Preorientation
Ans: B- The working stage, when the therapist and the patient are focusing on problems, is when the patient is most likely to experience transference. The therapist should be aware of his in order to facilitate working through this barrier
61. The nursing staff notes that a patient is constantly seeking attention and approval from the staff and other patients. The care plan must address the problem of:
a. Displacement
b. Regression
c. Manipulation
d. Compensation
Ans: D- The dependent patient usually experience low self-esteem and is constantly seeking approval and attention from to others.
62. A 16-year-old girl states that she doesn’t get along with her mother,” I hate her for what she has done to me.” Then, a few minutes later she tells the therapist, “I can’t help but love my mother for all she has done form e.” The patient is exhibiting:
a. Confusion
b. Helplessness
c. Manipulation
d. Ambivalence
Ans: D-When a person expresses a love-hate relationship, or exhibits two different behavior regarding another significant person, this is called ambivalence
63. An adolescent,16, who has been diagnosed with schizophrenia, is boasting to peers that he doesn’t need an education or “anything else.” He keeps insisting that he can make a million dollars before he is twenty by creating his own business. He is exhibiting:
a. Delusion thinking
b. Unrealistic thinking
c. Magical thinking
d. Delusions of grandeurs
Ans: C- Magical thinking is a type of primitive, prelogical thinking like that often seen in normal children with active imaginations. It is common to schizophrenia patients.
64. The nurse is assigned to assist in the administration of electroconvulsive therapy (ECT). She prepares to administer:
a. Valium
b. Ativan
c. Brevital
d. Morphine
Ans: C- Brevital is muscle relaxant that decreases the jerking movements caused by ECT.
65. The priority nursing intervention while ECT is being administered to the patient?
a. Controlling seizure
b. Controlling movements
c. Watching vital signs
d. Maintaining airway
Ans: D- since, the patient will undergo a seizure during ECT, the patency of the airway must be constantly monitored.
66. In caring for the alcoholic patient, the nurse recognizes the early signs and symptoms of DTs are:
a. Apathy and helplessness
b. Fever and chills
c. Headaches and restlessness
d. Sudden decrease in vital signs
Ans: C- The cause of headaches and restless during the onset of delirium tremens (DTs) is not known but is probably related to the response to abrupt withdrawal of alcohol.
67. A patient is admitted with physical restlessness and generalized apprehension. He is expressing pessimism and is having difficulty concentrating in therapy. He states. “I just don’t know what is the matter with me.” The nurse assesses the patient is experiencing:
a. Depression
b. Obsessions
c. Paranoid thoughts
d. Free-floating anxiety
Ans: D-Free-floating anxiety is the vague sensation that something is wrong. The patient feels helpless in coping with the feeling.
68. The depressed patient who has been taking Nardil states she is going to stop taking the drug. She asks the nurse, ”When can I start eating normally again?” The information that the nurse to a tyramine-free diet for:
a. 2-3 days
b. About a week
c. About 2 weeks
d. About a month
Ans: C-Nardil is a MAOI, and it takes about 14 days for it to clear the bloodstream. During this period the patient could experience a hypertensive reaction if food with tramline is ingested.
69. The patient has been taking in therapy six weeks working on experiencing and resolving issues related to anger. During on session the patient suddenly states,” I am really getting angry, ”The nurse evaluates this as:
a. Repression
b. Regression
c. Progress
d. Hopeless
Ans: c- when the patient begins to express anger and deal with openly, progress begins.
70. The fight-flight response causes increasing blood pressure and heart rate, quickening respiration, dilated pupils, and sweating. What body system initiates this physical stimulation to a psychological stressors?
a. Neurological
b. Cardiovascular
c. Sympathetic nervous system
d. Parasympathetic nervous system
Ans: C- When a stressors is encountered and a threatening situation occurs the sympathy nervous system responds with a primitive response that prepares the body for fight or flight.
71. A Retired postal worker is being admitted to the psychiatric unit He states to the nurse that he is the president of foreign country and postal executives from all over the world seek his advice on mailing letters. He is exhibiting :
a. Delirium
b. Illusions
c. Grandiosity
d. Confabulation
ANS: C-When a person, expresses feelings of great importance and delusions of wealth, he is experiencing grandiosity
72. While performing an initial assessment on a patient admitted with depression, what physical aspect is most important to assess?
a. Height and weight
b. Urinary functioning
c. Last menstrual period
d. Sleeping patterns
Ans: D-A patient suffering depression often complains of early morning awakening difficulty going back to sleep. Medication is sometimes prescribed, and some antidepressants such as Elavil have sedative qualities.
73. The nurse assesses increasing restless, agitation, swinging of legs, and pacing in the patient who has been talking Thorazine 400 mg daily. The nursing evaluation is:
a. EPS
b. NMS
c. Dystonia
d. Akathisia
Ans: D-Akathisia, a common side effect of phenothiazines is a feeling of uncontrollable restlessness. It is treated by decreasing dose, changing medications, and administering Benadryl.
74. The nurse calls the physician and requires an order for restraints. Which factor will be most decisive when the nurse is face with decision to implement the use of restraints?
a. Cooperation
b. Safety
c. Court orders
d. Family request
Ans: B-When a patient’s safety is at issue; the use of restrains is warranted. Then nurse should carefully document the safety issue.
75. The nurse is caring for a client with hypochondriasis. Which behavior would the nurse most likely encounter?
a.)Ready acceptance of the physician's explanation that all medical and laboratory tests are normal
b.)Expression of fear of dying after being diagnosed with advanced breast cancer
c.)Expression of fear of colorectal cancer following 3 days of constipation
d.)Lack of concern about having a serious disease
C. RATIONALE: The client with hypochondriasis is preoccupied with having a serious disease. She may convince herself that a relatively minor symptom, such as constipation, is a sign of a serious disorder. The client's fear of serious illness persists, even after a physician reassures her that all medical and laboratory tests are normal. The fear of dying after receiving a diagnosis of advanced breast cancer wouldn't be considered hypochondriasis. A client with hypochondriasis shows an exaggerated level of anxiety, rather than a lack of concern about having a serious disease or illness.
76. The nurse is caring for a client who has been diagnosed with hypochondriasis. The client attributes his cough to tuberculosis. A chest X-ray and skin test are negative for tuberculosis. The client begins to complain about the sudden onset of chest pain. How should the nurse react initially?
a.)Let the client know the nurse understands his fears of serious illness.
b.)Encourage the client to discuss his fear of having a serious illness.
c.)Report the complaint of chest pain to the physician.
d.)Determine if the illness is fulfilling a psychological need for the client.
C. RATIONALE: Because of the risk of missing an actual medical problem, any new symptoms reported by a client with hypochondriasis should be reported to the physician. The other interventions are appropriate after the nurse has determined that the client doesn't have a serious medical disorder.
77. The nurse is talking with a client who recently attempted suicide. The client asks her not to tell anyone one about their conversation. How should the nurse respond?
a.)I'll need to share information with the rest of your health care team if it's important to your care.
b.)I promise I won't tell anyone about the information you share with me today.
c.)I promise I won't tell anyone about the information you share with me today unless you give me permission to do so.
d.)Please don't tell me anything that you wouldn't want others on your health care team to know.
A. RATIONALE: The nurse must tell the client that she'll share information if it affects his safety or his care. The nurse shouldn't promise to withhold information because she may not be able to uphold her promise if the information must be shared with others. The nurse shouldn't promise to ask permission before disclosing information to others. The nurse also shouldn't encourage the client to withhold information from her. Doing so violates the nurse's responsibility to develop a therapeutic relationship with the client. The nurse & not the client & should judge what specific information must be shared with others on the health care team.
78. The nurse is administering atropine sulfate to a client about to undergo electroconvulsive therapy. Which assessment indicates that the medication is effective? a.)The client's heart rate is 48 beats/minute.
b.)The client states that his mouth is dry.
c.)The client appears calm and relaxed.
d.)The client falls asleep.
B. RATIONALE: Atropine sulfate is administered approximately 30 minutes before electroconvulsive therapy to reduce oral secretions; therefore, the client's mouth would feel dry. Atropine also blocks the vagal stimulation of the heart, causing a rise in heart rate (much higher than 48 beats/minute). Atropine sulfate isn't given to make the client feel calm and relaxed nor does it induce sleep.
79. The nurse is documenting a care plan for a client who has undergone electroconvulsive therapy. Which intervention should the nurse include?
a.)Monitoring the client's vital signs every hour for 4 hours
b.)Placing the client in Trendelenburg's position
c.)Encouraging early ambulation
d.)Reorienting the client to time and place
D. RATIONALE: Confusion and temporary memory loss are the most common adverse effects of electroconvulsive therapy. The nurse should continually reorient the client to time and place as he wakes up from the procedure. Following electroconvulsive therapy, the nurse should monitor the client's vital signs every 15 minutes for the 1st hour. The nurse should position the client on his side after the procedure to reduce the risk of aspiration. The client should remain on bed rest until he's fully awake and oriented.
80. The nurse is caring for a client in the manic phase of bipolar disorder who is ready for discharge from the psychiatric unit. As the nurse begins to terminate the nurse-client relationship, which client response is most appropriate?
a.)Expressing feelings of anxiety
b.)Displaying anger, shouting, and banging the table.
c.)Withdrawing from the nurse in silence
d.)Rationalizing the termination, saying that everything comes to an end
A. RATIONALE: Anxiety is a normal reaction to the termination of the nurse-client relationship. The nurse should help the client explore his feelings about the end of the therapeutic relationship. While anger about the termination may be a healthy response, banging the table, shouting, and other forms of acting out aren't appropriate behavior. Withdrawal isn't a healthy response to the termination of a relationship. By rationalizing the termination, the client avoids expressing his feelings and emotions.
81. A client with a borderline personality disorder has been playing one staff member against another. In formulating a care plan for this client, the nursing staff should include which intervention?
a.)Assigning the same staff members to work with the client
b.)Avoiding setting limits
c.)Rotating staff members who work with the client
d.)Avoiding interaction with the client until splitting behaviors stop
C. RATIONALE: Rotating staff members who care for a client with borderline personality disorder reduces the incidence of splitting behaviors. Helping the client to learn to relate to several staff members may reduce fears of abandonment. The staff should set limits on unacceptable behaviors; the client doesn't have the self-control to set his own limits. Avoiding the client won't reduce splitting behaviors. The client needs to interact with staff members to develop relationships and reduce fears of abandonment.
82. The nurse is planning care for a client admitted to the psychiatric unit with a diagnosis of paranoid schizophrenia. Which nursing diagnosis should receive the highest priority?
a.)Risk for self- or other-directed violence
b.)Imbalanced nutrition
c.)Ineffective coping
d.)Impaired verbal communication
A. RATIONALE: Because of such factors as suspiciousness, anxiety, and hallucinations, the client with paranoid schizophrenia is at risk for violence toward himself or others. The other options are also appropriate nursing diagnoses but should be addressed after the safety of the client and those around him is established.
83. 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
B. 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.
84. The nurse is leading group therapy with psychiatric clients. During the working phase, what should the nurse do?
a.)Explain the purposes and goals of the group.
b.)Offer advice to help resolve conflicts.
c.)Encourage group cohesiveness.
d.)Encourage a discussion of feelings of loss regarding termination of the group.
C. RATIONALE: During the working phase, or the middle phase of a group, the nurse continues to encourage cohesiveness among its members. During the orientation phase, or the initial phase, the nurse leading the group should explain the purpose and goals of the group. During the termination phase, or the final phase, the leader encourages a discussion of feelings associated with termination. When leading a group, the nurse should act as a facilitator; offering advice isn't appropriate. The group members should work together to resolve conflicts.
85. 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)
b.)Haloperidol (Haldol)
c.)Magnesium sulfate
d.)Chlordiazepoxide (Librium)
D. RATIONALE: Chlordiazepoxide and other tranquilizers help reduce the symptoms of alcohol withdrawal. Haloperidol may be given to treat clients with psychosis, severe agitation, or delirium. Naloxone is administered for narcotic overdose. Magnesium sulfate and other anticonvulsant medications are administered to treat seizures only if they occur during withdrawal.
86. The client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from the nurse?
a.)Why didn't you get someone else to drive you?
b.)Tell me how you feel about the accident.
c.)You should know better than to drink and drive.
d.)I recommend that you attend an Alcoholics Anonymous meeting.
B. RATIONALE: An open-ended statement or question is the most therapeutic response. It encourages the widest range of client responses, makes the client an active participant in the conversation, and shows the client that the nurse is interested in his feelings. Asking the client why he drove while intoxicated can make him feel defensive and intimidated. A judgmental approach isn't therapeutic. By giving advice, the nurse suggests that the client isn't capable of making decisions, thus fostering dependency.
87. A client suffers from depression after the accidental death of her daughter. After a suicide attempt, the client is admitted to the psychiatric unit. During the admission interview, the client tells the nurse that she no longer wants to die. The nurse should: a.)suggest that the client no longer requires close observation.
b.)place the client in a private room, away from the nurses' station, so that she has privacy to work through the stages of the grieving process.
c.)inspect the client's personal belongings for potentially dangerous objects. d.)avoid any further discussion of suicide, unless the client brings up the topic.
C. RATIONALE: The client must be protected from harming herself. This includes checking all personal items that the client brought to the hospital, such as a suitcase or pocketbook. The client must be closely observed until she has been evaluated and receives treatment. A client who is suicidal should be placed in a room near the nurses' station in full view of a nurse or other observer. The nurse shouldn't ignore the client's suicide attempt. The client may feel relief talking about the suicide attempt and knowing that she'll be protected from harm.
88. The nurse is caring for a client diagnosed with panic disorder. The client begins to hyperventilate. How should the nurse respond initially?
a.)Stay with the client during the panic attack.
b.)Shout for help and obtain assistance.
c.)Teach the client relaxation exercises.
d.)Help the client explore the reason for the anxiety.
A. RATIONALE: Because the presence of a calm nurse provides a feeling of security, the nurse should remain with a client during an anxiety attack and assure the client of his safety. Shouting for help and bringing others running to the scene can increase the client's anxiety. The nurse should keep the client's environment calm by reducing noise and limiting the number of people present. Teaching the client relaxation exercises and other methods to reduce stress and exploring the reasons underlying anxiety are important interventions but shouldn't be performed during an anxiety attack. During an attack a client isn't capable of learning new behaviors or achieving insight.
89. The nurse is caring for a client with panic disorder who has difficulty sleeping. Which nursing intervention would best help the client achieve healthy long-term sleeping habits? a.)Administering sleeping pills
b.)Encouraging the use of relaxation exercises
c.)Suggesting he talk with other clients until he feels ready to sleep
d.)Telling him to play ping-pong in the day room
B. RATIONALE: Relaxation exercises provide the client with a healthy way to gain control over anxiety. These exercises also produce a physiological response opposite to that produced by stress. Giving a sleeping pill would provide short-term relief for sleeplessness but wouldn't teach healthy sleep habits. Suggesting the client stay up and talk won't help him develop healthy sleep habits or control stress and anxiety. Playing ping-pong or engaging in other exercises just prior to sleep produces a physiological response similar to stress.
90. A teenager was driving a car that slipped off a road in Tagaytay, killing two of his friends. He repeatedly tells the nurse that he should be dead instead of his friends. The client's behavior is an example of:
a.)survivor's guilt.
b.)denial.
c.)anticipatory grief.
d.)repression.
A. RATIONALE: Individuals who survive a traumatic experience in which others have died commonly report powerful feelings of guilt that they survived and others didn't. This guilt is referred to as survivor's guilt. In denial, a person refuses to accept that a situation or feeling exists. Anticipatory grief occurs when an individual experiences grief before a loss occurs. In repression, an individual involuntarily blocks an unpleasant experience, memory, or feeling from consciousness.
91. The nurse is caring for a client with schizophrenia. Which of the following outcomes is 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.
A. RATIONALE: 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.
92. 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.
C. RATIONALE: 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.
93. 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)
A. RATIONALE: Benztropine mesylate 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.
94. 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
B. 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.
95. Which statement about somatoform pain disorder is accurate?
a.)The pain is intentionally fabricated by the client in order to receive attention.
b.)The pain is real to the client, even though there may not be an organic etiology for the pain.
c.)The pain is less than would be expected from what the client identifies as the underlying disorder.
d.)The pain is what would be expected from what the client identifies as the underlying disorder.
B. RATIONALE: In a somatoform pain disorder, the client has pain even though a thorough diagnostic work up reveals no organic cause. The nurse must recognize that the pain is real to the client. By refusing to believe that the client is in pain, the nurse impedes the development of a therapeutic relationship based on trust. While somatoform pain offers the client secondary gains, such as attention or avoidance of an unpleasant activity, the pain isn't intentionally fabricated by the client. Even if a pathologic cause of the pain can be identified, the pain is often in excess of what would normally be expected.
96. The nurse is caring for a client diagnosed with antisocial personality disorder. The client has a history of fighting, cruelty to animals, and stealing. Which of the following traits would the nurse be most likely to uncover during assessment?
a.)History of gainful employment
b.)Frequent expression of guilt regarding antisocial behavior
c.)Demonstrated ability to maintain close, stable relationships
d.)A low tolerance for frustration
D. RATIONALE: Clients with an antisocial personality disorder exhibit a low tolerance for frustration, emotional immaturity, and a lack of impulse control. They commonly have a history of unemployment, miss work repeatedly, and quit work without plans for other employment. They don't feel guilt about their behavior and commonly perceive themselves as victims. They also display a lack of responsibility for the outcome of their actions. Because of a lack of trust in others, clients with antisocial personality disorder commonly have difficulty developing stable, close relationships.
97. The nurse is caring for a client with antisocial personality disorder. Which of the following statements is most appropriate for the nurse to make when explaining unit rules and expectations to the client?
a.)"I and other members of the health care team would like you to attend group therapy each day."
b.)"You'll find your condition will improve much faster if you attend group therapy each day."
c.)"You'll be expected to attend group therapy each day."
d.)"Please try to attend group therapy each day."
C. RATIONALE: Rules and explanations must be brief, clear, and leave little room for misinterpretation. A client with antisocial personality disorder tends to disregard rules and authority and be socially irresponsible. The words "You'll be expected to attend" are concise and concrete and convey precisely what behavior is expected. The other options leave open the interpretation that attendance is suggested but not mandatory.
98. A 58-year-old client on a mental health unit has lost control, despite having been properly medicated, and is threatening to harm himself and others. He has been placed in four-point restraints. Which nursing measure should be taken next?
a.)Release one restraint every 15 minutes.
b.)Have a staff member stay with the client at all times.
c.)Leave the client alone to reduce his sensory stimulation and allow him to regain control.
d.)Restrict fluids until the restraint period is over.
B. RATIONALE: A client such as this one needs sensory stimulation and should never be left alone (although the nurse should maintain the client's privacy). Restraints should be removed for 5 minutes at least every 2 hours. A client in restraints should have someone with him at all times. Fluids are offered, and the client is given food at mealtimes.
99. Which nursing assessment has priority while a client's extremities are restrained? a.)Measuring urine output
b.)Checking circulation in extremities
c.)Assessing pupillary responses
d.)Noting respiratory pattern
B. RATIONALE: The nurse must check extremities for signs of circulatory impairment. Measuring urine output isn't crucial; the client may void into a urinal as necessary. Assessing pupillary responses isn't relevant to the situation. Although the nurse should check vital signs every 15 minutes for 1 hour, assessment for circulation takes priority over respiratory pattern.
100. A psychiatric client who was voluntarily admitted now wishes to be discharged from the hospital, against medical advice. What's the most important assessment the nurse should make of the client?
a.)Ability to care for himself
b.)Degree of danger to self and others
c.)Level of psychosis
d.)Intended compliance with aftercare
B. RATIONALE: A voluntary client who poses a danger to himself or others may be denied permission to leave the hospital. The other options are important assessments, but the client's danger to himself or others takes priority.
a. Alcoholic dementia
b. Huntington’s disease
c. Wernicke-korsakoff syndrome
d. Alcohol withdrawal syndrome
Ans: C - Chronic thiamine deficiency of alcoholism leads to the degenerative encephalopathy known as wernicke-korsakoff syndrome
2. When caring for a patient with organic brain disorder, the nurse evaluates outcomes by:
a. The emotional and financial support of a family
b. The elimination of antipsychotic medications
c. Maintenance of optimal level functioning
d. How safety the patient performs ADLs
Ans: C- This patient must be evaluated daily for activities that will help him achieve the highest level of functioning possible.
3. The patient is experiencing a fixed, false vbelief that cannot be corrected by logical reasoning. This is a/an:
a. Delusion
b. Hallucination
c. Illusion
d. Symbolism
Ans: A- A delusion is a false belief, and it is almost impossible for the patient to change that belief once it is in belief system.
4. A patient complains that he cannot get rid of the idea that harm is looming all around him. The thought comes, unbidden, and upsets him. This repeated, unbidden thought is a/an:
a. Obsession
b. Compulsion
c. Delusion
d. Illusion
Ans: A- an obsession is a repeated thought that the patient has little or nio control over. The anxiety that the obsessive thought causes usually leads to compulsive behavior.
5. An acutely patient is screaming, “I’m dead; I’m dying; my body is greeting stiff.” The nurse attempts to refocus on reality by stating to the patient:
a. “You are very upset. Let me help you”
b. “That’s hard to believe
c. “Why do you keep saying that?”
d. “You’re not dead. Your heart is still beating.”
Ans: A- This response reorients the patient to reality and offers assistance.
6. In planning care for the patient with a personally disorder, the nurse realizes that this patient will most likely.
a. Not need long-term therapy
b. Will not require medication
c. Require anti-anxiety medication
d. Resist any change in behavior
Ans: D- Persons who suffer from a personality disorder seldom see the need to change, causing much resistance to therapy.
7. To understand the meaning of the cleaning rituals the nurse must realize:
a. The patient cannot help herself
b. The patient cannot change
c. Rituals relieve intense anxiety
d. Medications cannot help
Ans: C- The level of intensity is so high the person must relieve it through some kind of physical activity.
8. The nursing assessment indicates the patient is creating new words. This is documented as:
a. Cryptic language
b. Magical thinking
c. Loose associations
d. Neologisms
Ans: D- Neologisms are expressed when a patient is experiencing serious disturbances of thought processes
9. You have been working with a nine-year-old client, and his parents, to help him stop sucking his thumb. Each time he sucks his thumb, you note it on the chart, and he does not get to have his next dessert. When he no longer sucks most thumbs, you evaluate his thumb-sucking behavior as most likely.
a. Reinforced
b. Faded
c. Extinguished
d. Generalized
Ans: C- Behavior is extinguished when the child realizes that the does not want to consequences of the of the behavior to continue.
10. Shaping of behavior occurs when:
a. Reinforcement is directed toward a desired is achieved
b. Behavior is separated in situations similar to the originally reinforced situation
c. The client changes behavior
d. Learning of appropriate behavior is achieved
Ans: A- Reinforcement ids directed toward a desired response
11. A patient has been given a diagnosis of Neuroleptic Malignant Syndrome (NMS). What would the movement plan include?
a. Monitor temperature and blood pressure
b. Administer neulroeptic medications
c. Encourage mild activity
d. Increase antipsychotic medication
Ans: A- Monitor temperature and blood pressure unexplained tachycardia, unstable blood pressure, tachypnea, muscle rigidity, cyanotic skin mottling, and rapidly rising body temperature at the onset; however, the signs are quite subtle and may resemble a cold or flu.
12. In providing supportive therapy to the depressed patient, the nurse is aware that depression is often caused by the repression of:
a. Anxiety
b. Anger
c. Fear
d. Grief
Ans: B- One of the most common causes anger is repressed anger and the inability to ventilate anger.
13. One morning, the patient says to the nurse.” I do love my mother, but sometimes I wish she would just go ahead and die.” This statement reflects feelings of:
a. Conversion
b. Ambivalence
c. Anxiety
d. Conflict
Ans: B- The love-hate relationship is a classic sign of ambivalence
14. A priority nursing intervention initially with this patient is to:
a. Help her substitute feeling for her mother
b. Encourage her to find other interests
c. Develop a trusting relationship with her
d. Tell her to forget the past
Ans: C- A therapeutic relationship that involves a basic trust in one another is essential before other therapy can occur.
15. A patient with Organic Brain Syndrome (OBS) is confused at night. The plan of care should include:
a. Keep the room well lighted
b. Keep sensory stimulation to a minimum
c. Offer a sedative at about 10 p.m
d. Always use physical restraints
Ans: B- This patient needs minimal stimulation and a quite environment as a Milieu therapy.
16. When a patient freely expresses his feelings, thoughts, anxieties and gets a sense of emotional relief. This experience is termed:
a. Revelation
b. Déjà vu
c. Catharsis
d. Projection
Ans: C- The patient may experience a catharsis in many ways, but most often through psychotherapy.
17. A suspicious patient says, “Its not for us to talk in the hospital. They are everything.” The nurse responds:
a. “Don’t worry about it. It is safe here.”
b. “Don’t be silly. We could see the recorders if they were here.”
c. “Who told you that you are being recorded?”
d. “You appear to be stressed. Let’s take a walk.”
Ans: D- The statement shows support, but does not feed into the patient’s paranoia
18. A patient is staying in his room very quite and withdrawn. The nurse approaches the patient and say:
a. “I’ve noticed that you have been very quiet.”
b. “Get out and join the others.”
c. You are suicidal today, aren’t you?”
d. “The doctor won’t like you staying secluded.”
Ans: A- The statement reflect the nurse’s assessment of the patient’s behavior and shows concern to which the patient can respond.
19. A patient speaks in a whisper. The nurse replies:
a. “I cannot hear you. Please speak more loudly.”
b. “Are you saying something?”
c. “Why aren’t you talking right?”
d. “Are you afraid someone is listening?”
Ans: A- This statement is the most supportive to which the patient might respond.
20. A patient complains,” My sister always hated me. She was jealous.” The nurse respond:
a. “Your sister was jealous?”
b. “Tell me about on e of the times she was jealous.”
c. “Why was she so hate full and jealous?”
d. “Mother are often jealous and teach their daughters.”
Ans: B- This reply takes a broad, generalized statement and asks for specific incident that can be addressed in therapy
21. While teaching the patient the nurse explains the purpose of antipsychotic drugs. These medications have been proven to be effective in:
a. Curing symptoms
b. Controlling symptoms
c. Preventing psychosis
d. Curing mental illness
Ans: B- The primary purpose of antipsychotic medication is to control symptoms so that the patient can begin functioning and participate in therapy:
22. The nursing interventions most effective in working with substances patient are:
a. Firm and Directive
b. Instillation of values
c. Helpful and advisory
d. Subjective and non-judgmental
Ans: A- The patient suffering with a addictive behaviors requires firm, directive, limit-setting in a structured environment.
23. The nurse promptive reports which symptom when the patient is taking psychotic medications?
a. Mild rash
b. Dry mouth
c. Sore throat
d. Photosensitivity
Ans: C- Sore throat and other flu-like symptoms, are often the first signs of neuroleptic malignant syndrome and should be reported immediately
24. A very angry patient is threatening to leave the hospital AMA. What action should be taken?
a. Let him check out of the hospital
b. Inform him of the consequences of leaving AMA
c. Tell him that no one is allowed to leave the hospital
d. Put the patient in restraints until the physician comes
Ans: B- The patient must be informed of the consequences of his behavior. Knowing there will be repercussions may make him changes his mind.
25. A 79-year-old patient spends a lot of time just talking about the past. What action is appropriate regarding their behavior?
a. Get him involved with others his age
b. Tell him he should talk about current events
c. Reorient him to present and ignore past
d. Listen attentively and encourage talking
Ans: D- Talking about the past can be quite therapeutic as the person grows older. Some units have “reminiscence therapy” based on this theory.
26. A patient is masturbating in his room. There is no one present. The nurse should:
a. Ask the patient to stop at once
b. Sternly criticize the patient’s behavior
c. Threaten to tell the doctor if he doesn’t stop
d. Quietly leave, allow the behavior
Ans: D-Masturbating under most circumstances is considered normal behavior.
27. A patient states, “I am a bird, you know, rat, cat, no one knows. He, That it.” This is an example of:
a. Word salad
b. Associate looseness
c. Flight of ideas
d. Cognitive distortion
Ans: A- This is classic sign of disturbance of thought processes, and this patient should be re-oriented
28. The best response to a patient who is verbalizing words that cannot be understood is:
a. “You are not making sense.”
b. “Go on says what you really mean.”
c. “Say that so I can understand.”
d. “Please repeat yourself.”
Ans: A-This statement is a caring way to re-orient the person to reality.
29. Maslow see the individual being capable of reaching a peak capacity of fulfilling his human potential and of being satisfied with this no matter what it is. Maslow called this peak experience:
a. Homeostesis
b. Alarm reaction
c. Existentialism
d. Self-actualization
Ans: D-The top level of Maslow’s hierarchy of need is self-actualization
30. In attempting to control a patient who is suffering panic, the nursing priority is:
a. Provide safety
b. Hold the patient
c. Describe crisis in detail
d. Demonstrate ADLs frequently
Ans: A-The patient who is in state of panic is out of control, and safety is the priority consideration.
31. The patient states, “ I want to talk about elusive bombardment.” The nurse respond:
a. “You don’t know what you are talking about.”
b. “Just what is elusive bombardment.”
c. “Tell me more about this.”
d. “Where did you study that?”
Ans: B- The nurse’s response should be one that will begin to reorient the patient to reality. This statement should be the opening to make the patient aware that there is no bombardment.
32. The nurse-therapies utilizing cognitive therapy in working with a 35-year-old woman diagnosed with depression. The focus of his approach to therapy is to:
a. Learn to intellectualize feelings
b. Learn to focus on thought, not feeling
c. Replace concrete thinking with abstract
d. Replace irrational, negative thinking
Ans: D- Cognitive therapy focuses on a resolving cognitive thinking or the making of assumptions without knowing the facts. Cognitive therapy helps to resolve these distortions through positive thinking and restructuring
33. A patient is constantly complaining with a variety of vague aches and pains. A physical exam shows no reason for her symptoms. The nurse:
a. Explains that she is not all
b. Encourage her to talk
c. Gives her sympathy
d. Tells her she is psychotic
Ans: B- The patient who has psychosomatic complains will benefit from verbalizing her anxieties.
34. During a family therapy session, the family is complaining about excessive bickering at mealtimes. The nurse instructs them to engage in bickering for the minutes at the beginning of each meal. This therapeutic techniques is:
a. Self- disclosure
b. Paradoxical intervention
c. Friendly confrontation
d. Family collaboration
Ans: B- This intervention is sometimes used when the therapist wants the family to become aware of the absurdity of their actions
35. The nurse is teaching new parents about parenting skills. She explains that a child’s mental health is best promoted by:
a. Material goods
b. Parents who stay together
c. Unconditional love
d. Strict discipline
Ans: C- From birth, the child needs the unconditional love of significant to feel secure and to learn to trust.
36. After several meetings, then nurse realizes that she has not been able to establish a therapeutic relationship with the patient. What action should be a priority in this situation?
a. Refer the patient to another nurse or another unit
b. Do a self-assessment on interactions with the patient
c. Limit the amount of time with this particular patient
d. Ask the unit manager to change nursing assignment
Ans: B- The nurse should assess why she is not able to implement the therapeutic Use of self-establishing a therapeutic relationship with this patient. The nurse should carefully monitor for transference or countertransference issues.
37. For patient in group therapy, the goal is:
a. Exchanging information and ideas
b. Developing insight by relating to others
c. Learning that everyone has problems
d. Identifying with other group members
e. All of the above
Ans: E- The instillation of hope, the imparting of information, altruism, the development of social skills, and corrective emotional experience are therapeutic factors of group therapy that contribute to positive outcomes.
38. A 76-year-old man is sobbing and is quite agitated following the death of his wife from cancer just 6 hours ago. He is not following anyone to talk with or comfort him. He repeats, “I can’t go on without her. I don’t know what I am going to do.” The nurse includes in the plan of care:
a. Nutritional needs
b. Sleep and rest
c. Calling family members
d. Suicide precautions
Ans: D- The threat of the impulsive act of committing suicide when the man is distraught with grief must be considered in this plan of care.
39. A 19-year-old female has been diagnosed with bulimia and is hospitalized. The nurse enters the room when the patient’s mothers is visiting and asks the patient a question. The mother interrupts as her daughter begins to answer, and the mother answers for her. The nurse should respond by saying:
a. To the mother: “ Thank you. I think you are correct.”
b. To the patient: “I would like for you to answer.”
c. To the patient: “ Do you always let your mother speak for you?”
d. To the patient: “ Do you agree with what your mother is saying?”
Ans: B-This reply speaks directly to the patient, and elicits a direct response from the patient while indirectly implying to the mother not to answer.
40. The priority in working with a patient with a thought disorder is:
a. Get him to understand what you’ve saying
b. Get him to do his ADLs
c. Reorient him to reality
d. Administer antipsychotic medications
Ans: C- The person with a thought disorder is not in touch with reality and must be reorient before any other communication takes place.
41. The nurse is taking a history on a female patient with migraine headaches. It is noted that the husband appears more attentive when the patient is complaining of headache pain. This attention may be assessed as a:
a. Coping mechanism
b. Caring behavior
c. Secondary gain
d. Positive reinforcement
Ans: C- A patient who experience chronic pain may experience a benefit related to having the pain. This benefit, whether it is negative or positive, is called a secondary gain.
42. The family is being taught the safety issues in taking care of the Alzheimer’s patient at home. I initiating the discharge planning, the nurse cautions:
a. Medications should be avoided
b. That nursing care is very expensive
c. Self-care can be accomplished eventually
d. Burn-out among family members is common
Ans: D- Family members, in the g\beginning, often do not realize the demands in keeping the Alzheimer’s patient in a safe environment.
43. Frustrated parents of a 5-year-old boy are being taught new parenting skills. The man problem is that he throws temper tantrums when he does not get his way. When the parents reward him for handling his frustration in ways other than throwing a tantrum, this concept is called:
a. Negative reinforcement
b. Positive reinforcement
c. Parental modeling
d. Cognitive reinforcement
Ans: B- Reinforcement is a significant concept of behavioral theory, which states that when a behavior is rewarded, or reinforced, in some way (whether negative or positive) it is likely to be repeated.
44. The nurse-therapist is utilizing cognitive therapy in working with 35-year-old woman diagnosed with depression. The focus of this approach to therapy is to:
a. Learn to intellectualize feelings
b. Learn to focus on thoughts, not feeling
c. Replace concrete thinking with abstract
d. Replace irrational, negative thinking
Ans: D- Cognitive therapy focuses on a resolving a cognitive distortion, which is irrational, negative thinking or the making of assumptions without knowing the facts. Cognitive therapy helps to resolve these distortions through positive thinking and restructuring
45. The function of encouraging communication and facilitating group interaction is accomplished by the:
a. Contributor
b. Hamonizer
c. Gate-keeper
d. Standard keeper
Ans: C- Several different labels are put on the roles that group members assume in group therapy. The gate-keeper assumes the role of regulating who will interact, or participate, ion the group therapy process.
46. The nurse is assessing a patient’s nonverbal behavior. Which is a priority in interpreting this behavior?
a. Consider the usual meaning of the behavior
b. Consider the patient’s cultural background
c. Validate any perceptions with patient
d. Consult best reference on nonverbal behavior
Ans: C- It is always best to clarify, and not interpret, any behavior the patient is exhibiting, whether it be verbal or nonverbal behavior.
47. The nurse finds a female patient crying in her room. The patient asks the nurse to leave. As the nurse lightly touches her shoulder, the nurse states, “ I would like to stay with you for a while.” The rationale for this action is:
a. To show sympathy and understanding
b. To show the patient how to help herself
c. Convey empathy and a willingness to listen
d. Find out what the patient is crying about
Ans: C-The best way for the nurse to comfort this patient is to provide a supportive atmosphere. With a light touch and an empathetic voice, this support is conveyed.
48. A young adolescent patient is to be discharged in two days. He has been prescribed Haldol for hallucinations, and will be given a prescription when he goes home. Patient teaching regarding Haldol should begin:
a. The day of discharge
b. With the discharge summary
c. Before the medication is administered
d. Whenever the patient can come to the hospital
Ans: C- Patient teaching regarding medication, especially psychotropic medications, should begin even before administration. Depending upon the state laws, the patient and /or significant others may be asked to sign an informed consent regarding the medication’s actions and side effects.
49. The patient diagnosed with schizophrenia exhibits an inappropriate affect and shows no interest in communicating with others. This is a part of the schizophrenia process called:
a. Paranoia
b. Delusions
c. Loosening
d. Ambivalence
Ans: D- One of the most obvious characteristic of schizophrenia is social withdrawal and indifference toward others
50. The nurse is explaining why the family of the schizophrenia patient should participate in therapy. The focus of therapy is:
a. Communication and interaction
b. Explanation of medications
c. Finding the identified patient
d. Establishing boundaries
Ans: A- The therapy will focus on communicating support to the patient and changing negative interactions.
51. An alcoholic patient asks. “Is there any medication to help me get over this alcoholism?” Which drug may be prescribed?
a. Xanax
b. Librium
c. Antabuse
d. Catapres
Ans: C- Antabuse is a medications often used in conjunction with behavior modification to stop drinking. If the alcoholic drinks while taking this medication, he will become very ill and will probably require emergency care.
52. In taking with the manipulative patient, the nurse realizes that she must set firm limits. This is particularly necessary because she realizes what this patient is attempting is to:
a. Help
b. Control
c. Gain acceptance
d. Be appreciated
Ans: B- The manipulative person always to control, and the nurse must be alert assertive in controlling this patient.
53. The nurse is providing patient to the patient who has just diagnosed with major depression and prescribed amitriptyline (Elavil) 50 mg hs. The patient is instructed that medication will take effect.
a. Immediately
b. In about 36 hours
c. In 14-21 days
d. In about a month
Ans: C- The depressed patient will begin to feel therapeutic effect of Elavil in 2-3 weeks. However, the patient should be instructed that the sedative effects will take effect immediately
54. In giving a patient information regarding psychotropic medications, the nurse stresses that the primary purpose of these medications is to:
a. Cure most psychosis
b. Modify learned behavior
c. Provide missing chemicals
d. Decrease psychotic symptoms
Ans: D- The greatest benefit of psychotropic medications is controlling the symptoms enough for the patient to participate in therapy
55. The patient asks the nurse, “What is this therapy for anyway. I just don’t understand it.” The best reply is:
a. “It keeps you from being put on medications.”
b. It helps you to change other in the family.”
c. “The purpose of therapy is to help you change.”
d. NO one but professionals can really understand it.”
Ans: C- When a person goes into therapy she is , in effect, saying, “I’m not happy with the way things are going.” The primary purpose is to facilitate the change that the person decides to make.
56. Blood levels are drawn on the patient who has been taking Lithium for about six months. The present level is 2.1 mEq/L. The nurse evaluate this level as:
a. Therapeutic
b. Below therapeutic
c. Potentially dangerous
d. Fatally toxic
Ans: D- The therapeutic level for Lithium is 0.8 to 1.8 mEq/L. Lithium has a narrow therapeutic range and blood levels can become toxic very quickly.
57. A manipulative alcoholic patients asks the nurse to go out with him when he gets out of the hospital. She discusses her role and the importance of a therapeutic relationship with him. Which techniques is she implementing?
a. Defining professionalism
b. Telling him no politely
c. Quietly reprimanding him
d. Defining boundaries
Ans: D-In a therapeutic relationship, it is important to set limits by establishing boundaries. When the patient attempts to overstep boundaries, the nurse must redefine the limits.
58. While discussing his recent divorce, the nurse states to the patient,” I notice you become anxious when we start talking out your ex-wife.” What communication techniques is being implement?
a. Confronting behavior
b. Initiating awareness
c. Initiating change
d. Making an observation
Ans: D- The nurse is stating was she assesses. The purpose is to get to patient to confirm the behavior and discuss it.
59. The new patient states,” I just don’t understand this therapy business. What does it do anyway?” The nurse explains that the focus of the therapeutic process is:
a. Identifying significant others as support system
b. Therapist telling patient what he needs to do
c. Recognizing needs and discovering ways to change
d. Discovering goals in life
Ans: C- Therapy often focuses on what the patient states his needs or problems are, and ideally, he will gain insight and make necessary changes to get these needs filled.
60. In working with a difficult patient, the nurse recognizes that transference is most likely to occur in which stages of therapy?
a. Initial
b. Working
c. Termination
d. Preorientation
Ans: B- The working stage, when the therapist and the patient are focusing on problems, is when the patient is most likely to experience transference. The therapist should be aware of his in order to facilitate working through this barrier
61. The nursing staff notes that a patient is constantly seeking attention and approval from the staff and other patients. The care plan must address the problem of:
a. Displacement
b. Regression
c. Manipulation
d. Compensation
Ans: D- The dependent patient usually experience low self-esteem and is constantly seeking approval and attention from to others.
62. A 16-year-old girl states that she doesn’t get along with her mother,” I hate her for what she has done to me.” Then, a few minutes later she tells the therapist, “I can’t help but love my mother for all she has done form e.” The patient is exhibiting:
a. Confusion
b. Helplessness
c. Manipulation
d. Ambivalence
Ans: D-When a person expresses a love-hate relationship, or exhibits two different behavior regarding another significant person, this is called ambivalence
63. An adolescent,16, who has been diagnosed with schizophrenia, is boasting to peers that he doesn’t need an education or “anything else.” He keeps insisting that he can make a million dollars before he is twenty by creating his own business. He is exhibiting:
a. Delusion thinking
b. Unrealistic thinking
c. Magical thinking
d. Delusions of grandeurs
Ans: C- Magical thinking is a type of primitive, prelogical thinking like that often seen in normal children with active imaginations. It is common to schizophrenia patients.
64. The nurse is assigned to assist in the administration of electroconvulsive therapy (ECT). She prepares to administer:
a. Valium
b. Ativan
c. Brevital
d. Morphine
Ans: C- Brevital is muscle relaxant that decreases the jerking movements caused by ECT.
65. The priority nursing intervention while ECT is being administered to the patient?
a. Controlling seizure
b. Controlling movements
c. Watching vital signs
d. Maintaining airway
Ans: D- since, the patient will undergo a seizure during ECT, the patency of the airway must be constantly monitored.
66. In caring for the alcoholic patient, the nurse recognizes the early signs and symptoms of DTs are:
a. Apathy and helplessness
b. Fever and chills
c. Headaches and restlessness
d. Sudden decrease in vital signs
Ans: C- The cause of headaches and restless during the onset of delirium tremens (DTs) is not known but is probably related to the response to abrupt withdrawal of alcohol.
67. A patient is admitted with physical restlessness and generalized apprehension. He is expressing pessimism and is having difficulty concentrating in therapy. He states. “I just don’t know what is the matter with me.” The nurse assesses the patient is experiencing:
a. Depression
b. Obsessions
c. Paranoid thoughts
d. Free-floating anxiety
Ans: D-Free-floating anxiety is the vague sensation that something is wrong. The patient feels helpless in coping with the feeling.
68. The depressed patient who has been taking Nardil states she is going to stop taking the drug. She asks the nurse, ”When can I start eating normally again?” The information that the nurse to a tyramine-free diet for:
a. 2-3 days
b. About a week
c. About 2 weeks
d. About a month
Ans: C-Nardil is a MAOI, and it takes about 14 days for it to clear the bloodstream. During this period the patient could experience a hypertensive reaction if food with tramline is ingested.
69. The patient has been taking in therapy six weeks working on experiencing and resolving issues related to anger. During on session the patient suddenly states,” I am really getting angry, ”The nurse evaluates this as:
a. Repression
b. Regression
c. Progress
d. Hopeless
Ans: c- when the patient begins to express anger and deal with openly, progress begins.
70. The fight-flight response causes increasing blood pressure and heart rate, quickening respiration, dilated pupils, and sweating. What body system initiates this physical stimulation to a psychological stressors?
a. Neurological
b. Cardiovascular
c. Sympathetic nervous system
d. Parasympathetic nervous system
Ans: C- When a stressors is encountered and a threatening situation occurs the sympathy nervous system responds with a primitive response that prepares the body for fight or flight.
71. A Retired postal worker is being admitted to the psychiatric unit He states to the nurse that he is the president of foreign country and postal executives from all over the world seek his advice on mailing letters. He is exhibiting :
a. Delirium
b. Illusions
c. Grandiosity
d. Confabulation
ANS: C-When a person, expresses feelings of great importance and delusions of wealth, he is experiencing grandiosity
72. While performing an initial assessment on a patient admitted with depression, what physical aspect is most important to assess?
a. Height and weight
b. Urinary functioning
c. Last menstrual period
d. Sleeping patterns
Ans: D-A patient suffering depression often complains of early morning awakening difficulty going back to sleep. Medication is sometimes prescribed, and some antidepressants such as Elavil have sedative qualities.
73. The nurse assesses increasing restless, agitation, swinging of legs, and pacing in the patient who has been talking Thorazine 400 mg daily. The nursing evaluation is:
a. EPS
b. NMS
c. Dystonia
d. Akathisia
Ans: D-Akathisia, a common side effect of phenothiazines is a feeling of uncontrollable restlessness. It is treated by decreasing dose, changing medications, and administering Benadryl.
74. The nurse calls the physician and requires an order for restraints. Which factor will be most decisive when the nurse is face with decision to implement the use of restraints?
a. Cooperation
b. Safety
c. Court orders
d. Family request
Ans: B-When a patient’s safety is at issue; the use of restrains is warranted. Then nurse should carefully document the safety issue.
75. The nurse is caring for a client with hypochondriasis. Which behavior would the nurse most likely encounter?
a.)Ready acceptance of the physician's explanation that all medical and laboratory tests are normal
b.)Expression of fear of dying after being diagnosed with advanced breast cancer
c.)Expression of fear of colorectal cancer following 3 days of constipation
d.)Lack of concern about having a serious disease
C. RATIONALE: The client with hypochondriasis is preoccupied with having a serious disease. She may convince herself that a relatively minor symptom, such as constipation, is a sign of a serious disorder. The client's fear of serious illness persists, even after a physician reassures her that all medical and laboratory tests are normal. The fear of dying after receiving a diagnosis of advanced breast cancer wouldn't be considered hypochondriasis. A client with hypochondriasis shows an exaggerated level of anxiety, rather than a lack of concern about having a serious disease or illness.
76. The nurse is caring for a client who has been diagnosed with hypochondriasis. The client attributes his cough to tuberculosis. A chest X-ray and skin test are negative for tuberculosis. The client begins to complain about the sudden onset of chest pain. How should the nurse react initially?
a.)Let the client know the nurse understands his fears of serious illness.
b.)Encourage the client to discuss his fear of having a serious illness.
c.)Report the complaint of chest pain to the physician.
d.)Determine if the illness is fulfilling a psychological need for the client.
C. RATIONALE: Because of the risk of missing an actual medical problem, any new symptoms reported by a client with hypochondriasis should be reported to the physician. The other interventions are appropriate after the nurse has determined that the client doesn't have a serious medical disorder.
77. The nurse is talking with a client who recently attempted suicide. The client asks her not to tell anyone one about their conversation. How should the nurse respond?
a.)I'll need to share information with the rest of your health care team if it's important to your care.
b.)I promise I won't tell anyone about the information you share with me today.
c.)I promise I won't tell anyone about the information you share with me today unless you give me permission to do so.
d.)Please don't tell me anything that you wouldn't want others on your health care team to know.
A. RATIONALE: The nurse must tell the client that she'll share information if it affects his safety or his care. The nurse shouldn't promise to withhold information because she may not be able to uphold her promise if the information must be shared with others. The nurse shouldn't promise to ask permission before disclosing information to others. The nurse also shouldn't encourage the client to withhold information from her. Doing so violates the nurse's responsibility to develop a therapeutic relationship with the client. The nurse & not the client & should judge what specific information must be shared with others on the health care team.
78. The nurse is administering atropine sulfate to a client about to undergo electroconvulsive therapy. Which assessment indicates that the medication is effective? a.)The client's heart rate is 48 beats/minute.
b.)The client states that his mouth is dry.
c.)The client appears calm and relaxed.
d.)The client falls asleep.
B. RATIONALE: Atropine sulfate is administered approximately 30 minutes before electroconvulsive therapy to reduce oral secretions; therefore, the client's mouth would feel dry. Atropine also blocks the vagal stimulation of the heart, causing a rise in heart rate (much higher than 48 beats/minute). Atropine sulfate isn't given to make the client feel calm and relaxed nor does it induce sleep.
79. The nurse is documenting a care plan for a client who has undergone electroconvulsive therapy. Which intervention should the nurse include?
a.)Monitoring the client's vital signs every hour for 4 hours
b.)Placing the client in Trendelenburg's position
c.)Encouraging early ambulation
d.)Reorienting the client to time and place
D. RATIONALE: Confusion and temporary memory loss are the most common adverse effects of electroconvulsive therapy. The nurse should continually reorient the client to time and place as he wakes up from the procedure. Following electroconvulsive therapy, the nurse should monitor the client's vital signs every 15 minutes for the 1st hour. The nurse should position the client on his side after the procedure to reduce the risk of aspiration. The client should remain on bed rest until he's fully awake and oriented.
80. The nurse is caring for a client in the manic phase of bipolar disorder who is ready for discharge from the psychiatric unit. As the nurse begins to terminate the nurse-client relationship, which client response is most appropriate?
a.)Expressing feelings of anxiety
b.)Displaying anger, shouting, and banging the table.
c.)Withdrawing from the nurse in silence
d.)Rationalizing the termination, saying that everything comes to an end
A. RATIONALE: Anxiety is a normal reaction to the termination of the nurse-client relationship. The nurse should help the client explore his feelings about the end of the therapeutic relationship. While anger about the termination may be a healthy response, banging the table, shouting, and other forms of acting out aren't appropriate behavior. Withdrawal isn't a healthy response to the termination of a relationship. By rationalizing the termination, the client avoids expressing his feelings and emotions.
81. A client with a borderline personality disorder has been playing one staff member against another. In formulating a care plan for this client, the nursing staff should include which intervention?
a.)Assigning the same staff members to work with the client
b.)Avoiding setting limits
c.)Rotating staff members who work with the client
d.)Avoiding interaction with the client until splitting behaviors stop
C. RATIONALE: Rotating staff members who care for a client with borderline personality disorder reduces the incidence of splitting behaviors. Helping the client to learn to relate to several staff members may reduce fears of abandonment. The staff should set limits on unacceptable behaviors; the client doesn't have the self-control to set his own limits. Avoiding the client won't reduce splitting behaviors. The client needs to interact with staff members to develop relationships and reduce fears of abandonment.
82. The nurse is planning care for a client admitted to the psychiatric unit with a diagnosis of paranoid schizophrenia. Which nursing diagnosis should receive the highest priority?
a.)Risk for self- or other-directed violence
b.)Imbalanced nutrition
c.)Ineffective coping
d.)Impaired verbal communication
A. RATIONALE: Because of such factors as suspiciousness, anxiety, and hallucinations, the client with paranoid schizophrenia is at risk for violence toward himself or others. The other options are also appropriate nursing diagnoses but should be addressed after the safety of the client and those around him is established.
83. 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
B. 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.
84. The nurse is leading group therapy with psychiatric clients. During the working phase, what should the nurse do?
a.)Explain the purposes and goals of the group.
b.)Offer advice to help resolve conflicts.
c.)Encourage group cohesiveness.
d.)Encourage a discussion of feelings of loss regarding termination of the group.
C. RATIONALE: During the working phase, or the middle phase of a group, the nurse continues to encourage cohesiveness among its members. During the orientation phase, or the initial phase, the nurse leading the group should explain the purpose and goals of the group. During the termination phase, or the final phase, the leader encourages a discussion of feelings associated with termination. When leading a group, the nurse should act as a facilitator; offering advice isn't appropriate. The group members should work together to resolve conflicts.
85. 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)
b.)Haloperidol (Haldol)
c.)Magnesium sulfate
d.)Chlordiazepoxide (Librium)
D. RATIONALE: Chlordiazepoxide and other tranquilizers help reduce the symptoms of alcohol withdrawal. Haloperidol may be given to treat clients with psychosis, severe agitation, or delirium. Naloxone is administered for narcotic overdose. Magnesium sulfate and other anticonvulsant medications are administered to treat seizures only if they occur during withdrawal.
86. The client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from the nurse?
a.)Why didn't you get someone else to drive you?
b.)Tell me how you feel about the accident.
c.)You should know better than to drink and drive.
d.)I recommend that you attend an Alcoholics Anonymous meeting.
B. RATIONALE: An open-ended statement or question is the most therapeutic response. It encourages the widest range of client responses, makes the client an active participant in the conversation, and shows the client that the nurse is interested in his feelings. Asking the client why he drove while intoxicated can make him feel defensive and intimidated. A judgmental approach isn't therapeutic. By giving advice, the nurse suggests that the client isn't capable of making decisions, thus fostering dependency.
87. A client suffers from depression after the accidental death of her daughter. After a suicide attempt, the client is admitted to the psychiatric unit. During the admission interview, the client tells the nurse that she no longer wants to die. The nurse should: a.)suggest that the client no longer requires close observation.
b.)place the client in a private room, away from the nurses' station, so that she has privacy to work through the stages of the grieving process.
c.)inspect the client's personal belongings for potentially dangerous objects. d.)avoid any further discussion of suicide, unless the client brings up the topic.
C. RATIONALE: The client must be protected from harming herself. This includes checking all personal items that the client brought to the hospital, such as a suitcase or pocketbook. The client must be closely observed until she has been evaluated and receives treatment. A client who is suicidal should be placed in a room near the nurses' station in full view of a nurse or other observer. The nurse shouldn't ignore the client's suicide attempt. The client may feel relief talking about the suicide attempt and knowing that she'll be protected from harm.
88. The nurse is caring for a client diagnosed with panic disorder. The client begins to hyperventilate. How should the nurse respond initially?
a.)Stay with the client during the panic attack.
b.)Shout for help and obtain assistance.
c.)Teach the client relaxation exercises.
d.)Help the client explore the reason for the anxiety.
A. RATIONALE: Because the presence of a calm nurse provides a feeling of security, the nurse should remain with a client during an anxiety attack and assure the client of his safety. Shouting for help and bringing others running to the scene can increase the client's anxiety. The nurse should keep the client's environment calm by reducing noise and limiting the number of people present. Teaching the client relaxation exercises and other methods to reduce stress and exploring the reasons underlying anxiety are important interventions but shouldn't be performed during an anxiety attack. During an attack a client isn't capable of learning new behaviors or achieving insight.
89. The nurse is caring for a client with panic disorder who has difficulty sleeping. Which nursing intervention would best help the client achieve healthy long-term sleeping habits? a.)Administering sleeping pills
b.)Encouraging the use of relaxation exercises
c.)Suggesting he talk with other clients until he feels ready to sleep
d.)Telling him to play ping-pong in the day room
B. RATIONALE: Relaxation exercises provide the client with a healthy way to gain control over anxiety. These exercises also produce a physiological response opposite to that produced by stress. Giving a sleeping pill would provide short-term relief for sleeplessness but wouldn't teach healthy sleep habits. Suggesting the client stay up and talk won't help him develop healthy sleep habits or control stress and anxiety. Playing ping-pong or engaging in other exercises just prior to sleep produces a physiological response similar to stress.
90. A teenager was driving a car that slipped off a road in Tagaytay, killing two of his friends. He repeatedly tells the nurse that he should be dead instead of his friends. The client's behavior is an example of:
a.)survivor's guilt.
b.)denial.
c.)anticipatory grief.
d.)repression.
A. RATIONALE: Individuals who survive a traumatic experience in which others have died commonly report powerful feelings of guilt that they survived and others didn't. This guilt is referred to as survivor's guilt. In denial, a person refuses to accept that a situation or feeling exists. Anticipatory grief occurs when an individual experiences grief before a loss occurs. In repression, an individual involuntarily blocks an unpleasant experience, memory, or feeling from consciousness.
91. The nurse is caring for a client with schizophrenia. Which of the following outcomes is 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.
A. RATIONALE: 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.
92. 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.
C. RATIONALE: 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.
93. 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)
A. RATIONALE: Benztropine mesylate 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.
94. 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
B. 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.
95. Which statement about somatoform pain disorder is accurate?
a.)The pain is intentionally fabricated by the client in order to receive attention.
b.)The pain is real to the client, even though there may not be an organic etiology for the pain.
c.)The pain is less than would be expected from what the client identifies as the underlying disorder.
d.)The pain is what would be expected from what the client identifies as the underlying disorder.
B. RATIONALE: In a somatoform pain disorder, the client has pain even though a thorough diagnostic work up reveals no organic cause. The nurse must recognize that the pain is real to the client. By refusing to believe that the client is in pain, the nurse impedes the development of a therapeutic relationship based on trust. While somatoform pain offers the client secondary gains, such as attention or avoidance of an unpleasant activity, the pain isn't intentionally fabricated by the client. Even if a pathologic cause of the pain can be identified, the pain is often in excess of what would normally be expected.
96. The nurse is caring for a client diagnosed with antisocial personality disorder. The client has a history of fighting, cruelty to animals, and stealing. Which of the following traits would the nurse be most likely to uncover during assessment?
a.)History of gainful employment
b.)Frequent expression of guilt regarding antisocial behavior
c.)Demonstrated ability to maintain close, stable relationships
d.)A low tolerance for frustration
D. RATIONALE: Clients with an antisocial personality disorder exhibit a low tolerance for frustration, emotional immaturity, and a lack of impulse control. They commonly have a history of unemployment, miss work repeatedly, and quit work without plans for other employment. They don't feel guilt about their behavior and commonly perceive themselves as victims. They also display a lack of responsibility for the outcome of their actions. Because of a lack of trust in others, clients with antisocial personality disorder commonly have difficulty developing stable, close relationships.
97. The nurse is caring for a client with antisocial personality disorder. Which of the following statements is most appropriate for the nurse to make when explaining unit rules and expectations to the client?
a.)"I and other members of the health care team would like you to attend group therapy each day."
b.)"You'll find your condition will improve much faster if you attend group therapy each day."
c.)"You'll be expected to attend group therapy each day."
d.)"Please try to attend group therapy each day."
C. RATIONALE: Rules and explanations must be brief, clear, and leave little room for misinterpretation. A client with antisocial personality disorder tends to disregard rules and authority and be socially irresponsible. The words "You'll be expected to attend" are concise and concrete and convey precisely what behavior is expected. The other options leave open the interpretation that attendance is suggested but not mandatory.
98. A 58-year-old client on a mental health unit has lost control, despite having been properly medicated, and is threatening to harm himself and others. He has been placed in four-point restraints. Which nursing measure should be taken next?
a.)Release one restraint every 15 minutes.
b.)Have a staff member stay with the client at all times.
c.)Leave the client alone to reduce his sensory stimulation and allow him to regain control.
d.)Restrict fluids until the restraint period is over.
B. RATIONALE: A client such as this one needs sensory stimulation and should never be left alone (although the nurse should maintain the client's privacy). Restraints should be removed for 5 minutes at least every 2 hours. A client in restraints should have someone with him at all times. Fluids are offered, and the client is given food at mealtimes.
99. Which nursing assessment has priority while a client's extremities are restrained? a.)Measuring urine output
b.)Checking circulation in extremities
c.)Assessing pupillary responses
d.)Noting respiratory pattern
B. RATIONALE: The nurse must check extremities for signs of circulatory impairment. Measuring urine output isn't crucial; the client may void into a urinal as necessary. Assessing pupillary responses isn't relevant to the situation. Although the nurse should check vital signs every 15 minutes for 1 hour, assessment for circulation takes priority over respiratory pattern.
100. A psychiatric client who was voluntarily admitted now wishes to be discharged from the hospital, against medical advice. What's the most important assessment the nurse should make of the client?
a.)Ability to care for himself
b.)Degree of danger to self and others
c.)Level of psychosis
d.)Intended compliance with aftercare
B. RATIONALE: A voluntary client who poses a danger to himself or others may be denied permission to leave the hospital. The other options are important assessments, but the client's danger to himself or others takes priority.