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PNLE IV for Psychiatric Nursing (PM)
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Question 1
A client is experiencing anxiety attack. The most appropriate nursing intervention should include?
A
Leaving the client alone
B
Staying with the client and speaking in short sentences
C
Turning on the television
D
Ask the client to play with other clients
Question 1 Explanation:
Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm and medicating as needed.
Question 2
Linda is pacing the floor and appears extremely anxious. The duty nurse approaches in an attempt to alleviate Linda’s anxiety. The most therapeutic question by the nurse would be?
A
Would you like me to talk with you?
B
Would you like to watch TV?
C
Are you feeling upset now?
D
Ignore the client
Question 2 Explanation:
The nurse presence may provide the client with support & feeling of control.
Question 3
Nurse Monette is aware that extremely depressed clients seem to do best in settings where they have:
A
Routine Activities
B
Minimal decision making
C
Multiple stimuli
D
Varied Activities
Question 3 Explanation:
Depression usually is both emotional & physical. A simple daily routine is the best, least stressful and least anxiety producing.
Question 4
Nurse Benjie is communicating with a male client with substance-induced persisting dementia; the client cannot remember facts and fills in the gaps with imaginary information. Nurse Benjie is aware that this is typical of?
A
Associative looseness
B
Flight of ideas
C
Concretism
D
Confabulation
Question 4 Explanation:
Confabulation or the filling in of memory gaps with imaginary facts is a defense mechanism used by people experiencing memory deficits.
Question 5
A neuromuscular blocking agent is administered to a client before ECT therapy. The Nurse should carefully observe the client for?
A
Dizziness
B
Nausea and vomiting
C
Respiratory difficulties
D
Seizures
Question 5 Explanation:
Neuromuscular Blocker, such as SUCCINYLCHOLINE (Anectine) produces respiratory depression because it inhibits contractions of respiratory muscles.
Question 6
A 32 year old male graduate student, who has become increasingly withdrawn and neglectful of his work and personal hygiene, is brought to the psychiatric hospital by his parents. After detailed assessment, a diagnosis of schizophrenia is made. It is unlikely that the client will demonstrate:
A
Concrete thinking
B
Effective self boundaries
C
Low self esteem
D
Weak ego
Question 6 Explanation:
A person with this disorder would not have adequate self-boundaries
Question 7
A male client is diagnosed with schizotypal personality disorder. Which signs would this client exhibit during social situation?
A
Independence need
B
Aggressive behavior
C
Paranoid thoughts
D
Emotional affect
Question 7 Explanation:
Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts
Question 8
During electroconvulsive therapy (ECT) the client receives oxygen by mask via positive pressure ventilation. The nurse assisting with this procedure knows that positive pressure ventilation is necessary because?
A
Decrease oxygen to the brain increases confusion and disorientation
B
Muscle relaxations given to prevent injury during seizure activity depress respirations.
C
Grand mal seizure activity depresses respirations
D
Anesthesia is administered during the procedure
Question 8 Explanation:
A short acting skeletal muscle relaxant such as succinylcholine (Anectine) is administered during this procedure to prevent injuries during seizure.
Question 9
A 23 year old client has been admitted with a diagnosis of schizophrenia says to the nurse “Yes, its march, March is little woman”. That’s literal you know”. These statement illustrate:
A
Flight of ideas
B
Echolalia
C
Loosening of association
D
Neologisms
Question 9 Explanation:
Loose associations are thoughts that are presented without the logical connections usually necessary for the listening to interpret the message.
Question 10
To establish open and trusting relationship with a female client who has been hospitalized with severe anxiety, the nurse in charge should?
A
Share an activity with the client
B
Encourage the staff to have frequent interaction with the client
C
Respect client’s need for personal space
D
Give client feedback about behavior
Question 10 Explanation:
Moving to a client’s personal space increases the feeling of threat, which increases anxiety.
Question 11
Nurse Hazel is caring for a male client who experience false sensory perceptions with no basis in reality. This perception is known as:
A
Neologisms
B
Hallucinations
C
Delusions
D
Loose associations
Question 11 Explanation:
Hallucinations are visual, auditory, gustatory, tactile or olfactory perceptions that have no basis in reality.
Question 12
Nurse Monette recognizes that the focus of environmental (MILIEU) therapy is to:
A
Manipulate the environment to bring about positive changes in behavior
B
Role play life events to meet individual needs
C
Use natural remedies rather than drugs to control behavior
D
Allow the client’s freedom to determine whether or not they will be involved in activities
Question 12 Explanation:
Environmental (MILIEU) therapy aims at having everything in the client’s surrounding area toward helping the client.
Question 13
Which of the following foods would the nurse Trish eliminate from the diet of a client in alcohol withdrawal?
A
Milk
B
Orange Juice
C
Soda
D
Regular Coffee
Question 13 Explanation:
Regular coffee contains caffeine which acts as psychomotor stimulants and leads to feelings of anxiety and agitation. Serving coffee top the client may add to tremors or wakefulness.
Question 14
Marco approached Nurse Trish asking for advice on how to deal with his alcohol addiction. Nurse Trish should tell the client that the only effective treatment for alcoholism is:
A
Aversion Therapy
B
Alcoholics anonymous (A.A.)
C
Psychotherapy
D
Total abstinence
Question 14 Explanation:
Total abstinence is the only effective treatment for alcoholism
Question 15
Nurse Penny is aware that the symptoms that distinguish post traumatic stress disorder from other anxiety disorder would be:
A
Re-experiencing the trauma in dreams or flashback
B
Lack of interest in family & others
C
Depression and a blunted affect when discussing the traumatic situation
D
Avoidance of situation & certain activities that resemble the stress
Question 15 Explanation:
Experiencing the actual trauma in dreams or flashback is the major symptom that distinguishes post traumatic stress disorder from other anxiety disorder.
Question 16
Nurse Tina is caring for a client with delirium and states that “look at the spiders on the wall”. What should the nurse respond to the client?
A
“Would you like me to kill the spiders”
B
“You’re having hallucination, there are no spiders in this room at all”
C
“I know you are frightened, but I do not see spiders on the wall”
D
“I can see the spiders on the wall, but they are not going to hurt you”
Question 16 Explanation:
When hallucination is present, the nurse should reinforce reality with the client.
Question 17
Nurse Monet is caring for a female client who has suicidal tendency. When accompanying the client to the restroom, Nurse Monet should…
A
Open the window and allow her to get some fresh air
B
Observe her
C
Allow her to urinate
D
Give her privacy
Question 17 Explanation:
The Nurse has a responsibility to observe continuously the acutely suicidal client. The Nurse should watch for clues, such as communicating suicidal thoughts, and messages; hoarding medications and talking about death.
Question 18
Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor. When Nurse Nina enters the client’s room, the client is found lying on the bed with a body pulled into a fetal position. Nurse Nina should?
A
Ask the client direct questions to encourage talking
B
Leave the client alone and continue with providing care to the other clients
C
Rake the client into the dayroom to be with other clients
D
Sit beside the client in silence and occasionally ask open-ended question
Question 18 Explanation:
Clients who are withdrawn may be immobile and mute, and require consistent, repeated interventions. Communication with withdrawn clients requires much patience from the nurse. The nurse facilitates communication with the client by sitting in silence, asking open-ended question and pausing to provide opportunities for the client to respond.
Question 19
Which of the following approaches would be most appropriate to use with a client suffering from narcissistic personality disorder when discrepancies exist between what the client states and what actually exist?
A
Rationalization
B
Consistency
C
Limit setting
D
Supportive confrontation
Question 19 Explanation:
The nurse would specifically use supportive confrontation with the client to point out discrepancies between what the client states and what actually exists to increase responsibility for self.
Question 20
Nurse Patricia is aware that the major health complication associated with intractable anorexia nervosa would be?
A
Glucose intolerance resulting in protracted hypoglycemia
B
Cardiac dysrhythmias resulting to cardiac arrest
C
Endocrine imbalance causing cold amenorrhea
D
Decreased metabolism causing cold intolerance
Question 20 Explanation:
These clients have severely depleted levels of sodium and potassium because of their starvation diet and energy expenditure, these electrolytes are necessary for cardiac functioning.
Question 21
Nurse Jonel is providing information to a community group about violence in the family. Which statement by a group member would indicate a need to provide additional information?
A
“Abuser use fear and intimidation”
B
“Abuser Are often jealous or self-centered”
C
“Abuser usually have poor self-esteem”
D
“Abuse occurs more in low-income families”
Question 21 Explanation:
Personal characteristics of abuser include low self-esteem, immaturity, dependence, insecurity and jealousy.
Question 22
A male client who is experiencing disordered thinking about food being poisoned is admitted to the mental health unit. The nurse uses which communication technique to encourage the client to eat dinner?
A
Focusing on self-disclosure of own food preference
B
Using open ended question and silence
C
Verbalizing reasons that the client may not choose to eat
D
Offering opinion about the need to eat
Question 22 Explanation:
Open ended questions and silence are strategies used to encourage clients to discuss their problem in descriptive manner.
Question 23
When planning care for a female client using ritualistic behavior, Nurse Gina must recognize that the ritual:
A
Is used by the client primarily for secondary gains
B
Is under the client’s conscious control
C
Helps the client control the anxiety
D
Helps the client focus on the inability to deal with reality
Question 23 Explanation:
The rituals used by a client with obsessive compulsive disorder help control the anxiety level by maintaining a set pattern of action.
Question 24
When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates achievement of the discharge maintenance goals. Which goal would be most appropriately having been included in the plan of care requiring evaluation?
A
The client ignores feelings of anxiety
B
The client maintains contact with a crisis counselor
C
The client identifies anxiety producing situations
D
The client eliminates all anxiety from daily situations
Question 24 Explanation:
Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid specific stimulus.
Question 25
Nurse Trish would expect a child with a diagnosis of reactive attachment disorder to:
A
Be able to develop only superficial relation with the others
B
Have been physically abuse
C
Cling to mother & cry on separation
D
Have more positive relation with the father than the mother
Question 25 Explanation:
Children who have experienced attachment difficulties with primary caregiver are not able to trust others and therefore relate superficially
Question 26
Nurse Tony was caring for a 41 year old female client. Which behavior by the client indicates adult cognitive development?
A
Her perception are based on reality
B
Assumes responsibility for her actions
C
Has maximum ability to solve problems and learn new skills
D
Generates new levels of awareness
Question 26 Explanation:
An adult age 31 to 45 generates new level of awareness.
Question 27
Which of the following would Nurse Hazel expect to assess for a client who is exhibiting late signs of heroin withdrawal?
A
Vomiting and Diarrhea
B
Restlessness & Irritability
C
Constipation & steatorrhea
D
Yawning & diaphoresis
Question 27 Explanation:
Vomiting and diarrhea are usually the late signs of heroin withdrawal, along with muscle spasm, fever, nausea, repetitive, abdominal cramps and backache.
Question 28
A long term goal for a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs would be to help the client develop:
A
Insight into his behavior
B
Faith in his wife
C
Feeling of self worth
D
Better self control
Question 28 Explanation:
Helping the client to develop feeling of self worth would reduce the client’s need to use pathologic defenses.
Question 29
Nurse Joey is aware that the signs & symptoms that would be most specific for diagnosis anorexia are?
A
Slow pulse, 10% weight loss & alopecia
B
Excessive activity, memory lapses & an increased pulse
These are the major signs of anorexia nervosa. Weight loss is excessive (15% of expected weight)
Question 30
When teaching parents about childhood depression Nurse Trina should say?
A
Is short in duration & resolves easily
B
It may appear acting out behavior
C
Does not respond to conventional treatment
D
Looks almost identical to adult depression
Question 30 Explanation:
Children have difficulty verbally expressing their feelings, acting out behavior, such as temper tantrums, may indicate underlying depression.
Question 31
A 60 year old female client who lives alone tells the nurse at the community health center “I really don’t need anyone to talk to”. The TV is my best friend. The nurse recognizes that the client is using the defense mechanism known as?
A
Sublimation
B
Displacement
C
Projection
D
Denial
Question 31 Explanation:
The client statement is an example of the use of denial, a defense that blocks problem by unconscious refusing to admit they exist
Question 32
Mario is complaining to other clients about not being allowed by staff to keep food in his room. Which of the following interventions would be most appropriate?
A
Allowing a snack to be kept in his room
B
Setting limits on the behavior
C
Reprimanding the client
D
Ignoring the clients behavior
Question 32 Explanation:
The nurse needs to set limits in the client’s manipulative behavior to help the client control dysfunctional behavior. A consistent approach by the staff is necessary to decrease manipulation.
Question 33
Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of prescribed antipsychotic medication. The most important piece of information the nurse in charge should obtain initially is the:
A
Reason for the suicide attempt
B
Name of the ingested medication & the amount ingested
C
Length of time on the med.
D
Name of the nearest relative & their phone number
Question 33 Explanation:
In an emergency, lives saving facts are obtained first. The name and the amount of medication ingested are of outmost important in treating this potentially life threatening situation.
Question 34
Nurse Trish is working in a mental health facility; the nurse priority nursing intervention for a newly admitted client with bulimia nervosa would be to?
A
Observe client during meals
B
Monitor client continuously
C
Teach client to measure I & O
D
Involve client in planning daily meal
Question 34 Explanation:
These clients often hide food or force vomiting; therefore they must be carefully monitored.
Question 35
A nursing care plan for a male client with bipolar I disorder should include:
A
Engaging the client in conversing about current affairs
B
Touching the client provide assurance
C
Providing a structured environment
D
Designing activities that will require the client to maintain contact with reality
Question 35 Explanation:
Structure tends to decrease agitation and anxiety and to increase the client’s feeling of security.
Question 36
Nurse Perry is aware that language development in autistic child resembles:
A
Echolalia
B
Scanning speech
C
Shuttering
D
Speech lag
Question 36 Explanation:
The autistic child repeat sounds or words spoken by others.
Question 37
Nurse Claire is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is?
A
Eat only three meals a day
B
Identify anxiety causing situations
C
Encourage to avoid foods
D
Avoid shopping plenty of groceries
Question 37 Explanation:
Bulimia disorder generally is a maladaptive coping response to stress and underlying issues. The client should identify anxiety causing situation that stimulate the bulimic behavior and then learn new ways of coping with the anxiety.
Question 38
Conney with borderline personality disorder who is to be discharge soon threatens to “do something” to herself if discharged. Which of the following actions by the nurse would be most important?
A
Request an immediate extension for the client
B
Ask a family member to stay with the client at home temporarily
C
Discuss the meaning of the client’s statement with her
D
Ignore the clients statement because it’s a sign of manipulation
Question 38 Explanation:
Any suicidal statement must be assessed by the nurse. The nurse should discuss the client’s statement with her to determine its meaning in terms of suicide.
Question 39
Nurse Maureen is developing a plan of care for a female client with anorexia nervosa. Which action should the nurse include in the plan?
A
Set-up a strict eating plan for the client
B
Restrict visits with the family
C
Encourage client to exercise to reduce anxiety
D
Provide privacy during meals
Question 39 Explanation:
Establishing a consistent eating plan and monitoring client’s weight are important to this disorder.
Question 40
A characteristic that would suggest to Nurse Anne that an adolescent may have bulimia would be:
A
Previous history of gastritis
B
Frequent regurgitation & re-swallowing of food
C
Badly stained teeth
D
Positive body image
Question 40 Explanation:
Dental enamel erosion occurs from repeated self-induced vomiting.
Question 41
Nurse Anna can minimize agitation in a disturbed client by?
A
limiting unnecessary interaction
B
Increasing stimulation
C
increasing appropriate sensory perception
D
ensuring constant client and staff contact
Question 41 Explanation:
Limiting unnecessary interaction will decrease stimulation and agitation.
Question 42
Nurse Tina is caring for a client with depression who has not responded to antidepressant medication. The nurse anticipates that what treatment procedure may be prescribed.
A
Short term seclusion
B
Psychosurgery
C
Electroconvulsive therapy
D
Neuroleptic medication
Question 42 Explanation:
Electroconvulsive therapy is an effective treatment for depression that has not responded to medication
Question 43
A 39 year old mother with obsessive-compulsive disorder has become immobilized by her elaborate hand washing and walking rituals. Nurse Trish recognizes that the basis of O.C. disorder is often:
A
Feeling of unworthiness and hopelessness
B
Problems with anger and remorse
C
Feelings of guilt and inadequacy
D
Problems with being too conscientious
Question 43 Explanation:
Ritualistic behavior seen in this disorder is aimed at controlling guilt and inadequacy by maintaining an absolute set pattern of behavior.
Question 44
A female client is admitted with a diagnosis of delusions of GRANDEUR. This diagnosis reflects a belief that one is:
A
Responsible for evil world
B
Highly famous and important
C
Being Killed
D
Connected to client unrelated to oneself
Question 44 Explanation:
Delusion of grandeur is a false belief that one is highly famous and important.
Question 45
Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis and hyperactivity. Blood pressure is 190/87 mmhg and pulse is 92 bpm. Which of the medications would the nurse expect to administer?
A
Lorazepam (Ativan)
B
Naloxone (Narcan)
C
Benzlropine (Cogentin)
D
Haloperidol (Haldol)
Question 45 Explanation:
The nurse would most likely administer benzodiazepine, such as lorazepan (ativan) to the client who is experiencing symptom: The client’s experiences symptoms of withdrawal because of the rebound phenomenon when the sedation of the CNS from alcohol begins to decrease.
Question 46
A 20 year old client was diagnosed with dependent personality disorder. Which behavior is not likely to be evidence of ineffective individual coping?
A
Inability to make choices and decision without advise
B
Recurrent self-destructive behavior
C
Showing interest in solitary activities
D
Avoiding relationship
Question 46 Explanation:
Individual with dependent personality disorder typically shows indecisiveness submissiveness and clinging behavior so that others will make decisions with them.
Question 47
Joey a client with antisocial personality disorder belches loudly. A staff member asks Joey, “Do you know why people find you repulsive?” this statement most likely would elicit which of the following client reaction?
A
Remorsefulness
B
Embarrassment
C
Defensiveness
D
Shame
Question 47 Explanation:
When the staff member ask the client if he wonders why others find him repulsive, the client is likely to feel defensive because the question is belittling. The natural tendency is to counterattack the threat to self image.
Question 48
To further assess a client’s suicidal potential. Nurse Katrina should be especially alert to the client expression of:
A
Frustration & fear of death
B
Anger & resentment
C
Helplessness & hopelessness
D
Anxiety & loneliness
Question 48 Explanation:
The expression of these feeling may indicate that this client is unable to continue the struggle of life.
Question 49
When working with a male client suffering phobia about black cats, Nurse Trish should anticipate that a problem for this client would be?
A
Anger toward the feared object
B
Distortion of reality when completing daily routines
C
Anxiety when discussing phobia
D
Denying that the phobia exist
Question 49 Explanation:
Discussion of the feared object triggers an emotional response to the object.
Question 50
A 75 year old client is admitted to the hospital with the diagnosis of dementia of the Alzheimer’s type and depression. The symptom that is unrelated to depression would be?
A
“I don’t know” answer to questions
B
Neglect of personal hygiene
C
Shallow of labile effect
D
Apathetic response to the environment
Question 50 Explanation:
With depression, there is little or no emotional involvement therefore little alteration in affect.
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Exam Mode
Exam Mode – Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam.
PNLE IV for Psychiatric Nursing (EM)
Choose the letter of the correct answer. You got 50 minutes to finish the exam .Good luck!
Start
Congratulations - you have completed PNLE IV for Psychiatric Nursing (EM).
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%%
Your answers are highlighted below.
Question 1
Nurse Claire is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is?
A
Encourage to avoid foods
B
Eat only three meals a day
C
Avoid shopping plenty of groceries
D
Identify anxiety causing situations
Question 1 Explanation:
Bulimia disorder generally is a maladaptive coping response to stress and underlying issues. The client should identify anxiety causing situation that stimulate the bulimic behavior and then learn new ways of coping with the anxiety.
Question 2
A client is experiencing anxiety attack. The most appropriate nursing intervention should include?
A
Turning on the television
B
Leaving the client alone
C
Ask the client to play with other clients
D
Staying with the client and speaking in short sentences
Question 2 Explanation:
Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm and medicating as needed.
Question 3
Nurse Hazel is caring for a male client who experience false sensory perceptions with no basis in reality. This perception is known as:
A
Loose associations
B
Hallucinations
C
Neologisms
D
Delusions
Question 3 Explanation:
Hallucinations are visual, auditory, gustatory, tactile or olfactory perceptions that have no basis in reality.
Question 4
Nurse Tina is caring for a client with delirium and states that “look at the spiders on the wall”. What should the nurse respond to the client?
A
“You’re having hallucination, there are no spiders in this room at all”
B
“I can see the spiders on the wall, but they are not going to hurt you”
C
“I know you are frightened, but I do not see spiders on the wall”
D
“Would you like me to kill the spiders”
Question 4 Explanation:
When hallucination is present, the nurse should reinforce reality with the client.
Question 5
When teaching parents about childhood depression Nurse Trina should say?
A
Is short in duration & resolves easily
B
Does not respond to conventional treatment
C
It may appear acting out behavior
D
Looks almost identical to adult depression
Question 5 Explanation:
Children have difficulty verbally expressing their feelings, acting out behavior, such as temper tantrums, may indicate underlying depression.
Question 6
Joey a client with antisocial personality disorder belches loudly. A staff member asks Joey, “Do you know why people find you repulsive?” this statement most likely would elicit which of the following client reaction?
A
Shame
B
Defensiveness
C
Embarrassment
D
Remorsefulness
Question 6 Explanation:
When the staff member ask the client if he wonders why others find him repulsive, the client is likely to feel defensive because the question is belittling. The natural tendency is to counterattack the threat to self image.
Question 7
To further assess a client’s suicidal potential. Nurse Katrina should be especially alert to the client expression of:
A
Anger & resentment
B
Anxiety & loneliness
C
Helplessness & hopelessness
D
Frustration & fear of death
Question 7 Explanation:
The expression of these feeling may indicate that this client is unable to continue the struggle of life.
Question 8
Nurse Trish is working in a mental health facility; the nurse priority nursing intervention for a newly admitted client with bulimia nervosa would be to?
A
Involve client in planning daily meal
B
Teach client to measure I & O
C
Observe client during meals
D
Monitor client continuously
Question 8 Explanation:
These clients often hide food or force vomiting; therefore they must be carefully monitored.
Question 9
Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of prescribed antipsychotic medication. The most important piece of information the nurse in charge should obtain initially is the:
A
Reason for the suicide attempt
B
Name of the ingested medication & the amount ingested
C
Name of the nearest relative & their phone number
D
Length of time on the med.
Question 9 Explanation:
In an emergency, lives saving facts are obtained first. The name and the amount of medication ingested are of outmost important in treating this potentially life threatening situation.
Question 10
A 32 year old male graduate student, who has become increasingly withdrawn and neglectful of his work and personal hygiene, is brought to the psychiatric hospital by his parents. After detailed assessment, a diagnosis of schizophrenia is made. It is unlikely that the client will demonstrate:
A
Effective self boundaries
B
Low self esteem
C
Weak ego
D
Concrete thinking
Question 10 Explanation:
A person with this disorder would not have adequate self-boundaries
Question 11
Nurse Tina is caring for a client with depression who has not responded to antidepressant medication. The nurse anticipates that what treatment procedure may be prescribed.
A
Electroconvulsive therapy
B
Neuroleptic medication
C
Psychosurgery
D
Short term seclusion
Question 11 Explanation:
Electroconvulsive therapy is an effective treatment for depression that has not responded to medication
Question 12
A 39 year old mother with obsessive-compulsive disorder has become immobilized by her elaborate hand washing and walking rituals. Nurse Trish recognizes that the basis of O.C. disorder is often:
A
Problems with anger and remorse
B
Problems with being too conscientious
C
Feelings of guilt and inadequacy
D
Feeling of unworthiness and hopelessness
Question 12 Explanation:
Ritualistic behavior seen in this disorder is aimed at controlling guilt and inadequacy by maintaining an absolute set pattern of behavior.
Question 13
Nurse Trish would expect a child with a diagnosis of reactive attachment disorder to:
A
Cling to mother & cry on separation
B
Have more positive relation with the father than the mother
C
Be able to develop only superficial relation with the others
D
Have been physically abuse
Question 13 Explanation:
Children who have experienced attachment difficulties with primary caregiver are not able to trust others and therefore relate superficially
Question 14
To establish open and trusting relationship with a female client who has been hospitalized with severe anxiety, the nurse in charge should?
A
Respect client’s need for personal space
B
Encourage the staff to have frequent interaction with the client
C
Give client feedback about behavior
D
Share an activity with the client
Question 14 Explanation:
Moving to a client’s personal space increases the feeling of threat, which increases anxiety.
Question 15
Which of the following foods would the nurse Trish eliminate from the diet of a client in alcohol withdrawal?
A
Milk
B
Soda
C
Regular Coffee
D
Orange Juice
Question 15 Explanation:
Regular coffee contains caffeine which acts as psychomotor stimulants and leads to feelings of anxiety and agitation. Serving coffee top the client may add to tremors or wakefulness.
Question 16
A male client is diagnosed with schizotypal personality disorder. Which signs would this client exhibit during social situation?
A
Emotional affect
B
Paranoid thoughts
C
Aggressive behavior
D
Independence need
Question 16 Explanation:
Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts
Question 17
Nurse Anna can minimize agitation in a disturbed client by?
A
limiting unnecessary interaction
B
ensuring constant client and staff contact
C
Increasing stimulation
D
increasing appropriate sensory perception
Question 17 Explanation:
Limiting unnecessary interaction will decrease stimulation and agitation.
Question 18
Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor. When Nurse Nina enters the client’s room, the client is found lying on the bed with a body pulled into a fetal position. Nurse Nina should?
A
Leave the client alone and continue with providing care to the other clients
B
Ask the client direct questions to encourage talking
C
Sit beside the client in silence and occasionally ask open-ended question
D
Rake the client into the dayroom to be with other clients
Question 18 Explanation:
Clients who are withdrawn may be immobile and mute, and require consistent, repeated interventions. Communication with withdrawn clients requires much patience from the nurse. The nurse facilitates communication with the client by sitting in silence, asking open-ended question and pausing to provide opportunities for the client to respond.
Question 19
Nurse Monette recognizes that the focus of environmental (MILIEU) therapy is to:
A
Manipulate the environment to bring about positive changes in behavior
B
Role play life events to meet individual needs
C
Use natural remedies rather than drugs to control behavior
D
Allow the client’s freedom to determine whether or not they will be involved in activities
Question 19 Explanation:
Environmental (MILIEU) therapy aims at having everything in the client’s surrounding area toward helping the client.
Question 20
Nurse Perry is aware that language development in autistic child resembles:
A
Shuttering
B
Speech lag
C
Scanning speech
D
Echolalia
Question 20 Explanation:
The autistic child repeat sounds or words spoken by others.
Question 21
Nurse Maureen is developing a plan of care for a female client with anorexia nervosa. Which action should the nurse include in the plan?
A
Set-up a strict eating plan for the client
B
Encourage client to exercise to reduce anxiety
C
Restrict visits with the family
D
Provide privacy during meals
Question 21 Explanation:
Establishing a consistent eating plan and monitoring client’s weight are important to this disorder.
Question 22
A neuromuscular blocking agent is administered to a client before ECT therapy. The Nurse should carefully observe the client for?
A
Nausea and vomiting
B
Dizziness
C
Respiratory difficulties
D
Seizures
Question 22 Explanation:
Neuromuscular Blocker, such as SUCCINYLCHOLINE (Anectine) produces respiratory depression because it inhibits contractions of respiratory muscles.
Question 23
A characteristic that would suggest to Nurse Anne that an adolescent may have bulimia would be:
A
Frequent regurgitation & re-swallowing of food
B
Positive body image
C
Badly stained teeth
D
Previous history of gastritis
Question 23 Explanation:
Dental enamel erosion occurs from repeated self-induced vomiting.
Question 24
A 75 year old client is admitted to the hospital with the diagnosis of dementia of the Alzheimer’s type and depression. The symptom that is unrelated to depression would be?
A
Apathetic response to the environment
B
Shallow of labile effect
C
“I don’t know” answer to questions
D
Neglect of personal hygiene
Question 24 Explanation:
With depression, there is little or no emotional involvement therefore little alteration in affect.
Question 25
Marco approached Nurse Trish asking for advice on how to deal with his alcohol addiction. Nurse Trish should tell the client that the only effective treatment for alcoholism is:
A
Alcoholics anonymous (A.A.)
B
Psychotherapy
C
Total abstinence
D
Aversion Therapy
Question 25 Explanation:
Total abstinence is the only effective treatment for alcoholism
Question 26
Nurse Monette is aware that extremely depressed clients seem to do best in settings where they have:
A
Minimal decision making
B
Routine Activities
C
Varied Activities
D
Multiple stimuli
Question 26 Explanation:
Depression usually is both emotional & physical. A simple daily routine is the best, least stressful and least anxiety producing.
Question 27
Nurse Benjie is communicating with a male client with substance-induced persisting dementia; the client cannot remember facts and fills in the gaps with imaginary information. Nurse Benjie is aware that this is typical of?
A
Associative looseness
B
Concretism
C
Flight of ideas
D
Confabulation
Question 27 Explanation:
Confabulation or the filling in of memory gaps with imaginary facts is a defense mechanism used by people experiencing memory deficits.
Question 28
Linda is pacing the floor and appears extremely anxious. The duty nurse approaches in an attempt to alleviate Linda’s anxiety. The most therapeutic question by the nurse would be?
A
Are you feeling upset now?
B
Ignore the client
C
Would you like to watch TV?
D
Would you like me to talk with you?
Question 28 Explanation:
The nurse presence may provide the client with support & feeling of control.
Question 29
Nurse Joey is aware that the signs & symptoms that would be most specific for diagnosis anorexia are?
Excessive activity, memory lapses & an increased pulse
Question 29 Explanation:
These are the major signs of anorexia nervosa. Weight loss is excessive (15% of expected weight)
Question 30
A long term goal for a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs would be to help the client develop:
A
Insight into his behavior
B
Faith in his wifeHelping the client to develop feeling of self worth would reduce the client’s need to use pathologic defenses.
C
Better self control
D
Feeling of self worth
Question 30 Explanation:
Helping the client to develop feeling of self worth would reduce the client’s need to use pathologic defenses.
Question 31
Nurse Penny is aware that the symptoms that distinguish post traumatic stress disorder from other anxiety disorder would be:
A
Lack of interest in family & others
B
Re-experiencing the trauma in dreams or flashback
C
Depression and a blunted affect when discussing the traumatic situation
D
Avoidance of situation & certain activities that resemble the stress
Question 31 Explanation:
Experiencing the actual trauma in dreams or flashback is the major symptom that distinguishes post traumatic stress disorder from other anxiety disorder.
Question 32
Which of the following would Nurse Hazel expect to assess for a client who is exhibiting late signs of heroin withdrawal?
A
Yawning & diaphoresis
B
Vomiting and Diarrhea
C
Restlessness & Irritability
D
Constipation & steatorrhea
Question 32 Explanation:
Vomiting and diarrhea are usually the late signs of heroin withdrawal, along with muscle spasm, fever, nausea, repetitive, abdominal cramps and backache.
Question 33
A male client who is experiencing disordered thinking about food being poisoned is admitted to the mental health unit. The nurse uses which communication technique to encourage the client to eat dinner?
A
Verbalizing reasons that the client may not choose to eat
B
Offering opinion about the need to eat
C
Focusing on self-disclosure of own food preference
D
Using open ended question and silence
Question 33 Explanation:
Open ended questions and silence are strategies used to encourage clients to discuss their problem in descriptive manner.
Question 34
Mario is complaining to other clients about not being allowed by staff to keep food in his room. Which of the following interventions would be most appropriate?
A
Allowing a snack to be kept in his room
B
Setting limits on the behavior
C
Reprimanding the client
D
Ignoring the clients behavior
Question 34 Explanation:
The nurse needs to set limits in the client’s manipulative behavior to help the client control dysfunctional behavior. A consistent approach by the staff is necessary to decrease manipulation.
Question 35
Nurse Monet is caring for a female client who has suicidal tendency. When accompanying the client to the restroom, Nurse Monet should…
A
Observe her
B
Allow her to urinate
C
Give her privacy
D
Open the window and allow her to get some fresh air
Question 35 Explanation:
The Nurse has a responsibility to observe continuously the acutely suicidal client. The Nurse should watch for clues, such as communicating suicidal thoughts, and messages; hoarding medications and talking about death.
Question 36
When working with a male client suffering phobia about black cats, Nurse Trish should anticipate that a problem for this client would be?
A
Anxiety when discussing phobia
B
Denying that the phobia exist
C
Anger toward the feared object
D
Distortion of reality when completing daily routines
Question 36 Explanation:
Discussion of the feared object triggers an emotional response to the object.
Question 37
During electroconvulsive therapy (ECT) the client receives oxygen by mask via positive pressure ventilation. The nurse assisting with this procedure knows that positive pressure ventilation is necessary because?
A
Muscle relaxations given to prevent injury during seizure activity depress respirations.
B
Decrease oxygen to the brain increases confusion and disorientation
C
Anesthesia is administered during the procedure
D
Grand mal seizure activity depresses respirations
Question 37 Explanation:
A short acting skeletal muscle relaxant such as succinylcholine (Anectine) is administered during this procedure to prevent injuries during seizure.
Question 38
A 23 year old client has been admitted with a diagnosis of schizophrenia says to the nurse “Yes, its march, March is little woman”. That’s literal you know”. These statement illustrate:
A
Loosening of association
B
Flight of ideas
C
Echolalia
D
Neologisms
Question 38 Explanation:
Loose associations are thoughts that are presented without the logical connections usually necessary for the listening to interpret the message.
Question 39
A female client is admitted with a diagnosis of delusions of GRANDEUR. This diagnosis reflects a belief that one is:
A
Responsible for evil world
B
Being Killed
C
Connected to client unrelated to oneself
D
Highly famous and important
Question 39 Explanation:
Delusion of grandeur is a false belief that one is highly famous and important.
Question 40
Conney with borderline personality disorder who is to be discharge soon threatens to “do something” to herself if discharged. Which of the following actions by the nurse would be most important?
A
Ask a family member to stay with the client at home temporarily
B
Discuss the meaning of the client’s statement with her
C
Ignore the clients statement because it’s a sign of manipulation
D
Request an immediate extension for the client
Question 40 Explanation:
Any suicidal statement must be assessed by the nurse. The nurse should discuss the client’s statement with her to determine its meaning in terms of suicide.
Question 41
A nursing care plan for a male client with bipolar I disorder should include:
A
Touching the client provide assurance
B
Designing activities that will require the client to maintain contact with reality
C
Providing a structured environment
D
Engaging the client in conversing about current affairs
Question 41 Explanation:
Structure tends to decrease agitation and anxiety and to increase the client’s feeling of security.
Question 42
Which of the following approaches would be most appropriate to use with a client suffering from narcissistic personality disorder when discrepancies exist between what the client states and what actually exist?
A
Supportive confrontation
B
Rationalization
C
Limit setting
D
Consistency
Question 42 Explanation:
The nurse would specifically use supportive confrontation with the client to point out discrepancies between what the client states and what actually exists to increase responsibility for self.
Question 43
When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates achievement of the discharge maintenance goals. Which goal would be most appropriately having been included in the plan of care requiring evaluation?
A
The client maintains contact with a crisis counselor
B
The client ignores feelings of anxiety
C
The client eliminates all anxiety from daily situations
D
The client identifies anxiety producing situations
Question 43 Explanation:
Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid specific stimulus.
Question 44
Nurse Tony was caring for a 41 year old female client. Which behavior by the client indicates adult cognitive development?
A
Her perception are based on reality
B
Has maximum ability to solve problems and learn new skills
C
Generates new levels of awareness
D
Assumes responsibility for her actions
Question 44 Explanation:
An adult age 31 to 45 generates new level of awareness.
Question 45
When planning care for a female client using ritualistic behavior, Nurse Gina must recognize that the ritual:
A
Helps the client control the anxiety
B
Is used by the client primarily for secondary gains
C
Helps the client focus on the inability to deal with reality
D
Is under the client’s conscious control
Question 45 Explanation:
The rituals used by a client with obsessive compulsive disorder help control the anxiety level by maintaining a set pattern of action.
Question 46
Nurse Patricia is aware that the major health complication associated with intractable anorexia nervosa would be?
A
Glucose intolerance resulting in protracted hypoglycemia
These clients have severely depleted levels of sodium and potassium because of their starvation diet and energy expenditure, these electrolytes are necessary for cardiac functioning.
Question 47
Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis and hyperactivity. Blood pressure is 190/87 mmhg and pulse is 92 bpm. Which of the medications would the nurse expect to administer?
A
Benzlropine (Cogentin)
B
Naloxone (Narcan)
C
Haloperidol (Haldol)
D
Lorazepam (Ativan)
Question 47 Explanation:
The nurse would most likely administer benzodiazepine, such as lorazepan (ativan) to the client who is experiencing symptom: The client’s experiences symptoms of withdrawal because of the rebound phenomenon when the sedation of the CNS from alcohol begins to decrease.
Question 48
A 20 year old client was diagnosed with dependent personality disorder. Which behavior is not likely to be evidence of ineffective individual coping?
A
Recurrent self-destructive behavior
B
Avoiding relationship
C
Showing interest in solitary activities
D
Inability to make choices and decision without advise
Question 48 Explanation:
Individual with dependent personality disorder typically shows indecisiveness submissiveness and clinging behavior so that others will make decisions with them.
Question 49
Nurse Jonel is providing information to a community group about violence in the family. Which statement by a group member would indicate a need to provide additional information?
A
“Abuser usually have poor self-esteem”
B
“Abuser use fear and intimidation”
C
“Abuse occurs more in low-income families”
D
“Abuser Are often jealous or self-centered”
Question 49 Explanation:
Personal characteristics of abuser include low self-esteem, immaturity, dependence, insecurity and jealousy.
Question 50
A 60 year old female client who lives alone tells the nurse at the community health center “I really don’t need anyone to talk to”. The TV is my best friend. The nurse recognizes that the client is using the defense mechanism known as?
A
Projection
B
Sublimation
C
Denial
D
Displacement
Question 50 Explanation:
The client statement is an example of the use of denial, a defense that blocks problem by unconscious refusing to admit they exist
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1. Marco approached Nurse Trish asking for advice on how to deal with his alcohol addiction. Nurse Trish should tell the client that the only effective treatment for alcoholism is:
Psychotherapy
Alcoholics anonymous (A.A.)
Total abstinence
Aversion Therapy
2. Nurse Hazel is caring for a male client who experience false sensory perceptions with no basis in reality. This perception is known as:
Hallucinations
Delusions
Loose associations
Neologisms
3. Nurse Monet is caring for a female client who has suicidal tendency. When accompanying the client to the restroom, Nurse Monet should…
Give her privacy
Allow her to urinate
Open the window and allow her to get some fresh air
Observe her
4. Nurse Maureen is developing a plan of care for a female client with anorexia nervosa. Which action should the nurse include in the plan?
Provide privacy during meals
Set-up a strict eating plan for the client
Encourage client to exercise to reduce anxiety
Restrict visits with the family
5. A client is experiencing anxiety attack. The most appropriate nursing intervention should include?
Turning on the television
Leaving the client alone
Staying with the client and speaking in short sentences
Ask the client to play with other clients
6. A female client is admitted with a diagnosis of delusions of GRANDEUR. This diagnosis reflects a belief that one is:
Being Killed
Highly famous and important
Responsible for evil world
Connected to client unrelated to oneself
7. A 20 year old client was diagnosed with dependent personality disorder. Which behavior is not likely to be evidence of ineffective individual coping?
Recurrent self-destructive behavior
Avoiding relationship
Showing interest in solitary activities
Inability to make choices and decision without advise
8. A male client is diagnosed with schizotypal personality disorder. Which signs would this client exhibit during social situation?
Paranoid thoughts
Emotional affect
Independence need
Aggressive behavior
9. Nurse Claire is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is?
Encourage to avoid foods
Identify anxiety causing situations
Eat only three meals a day
Avoid shopping plenty of groceries
10. Nurse Tony was caring for a 41 year old female client. Which behavior by the client indicates adult cognitive development?
Generates new levels of awareness
Assumes responsibility for her actions
Has maximum ability to solve problems and learn new skills
Her perception are based on reality
11.A neuromuscular blocking agent is administered to a client before ECT therapy. The Nurse should carefully observe the client for?
Respiratory difficulties
Nausea and vomiting
Dizziness
Seizures
12.A 75 year old client is admitted to the hospital with the diagnosis of dementia of the Alzheimer’s type and depression. The symptom that is unrelated to depression would be?
Apathetic response to the environment
“I don’t know” answer to questions
Shallow of labile effect
Neglect of personal hygiene
13.Nurse Trish is working in a mental health facility; the nurse priority nursing intervention for a newly admitted client with bulimia nervosa would be to?
Teach client to measure I & O
Involve client in planning daily meal
Observe client during meals
Monitor client continuously
14.Nurse Patricia is aware that the major health complication associated with intractable anorexia nervosa would be?
Cardiac dysrhythmias resulting to cardiac arrest
Glucose intolerance resulting in protracted hypoglycemia
Endocrine imbalance causing cold amenorrhea
Decreased metabolism causing cold intolerance
15.Nurse Anna can minimize agitation in a disturbed client by?
Increasing stimulation
limiting unnecessary interaction
increasing appropriate sensory perception
ensuring constant client and staff contact
16.A 39 year old mother with obsessive-compulsive disorder has become immobilized by her elaborate hand washing and walking rituals. Nurse Trish recognizes that the basis of O.C. disorder is often:
Problems with being too conscientious
Problems with anger and remorse
Feelings of guilt and inadequacy
Feeling of unworthiness and hopelessness
17.Mario is complaining to other clients about not being allowed by staff to keep food in his room. Which of the following interventions would be most appropriate?
Allowing a snack to be kept in his room
Reprimanding the client
Ignoring the clients behavior
Setting limits on the behavior
18.Conney with borderline personality disorder who is to be discharge soon threatens to “do something” to herself if discharged. Which of the following actions by the nurse would be most important?
Ask a family member to stay with the client at home temporarily
Discuss the meaning of the client’s statement with her
Request an immediate extension for the client
Ignore the clients statement because it’s a sign of manipulation
19.Joey a client with antisocial personality disorder belches loudly. A staff member asks Joey, “Do you know why people find you repulsive?” this statement most likely would elicit which of the following client reaction?
Depensiveness
Embarrassment
Shame
Remorsefulness
20.Which of the following approaches would be most appropriate to use with a client suffering from narcissistic personality disorder when discrepancies exist between what the client states and what actually exist?
Rationalization
Supportive confrontation
Limit setting
Consistency
21.Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis and hyperactivity. Blood pressure is 190/87 mmhg and pulse is 92 bpm. Which of the medications would the nurse expect to administer?
Naloxone (Narcan)
Benzlropine (Cogentin)
Lorazepam (Ativan)
Haloperidol (Haldol)
22.Which of the following foods would the nurse Trish eliminate from the diet of a client in alcohol withdrawal?
Milk
Orange Juice
Soda
Regular Coffee
23.Which of the following would Nurse Hazel expect to assess for a client who is exhibiting late signs of heroin withdrawal?
Yawning & diaphoresis
Restlessness & Irritability
Constipation & steatorrhea
Vomiting and Diarrhea
24.To establish open and trusting relationship with a female client who has been hospitalized with severe anxiety, the nurse in charge should?
Encourage the staff to have frequent interaction with the client
Share an activity with the client
Give client feedback about behavior
Respect client’s need for personal space
25. Nurse Monette recognizes that the focus of environmental (MILIEU) therapy is to:
Manipulate the environment to bring about positive changes in behavior
Allow the client’s freedom to determine whether or not they will be involved in activities
Role play life events to meet individual needs
Use natural remedies rather than drugs to control behavior
26.Nurse Trish would expect a child with a diagnosis of reactive attachment disorder to:
Have more positive relation with the father than the mother
Cling to mother & cry on separation
Be able to develop only superficial relation with the others
Have been physically abuse
27.When teaching parents about childhood depression Nurse Trina should say?
It may appear acting out behavior
Does not respond to conventional treatment
Is short in duration & resolves easily
Looks almost identical to adult depression
28.Nurse Perry is aware that language development in autistic child resembles:
Scanning speech
Speech lag
Shuttering
Echolalia
29.A 60 year old female client who lives alone tells the nurse at the community health center “I really don’t need anyone to talk to”. The TV is my best friend. The nurse recognizes that the client is using the defense mechanism known as?
Displacement
Projection
Sublimation
Denial
30.When working with a male client suffering phobia about black cats, Nurse Trish should anticipate that a problem for this client would be?
Anxiety when discussing phobia
Anger toward the feared object
Denying that the phobia exist
Distortion of reality when completing daily routines
31.Linda is pacing the floor and appears extremely anxious. The duty nurse approaches in an attempt to alleviate Linda’s anxiety. The most therapeutic question by the nurse would be?
Would you like to watch TV?
Would you like me to talk with you?
Are you feeling upset now?
Ignore the client
32.Nurse Penny is aware that the symptoms that distinguish post traumatic stress disorder from other anxiety disorder would be:
Avoidance of situation & certain activities that resemble the stress
Depression and a blunted affect when discussing the traumatic situation
Lack of interest in family & others
Re-experiencing the trauma in dreams or flashback
33.Nurse Benjie is communicating with a male client with substance-induced persisting dementia; the client cannot remember facts and fills in the gaps with imaginary information. Nurse Benjie is aware that this is typical of?
Flight of ideas
Associative looseness
Confabulation
Concretism
34.Nurse Joey is aware that the signs & symptoms that would be most specific for diagnosis anorexia are?
Excessive activity, memory lapses & an increased pulse
35.A characteristic that would suggest to Nurse Anne that an adolescent may have bulimia would be:
Frequent regurgitation & re-swallowing of food
Previous history of gastritis
Badly stained teeth
Positive body image
36.Nurse Monette is aware that extremely depressed clients seem to do best in settings where they have:
Multiple stimuli
Routine Activities
Minimal decision making
Varied Activities
37.To further assess a client’s suicidal potential. Nurse Katrina should be especially alert to the client expression of:
Frustration & fear of death
Anger & resentment
Anxiety & loneliness
Helplessness & hopelessness
38.A nursing care plan for a male client with bipolar I disorder should include:
Providing a structured environment
Designing activities that will require the client to maintain contact with reality
Engaging the client in conversing about current affairs
Touching the client provide assurance
39.When planning care for a female client using ritualistic behavior, Nurse Gina must recognize that the ritual:
Helps the client focus on the inability to deal with reality
Helps the client control the anxiety
Is under the client’s conscious control
Is used by the client primarily for secondary gains
40.A 32 year old male graduate student, who has become increasingly withdrawn and neglectful of his work and personal hygiene, is brought to the psychiatric hospital by his parents. After detailed assessment, a diagnosis of schizophrenia is made. It is unlikely that the client will demonstrate:
Low self esteem
Concrete thinking
Effective self boundaries
Weak ego
41.A 23 year old client has been admitted with a diagnosis of schizophrenia says to the nurse “Yes, its march, March is little woman”. That’s literal you know”. These statement illustrate:
Neologisms
Echolalia
Flight of ideas
Loosening of association
42.A long term goal for a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs would be to help the client develop:
Insight into his behavior
Better self control
Feeling of self worth
Faith in his wife
43.A male client who is experiencing disordered thinking about food being poisoned is admitted to the mental health unit. The nurse uses which communication technique to encourage the client to eat dinner?
Focusing on self-disclosure of own food preference
Using open ended question and silence
Offering opinion about the need to eat
Verbalizing reasons that the client may not choose to eat
44.Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor. When Nurse Nina enters the client’s room, the client is found lying on the bed with a body pulled into a fetal position. Nurse Nina should?
Ask the client direct questions to encourage talking
Rake the client into the dayroom to be with other clients
Sit beside the client in silence and occasionally ask open-ended question
Leave the client alone and continue with providing care to the other clients
45.Nurse Tina is caring for a client with delirium and states that “look at the spiders on the wall”. What should the nurse respond to the client?
“You’re having hallucination, there are no spiders in this room at all”
“I can see the spiders on the wall, but they are not going to hurt you”
“Would you like me to kill the spiders”
“I know you are frightened, but I do not see spiders on the wall”
46.Nurse Jonel is providing information to a community group about violence in the family. Which statement by a group member would indicate a need to provide additional information?
“Abuse occurs more in low-income families”
“Abuser Are often jealous or self-centered”
“Abuser use fear and intimidation”
“Abuser usually have poor self-esteem”
47.During electroconvulsive therapy (ECT) the client receives oxygen by mask via positive pressure ventilation. The nurse assisting with this procedure knows that positive pressure ventilation is necessary because?
Anesthesia is administered during the procedure
Decrease oxygen to the brain increases confusion and disorientation
Grand mal seizure activity depresses respirations
Muscle relaxations given to prevent injury during seizure activity depress respirations.
48.When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates achievement of the discharge maintenance goals. Which goal would be most appropriately having been included in the plan of care requiring evaluation?
The client eliminates all anxiety from daily situations
The client ignores feelings of anxiety
The client identifies anxiety producing situations
The client maintains contact with a crisis counselor
49.Nurse Tina is caring for a client with depression who has not responded to antidepressant medication. The nurse anticipates that what treatment procedure may be prescribed.
Neuroleptic medication
Short term seclusion
Psychosurgery
Electroconvulsive therapy
50.Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of prescribed antipsychotic medication. The most important piece of information the nurse in charge should obtain initially is the:
Length of time on the med.
Name of the ingested medication & the amount ingested
Reason for the suicide attempt
Name of the nearest relative & their phone number
Answers and Rationales
C . Total abstinence is the only effective treatment for alcoholism
A . Hallucinations are visual, auditory, gustatory, tactile or olfactory perceptions that have no basis in reality.
D . The Nurse has a responsibility to observe continuously the acutely suicidal client. The Nurse should watch for clues, such as communicating suicidal thoughts, and messages; hoarding medications and talking about death.
B . Establishing a consistent eating plan and monitoring client’s weight are important to this disorder.
C . Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm and medicating as needed.
B . Delusion of grandeur is a false belief that one is highly famous and important.
D . Individual with dependent personality disorder typically shows indecisiveness submissiveness and clinging behavior so that others will make decisions with them.
A . Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts
B . Bulimia disorder generally is a maladaptive coping response to stress and underlying issues. The client should identify anxiety causing situation that stimulate the bulimic behavior and then learn new ways of coping with the anxiety.
A . An adult age 31 to 45 generates new level of awareness.
A . Neuromuscular Blocker, such as SUCCINYLCHOLINE (Anectine) produces respiratory depression because it inhibits contractions of respiratory muscles.
C . With depression, there is little or no emotional involvement therefore little alteration in affect.
D . These clients often hide food or force vomiting; therefore they must be carefully monitored.
A . These clients have severely depleted levels of sodium and potassium because of their starvation diet and energy expenditure, these electrolytes are necessary for cardiac functioning.
B . Limiting unnecessary interaction will decrease stimulation and agitation.
C . Ritualistic behavior seen in this disorder is aimed at controlling guilt and inadequacy by maintaining an absolute set pattern of behavior.
D . The nurse needs to set limits in the client’s manipulative behavior to help the client control dysfunctional behavior. A consistent approach by the staff is necessary to decrease manipulation.
B . Any suicidal statement must be assessed by the nurse. The nurse should discuss the client’s statement with her to determine its meaning in terms of suicide.
A . When the staff member ask the client if he wonders why others find him repulsive, the client is likely to feel defensive because the question is belittling. The natural tendency is to counterattack the threat to self image.
B . The nurse would specifically use supportive confrontation with the client to point out discrepancies between what the client states and what actually exists to increase responsibility for self.
C . The nurse would most likely administer benzodiazepine, such as lorazepan (ativan) to the client who is experiencing symptom: The client’s experiences symptoms of withdrawal because of the rebound phenomenon when the sedation of the CNS from alcohol begins to decrease.
D . Regular coffee contains caffeine which acts as psychomotor stimulants and leads to feelings of anxiety and agitation. Serving coffee top the client may add to tremors or wakefulness.
D . Vomiting and diarrhea are usually the late signs of heroin withdrawal, along with muscle spasm, fever, nausea, repetitive, abdominal cramps and backache.
D . Moving to a client’s personal space increases the feeling of threat, which increases anxiety.
A . Environmental (MILIEU) therapy aims at having everything in the client’s surrounding area toward helping the client.
C . Children who have experienced attachment difficulties with primary caregiver are not able to trust others and therefore relate superficially
A . Children have difficulty verbally expressing their feelings, acting out behavior, such as temper tantrums, may indicate underlying depression.
D . The autistic child repeat sounds or words spoken by others.
D . The client statement is an example of the use of denial, a defense that blocks problem by unconscious refusing to admit they exist
A . Discussion of the feared object triggers an emotional response to the object.
B . The nurse presence may provide the client with support & feeling of control.
D . Experiencing the actual trauma in dreams or flashback is the major symptom that distinguishes post traumatic stress disorder from other anxiety disorder.
C . Confabulation or the filling in of memory gaps with imaginary facts is a defense mechanism used by people experiencing memory deficits.
A . These are the major signs of anorexia nervosa. Weight loss is excessive (15% of expected weight)
C . Dental enamel erosion occurs from repeated self-induced vomiting.
B . Depression usually is both emotional & physical. A simple daily routine is the best, least stressful and least anxiety producing.
D . The expression of these feeling may indicate that this client is unable to continue the struggle of life.
A . Structure tends to decrease agitation and anxiety and to increase the client’s feeling of security.
B . The rituals used by a client with obsessive compulsive disorder help control the anxiety level by maintaining a set pattern of action.
C . A person with this disorder would not have adequate self-boundaries
D . Loose associations are thoughts that are presented without the logical connections usually necessary for the listening to interpret the message.
C . Helping the client to develop feeling of self worth would reduce the client’s need to use pathologic defenses.
B . Open ended questions and silence are strategies used to encourage clients to discuss their problem in descriptive manner.
C . Clients who are withdrawn may be immobile and mute, and require consistent, repeated interventions. Communication with withdrawn clients requires much patience from the nurse. The nurse facilitates communication with the client by sitting in silence, asking open-ended question and pausing to provide opportunities for the client to respond.
D . When hallucination is present, the nurse should reinforce reality with the client.
A . Personal characteristics of abuser include low self-esteem, immaturity, dependence, insecurity and jealousy.
D . A short acting skeletal muscle relaxant such as succinylcholine (Anectine) is administered during this procedure to prevent injuries during seizure.
C . Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid specific stimulus.
D . Electroconvulsive therapy is an effective treatment for depression that has not responded to medication
B . In an emergency, lives saving facts are obtained first. The name and the amount of medication ingested are of outmost important in treating this potentially life threatening situation.