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PNLE V Nursing Practice (PM)
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Question 1
The nurse is about to administer Imipramine HCI (Tofranil) to the client, the client says, “Why should I take this?” The doctor started me on this 10days ago; it didn’t help me at all.” Which of the following is the best nursing response:
A
“That’s a long time wait when you feel so depressed.”
B
“What were you expecting to happen?”
C
“It usually takes 2-3 weeks to be effective.”
D
“Do you want to refuse this medication? You have the right.”
Question 1 Explanation:
The patient needs a brief, factual answer.
Question 2
Which of the following person will be at highest risk for suicide?
A
A student at exam time
B
A married woman, age 40, with 6 children.
C
A person who made a previous suicide attempt.
D
A person who is an alcoholic.
Question 2 Explanation:
The likelihood of multiple contributing factors may make this person at higher risk for suicide. Some factors that may exist are physical illness related to alcoholism, emotional factors ( anxiety, guilt, remorse), social isolation due to impaired relationships and economic problems related to employment.
Question 3
A 3-year-old boy is brought to the emergency department. After an hour, the boy dies of respiratory failure. The mother of the boy becomes upset, shouting and abusive, saying to the nurse, “If it had been your son, they would have done more to save it. “What should the nurse say or do?
A
“No, all clients are given the same good care.”
B
“Yes, you’re probably right. Your son did not get better care.”
C
Allow the mother to continue her present behavior while sitting quietly with her.
D
Touch her and tell her exactly what was done for her baby.
Question 3 Explanation:
This option allows a normal grief response (anger).
Question 4
The nurse enters the room of the male client and found out that the client urinates on the floor. The client hides when the nurse is about to talk to him. Which of the following is the best nursing intervention?
A
Take the client to the bathroom at regular intervals.
B
Place restriction on the client’s activities when his behavior occurs.
C
Ask the client to clean the soiled floor.
D
Limit fluid intake.
Question 4 Explanation:
The client is most likely confused, rather than exhibiting acting-out, hostile behavior. Frequent toileting will allow urination in an appropriate place.
Question 5
A male client is repetitively doing the handwashing every time he touches things. It is important for a nurse to understand that the client’s behavior is probably an attempt to:
A
Punish himself or herself for guilt feeling.
B
Do what the voices the patient hears tell him or her to do.
C
Control unacceptable impulses or feelings.
D
Seek attention from the staff.
Question 5 Explanation:
A ritual, such as compulsive handwashing, is an attempt to allay anxiety caused by unconscious impulses that are frightening.
Question 6
Which of the following nursing approach is most important in a client with depression?
A
Providing motor outlets for aggressive, hostile feelings.
B
Protecting against harm to others.
C
Reducing interpersonal contacts.
D
Deemphasizing preoccupation with elimination, nourishment, and sleep.
Question 6 Explanation:
It is important to externalize the anger away from self.
Question 7
A female client was diagnosed with breast cancer. It is found to be stage IV, and a modified mastectomy is performed. After the procedure, what behaviors could the nurse expects the client to display?
A
Signs of grief reaction.
B
Signs of deep depression.
C
Relief that the operation is over.
D
Denial of the possibility of carcinoma.
Question 7 Explanation:
It is mostly likely that grief would be expressed because of object loss.
Question 8
A medical representative comes to the hospital unit for the promotion of a new product. A female client, admitted for hysterical behavior, is found embracing him. What should the nurse say?
A
“Have you considered birth control?”
B
“I see you’ve made a new friend.”
C
“This isn’t the purpose of either of you being here.”
D
“Think about what you are doing.”
Question 8 Explanation:
This response is aimed at redirecting the inappropriate behavior.
Question 9
A 20-year-old female client is diagnosed with anxiety disorder. The physician prescribed Flouxetine (Prozac). What is the most important side effects should a nurse be concerned?
A
Tremor, drowsiness.
B
Excessive diaphoresis, diarrhea.
C
Seizures, suicidal tendencies.
D
Visual disturbance, headache.
Question 9 Explanation:
Assess for suicidal tendencies, especially during early therapy. There is an increased risk of seizures in debilitated client and those with a history of seizures.
Question 10
A nurse is going to give a rectal suppository as a preoperative medication to a 4-year-old boy. The boy is very anxious and frightened. Which of the following statement by the nurse would be most appropriate to gain the child’s cooperation?
A
“Lie still now and I’ll let you have one of your presents before you even have your operation.”
B
“Take a nice, big, deep breath and then let me hear you count to five.”
C
“You look so scared. Want to know a secret? This won’t hurt a bit!”
D
“Be a big kid! Everyone’s waiting for you.”
Question 10 Explanation:
Preschool children commonly experience fears and fantasies regarding invasive procedures. The nurse should attempts to momentarily distract the child with a simple task that can be easily accomplished while the child remains in the side-lying position. The suppository can be slipped into place while the child is counting, and then the nurse can praise the child for cooperating, while holding the buttocks together to prevent expulsion of the suppository.
Question 11
A 55-year-old male client tells the nurse that he needs his glasses and hearing aid with him in the recovery room after the surgery, or he will be upset for not granting his request. What is the appropriate nursing response?
A
“You won’t need your glasses or hearing aid. The nurses will take care of you.”
B
“I understand. You will be able to cooperate best if you know what is going on, so I will find out how I can arrange to have your glasses and hearing aid available to you in the recovery room.”
C
I understand you might be more cooperative if you have your aid and glasses, but that is just not possible. Rules, you know.”
D
“Do you get upset and confused often?”
Question 11 Explanation:
The client will be easier to care for if he has his hearing aid and glasses.
Question 12
Which of the following drugs the nurse should choose to administer to a client to prevent pseudoparkinsonism?
A
Chlorpromazine HCI (Thorazine)
B
Trihexyphenidyl HCI (Artane)
C
Trifluoperazine HCI (Stelazine)
D
Isocarboxazid (Marplan)
Question 12 Explanation:
Trihexyphenidyl HCI (Artane) is often used to counteract side effect of pseudoparkinsonism, which often accompanies the use of phenothiazine, such as chlorpromazine HCI (Thorazine or Trifluoperazine HCI (Stelazine).
Question 13
On an adolescent unit, a nurse caring to a client was informed that her client’s closest roommate dies at night. What would be the most appropriate nursing action?
A
Do not bring it up unless the client asks.
B
Tell the client, if asked, “You should ask the doctor.”
C
Tell the client that her closest roommate died.
D
Tell the client that her roommate went home.
Question 13 Explanation:
The nurse needs to wait and see: do not “jump the gun”; do not assume that the client wants to know now.
Question 14
A client tells the nurse, “Yesterday, I was planning to kill myself.” What is the best nursing response to this cient?
A
Say nothing. Wait for the client’s next comment
B
“You seem upset. I am going to be here with you; perhaps you will want to talk about it”
C
“Have you felt this way before?”
D
“What are you going to do this time?”
Question 14 Explanation:
The client needs to have his or her feelings acknowledged, with encouragement to discuss feelings, and be reassured about the nurse’s presence.
Question 15
In a mental health settings, the basic goal of nursing is to:
A
Maintain a therapeutic environment.
B
Plan activity programs for clients.
C
Understand various types of family therapy and psychological tests and how to interpret them.
D
Advance the science of psychiatry by initiating research and gathering data for current statistics on emotional illness.
Question 15 Explanation:
This is the most neutral answer by process of elimination.
Question 16
A client in the psychiatric unit is shouting out loud and tells the nurse, “Please, help me. They are coming to get me.” What would be the appropriate nursing response?
A
“Who are they?”
B
“You look frightened.”
C
“I don’t see anyone coming.”
D
“ I won’t let anyone get you.”
Question 16 Explanation:
This option is an example of pointing out reality- the nurse’s perception.
Question 17
A nurse is assigned to activate a client who is withdrawn, hears voices and negativistic. What would be the best nursing approach?
A
Demand that the client must join a group activity.
B
Mention that the “voices” would want the client to participate.
C
Give the client a long explanation of the benefits of activity.
D
Tell the client that the nurse needs a partner for an activity.
Question 17 Explanation:
The nurse helps to activate by doing something with the client.
Question 18
A nurse is completing the routine physical examination to a healthy 16-year-old male client. The client shares to the nurse that he feels like killing his girlfriend because he found out that her girlfriend had another boyfriend. He then laughs, and asks the nurse to keep this a secret just between the two of them. The nurse reviews his chart and notes that there is no previously history of violence or psychiatric illness. Which of the following would be the best action of the nurse to take at this time?
A
Suggest the teen meet with a counselor to discuss his feelings about his girlfriend.
B
Tell the teen that his feelings are normal, and recommend that he find another girlfriend to take his mind off the problem.
C
Recall the teenage boys often say things they really do not mean and ignore the comment.
D
Regard the comment seriously and notify the teen’s primary health care provider and parents
Question 18 Explanation:
Any threat to the safety of oneself or other should always be taken seriously and never disregarded by the nurse.
Question 19
A client tells the nurse, “I don’t want to eat any meals offered in this hospital because the food is poisoned.” The nurse is aware that the client is expressing an example of:
A
Delusion.
B
Negativism.
C
Hallucination.
D
Illusion.
Question 19 Explanation:
This is a false belief developed in response to an emotional need.
Question 20
The client in the psychiatric unit states that, “The goodas are coming! I must be ready.” In response to this neologism, the nurse’s initial response is to:
A
Try to interpret what the client means.
B
State that what the client is saying has not been understood and then divert attention to something that is really bound.
C
Divert the client’s attention to an aspect of reality.
D
Acknowledge that the word has some special meaning for the client.
Question 20 Explanation:
It is important to acknowledge a statement, even if it is not understood.
Question 21
The nurse is interacting to a client with an antisocial personality disorder. What would be the most therapeutic approach of the nurse to an antisocial behavior?
A
Gratify the client’s inner needs.
B
Give the client opportunities to test reality.
C
Reinforce the client’s self-concept.
D
Provide external controls.
Question 21 Explanation:
Personality disorders stem from a weak superego, implying a lack of adequate controls.
Question 22
A 6-year-old client dies in the nursing unit. The parents want to see the child. What is the most appropriate nursing action?
A
Suggest the parents to wait until the funeral service to say “good-bye.”
B
Complete the postmortem care and quietly accompany the family to the child’s room.
C
Give the parents time alone with the body.
D
Ask the physician for permission.
Question 22 Explanation:
This allows the parents/family to grieve over the loss of the child, by going through the steps of leave taking.
Question 23
The male client had fight with his roommates in the psychiatric unit. The client agitated client is placed in isolation for seclusion. The nurse knows it is essential that:
A
Restraints are applied.
B
All the furniture is removed form the isolation room.
C
A staff member has frequent contacts with the client.
D
The client is allowed to come out after 4 hours.
Question 23 Explanation:
Frequent contacts at times of stress are important, especially when a client is isolated.
Question 24
A 17-year-old client has a record of being absent in the class without permission, and “borrowing” other people’s things without asking permission. The client denies stealing; rationalizing instead that as long as no one was using the items, there is no problem to use it by other people. It is important for the nurse to understand that psychodynamically, the behavior of the client may be largely attributed to a development defect related to the:
A
Superego
B
Oedipal complex
C
Ego
D
Id
Question 24 Explanation:
This shows a weak sense of moral consciousness. According to Freudian theory, personality disorders stem from a weak superego.
Question 25
The client needs to have his or her feelings acknowledged, with encouragement to discuss feelings, and be reassured about the nurse’s presence.
A
Crises may go on indefinitely.
B
Crises usually resolved in 4-6 weeks.
C
Crises seldom occur in normal people’s lives
D
Crises are related to deep, underlying problems
Question 25 Explanation:
Part of the definition of a crisis is a time span of 4-6 weeks.
Question 26
A nurse is caring to a female client with five young children. The family member told the client that her ex-husband has died 2 days ago. The reaction of the client is stunned silence, followed by anger that the ex-husband left no insurance money for their young children. The nurse should understand that:
A
To explain the woman’s reaction, the nurse needs more information about the relationship and breakup.
B
The woman is not reacting normally to the news.
C
The woman is experiencing a normal bereavement reaction.
D
The children and the injustice done to them by their father’s death are the woman’s main concern.
Question 26 Explanation:
Shock and anger are commonly the primary initial reactions.
Question 27
A client with a diagnosis of paranoid disorder is admitted in the psychiatric hospital. The client tells the nurse, “the FBI is following me. These people are plotting against me.” With this statement the nurse will need to:
A
Show the client that no one is behind.
B
Acknowledge that this is the client’s belief but not the nurse’s belief.
C
Use logic to help the client doubt this belief.
D
Ask how that makes the client feel.
Question 27 Explanation:
The nurse should neither challenge nor use logic to dispel an irrational belief.
Question 28
A young lady with a diagnosis of schizophrenic reaction is admitted to the psychiatric unit. In the past two months, the client has poor appetite, experienced difficulty in sleeping, was mute for long periods of time, just stayed in her room, grinning and pointing at things. What would be the initial nursing action on admitting the client to the unit?
A
Take the client to the assigned room.
B
Assure the client that “ You will be well cared for.”
C
Ask “Do you know where you are?”
D
Introduce the client to some of the other clients.
Question 28 Explanation:
The client needs basic, simple orientation that directly relates to the here-and-now, and does not require verbal interaction.
Question 29
A 30-year-old married woman comes to the hospital for treatment of fractures. The woman tells the nurse that she was physically abused by her husband. The woman receives a call from her husband telling her to get home and things will be different. He felt sorry of what he did. What can the nurse advise her?
A
“Do you think so?”
B
“I hope so, for your sake.”
C
“What will be different?”
D
“It’s not likely.”
Question 29 Explanation:
This option helps the woman to think through and elaborate on her own thoughts and prognosis.
Question 30
A male client is quiet when the physician told him that he has stage IV cancer and has 4 months to live. The nurse determines that this reaction may be an example of:
A
Resignation
B
Indifference
C
Denial
D
Anger
Question 30 Explanation:
Reactions when told of a life-threatening illness stem from Kübler-Ross’ ideas on death and dying. Denial is a typical grief response, and usually is a first reaction.
Question 31
A client is withdrawn and does not want to interact to anybody even to the nurse. What is the best initial nursing approach to encourage communication with this client?
A
Bring up neutral topics.
B
Look through a photo album together.
C
Use simple questions that call for a response.
D
Encourage discussion of feelings.
Question 31 Explanation:
Neutral, nonthreatening topics are best in attempting to encourage a response.
Question 32
The child is brought to the hospital by the parents. During assessment of the nurse, what parental behavior toward a child should alert the nurse to suspect child abuse?
A
Flat affect.
B
Ignoring the child.
C
Acting overly solicitous toward the child
D
Expressions of guilt.
Question 32 Explanation:
This is an example of reaction formation, a coping mechanism.
Question 33
A female client tells the nurse that she is afraid to go out from her room because she thinks that the other client might kill her. The nurse is aware that this behavior is related to:
A
Hallucination.
B
Illusion.
C
Delusion of persecution.
D
Ideas of reference.
Question 33 Explanation:
The client has ideas that someone is out to kill her.
Question 34
A female client is taking Imipramine HCI (Tofranil) for almost 1 week and shows less awareness of the physical body. What problem would the nurse be most concerned?
A
Voiding.
B
Nausea.
C
Gait disturbances.
D
Bowel movements.
Question 34 Explanation:
A serious side effect of Imipramine HCI (Tofranil) is urinary retention (voiding problems)
Question 35
A nurse is caring to a client with manic disorder in the psychiatric ward. On the morning shift, the nurse is talking with the client who is now exhibiting a manic episode with flight of ideas. The nurse primarily needs to:
A
Focus on the feelings conveyed rather than the thoughts expressed.
B
Speak loudly and rapidly to keep the client’s attention, because the client is easily distracted.
C
Encourage the client to complete one thought at a time.
D
Allow the client to talk freely.
Question 35 Explanation:
Often the verbalized ideas are jumbled, but the underlying feelings are discernible and must be acknowledged.
Question 36
A woman gave birth to an unhealthy infant, and with some body defects. The nurse should expect the woman’s initial reactions to include:
A
Withdrawal
B
Anger
C
Depression
D
Apathy
Question 36 Explanation:
The woman is experiencing an actual loss and will probably exhibit many of the same symptoms as a person who has lost someone to death.
Question 37
A 16-year-old girl was diagnosed with anorexia. What would be the first assessment of the nurse?
A
What food she likes.
B
Her body image.
C
Her desired weight.
D
What causes her behavior.
Question 37 Explanation:
Although all options may appear correct. A is the best because it focuses on a range of possible positive reinforcers, a basis for an effective behavior modification program. It can lead to concrete, specific nursing interventions right away and provides a therapeutic use of “control” for the 16-year-old.
Question 38
A client is admitted in the hospital. On assessment, the nurse found out that the client had several suicidal attempts. Which of the following is the most important nursing action?
A
Maintain constant awareness of the client’s whereabouts.
B
Ignore the client as long as he or she is talking about suicide, because suicide attempt is unlikely.
C
Relax vigilance when the client seems to be recovering from depression.
D
Administer medication.
Question 38 Explanation:
The client must be constantly observed.
Question 39
A 16-year-old girl is admitted for treatment of a fracture. The client shares to the nurse caring to her that her step-father has made sexual advances to her. She got the chance to tell it to her mother but refuses to believe. What is the most therapeutic action of the nurse would be:
A
Tell the client to discuss it with her mother.
B
Tell the client to work it out with her father.
C
Ask the father about it.
D
Ask the mother what she thinks.
Question 39 Explanation:
This comes closest to beginning to focus on family-centered approach to intervene in the “conspiracy of silence”. This is therefore the best among the options.
Question 40
The nurse is caring to an autistic child. Which of the following play behavior would the nurse expect to see in a child?
A
solitary play
B
competitive play
C
nonverbal play
D
cooperative play
Question 40 Explanation:
Autistic children do best with solitary play because they typically do not interact with others in a socially comprehensible and acceptable way.
Question 41
The mother visits her son with major depression in the psychiatric unit. After the conversation of the client and the mother, the nurse asks the mother how it is talking to her son. The mother tells the nurse that it was a stressful time. During an interview with the client, the client says, “we had a marvelous visit.” Which of the following coping mechanism can be described to the statement of the client?
A
Identification.
B
Denial.
C
Compensation.
D
Rationalization.
Question 41 Explanation:
Denial is the act of avoiding disagreeable realities by ignoring them.
Question 42
A depressed client is on an MAO inhibitor? What should the nurse watch out for?
A
Exposure to sunlight.
B
Taking medication with meals.
C
Diet restrictions.
D
Hypertensive crisis.
Question 42 Explanation:
This is the more inclusive answer, although diet restrictions (answer1) are important, their purpose is to prevent hypertensive crisis (answer 2).
Question 43
The client is telling the nurse in the psychiatric ward, “I hate them.” Which of the following is the most appropriate nursing response to the client?
A
“I understand how you can feel this way.”
B
“For whom do you have these feelings?”
C
“Tell me about your hate.”
D
“I will stay with you as long as you feel this way.”
Question 43 Explanation:
The nurse is asking the client to clarify and further discuss feelings.
Question 44
After the discussion about the procedure the physician scheduled the client for mastectomy. The client tells the nurse, “If my breasts will be removed, I’m afraid my husband will not love me anymore and maybe he will never touch me.” What should the nurse’s response?
A
“What makes you feel that way?”
B
“Have you discussed your feelings with your husband?”
C
“I doubt that he feels that way.”
D
Ask the husband, in front of the wife, how he feels about this.
Question 44 Explanation:
This option redirects the client to talk to her husband.
Question 45
A client who is manic comes to the outpatient department. The nurse is assigning an activity for the client. What activity is best for the nurse to encourage for a client in a manic phase?
A
Solitary activity, such as walking with the nurse, to decrease stimulation.
B
Intellectual activity, such as scrabble, to increase concentration.
C
Group activity, such as basketball, to decrease isolation.
D
Competitive activity, such as bingo, to increase the client’s self-esteem.
Question 45 Explanation:
This option avoids external stimuli, yet channels the excess motor activity that is often part of the manic phase.
Question 46
A client who is severely obese tells the nurse, “My therapist told me that I eat a lot because I didn’t get any attention and love from my mother. What does the therapist mean?” What is the best nursing response?
A
“Tell me what you think the therapist means.”
B
“You need to ask your therapist.”
C
“What do you think is the connection between your not getting enough love and overeating?”
D
“ We are here to deal with your diet, not with your psychological problems.”
Question 46 Explanation:
This response asks information that the nurse can use. If the client understands the statement, the nurse can support the therapist when focusing on connection between food, love, and mother. If the client does not understand the statement, the nurse can help get clarification from the therapist.
Question 47
The nurse suspects that the client is suffering from depression. During assessment, what are the most characteristic signs and symptoms of depression the nurse would note?
A
Verbosity, increased social interaction.
B
Diarrhea, anger.
C
Constipation, increased appetite.
D
Anorexia, insomnia.
Question 47 Explanation:
The appetite is diminished and sleeping is affected to a client with depression.
Question 48
A male client diagnosed with depression tells the nurse, “I don’t want to look weak and I don’t even cry because my wife and my kids can’t bear it.” The nurse understands that this is an example of:
A
Rationalization.
B
Undoing.
C
Suppression.
D
Repression.
Question 48 Explanation:
Rationalization is the process of constructing plausible reasons for one’s responses.
Question 49
The nurse is caring to an 80-year-old client with dementia? What is the most important psychosocial need for this client?
A
Variety in their daily life, to decrease depression.
B
Limit in the number of visitors, to minimize confusion.
C
A structured environment, to minimize regressive behaviors.
D
Focus on the there-and-then rather the here-and-now.
Question 49 Explanation:
Persons with dementia needs sameness, consistency, structure, routine, and predictability.
Question 50
A client with dementia is for discharge. The nurse is providing a discharge instruction to the family member regarding safety measures at home. What suggestion can the nurse make to the family members?
A
Use restraints while the client is sitting in a chair to keep him or her from wandering off during the day.
B
Avoid stairs without banisters.
C
Use restraints while the client is in bed to keep him or her from wandering off during the night.
D
Provide a night-light and a big clock.
Question 50 Explanation:
This option is best to decrease confusion and disorientation to place and time.
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PNLE V Nursing Practice (EM)
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Question 1
The nurse is caring to an 80-year-old client with dementia? What is the most important psychosocial need for this client?
A
Variety in their daily life, to decrease depression.
B
A structured environment, to minimize regressive behaviors.
C
Limit in the number of visitors, to minimize confusion.
D
Focus on the there-and-then rather the here-and-now.
Question 1 Explanation:
Persons with dementia needs sameness, consistency, structure, routine, and predictability.
Question 2
A 55-year-old male client tells the nurse that he needs his glasses and hearing aid with him in the recovery room after the surgery, or he will be upset for not granting his request. What is the appropriate nursing response?
A
“Do you get upset and confused often?”
B
“I understand. You will be able to cooperate best if you know what is going on, so I will find out how I can arrange to have your glasses and hearing aid available to you in the recovery room.”
C
I understand you might be more cooperative if you have your aid and glasses, but that is just not possible. Rules, you know.”
D
“You won’t need your glasses or hearing aid. The nurses will take care of you.”
Question 2 Explanation:
The client will be easier to care for if he has his hearing aid and glasses.
Question 3
A male client is quiet when the physician told him that he has stage IV cancer and has 4 months to live. The nurse determines that this reaction may be an example of:
A
Indifference
B
Anger
C
Resignation
D
Denial
Question 3 Explanation:
Reactions when told of a life-threatening illness stem from Kübler-Ross’ ideas on death and dying. Denial is a typical grief response, and usually is a first reaction.
Question 4
A nurse is assigned to activate a client who is withdrawn, hears voices and negativistic. What would be the best nursing approach?
A
Mention that the “voices” would want the client to participate.
B
Give the client a long explanation of the benefits of activity.
C
Tell the client that the nurse needs a partner for an activity.
D
Demand that the client must join a group activity.
Question 4 Explanation:
The nurse helps to activate by doing something with the client.
Question 5
A male client diagnosed with depression tells the nurse, “I don’t want to look weak and I don’t even cry because my wife and my kids can’t bear it.” The nurse understands that this is an example of:
A
Rationalization.
B
Suppression.
C
Repression.
D
Undoing.
Question 5 Explanation:
Rationalization is the process of constructing plausible reasons for one’s responses.
Question 6
The client is telling the nurse in the psychiatric ward, “I hate them.” Which of the following is the most appropriate nursing response to the client?
A
“I will stay with you as long as you feel this way.”
B
“For whom do you have these feelings?”
C
“Tell me about your hate.”
D
“I understand how you can feel this way.”
Question 6 Explanation:
The nurse is asking the client to clarify and further discuss feelings.
Question 7
Which of the following nursing approach is most important in a client with depression?
A
Protecting against harm to others.
B
Reducing interpersonal contacts.
C
Providing motor outlets for aggressive, hostile feelings.
D
Deemphasizing preoccupation with elimination, nourishment, and sleep.
Question 7 Explanation:
It is important to externalize the anger away from self.
Question 8
A depressed client is on an MAO inhibitor? What should the nurse watch out for?
A
Diet restrictions.
B
Exposure to sunlight.
C
Hypertensive crisis.
D
Taking medication with meals.
Question 8 Explanation:
This is the more inclusive answer, although diet restrictions (answer1) are important, their purpose is to prevent hypertensive crisis (answer 2).
Question 9
The child is brought to the hospital by the parents. During assessment of the nurse, what parental behavior toward a child should alert the nurse to suspect child abuse?
A
Acting overly solicitous toward the child
B
Expressions of guilt.
C
Flat affect.
D
Ignoring the child.
Question 9 Explanation:
This is an example of reaction formation, a coping mechanism.
Question 10
The nurse is about to administer Imipramine HCI (Tofranil) to the client, the client says, “Why should I take this?” The doctor started me on this 10days ago; it didn’t help me at all.” Which of the following is the best nursing response:
A
“That’s a long time wait when you feel so depressed.”
B
“Do you want to refuse this medication? You have the right.”
C
“It usually takes 2-3 weeks to be effective.”
D
“What were you expecting to happen?”
Question 10 Explanation:
The patient needs a brief, factual answer.
Question 11
A 3-year-old boy is brought to the emergency department. After an hour, the boy dies of respiratory failure. The mother of the boy becomes upset, shouting and abusive, saying to the nurse, “If it had been your son, they would have done more to save it. “What should the nurse say or do?
A
“Yes, you’re probably right. Your son did not get better care.”
B
“No, all clients are given the same good care.”
C
Touch her and tell her exactly what was done for her baby.
D
Allow the mother to continue her present behavior while sitting quietly with her.
Question 11 Explanation:
This option allows a normal grief response (anger).
Question 12
A nurse is completing the routine physical examination to a healthy 16-year-old male client. The client shares to the nurse that he feels like killing his girlfriend because he found out that her girlfriend had another boyfriend. He then laughs, and asks the nurse to keep this a secret just between the two of them. The nurse reviews his chart and notes that there is no previously history of violence or psychiatric illness. Which of the following would be the best action of the nurse to take at this time?
A
Regard the comment seriously and notify the teen’s primary health care provider and parents
B
Tell the teen that his feelings are normal, and recommend that he find another girlfriend to take his mind off the problem.
C
Recall the teenage boys often say things they really do not mean and ignore the comment.
D
Suggest the teen meet with a counselor to discuss his feelings about his girlfriend.
Question 12 Explanation:
Any threat to the safety of oneself or other should always be taken seriously and never disregarded by the nurse.
Question 13
The client in the psychiatric unit states that, “The goodas are coming! I must be ready.” In response to this neologism, the nurse’s initial response is to:
A
State that what the client is saying has not been understood and then divert attention to something that is really bound.
B
Divert the client’s attention to an aspect of reality.
C
Try to interpret what the client means.
D
Acknowledge that the word has some special meaning for the client.
Question 13 Explanation:
It is important to acknowledge a statement, even if it is not understood.
Question 14
The mother visits her son with major depression in the psychiatric unit. After the conversation of the client and the mother, the nurse asks the mother how it is talking to her son. The mother tells the nurse that it was a stressful time. During an interview with the client, the client says, “we had a marvelous visit.” Which of the following coping mechanism can be described to the statement of the client?
A
Denial.
B
Identification.
C
Rationalization.
D
Compensation.
Question 14 Explanation:
Denial is the act of avoiding disagreeable realities by ignoring them.
Question 15
A female client is taking Imipramine HCI (Tofranil) for almost 1 week and shows less awareness of the physical body. What problem would the nurse be most concerned?
A
Nausea.
B
Bowel movements.
C
Gait disturbances.
D
Voiding.
Question 15 Explanation:
A serious side effect of Imipramine HCI (Tofranil) is urinary retention (voiding problems)
Question 16
A 6-year-old client dies in the nursing unit. The parents want to see the child. What is the most appropriate nursing action?
A
Suggest the parents to wait until the funeral service to say “good-bye.”
B
Complete the postmortem care and quietly accompany the family to the child’s room.
C
Ask the physician for permission.
D
Give the parents time alone with the body.
Question 16 Explanation:
This allows the parents/family to grieve over the loss of the child, by going through the steps of leave taking.
Question 17
In a mental health settings, the basic goal of nursing is to:
A
Advance the science of psychiatry by initiating research and gathering data for current statistics on emotional illness.
B
Plan activity programs for clients.
C
Maintain a therapeutic environment.
D
Understand various types of family therapy and psychological tests and how to interpret them.
Question 17 Explanation:
This is the most neutral answer by process of elimination.
Question 18
A client tells the nurse, “Yesterday, I was planning to kill myself.” What is the best nursing response to this cient?
A
“What are you going to do this time?”
B
“You seem upset. I am going to be here with you; perhaps you will want to talk about it”
C
Say nothing. Wait for the client’s next comment
D
“Have you felt this way before?”
Question 18 Explanation:
The client needs to have his or her feelings acknowledged, with encouragement to discuss feelings, and be reassured about the nurse’s presence.
Question 19
A 17-year-old client has a record of being absent in the class without permission, and “borrowing” other people’s things without asking permission. The client denies stealing; rationalizing instead that as long as no one was using the items, there is no problem to use it by other people. It is important for the nurse to understand that psychodynamically, the behavior of the client may be largely attributed to a development defect related to the:
A
Ego
B
Id
C
Oedipal complex
D
Superego
Question 19 Explanation:
This shows a weak sense of moral consciousness. According to Freudian theory, personality disorders stem from a weak superego.
Question 20
The male client had fight with his roommates in the psychiatric unit. The client agitated client is placed in isolation for seclusion. The nurse knows it is essential that:
A
A staff member has frequent contacts with the client.
B
All the furniture is removed form the isolation room.
C
The client is allowed to come out after 4 hours.
D
Restraints are applied.
Question 20 Explanation:
Frequent contacts at times of stress are important, especially when a client is isolated.
Question 21
The nurse suspects that the client is suffering from depression. During assessment, what are the most characteristic signs and symptoms of depression the nurse would note?
A
Constipation, increased appetite.
B
Verbosity, increased social interaction.
C
Anorexia, insomnia.
D
Diarrhea, anger.
Question 21 Explanation:
The appetite is diminished and sleeping is affected to a client with depression.
Question 22
The nurse is caring to an autistic child. Which of the following play behavior would the nurse expect to see in a child?
A
cooperative play
B
solitary play
C
nonverbal play
D
competitive play
Question 22 Explanation:
Autistic children do best with solitary play because they typically do not interact with others in a socially comprehensible and acceptable way.
Question 23
Which of the following person will be at highest risk for suicide?
A
A person who made a previous suicide attempt.
B
A married woman, age 40, with 6 children.
C
A person who is an alcoholic.
D
A student at exam time
Question 23 Explanation:
The likelihood of multiple contributing factors may make this person at higher risk for suicide. Some factors that may exist are physical illness related to alcoholism, emotional factors ( anxiety, guilt, remorse), social isolation due to impaired relationships and economic problems related to employment.
Question 24
A young lady with a diagnosis of schizophrenic reaction is admitted to the psychiatric unit. In the past two months, the client has poor appetite, experienced difficulty in sleeping, was mute for long periods of time, just stayed in her room, grinning and pointing at things. What would be the initial nursing action on admitting the client to the unit?
A
Take the client to the assigned room.
B
Ask “Do you know where you are?”
C
Introduce the client to some of the other clients.
D
Assure the client that “ You will be well cared for.”
Question 24 Explanation:
The client needs basic, simple orientation that directly relates to the here-and-now, and does not require verbal interaction.
Question 25
A client in the psychiatric unit is shouting out loud and tells the nurse, “Please, help me. They are coming to get me.” What would be the appropriate nursing response?
A
“ I won’t let anyone get you.”
B
“You look frightened.”
C
“Who are they?”
D
“I don’t see anyone coming.”
Question 25 Explanation:
This option is an example of pointing out reality- the nurse’s perception.
Question 26
Which of the following drugs the nurse should choose to administer to a client to prevent pseudoparkinsonism?
A
Trihexyphenidyl HCI (Artane)
B
Trifluoperazine HCI (Stelazine)
C
Isocarboxazid (Marplan)
D
Chlorpromazine HCI (Thorazine)
Question 26 Explanation:
Trihexyphenidyl HCI (Artane) is often used to counteract side effect of pseudoparkinsonism, which often accompanies the use of phenothiazine, such as chlorpromazine HCI (Thorazine or Trifluoperazine HCI (Stelazine).
Question 27
The nurse enters the room of the male client and found out that the client urinates on the floor. The client hides when the nurse is about to talk to him. Which of the following is the best nursing intervention?
A
Ask the client to clean the soiled floor.
B
Place restriction on the client’s activities when his behavior occurs.
C
Limit fluid intake.
D
Take the client to the bathroom at regular intervals.
Question 27 Explanation:
The client is most likely confused, rather than exhibiting acting-out, hostile behavior. Frequent toileting will allow urination in an appropriate place.
Question 28
A male client is repetitively doing the handwashing every time he touches things. It is important for a nurse to understand that the client’s behavior is probably an attempt to:
A
Do what the voices the patient hears tell him or her to do.
B
Seek attention from the staff.
C
Control unacceptable impulses or feelings.
D
Punish himself or herself for guilt feeling.
Question 28 Explanation:
A ritual, such as compulsive handwashing, is an attempt to allay anxiety caused by unconscious impulses that are frightening.
Question 29
A client with a diagnosis of paranoid disorder is admitted in the psychiatric hospital. The client tells the nurse, “the FBI is following me. These people are plotting against me.” With this statement the nurse will need to:
A
Acknowledge that this is the client’s belief but not the nurse’s belief.
B
Use logic to help the client doubt this belief.
C
Show the client that no one is behind.
D
Ask how that makes the client feel.
Question 29 Explanation:
The nurse should neither challenge nor use logic to dispel an irrational belief.
Question 30
A client tells the nurse, “I don’t want to eat any meals offered in this hospital because the food is poisoned.” The nurse is aware that the client is expressing an example of:
A
Delusion.
B
Hallucination.
C
Illusion.
D
Negativism.
Question 30 Explanation:
This is a false belief developed in response to an emotional need.
Question 31
A 20-year-old female client is diagnosed with anxiety disorder. The physician prescribed Flouxetine (Prozac). What is the most important side effects should a nurse be concerned?
A
Visual disturbance, headache.
B
Excessive diaphoresis, diarrhea.
C
Tremor, drowsiness.
D
Seizures, suicidal tendencies.
Question 31 Explanation:
Assess for suicidal tendencies, especially during early therapy. There is an increased risk of seizures in debilitated client and those with a history of seizures.
Question 32
A client is admitted in the hospital. On assessment, the nurse found out that the client had several suicidal attempts. Which of the following is the most important nursing action?
A
Relax vigilance when the client seems to be recovering from depression.
B
Maintain constant awareness of the client’s whereabouts.
C
Administer medication.
D
Ignore the client as long as he or she is talking about suicide, because suicide attempt is unlikely.
Question 32 Explanation:
The client must be constantly observed.
Question 33
A 30-year-old married woman comes to the hospital for treatment of fractures. The woman tells the nurse that she was physically abused by her husband. The woman receives a call from her husband telling her to get home and things will be different. He felt sorry of what he did. What can the nurse advise her?
A
“I hope so, for your sake.”
B
“What will be different?”
C
“It’s not likely.”
D
“Do you think so?”
Question 33 Explanation:
This option helps the woman to think through and elaborate on her own thoughts and prognosis.
Question 34
A nurse is caring to a female client with five young children. The family member told the client that her ex-husband has died 2 days ago. The reaction of the client is stunned silence, followed by anger that the ex-husband left no insurance money for their young children. The nurse should understand that:
A
The woman is not reacting normally to the news.
B
The children and the injustice done to them by their father’s death are the woman’s main concern.
C
The woman is experiencing a normal bereavement reaction.
D
To explain the woman’s reaction, the nurse needs more information about the relationship and breakup.
Question 34 Explanation:
Shock and anger are commonly the primary initial reactions.
Question 35
A client is withdrawn and does not want to interact to anybody even to the nurse. What is the best initial nursing approach to encourage communication with this client?
A
Look through a photo album together.
B
Encourage discussion of feelings.
C
Bring up neutral topics.
D
Use simple questions that call for a response.
Question 35 Explanation:
Neutral, nonthreatening topics are best in attempting to encourage a response.
Question 36
A 16-year-old girl was diagnosed with anorexia. What would be the first assessment of the nurse?
A
What food she likes.
B
Her desired weight.
C
What causes her behavior.
D
Her body image.
Question 36 Explanation:
Although all options may appear correct. A is the best because it focuses on a range of possible positive reinforcers, a basis for an effective behavior modification program. It can lead to concrete, specific nursing interventions right away and provides a therapeutic use of “control” for the 16-year-old.
Question 37
A nurse is going to give a rectal suppository as a preoperative medication to a 4-year-old boy. The boy is very anxious and frightened. Which of the following statement by the nurse would be most appropriate to gain the child’s cooperation?
A
“Take a nice, big, deep breath and then let me hear you count to five.”
B
“Be a big kid! Everyone’s waiting for you.”
C
“You look so scared. Want to know a secret? This won’t hurt a bit!”
D
“Lie still now and I’ll let you have one of your presents before you even have your operation.”
Question 37 Explanation:
Preschool children commonly experience fears and fantasies regarding invasive procedures. The nurse should attempts to momentarily distract the child with a simple task that can be easily accomplished while the child remains in the side-lying position. The suppository can be slipped into place while the child is counting, and then the nurse can praise the child for cooperating, while holding the buttocks together to prevent expulsion of the suppository.
Question 38
A female client was diagnosed with breast cancer. It is found to be stage IV, and a modified mastectomy is performed. After the procedure, what behaviors could the nurse expects the client to display?
A
Denial of the possibility of carcinoma.
B
Signs of deep depression.
C
Relief that the operation is over.
D
Signs of grief reaction.
Question 38 Explanation:
It is mostly likely that grief would be expressed because of object loss.
Question 39
A female client tells the nurse that she is afraid to go out from her room because she thinks that the other client might kill her. The nurse is aware that this behavior is related to:
A
Illusion.
B
Delusion of persecution.
C
Ideas of reference.
D
Hallucination.
Question 39 Explanation:
The client has ideas that someone is out to kill her.
Question 40
The client needs to have his or her feelings acknowledged, with encouragement to discuss feelings, and be reassured about the nurse’s presence.
A
Crises usually resolved in 4-6 weeks.
B
Crises are related to deep, underlying problems
C
Crises seldom occur in normal people’s lives
D
Crises may go on indefinitely.
Question 40 Explanation:
Part of the definition of a crisis is a time span of 4-6 weeks.
Question 41
A medical representative comes to the hospital unit for the promotion of a new product. A female client, admitted for hysterical behavior, is found embracing him. What should the nurse say?
A
“I see you’ve made a new friend.”
B
“Think about what you are doing.”
C
“Have you considered birth control?”
D
“This isn’t the purpose of either of you being here.”
Question 41 Explanation:
This response is aimed at redirecting the inappropriate behavior.
Question 42
A client with dementia is for discharge. The nurse is providing a discharge instruction to the family member regarding safety measures at home. What suggestion can the nurse make to the family members?
A
Use restraints while the client is sitting in a chair to keep him or her from wandering off during the day.
B
Use restraints while the client is in bed to keep him or her from wandering off during the night.
C
Avoid stairs without banisters.
D
Provide a night-light and a big clock.
Question 42 Explanation:
This option is best to decrease confusion and disorientation to place and time.
Question 43
A client who is manic comes to the outpatient department. The nurse is assigning an activity for the client. What activity is best for the nurse to encourage for a client in a manic phase?
A
Intellectual activity, such as scrabble, to increase concentration.
B
Solitary activity, such as walking with the nurse, to decrease stimulation.
C
Competitive activity, such as bingo, to increase the client’s self-esteem.
D
Group activity, such as basketball, to decrease isolation.
Question 43 Explanation:
This option avoids external stimuli, yet channels the excess motor activity that is often part of the manic phase.
Question 44
A 16-year-old girl is admitted for treatment of a fracture. The client shares to the nurse caring to her that her step-father has made sexual advances to her. She got the chance to tell it to her mother but refuses to believe. What is the most therapeutic action of the nurse would be:
A
Ask the mother what she thinks.
B
Ask the father about it.
C
Tell the client to discuss it with her mother.
D
Tell the client to work it out with her father.
Question 44 Explanation:
This comes closest to beginning to focus on family-centered approach to intervene in the “conspiracy of silence”. This is therefore the best among the options.
Question 45
A woman gave birth to an unhealthy infant, and with some body defects. The nurse should expect the woman’s initial reactions to include:
A
Depression
B
Withdrawal
C
Apathy
D
Anger
Question 45 Explanation:
The woman is experiencing an actual loss and will probably exhibit many of the same symptoms as a person who has lost someone to death.
Question 46
A client who is severely obese tells the nurse, “My therapist told me that I eat a lot because I didn’t get any attention and love from my mother. What does the therapist mean?” What is the best nursing response?
A
“What do you think is the connection between your not getting enough love and overeating?”
B
“Tell me what you think the therapist means.”
C
“You need to ask your therapist.”
D
“ We are here to deal with your diet, not with your psychological problems.”
Question 46 Explanation:
This response asks information that the nurse can use. If the client understands the statement, the nurse can support the therapist when focusing on connection between food, love, and mother. If the client does not understand the statement, the nurse can help get clarification from the therapist.
Question 47
The nurse is interacting to a client with an antisocial personality disorder. What would be the most therapeutic approach of the nurse to an antisocial behavior?
A
Reinforce the client’s self-concept.
B
Give the client opportunities to test reality.
C
Provide external controls.
D
Gratify the client’s inner needs.
Question 47 Explanation:
Personality disorders stem from a weak superego, implying a lack of adequate controls.
Question 48
On an adolescent unit, a nurse caring to a client was informed that her client’s closest roommate dies at night. What would be the most appropriate nursing action?
A
Tell the client that her roommate went home.
B
Tell the client that her closest roommate died.
C
Tell the client, if asked, “You should ask the doctor.”
D
Do not bring it up unless the client asks.
Question 48 Explanation:
The nurse needs to wait and see: do not “jump the gun”; do not assume that the client wants to know now.
Question 49
After the discussion about the procedure the physician scheduled the client for mastectomy. The client tells the nurse, “If my breasts will be removed, I’m afraid my husband will not love me anymore and maybe he will never touch me.” What should the nurse’s response?
A
“What makes you feel that way?”
B
“Have you discussed your feelings with your husband?”
C
Ask the husband, in front of the wife, how he feels about this.
D
“I doubt that he feels that way.”
Question 49 Explanation:
This option redirects the client to talk to her husband.
Question 50
A nurse is caring to a client with manic disorder in the psychiatric ward. On the morning shift, the nurse is talking with the client who is now exhibiting a manic episode with flight of ideas. The nurse primarily needs to:
A
Focus on the feelings conveyed rather than the thoughts expressed.
B
Encourage the client to complete one thought at a time.
C
Allow the client to talk freely.
D
Speak loudly and rapidly to keep the client’s attention, because the client is easily distracted.
Question 50 Explanation:
Often the verbalized ideas are jumbled, but the underlying feelings are discernible and must be acknowledged.
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The scope of this Nursing Test V is parallel to the NP5 NLE Coverage:
Psychiatric Nursing
1. A 17-year-old client has a record of being absent in the class without permission, and “borrowing” other people’s things without asking permission. The client denies stealing; rationalizing instead that as long as no one was using the items, there is no problem to use it by other people. It is important for the nurse to understand that psychodynamically, the behavior of the client may be largely attributed to a development defect related to the:
Oedipal complex
Superego
Id
Ego
2. A client tells the nurse, “Yesterday, I was planning to kill myself.” What is the best nursing response to this cient?
“What are you going to do this time?”
Say nothing. Wait for the client’s next comment
“You seem upset. I am going to be here with you; perhaps you will want to talk about it”
“Have you felt this way before?”
3. In crisis intervention therapy, which of the following principle that the nurse will use to plan her/his goals?
Crises are related to deep, underlying problems
Crises seldom occur in normal people’s lives
Crises may go on indefinitely.
Crises usually resolved in 4-6 weeks.
4. The nurse enters the room of the male client and found out that the client urinates on the floor. The client hides when the nurse is about to talk to him. Which of the following is the best nursing intervention?
Place restriction on the client’s activities when his behavior occurs.
Ask the client to clean the soiled floor.
Take the client to the bathroom at regular intervals.
Limit fluid intake.
5. A young lady with a diagnosis of schizophrenic reaction is admitted to the psychiatric unit. In the past two months, the client has poor appetite, experienced difficulty in sleeping, was mute for long periods of time, just stayed in her room, grinning and pointing at things. What would be the initial nursing action on admitting the client to the unit?
Assure the client that “ You will be well cared for.”
Introduce the client to some of the other clients.
Ask “Do you know where you are?”
Take the client to the assigned room.
6. A 16-year-old girl was diagnosed with anorexia. What would be the first assessment of the nurse?
What food she likes.
Her desired weight.
Her body image.
What causes her behavior.
7. On an adolescent unit, a nurse caring to a client was informed that her client’s closest roommate dies at night. What would be the most appropriate nursing action?
Do not bring it up unless the client asks.
Tell the client that her roommate went home.
Tell the client, if asked, “You should ask the doctor.”
Tell the client that her closest roommate died.
8. A woman gave birth to an unhealthy infant, and with some body defects. The nurse should expect the woman’s initial reactions to include:
Depression
Withdrawal
Apathy
Anger
9. A client in the psychiatric unit is shouting out loud and tells the nurse, “Please, help me. They are coming to get me.” What would be the appropriate nursing response?
“ I won’t let anyone get you.”
“Who are they?”
“I don’t see anyone coming.”
“You look frightened.”
10. A client who is severely obese tells the nurse, “My therapist told me that I eat a lot because I didn’t get any attention and love from my mother. What does the therapist mean?” What is the best nursing response?
“What do you think is the connection between your not getting enough love and overeating?”
“Tell me what you think the therapist means.”
“You need to ask your therapist.”
“ We are here to deal with your diet, not with your psychological problems.”
11. After the discussion about the procedure the physician scheduled the client for mastectomy. The client tells the nurse, “If my breasts will be removed, I’m afraid my husband will not love me anymore and maybe he will never touch me.” What should the nurse’s response?
“I doubt that he feels that way.”
“What makes you feel that way?”
“Have you discussed your feelings with your husband?”
Ask the husband, in front of the wife, how he feels about this.
12. The child is brought to the hospital by the parents. During assessment of the nurse, what parental behavior toward a child should alert the nurse to suspect child abuse?
Ignoring the child.
Flat affect.
Expressions of guilt.
Acting overly solicitous toward the child
13. A nurse is caring to a client with manic disorder in the psychiatric ward. On the morning shift, the nurse is talking with the client who is now exhibiting a manic episode with flight of ideas. The nurse primarily needs to:
Focus on the feelings conveyed rather than the thoughts expressed.
Speak loudly and rapidly to keep the client’s attention, because the client is easily distracted.
Allow the client to talk freely.
Encourage the client to complete one thought at a time.
14. The nurse is caring to an autistic child. Which of the following play behavior would the nurse expect to see in a child?
competitive play
nonverbal play
cooperative play
solitary play
15. The client is telling the nurse in the psychiatric ward, “I hate them.” Which of the following is the most appropriate nursing response to the client?
“Tell me about your hate.”
“I will stay with you as long as you feel this way.”
“For whom do you have these feelings?”
“I understand how you can feel this way.”
16. The mother visits her son with major depression in the psychiatric unit. After the conversation of the client and the mother, the nurse asks the mother how it is talking to her son. The mother tells the nurse that it was a stressful time. During an interview with the client, the client says, “we had a marvelous visit.” Which of the following coping mechanism can be described to thestatement of the client?
Identification.
Rationalization.
Denial.
Compensation.
17. A male client is quiet when the physician told him that he has stage IV cancer and has 4 months to live. The nurse determines that this reaction may be an example of:
Indifference
Denial
Resignation
Anger
18. A nurse is caring to a female client with five young children. The family member told the client that her ex-husband has died 2 days ago. The reaction of the client is stunned silence, followed by anger that the ex-husband left no insurance money for their young children. The nurse should understand that:
The children and the injustice done to them by their father’s death are the woman’s main concern.
To explain the woman’s reaction, the nurse needs more information about the relationship and breakup.
The woman is not reacting normally to the news.
The woman is experiencing a normal bereavement reaction.
19. A client who is manic comes to the outpatient department. The nurse is assigning an activity for the client. What activity is best for the nurse to encourage for a client in a manic phase?
Solitary activity, such as walking with the nurse, to decrease stimulation.
Competitive activity, such as bingo, to increase the client’s self-esteem.
Group activity, such as basketball, to decrease isolation.
Intellectual activity, such as scrabble, to increase concentration.
20. The nurse is about to administer Imipramine HCI (Tofranil) to the client, the client says, “Why should I take this?” The doctor started me on this 10days ago; it didn’t help me at all.” Which of the following is the best nursing response:
“What were you expecting to happen?”
“It usually takes 2-3 weeks to be effective.”
“Do you want to refuse this medication? You have the right.”
“That’s a long time wait when you feel so depressed.”
21. Which of the following drugs the nurse should choose to administer to a client to prevent pseudoparkinsonism?
Isocarboxazid (Marplan)
Chlorpromazine HCI (Thorazine)
Trihexyphenidyl HCI (Artane)
Trifluoperazine HCI (Stelazine)
22. The nurse is caring to an 80-year-old client with dementia? What is the most important psychosocial need for this client?
Focus on the there-and-then rather the here-and-now.
Limit in the number of visitors, to minimize confusion.
Variety in their daily life, to decrease depression.
A structured environment, to minimize regressive behaviors.
23. A client tells the nurse, “I don’t want to eat any meals offered in this hospital because the food is poisoned.” The nurse is aware that the client is expressing an example of:
Delusion.
Hallucination.
Negativism.
Illusion.
24. A client is admitted in the hospital. On assessment, the nurse found out that the client had several suicidal attempts. Which of the following is the most important nursing action?
Ignore the client as long as he or she is talking about suicide, because suicide attempt is unlikely.
Administer medication.
Relax vigilance when the client seems to be recovering from depression.
Maintain constant awareness of the client’s whereabouts.
25. The nurse suspects that the client is suffering from depression. During assessment, what are the most characteristic signs and symptoms of depression the nurse would note?
Constipation, increased appetite.
Anorexia, insomnia.
Diarrhea, anger.
Verbosity, increased social interaction.
26. The client in the psychiatric unit states that, “The goodas are coming! I must be ready.” In response to this neologism, the nurse’s initial response is to:
Acknowledge that the word has some special meaning for the client.
Try to interpret what the client means.
Divert the client’s attention to an aspect of reality.
State that what the client is saying has not been understood and then divert attention to something that is really bound.
27. A male client diagnosed with depression tells the nurse, “I don’t want to look weak and I don’t even cry because my wife and my kids can’t bear it.” The nurse understands that this is an example of:
Repression.
Suppression.
Undoing.
Rationalization.
28. A female client tells the nurse that she is afraid to go out from her room because she thinks that the other client might kill her. The nurse is aware that this behavior is related to:
Hallucination.
Ideas of reference.
Delusion of persecution.
Illusion.
29. A female client is taking Imipramine HCI (Tofranil) for almost 1 week and shows less awareness of the physical body. What problem would the nurse be most concerned?
Nausea.
Gait disturbances.
Bowel movements.
Voiding.
30. A 6-year-old client dies in the nursing unit. The parents want to see the child. What is the most appropriate nursing action?
Give the parents time alone with the body.
Ask the physician for permission.
Complete the postmortem care and quietly accompany the family to the child’s room.
Suggest the parents to wait until the funeral service to say “good-bye.”
31. A 20-year-old female client is diagnosed with anxiety disorder. The physician prescribed Flouxetine (Prozac). What is the most important side effects should a nurse be concerned?
Tremor, drowsiness.
Seizures, suicidal tendencies.
Visual disturbance, headache.
Excessive diaphoresis, diarrhea.
32. A nurse is assigned to activate a client who is withdrawn, hears voices and negativistic. What would be the best nursing approach?
Mention that the “voices” would want the client to participate.
Demand that the client must join a group activity.
Give the client a long explanation of the benefits of activity.
Tell the client that the nurse needs a partner for an activity.
33. A nurse is going to give a rectal suppository as a preoperative medication to a 4-year-old boy. The boy is very anxious and frightened. Which of the following statement by the nurse would be most appropriate to gain the child’s cooperation?
“Be a big kid! Everyone’s waiting for you.”
“Lie still now and I’ll let you have one of your presents before you even have your operation.”
“Take a nice, big, deep breath and then let me hear you count to five.”
“You look so scared. Want to know a secret? This won’t hurt a bit!”
34. A depressed client is on an MAO inhibitor? What should the nurse watch out for?
Hypertensive crisis.
Diet restrictions.
Taking medication with meals.
Exposure to sunlight.
35. A 16-year-old girl is admitted for treatment of a fracture. The client shares to the nurse caring to her that her step-father has made sexual advances to her. She got the chance to tell it to her mother but refuses to believe. What is the most therapeutic action of the nurse would be:
Tell the client to work it out with her father.
Tell the client to discuss it with her mother.
Ask the father about it.
Ask the mother what she thinks.
36. A client with a diagnosis of paranoid disorder is admitted in the psychiatric hospital. The client tells the nurse, “the FBI is following me. These people are plotting against me.” With this statement the nurse will need to:
Acknowledge that this is the client’s belief but not the nurse’s belief.
Ask how that makes the client feel.
Show the client that no one is behind.
Use logic to help the client doubt this belief.
37. A nurse is completing the routine physical examination to a healthy 16-year-old male client. The client shares to the nurse that he feels like killing his girlfriend because he found out that her girlfriend had another boyfriend. He then laughs, and asks the nurse to keep this a secret just between the two of them. The nurse reviews his chart and notes that there is no previously history of violence or psychiatric illness. Which of the following would be the best action of the nurse to take at this time?
Suggest the teen meet with a counselor to discuss his feelings about his girlfriend.
Tell the teen that his feelings are normal, and recommend that he find another girlfriend to take his mind off the problem.
Recall the teenage boys often say things they really do not mean and ignore the comment.
Regard the comment seriously and notify the teen’s primary health care provider and parents
38. Which of the following person will be at highest risk for suicide?
A student at exam time
A married woman, age 40, with 6 children.
A person who is an alcoholic.
A person who made a previous suicide attempt.
39. A male client is repetitively doing the handwashing every time he touches things. It is important for a nurse to understand that the client’s behavior is probably an attempt to:
Seek attention from the staff.
Control unacceptable impulses or feelings.
Do what the voices the patient hears tell him or her to do.
Punish himself or herself for guilt feeling.
40. In a mental health settings, the basic goal of nursing is to:
Advance the science of psychiatry by initiating research and gathering data for current statistics on emotional illness.
Plan activity programs for clients.
Understand various types of family therapy and psychological tests and how to interpret them.
Maintain a therapeutic environment.
41. A 3-year-old boy is brought to the emergency department. After an hour, the boy dies of respiratory failure. The mother of the boy becomes upset, shouting and abusive, saying to the nurse, “If it had been your son, they would have done more to save it. “What should the nurse say or do?
Touch her and tell her exactly what was done for her baby.
Allow the mother to continue her present behavior while sitting quietly with her.
“No, all clients are given the same good care.”
“Yes, you’re probably right. Your son did not get better care.”
42. The nurse is interacting to a client with an antisocial personality disorder. What would be the most therapeutic approach of the nurse to an antisocial behavior?
Gratify the client’s inner needs.
Give the client opportunities to test reality.
Provide external controls.
Reinforce the client’s self-concept.
43. A 55-year-old male client tells the nurse that he needs his glasses and hearing aid with him in the recovery room after the surgery, or he will be upset for not granting his request. What is the appropriate nursing response?
“Do you get upset and confused often?”
“You won’t need your glasses or hearing aid. The nurses will take care of you.”
“I understand. You will be able to cooperate best if you know what is going on, so I will find out how I can arrange to have your glasses and hearing aid available to you in the recovery room.”
I understand you might be more cooperative if you have your aid and glasses, but that is just not possible. Rules, you know.”
44. The male client had fight with his roommates in the psychiatric unit. The client agitated client is placed in isolation for seclusion. The nurse knows it is essential that:
A staff member has frequent contacts with the client.
Restraints are applied.
The client is allowed to come out after 4 hours.
All the furniture is removed form the isolation room.
45. A medical representative comes to the hospital unit for the promotion of a new product. A female client, admitted for hysterical behavior, is found embracing him. What should the nurse say?
“Have you considered birth control?”
“This isn’t the purpose of either of you being here.”
“I see you’ve made a new friend.”
“Think about what you are doing.”
46. A client with dementia is for discharge. The nurse is providing a discharge instruction to the family member regarding safety measures at home. What suggestion can the nurse make to the family members?
Avoid stairs without banisters.
Use restraints while the client is in bed to keep him or her from wandering off during the night.
Use restraints while the client is sitting in a chair to keep him or her from wandering off during the day.
Provide a night-light and a big clock.
47. A 30-year-old married woman comes to the hospital for treatment of fractures. The woman tells the nurse that she was physically abused by her husband. The woman receives a call from her husband telling her to get home and things will be different. He felt sorry of what he did. What can the nurse advise her?
“Do you think so?”
“It’s not likely.”
“What will be different?”
“I hope so, for your sake.”
48. A female client was diagnosed with breast cancer. It is found to be stage IV, and a modified mastectomy is performed. After the procedure, what behaviors could the nurse expects the client to display?
Denial of the possibility of carcinoma.
Signs of grief reaction.
Relief that the operation is over.
Signs of deep depression.
49. A client is withdrawn and does not want to interact to anybody even to the nurse. What is the best initial nursing approach to encourage communication with this client?
Use simple questions that call for a response.
Encourage discussion of feelings.
Look through a photo album together.
Bring up neutral topics.
50. Which of the following nursing approach is most important in a client with depression?
Deemphasizing preoccupation with elimination, nourishment, and sleep.
Protecting against harm to others.
Providing motor outlets for aggressive, hostile feelings.
Reducing interpersonal contacts.
Answers and Rationales
B. This shows a weak sense of moral consciousness. According to Freudian theory, personality disorders stem from a weak superego.
C. The client needs to have his or her feelings acknowledged, with encouragement to discuss feelings, and be reassured about the nurse’s presence.
D. Part of the definition of a crisis is a time span of 4-6 weeks.
C. The client is most likely confused, rather than exhibiting acting-out, hostile behavior. Frequent toileting will allow urination in an appropriate place.
D. The client needs basic, simple orientation that directly relates to the here-and-now, and does not require verbal interaction.
A. Although all options may appear correct. A is the best because it focuses on a range of possible positive reinforcers, a basis for an effective behavior modification program. It can lead to concrete, specific nursing interventions right away and provides a therapeutic use of “control” for the 16-year-old.
A. The nurse needs to wait and see: do not “jump the gun”; do not assume that the client wants to know now.
D. The woman is experiencing an actual loss and will probably exhibit many of the same symptoms as a person who has lost someone to death.
C. This option is an example of pointing out reality- the nurse’s perception.
B. This response asks information that the nurse can use. If the client understands the statement, the nurse can support the therapist when focusing on connection between food, love, and mother. If the client does not understand thestatement, the nurse can help get clarification from the therapist.
C. This option redirects the client to talk to her husband.
D. This is an example of reaction formation, a coping mechanism.
A. Often the verbalized ideas are jumbled, but the underlying feelings are discernible and must be acknowledged.
D. Autistic children do best with solitary play because they typically do not interact with others in a socially comprehensible and acceptable way.
A. The nurse is asking the client to clarify and further discuss feelings.
C. Denial is the act of avoiding disagreeable realities by ignoring them.
B. Reactions when told of a life-threatening illness stem from Kübler-Ross’ ideas on death and dying. Denial is a typical grief response, and usually is a first reaction.
D. Shock and anger are commonly the primary initial reactions.
A. This option avoids external stimuli, yet channels the excess motor activity that is often part of the manic phase.
B. The patient needs a brief, factual answer.
C. Trihexyphenidyl HCI (Artane) is often used to counteract side effect of pseudoparkinsonism, which often accompanies the use of phenothiazine, such as chlorpromazine HCI (Thorazine or Trifluoperazine HCI (Stelazine).
D. Persons with dementia needs sameness, consistency, structure, routine, and predictability.
A. This is a false belief developed in response to an emotional need.
D. The client must be constantly observed.
B. The appetite is diminished and sleeping is affected to a client with depression.
A. It is important to acknowledge a statement, even if it is not understood.
D. Rationalization is the process of constructing plausible reasons for one’s responses.
C. The client has ideas that someone is out to kill her.
D. A serious side effect of Imipramine HCI (Tofranil) is urinary retention (voiding problems)
A. This allows the parents/family to grieve over the loss of the child, by going through the steps of leave taking.
B. Assess for suicidal tendencies, especially during early therapy. There is an increased risk of seizures in debilitated client and those with a history of seizures.
D. The nurse helps to activate by doing something with the client.
C. Preschool children commonly experience fears and fantasies regarding invasive procedures. The nurse should attempts to momentarily distract the child with a simple task that can be easily accomplished while the child remains in the side-lying position. The suppository can be slipped into place while the child is counting, and then the nurse can praise the child for cooperating, while holding the buttocks together to prevent expulsion of the suppository.
A. This is the more inclusive answer, although diet restrictions (answer1) are important, their purpose is to prevent hypertensive crisis (answer 2).
D. This comes closest to beginning to focus on family-centered approach to intervene in the “conspiracy of silence”. This is therefore the best among the options.
A. The nurse should neither challenge nor use logic to dispel an irrational belief.
D. Any threat to the safety of oneself or other should always be taken seriously and never disregarded by the nurse.
C. The likelihood of multiple contributing factors may make this person at higher risk for suicide. Some factors that may exist are physical illness related to alcoholism, emotional factors ( anxiety, guilt, remorse), social isolation due to impaired relationships and economic problems related to employment.
B. A ritual, such as compulsive handwashing, is an attempt to allay anxiety caused by unconscious impulses that are frightening.
D. This is the most neutral answer by process of elimination.
B. This option allows a normal grief response (anger).
C. Personality disorders stem from a weak superego, implying a lack of adequate controls.
C. The client will be easier to care for if he has his hearing aid and glasses.
A. Frequent contacts at times of stress are important, especially when a client is isolated.
B. This response is aimed at redirecting the inappropriate behavior.
D. This option is best to decrease confusion and disorientation to place and time.
C. This option helps the woman to think through and elaborate on her own thoughts and prognosis.
B. It is mostly likely that grief would be expressed because of object loss.
D. Neutral, nonthreatening topics are best in attempting to encourage a response.
C. It is important to externalize the anger away from self.