Post by Nursing Board 101 on Aug 18, 2010 13:26:21 GMT -5
1. A client has approached the nurse asking for advice on how to deal with his alcohol addiction. The nurse should tell the client that the only effective treatment for alcoholism is:
a.)psychotherapy.
b.)total abstinence.
c.)Alcoholics Anonymous (AA).
d.)aversion therapy.
B. RATIONALE: Total abstinence is the only effective treatment for alcoholism. Psychotherapy, attendance at AA meetings, and aversion therapy are all adjunctive therapies that can support the client in his efforts to abstain.
2. The nurse is providing care for a client undergoing opiate withdrawal. Opiate withdrawal causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with:
a.)barbiturates.
b.)amphetamines.
c.)methadone.
d.)benzodiazepines.
C. RATIONALE: Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system but doesn't have the same deleterious effects as other opiates, such as cocaine, heroin, and morphine. Barbiturates, amphetamines, and benzodiazepines are highly addictive and would require detoxification treatment.
3. The nurse is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as:
a.)delusions.
b.)hallucinations.
c.)loose associations.
d.)neologisms.
B. RATIONALE: Hallucinations are visual, auditory, gustatory, tactile, or olfactory perceptions that have no basis in reality. Delusions are false beliefs, rather than perceptions, that the client accepts as real. Loose associations are rapid shifts among unrelated ideas. Neologisms are bizarre words that have meaning only to the client.
4. The nurse is caring for a client who is suicidal. When accompanying the client to the bathroom, the nurse should:
a.)give him privacy in the bathroom.
b.)allow him to shave.
c.)open the window and allow him to get some fresh air.
d.)observe him.
D. RATIONALE: The nurse has a responsibility to observe continuously the acutely suicidal client & not provide privacy. The nurse should watch for clues, such as communicating suicidal thoughts, threats, and messages; hoarding medications; and talking about death. By accompanying the client to the bathroom, the nurse will naturally prevent hanging or other injury. The nurse will check the client's area and fix dangerous conditions, such as exposed pipes and windows without safety glass. The nurse will also remove potentially dangerous objects, such as belts, razors, suspenders, glass, and knives.
5. The nurse is developing a care plan for a client with anorexia nervosa. Which action should the nurse include in the plan?
a.)Restrict visits with the family until the client begins to eat.
b.)Provide privacy during meals.
c.)Set up a strict eating plan for the client.
d.)Encourage the client to exercise, which will reduce her anxiety.
C. RATIONALE: Establishing a consistent eating plan and monitoring the client's weight are important for this disorder. The family should be included in the client's care. The client should be monitored during meals & not given privacy. Exercise must be limited and supervised.
6. A client whose husband recently left her is admitted to the hospital with severe depression. The nurse suspects that the client is at risk for suicide. Which of the following questions would be most appropriate and helpful for the nurse to ask during an assessment for suicide risk?
a.)"Are you sure you want to kill yourself?"
b.)"I know if my husband left me, I'd want to kill myself. Is that what you think?"
c.)"How do you think you would kill yourself?"
d.)"Why don't you just look at the positives in your life?"
C. RATIONALE: To determine if a client is at risk for suicide, ask, "How do you think you would kill yourself?" If the client has a plan, she may be closer to carrying out the act. Option a requires a yes-or-no response and is self-limiting. In Option b, the nurse is telling the client what to think and feel. Option d dismisses the client's feelings.
7. The nurse is caring for a client who she believes has been abusing opiates. Assessment findings in a client abusing opiates, such as morphine, include:
a.)dilated pupils and slurred speech.
b.)rapid speech and agitation.
c.)dilated pupils and agitation.
d.)euphoria and constricted pupils.
D. RATIONALE: Assessment findings in a client abusing opiates include agitation, slurred speech, euphoria, and constricted pupils.
8. The nurse is caring for a client experiencing an anxiety attack. Appropriate nursing interventions include:
a.)turning on the lights and opening the windows so that the client doesn't feel crowded. b.)leaving the client alone.
c.)staying with the client and speaking in short sentences.
d.)turning on stereo music.
C. RATIONALE: Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm, and medicating as needed. Leaving the client alone, turning on a stereo or lights, and opening windows may increase the client's anxiety.
9. The nurse is teaching a new group of mental health aides. The nurse should teach the aides that setting limits is most important for:
a.)a depressed client.
b.)a manic client.
c.)a suicidal client.
d.)an anxious client.
B. RATIONALE: Setting limits for unacceptable behavior is most important in a manic client. Typically, depressed, anxious, or suicidal clients don't physically or mentally test the limits of the caregiver.
10. A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects a belief that one is:
a.)highly important or famous.
b.)being persecuted.
c.)connected to events unrelated to oneself.
d.)responsible for the evil in the world.
A. RATIONALE: A delusion of grandeur is a false belief that one is highly important or famous. A delusion of persecution is a false belief that one is being persecuted. A delusion of reference is a false belief that one is connected to events unrelated to oneself or a belief that one is responsible for the evil in the world.
11. The nurse is caring for a client, a Vietnam veteran, who exhibits signs and symptoms of posttraumatic stress disorder. Signs and symptoms of posttraumatic stress disorder include:
a.)hyperalertness and sleep disturbances.
b.)memory loss of traumatic event and somatic distress.
c.)feelings of hostility and violent behavior.
d.)sudden behavioral changes and anorexia.
A. RATIONALE: Signs and symptoms of posttraumatic stress disorder include hyperalertness, sleep disturbances, exaggerated startle, survival guilt, and memory impairment. Also, the client relives the traumatic event through dreams and recollections. Hostility, violent behavior, and anorexia aren't usual signs or symptoms of posttraumatic stress disorder.
12. The nurse is caring for a client with manic depression. The care plan for a client in a manic state would include:
a.)offering high-calorie meals and strongly encouraging the client to finish all food.
b.)insisting that the client remain active throughout the day so that he'll sleep at night. c.)allowing the client to exhibit hyperactive, demanding, manipulative behavior without setting limits.
d.)listening attentively with a neutral attitude and avoiding power struggles.
D. RATIONALE: The nurse should listen to the client's requests, express willingness to seriously consider the requests, and respond later. The nurse should encourage the client to take short daytime naps because he expends so much energy. The nurse shouldn't try to restrain the client when he feels the need to move around as long as his activity isn't harmful. High-calorie finger foods should be offered to supplement the client's diet, if he can't remain seated long enough to eat a complete meal. The client shouldn't be forced to stay seated at the table to finish a meal. The nurse should set limits in a calm, clear, and self-confident tone of voice.
13. A client is a Vietnam War veteran with a diagnosis of posttraumatic stress disorder. He has a history of nightmares, depression, hopelessness, and alcohol abuse. Which option offers the client the most lasting relief of his symptoms?
a.)The opportunity to verbalize memories of trauma to a sympathetic listener b.)Family support
c.)Prescribed medications taken as ordered
d.)Alcoholics Anonymous (AA) meetings
A. RATIONALE: Although it's difficult, clients with posttraumatic stress disorder can obtain the most lasting relief if they verbalize memories of the trauma to a sympathetic listener. Family members are commonly frightened by the information and can't be consistently supportive. Antidepressants may help but these drugs can mask feelings and can't provide lasting relief. Treatment for alcohol abuse, including AA meetings, must be considered when planning care but alone doesn't provide lasting relief.
14. A client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but that he can control his use if he chooses. Which coping mechanism is he using?
a.)Withdrawal
b.)Logical thinking
c.)Repression
d.)Denial
D. RATIONALE: Denial is an unconscious defense mechanism in which emotional conflict and anxiety is avoided by refusing to acknowledge feelings, desires, impulses, or external facts that are consciously intolerable. Withdrawal is a common response to stress, characterized by apathy. Logical thinking is the ability to think rationally and make responsible decisions, which would lead the client to admitting the problem and seeking help. Repression is suppressing past events from the consciousness because of guilty association.
15. A 22-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely evidence of ineffective individual coping?
a.)Inability to make choices and decisions without advice
b.)Showing interest only in solitary activities
c.)Avoiding developing relationships
d.)Recurrent self-destructive behavior with history of depression
A. RATIONALE: Individuals with dependent personality disorder typically show indecisiveness, submissiveness, and clinging behaviors so that others will make decisions for them. These clients feel helpless and uncomfortable when alone and don't show interest in solitary activities. They also pursue relationships in order to have someone to take care of them. Although clients with dependent personality disorder may become depressed and suicidal if their needs aren't met, this isn't a typical response.
16. The major goal of therapy in crisis intervention is to:
a.)withdraw from the stress.
b.)resolve the immediate problem.
c.)decrease anxiety.
d.)provide documentation of events.
B. RATIONALE: During a period of crisis, the major goal is to resolve the immediate problem with hopes of getting the individual to the level of functioning that existed before the crisis. Withdrawing from stress doesn't address the immediate problem and isn't therapeutic. Anxiety will decrease after the immediate problem is resolved. Providing support and safety are necessary interventions while working toward accomplishing the goal. Documentation is necessary for maintaining accurate records of treatment.
17. A 38-year-old client is admitted for alcohol withdrawal. The most common early sign or symptom that this client is likely to experience is:
a.)impending coma.
b.)manipulating behavior.
c.)suppression.
d.)perceptual disorders.
D. RATIONALE: Perceptual disorders, especially frightening visual hallucinations, are very common with alcohol withdrawal. Coma isn't an immediate consequence. Manipulative behaviors are part of the alcoholic client's personality but not a sign of alcohol withdrawal. Suppression is a conscious effort to conceal unacceptable thoughts, feelings, impulses, or acts and serves as a coping mechanism for most alcoholics.
18. A client is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations?
a.)Aggressive behavior
b.)Paranoid thoughts
c.)Emotional affect
d.)Independence needs
B. RATIONALE: Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts. Aggressive behavior is uncommon, although these clients may experience agitation with anxiety. Their behavior is emotionally cold with a flattened affect, regardless of the situation. These clients demonstrate a reduced capacity for close or dependent relationships.
19. The nurse is caring for a client in an acute manic state. What's the most effective nursing action for this client?
a.)Assigning him to group activities
b.)Reducing his stimulation
c.)Assisting him with self-care
d.)Helping him express his feelings
B. RATIONALE: Reducing stimuli helps to reduce hyperactivity during a manic state. Group activities would provide too much stimulation. Trying to assist the client with self-care could cause increased agitation. When in a manic state, these clients aren't able to express their inner feelings in a productive, introspective manner. The focus of treatment for a client in the manic state is behavior control.
20. The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:
a.)avoid shopping for large amounts of food.
b.)control eating impulses.
c.)identify anxiety-causing situations.
d.)eat only three meals per day.
C. RATIONALE: Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping for large amounts of food isn't a goal early in treatment. Managing eating impulses and replacing them with adaptive coping mechanisms can be integrated into the care plan after initially addressing stress and underlying issues. Eating three meals per day isn't a realistic goal early in treatment.
21. The nurse is caring for a 40-year-old client. Which behavior by the client indicates adult cognitive development?
a.)Has perceptions based on reality
b.)Assumes responsibility for actions
c.)Generates new levels of awareness
d.)Has maximum ability to solve problems and learn new skills
C. RATIONALE: Adults between ages 31 and 45 generate new levels of awareness. Having perceptions based on reality and assuming responsibility for actions indicate socialization development & not cognitive development. Demonstrating maximum ability to solve problems and learning new skills occur in young adults between ages 20 and 30.
22. The nurse is assessing a client suffering from stress and anxiety. A common physiological response to stress and anxiety is:
a.)sedation.
b.)diarrhea.
c.)vertigo.
d.)urticaria.
B. RATIONALE: Diarrhea is a common physiological response to stress and anxiety. The other choices could also be related to stress and anxiety but they don't occur as frequently or as commonly as diarrhea.
23. The nurse is assessing a client for lifestyle factors that might affect normal coping. Which factor would the nurse most likely consider?
a.)Inadequate diet
b.)Divorce
c.)Job promotion
d.)Adopting a child
A. RATIONALE: Poor, inadequate diet is the only option considered a lifestyle factor. The other choices & divorce, job promotion, and adopting a child & are considered life events.
24. A client with bipolar disorder is being treated with lithium for the first time. The nurse should observe the client for which common adverse effect of lithium?
a.)Sexual dysfunction
b.)Constipation
c.)Polyuria
d.)Seizures
C. RATIONALE: Polyuria commonly occurs early in the treatment with lithium and could result in fluid volume deficit. Sexual dysfunction isn't a common adverse effect of lithium; it's more common with sedatives and tricyclic antidepressants. Diarrhea, not constipation, occurs with lithium. Constipation can occur with other psychiatric drugs, such as antipsychotic drugs. Seizures may be a later sign of lithium toxicity.
25. A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see:
a.)tension and irritability.
b.)slow pulse.
c.)hypotension.
d.)constipation.
A. RATIONALE: An amphetamine is a nervous system stimulant that's subject to abuse because of its ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Options B and C are incorrect because amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea is a common adverse effect, so option D is incorrect.
26. During a shift report, the nurse learns that she'll be providing care for a client who is vulnerable to panic attack. Treatment for panic attacks includes behavioral therapy, supportive psychotherapy, and medication such as:
a.)barbiturates.
b.)antianxiety drugs.
c.)depressants.
d.)amphetamines.
B. RATIONALE: Antianxiety drugs provide symptomatic relief. Barbiturates and amphetamines can precipitate panic attacks. Depressants aren't appropriate for treating panic attacks.
27. A client comes to the emergency department while experiencing a panic attack. The nurse can best respond to a client having a panic attack by:
a.)staying with the client until the attack subsides.
b.)telling the client everything is under control.
c.)telling the client to lie down and rest.
d.)talking continually to the client by explaining what's happening.
A. RATIONALE: The nurse should remain with the client until the attack subsides. If the client is left alone, he may become more anxious. Giving false reassurance is inappropriate in this situation. The client should be allowed to move around and pace to help expend energy. The client may be so overwhelmed that he can't follow lengthy explanations or instructions, so the nurse should use short phrases and slowly give one direction at a time.
28. A 24-year-old client is experiencing an acute schizophrenic episode. He has vivid hallucinations that are making him agitated. The nurse's best response at this time would be to:
a.)take the client's vital signs.
b.)explore the content of the hallucinations.
c.)tell him his fear is unrealistic.
d.)engage the client in reality-oriented activities.
B. RATIONALE: Exploring the content of the hallucinations will help the nurse understand the client's perspective on the situation. The client shouldn't be touched, such as in taking vital signs, without telling him exactly what's going to happen. Debating with the client about his emotions isn't therapeutic. When the client is calm, engage him in reality-based activities.
29. A client with paranoid type schizophrenia becomes angry and tells the nurse to leave him alone. The nurse should:
a.)tell him that she'll leave for now but will return soon.
b.)ask him if it's okay if she sits quietly with him.
c.)ask him why he wants to be left alone.
d.)tell him that she won't let anything happen to him.
A. RATIONALE: If the client tells the nurse to leave, the nurse should leave but let the client know that she'll return so that he doesn't feel abandoned. Not heeding the client's request can agitate him further. Also, challenging the client isn't therapeutic and may increase his anger. False reassurance isn't warranted in this situation.
30. A client begins taking haloperidol (Haldol). After a few days, he experiences severe tonic contractures of muscles in the neck, mouth, and tongue. The nurse should recognize this as:
a.)psychotic symptoms.
b.)parkinsonism.
c.)akathisia.
d.)dystonia.
D. RATIONALE: These symptoms describe dystonia, which commonly occurs after a few days of treatment with haloperidol. The symptoms may be confused with psychotic symptoms and misdiagnosed. Parkinsonism results in muscle rigidity, shuffling gait, stooped posture, flat-faced affect, tremors, and drooling. Signs and symptoms of akathisia are restlessness, pacing, and inability to sit still.
a.)psychotherapy.
b.)total abstinence.
c.)Alcoholics Anonymous (AA).
d.)aversion therapy.
B. RATIONALE: Total abstinence is the only effective treatment for alcoholism. Psychotherapy, attendance at AA meetings, and aversion therapy are all adjunctive therapies that can support the client in his efforts to abstain.
2. The nurse is providing care for a client undergoing opiate withdrawal. Opiate withdrawal causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with:
a.)barbiturates.
b.)amphetamines.
c.)methadone.
d.)benzodiazepines.
C. RATIONALE: Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system but doesn't have the same deleterious effects as other opiates, such as cocaine, heroin, and morphine. Barbiturates, amphetamines, and benzodiazepines are highly addictive and would require detoxification treatment.
3. The nurse is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as:
a.)delusions.
b.)hallucinations.
c.)loose associations.
d.)neologisms.
B. RATIONALE: Hallucinations are visual, auditory, gustatory, tactile, or olfactory perceptions that have no basis in reality. Delusions are false beliefs, rather than perceptions, that the client accepts as real. Loose associations are rapid shifts among unrelated ideas. Neologisms are bizarre words that have meaning only to the client.
4. The nurse is caring for a client who is suicidal. When accompanying the client to the bathroom, the nurse should:
a.)give him privacy in the bathroom.
b.)allow him to shave.
c.)open the window and allow him to get some fresh air.
d.)observe him.
D. RATIONALE: The nurse has a responsibility to observe continuously the acutely suicidal client & not provide privacy. The nurse should watch for clues, such as communicating suicidal thoughts, threats, and messages; hoarding medications; and talking about death. By accompanying the client to the bathroom, the nurse will naturally prevent hanging or other injury. The nurse will check the client's area and fix dangerous conditions, such as exposed pipes and windows without safety glass. The nurse will also remove potentially dangerous objects, such as belts, razors, suspenders, glass, and knives.
5. The nurse is developing a care plan for a client with anorexia nervosa. Which action should the nurse include in the plan?
a.)Restrict visits with the family until the client begins to eat.
b.)Provide privacy during meals.
c.)Set up a strict eating plan for the client.
d.)Encourage the client to exercise, which will reduce her anxiety.
C. RATIONALE: Establishing a consistent eating plan and monitoring the client's weight are important for this disorder. The family should be included in the client's care. The client should be monitored during meals & not given privacy. Exercise must be limited and supervised.
6. A client whose husband recently left her is admitted to the hospital with severe depression. The nurse suspects that the client is at risk for suicide. Which of the following questions would be most appropriate and helpful for the nurse to ask during an assessment for suicide risk?
a.)"Are you sure you want to kill yourself?"
b.)"I know if my husband left me, I'd want to kill myself. Is that what you think?"
c.)"How do you think you would kill yourself?"
d.)"Why don't you just look at the positives in your life?"
C. RATIONALE: To determine if a client is at risk for suicide, ask, "How do you think you would kill yourself?" If the client has a plan, she may be closer to carrying out the act. Option a requires a yes-or-no response and is self-limiting. In Option b, the nurse is telling the client what to think and feel. Option d dismisses the client's feelings.
7. The nurse is caring for a client who she believes has been abusing opiates. Assessment findings in a client abusing opiates, such as morphine, include:
a.)dilated pupils and slurred speech.
b.)rapid speech and agitation.
c.)dilated pupils and agitation.
d.)euphoria and constricted pupils.
D. RATIONALE: Assessment findings in a client abusing opiates include agitation, slurred speech, euphoria, and constricted pupils.
8. The nurse is caring for a client experiencing an anxiety attack. Appropriate nursing interventions include:
a.)turning on the lights and opening the windows so that the client doesn't feel crowded. b.)leaving the client alone.
c.)staying with the client and speaking in short sentences.
d.)turning on stereo music.
C. RATIONALE: Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm, and medicating as needed. Leaving the client alone, turning on a stereo or lights, and opening windows may increase the client's anxiety.
9. The nurse is teaching a new group of mental health aides. The nurse should teach the aides that setting limits is most important for:
a.)a depressed client.
b.)a manic client.
c.)a suicidal client.
d.)an anxious client.
B. RATIONALE: Setting limits for unacceptable behavior is most important in a manic client. Typically, depressed, anxious, or suicidal clients don't physically or mentally test the limits of the caregiver.
10. A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects a belief that one is:
a.)highly important or famous.
b.)being persecuted.
c.)connected to events unrelated to oneself.
d.)responsible for the evil in the world.
A. RATIONALE: A delusion of grandeur is a false belief that one is highly important or famous. A delusion of persecution is a false belief that one is being persecuted. A delusion of reference is a false belief that one is connected to events unrelated to oneself or a belief that one is responsible for the evil in the world.
11. The nurse is caring for a client, a Vietnam veteran, who exhibits signs and symptoms of posttraumatic stress disorder. Signs and symptoms of posttraumatic stress disorder include:
a.)hyperalertness and sleep disturbances.
b.)memory loss of traumatic event and somatic distress.
c.)feelings of hostility and violent behavior.
d.)sudden behavioral changes and anorexia.
A. RATIONALE: Signs and symptoms of posttraumatic stress disorder include hyperalertness, sleep disturbances, exaggerated startle, survival guilt, and memory impairment. Also, the client relives the traumatic event through dreams and recollections. Hostility, violent behavior, and anorexia aren't usual signs or symptoms of posttraumatic stress disorder.
12. The nurse is caring for a client with manic depression. The care plan for a client in a manic state would include:
a.)offering high-calorie meals and strongly encouraging the client to finish all food.
b.)insisting that the client remain active throughout the day so that he'll sleep at night. c.)allowing the client to exhibit hyperactive, demanding, manipulative behavior without setting limits.
d.)listening attentively with a neutral attitude and avoiding power struggles.
D. RATIONALE: The nurse should listen to the client's requests, express willingness to seriously consider the requests, and respond later. The nurse should encourage the client to take short daytime naps because he expends so much energy. The nurse shouldn't try to restrain the client when he feels the need to move around as long as his activity isn't harmful. High-calorie finger foods should be offered to supplement the client's diet, if he can't remain seated long enough to eat a complete meal. The client shouldn't be forced to stay seated at the table to finish a meal. The nurse should set limits in a calm, clear, and self-confident tone of voice.
13. A client is a Vietnam War veteran with a diagnosis of posttraumatic stress disorder. He has a history of nightmares, depression, hopelessness, and alcohol abuse. Which option offers the client the most lasting relief of his symptoms?
a.)The opportunity to verbalize memories of trauma to a sympathetic listener b.)Family support
c.)Prescribed medications taken as ordered
d.)Alcoholics Anonymous (AA) meetings
A. RATIONALE: Although it's difficult, clients with posttraumatic stress disorder can obtain the most lasting relief if they verbalize memories of the trauma to a sympathetic listener. Family members are commonly frightened by the information and can't be consistently supportive. Antidepressants may help but these drugs can mask feelings and can't provide lasting relief. Treatment for alcohol abuse, including AA meetings, must be considered when planning care but alone doesn't provide lasting relief.
14. A client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but that he can control his use if he chooses. Which coping mechanism is he using?
a.)Withdrawal
b.)Logical thinking
c.)Repression
d.)Denial
D. RATIONALE: Denial is an unconscious defense mechanism in which emotional conflict and anxiety is avoided by refusing to acknowledge feelings, desires, impulses, or external facts that are consciously intolerable. Withdrawal is a common response to stress, characterized by apathy. Logical thinking is the ability to think rationally and make responsible decisions, which would lead the client to admitting the problem and seeking help. Repression is suppressing past events from the consciousness because of guilty association.
15. A 22-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely evidence of ineffective individual coping?
a.)Inability to make choices and decisions without advice
b.)Showing interest only in solitary activities
c.)Avoiding developing relationships
d.)Recurrent self-destructive behavior with history of depression
A. RATIONALE: Individuals with dependent personality disorder typically show indecisiveness, submissiveness, and clinging behaviors so that others will make decisions for them. These clients feel helpless and uncomfortable when alone and don't show interest in solitary activities. They also pursue relationships in order to have someone to take care of them. Although clients with dependent personality disorder may become depressed and suicidal if their needs aren't met, this isn't a typical response.
16. The major goal of therapy in crisis intervention is to:
a.)withdraw from the stress.
b.)resolve the immediate problem.
c.)decrease anxiety.
d.)provide documentation of events.
B. RATIONALE: During a period of crisis, the major goal is to resolve the immediate problem with hopes of getting the individual to the level of functioning that existed before the crisis. Withdrawing from stress doesn't address the immediate problem and isn't therapeutic. Anxiety will decrease after the immediate problem is resolved. Providing support and safety are necessary interventions while working toward accomplishing the goal. Documentation is necessary for maintaining accurate records of treatment.
17. A 38-year-old client is admitted for alcohol withdrawal. The most common early sign or symptom that this client is likely to experience is:
a.)impending coma.
b.)manipulating behavior.
c.)suppression.
d.)perceptual disorders.
D. RATIONALE: Perceptual disorders, especially frightening visual hallucinations, are very common with alcohol withdrawal. Coma isn't an immediate consequence. Manipulative behaviors are part of the alcoholic client's personality but not a sign of alcohol withdrawal. Suppression is a conscious effort to conceal unacceptable thoughts, feelings, impulses, or acts and serves as a coping mechanism for most alcoholics.
18. A client is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations?
a.)Aggressive behavior
b.)Paranoid thoughts
c.)Emotional affect
d.)Independence needs
B. RATIONALE: Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts. Aggressive behavior is uncommon, although these clients may experience agitation with anxiety. Their behavior is emotionally cold with a flattened affect, regardless of the situation. These clients demonstrate a reduced capacity for close or dependent relationships.
19. The nurse is caring for a client in an acute manic state. What's the most effective nursing action for this client?
a.)Assigning him to group activities
b.)Reducing his stimulation
c.)Assisting him with self-care
d.)Helping him express his feelings
B. RATIONALE: Reducing stimuli helps to reduce hyperactivity during a manic state. Group activities would provide too much stimulation. Trying to assist the client with self-care could cause increased agitation. When in a manic state, these clients aren't able to express their inner feelings in a productive, introspective manner. The focus of treatment for a client in the manic state is behavior control.
20. The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:
a.)avoid shopping for large amounts of food.
b.)control eating impulses.
c.)identify anxiety-causing situations.
d.)eat only three meals per day.
C. RATIONALE: Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping for large amounts of food isn't a goal early in treatment. Managing eating impulses and replacing them with adaptive coping mechanisms can be integrated into the care plan after initially addressing stress and underlying issues. Eating three meals per day isn't a realistic goal early in treatment.
21. The nurse is caring for a 40-year-old client. Which behavior by the client indicates adult cognitive development?
a.)Has perceptions based on reality
b.)Assumes responsibility for actions
c.)Generates new levels of awareness
d.)Has maximum ability to solve problems and learn new skills
C. RATIONALE: Adults between ages 31 and 45 generate new levels of awareness. Having perceptions based on reality and assuming responsibility for actions indicate socialization development & not cognitive development. Demonstrating maximum ability to solve problems and learning new skills occur in young adults between ages 20 and 30.
22. The nurse is assessing a client suffering from stress and anxiety. A common physiological response to stress and anxiety is:
a.)sedation.
b.)diarrhea.
c.)vertigo.
d.)urticaria.
B. RATIONALE: Diarrhea is a common physiological response to stress and anxiety. The other choices could also be related to stress and anxiety but they don't occur as frequently or as commonly as diarrhea.
23. The nurse is assessing a client for lifestyle factors that might affect normal coping. Which factor would the nurse most likely consider?
a.)Inadequate diet
b.)Divorce
c.)Job promotion
d.)Adopting a child
A. RATIONALE: Poor, inadequate diet is the only option considered a lifestyle factor. The other choices & divorce, job promotion, and adopting a child & are considered life events.
24. A client with bipolar disorder is being treated with lithium for the first time. The nurse should observe the client for which common adverse effect of lithium?
a.)Sexual dysfunction
b.)Constipation
c.)Polyuria
d.)Seizures
C. RATIONALE: Polyuria commonly occurs early in the treatment with lithium and could result in fluid volume deficit. Sexual dysfunction isn't a common adverse effect of lithium; it's more common with sedatives and tricyclic antidepressants. Diarrhea, not constipation, occurs with lithium. Constipation can occur with other psychiatric drugs, such as antipsychotic drugs. Seizures may be a later sign of lithium toxicity.
25. A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see:
a.)tension and irritability.
b.)slow pulse.
c.)hypotension.
d.)constipation.
A. RATIONALE: An amphetamine is a nervous system stimulant that's subject to abuse because of its ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Options B and C are incorrect because amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea is a common adverse effect, so option D is incorrect.
26. During a shift report, the nurse learns that she'll be providing care for a client who is vulnerable to panic attack. Treatment for panic attacks includes behavioral therapy, supportive psychotherapy, and medication such as:
a.)barbiturates.
b.)antianxiety drugs.
c.)depressants.
d.)amphetamines.
B. RATIONALE: Antianxiety drugs provide symptomatic relief. Barbiturates and amphetamines can precipitate panic attacks. Depressants aren't appropriate for treating panic attacks.
27. A client comes to the emergency department while experiencing a panic attack. The nurse can best respond to a client having a panic attack by:
a.)staying with the client until the attack subsides.
b.)telling the client everything is under control.
c.)telling the client to lie down and rest.
d.)talking continually to the client by explaining what's happening.
A. RATIONALE: The nurse should remain with the client until the attack subsides. If the client is left alone, he may become more anxious. Giving false reassurance is inappropriate in this situation. The client should be allowed to move around and pace to help expend energy. The client may be so overwhelmed that he can't follow lengthy explanations or instructions, so the nurse should use short phrases and slowly give one direction at a time.
28. A 24-year-old client is experiencing an acute schizophrenic episode. He has vivid hallucinations that are making him agitated. The nurse's best response at this time would be to:
a.)take the client's vital signs.
b.)explore the content of the hallucinations.
c.)tell him his fear is unrealistic.
d.)engage the client in reality-oriented activities.
B. RATIONALE: Exploring the content of the hallucinations will help the nurse understand the client's perspective on the situation. The client shouldn't be touched, such as in taking vital signs, without telling him exactly what's going to happen. Debating with the client about his emotions isn't therapeutic. When the client is calm, engage him in reality-based activities.
29. A client with paranoid type schizophrenia becomes angry and tells the nurse to leave him alone. The nurse should:
a.)tell him that she'll leave for now but will return soon.
b.)ask him if it's okay if she sits quietly with him.
c.)ask him why he wants to be left alone.
d.)tell him that she won't let anything happen to him.
A. RATIONALE: If the client tells the nurse to leave, the nurse should leave but let the client know that she'll return so that he doesn't feel abandoned. Not heeding the client's request can agitate him further. Also, challenging the client isn't therapeutic and may increase his anger. False reassurance isn't warranted in this situation.
30. A client begins taking haloperidol (Haldol). After a few days, he experiences severe tonic contractures of muscles in the neck, mouth, and tongue. The nurse should recognize this as:
a.)psychotic symptoms.
b.)parkinsonism.
c.)akathisia.
d.)dystonia.
D. RATIONALE: These symptoms describe dystonia, which commonly occurs after a few days of treatment with haloperidol. The symptoms may be confused with psychotic symptoms and misdiagnosed. Parkinsonism results in muscle rigidity, shuffling gait, stooped posture, flat-faced affect, tremors, and drooling. Signs and symptoms of akathisia are restlessness, pacing, and inability to sit still.