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Psychiatric Nursing Practice Exam 2 (PM)
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Question 1
Jon a suspicious client states that “I know you nurses are spraying my food with poison as you take it out of the cart.” Which of the following would be the best response of the nurse?
A
Giving the client canned supplements until the delusion subsides
B
Allowing the client to be the first to open the cart and get a tray
C
Serving foods that come in sealed packages
D
Asking what kind of poison the client suspects is being used
Question 1 Explanation:
Allowing the client to be the first to open the cart & take a tray presents the client with the reality that the nurses are not touching the food & tray, thereby dispelling the delusion.
Question 2
Terry with mania is skipping up and down the hallway practically running into other clients. Which of the following activities would the nurse in charge expect to include in Terry’s plan of care?
A
Watching TV
B
Reading a book
C
Cleaning dayroom tables
D
Leading group activity
Question 2 Explanation:
The client with mania is very active & needs to have this energy channeled in a constructive task such as cleaning or tidying the room.
Question 3
Which of the following activities would Nurse Trish recommend to the client who becomes very anxious when thoughts of suicide occur?
A
Using exercise bicycle
B
Meditating
C
Reading comics
D
Watching TV
Question 3 Explanation:
Using exercise bicycle is appropriate for the client who becomes very anxious when thoughts of suicidal occur.
Question 4
Which statement about an individual with a personality disorder is true?
A
The individual usually seeks treatment willingly for symptoms that are personally distressful.
B
Prognosis for recovery is good with therapeutic intervention
C
The individual typically remains in the mainstream of society, although he has problems in social and occupational roles
D
Psychotic behavior is common during acute episodes
Question 4 Explanation:
An individual with personality disorder usually is not hospitalized unless a coexisting Axis I psychiatric disorder is present. Generally, these individuals make marginal adjustments and remain in society, although they typically experience relationship and occupational problems related to their inflexible behaviors. Personality disorders are chronic lifelong patterns of behavior; acute episodes do not occur. Psychotic behavior is usually not common, although it can occur in either schizotypal personality disorder or borderline personality disorder. Because these disorders are enduring and evasive and the individual is inflexible, prognosis for recovery is unfavorable. Generally, the individual does not seek treatment because he does not perceive problems with his own behavior. Distress can occur based on other people’s reaction to the individual’s behavior.
Question 5
One morning, nurse Diane finds a disturbed client curled up in the fetal position in the corner of the dayroom. The most accurate initial evaluation of the behavior would be that the client is:
A
Physically ill and experiencing abdominal discomfort
B
Attempting to hide from the nurse
C
Feeling more anxious today
D
Tired and probably did not sleep well last night
Question 5 Explanation:
The fetal position represents regressed behavior. Regression is a way of responding to overwhelming anxiety.
Question 6
Grace is exhibiting withdrawn patterns of behavior. Nurse Johnny is aware that this type of behavior eventually produces feeling of:
A
Anger
B
Repression
C
Loneliness
D
Paranoia
Question 6 Explanation:
The withdrawn pattern of behavior presents the individual from reaching out to others for sharing the isolation produces feeling of loneliness.
Question 7
When planning care for a male client using paranoid ideation, nurse Jasmin should realize the importance of:
A
Giving the client difficult tasks to provide stimulation
B
Providing the client with activities in which success can be achieved
C
Not placing any demands on the client
D
Removing stress so that the client can relax
Question 7 Explanation:
This will help the client develop self-esteem and reduce the use of paranoid ideation.
Question 8
Nurse Gerry is aware that the defense mechanism commonly used by clients who are alcoholics is:
A
Displacement
B
Denial
C
Projection
D
Compensation
Question 8 Explanation:
Denial is a method of resolving conflict or escaping unpleasant realities by ignoring their existence.
Question 9
A client is suffering from catatonic behaviors. Which of the following would the nurse use to determine that the medication administered PRN have been most effective?
A
The client responds to verbal directions to eat
B
The client is able to move all extremities occasionally
C
The client walks with the nurse to her room
D
The client initiates simple activities without direction
Question 9 Explanation:
Although all the actions indicate improvement, the ability to initiate simple activities without directions indicates the most improvement in the catatonic behaviors.
Question 10
Jerome who has eating disorder often exhibits similar symptoms.Nurse Lhey would expect an adolescent client with anorexia to exhibit:
A
Depersonalization and derealization
B
Affective instability
C
Dishered, unkempt physical appearance
D
Repetitive motor mechanisms
Question 10 Explanation:
Individuals with anorexia often display irritability, hospitality, and a depressed mood.
Question 11
A nursing diagnosis for a male client with a diagnosed multiple personality disorder is chronic low self-esteem probably related to childhood abuse. The most appropriate short term client outcome would be:
A
Verbalizing the need for anxiety medications
B
Engaging in object-oriented activities
C
Recognizing each existing personality
D
Eliminating defense mechanisms and phobia
Question 11 Explanation:
The client must recognize the existence of the sub personalities so that interpretation can occur.
Question 12
What is the priority care for a client with a dementia resulting from AIDS?
A
Planning for remotivational therapy
B
Arranging for long term custodial care
C
Assessing pain frequently
D
Providing basic intellectual stimulation
Question 12 Explanation:
This action maintains for as long as possible, the clients intellectual functions by providing an opportunity to use them.
Question 13
Which of the following would nurse Ronald use as the best measure to determine a client’s progress in rehabilitation?
A
The kinds of friends he makes
B
The number of drug-free days he has
C
The way he gets along with his parents
D
The amount of responsibility his job entails
Question 13 Explanation:
The best measure to determine a client’s progress in rehabilitation is the number of drug- free days he has. The longer the client is free of drugs, the better the prognosis is
Question 14
Which of the following liquids would nurse Leng administer to a female client who is intoxicated with phencyclidine (PCP) to hasten excretion of the chemical?
A
Cranberry Juice
B
Tea
C
Shake
D
Grape juice
Question 14 Explanation:
An acid environment aids in the excretion of PCP. The nurse will definitely give the client with PCP intoxication cranberry juice to acidify the urine to a ph of 5.5 & accelerate excretion.
Question 15
The primary nursing diagnosis for a female client with a medical diagnosis of major depression would be:
A
Spiritual distress related to depression
B
Situational low self-esteem related to altered role
C
Impaired verbal communication related to depression
D
Powerlessness related to the loss of idealized self
Question 15 Explanation:
Depressed clients demonstrate decreased communication because of lack of psychic or physical energy.
Question 16
Nurse Tony should first discuss terminating the nurse-client relationship with a client during the:
A
Termination phase when discharge plans are being made.
B
Working phase when the client brings it up.
C
Orientation phase when a contract is established.
D
Working phase when the client shows some progress.
Question 16 Explanation:
When the nurse and client agree to work together, a contract should be established, the length of the relationship should be discussed in terms of its ultimate termination.
Question 17
One morning a female client on the inpatient psychiatric service complains to nurse Hazel that she has been waiting for over an hour for someone to accompany her to activities. Nurse Hazel replies to the client “We’re doing the best we can. There are a lot of other people on the unit who needs attention too.” This statement shows that the nurse’s use of:
A
Defensive behavior
B
Reality reinforcement
C
Limit-setting behavior
D
Impulse control
Question 17 Explanation:
The nurse’s response is not therapeutic because it does not recognize the client’s needs but tries to make the client feel guilty for being demanding.
Question 18
Within a few hours of alcohol withdrawal, nurse John should assess the male client for the presence of:
Alcohol is a central nervous system depressant. These symptoms are the body’s neurologic adaptation to the withdrawal of alcohol.
Question 19
Joy’s stream of consciousness is occupied exclusively with thoughts of her father’s death. Nurse Ronald should plan to help Joy through this stage of grieving, which is known as:
A
Shock and disbelief
B
Restitution
C
Resolving the loss
D
Developing awareness
Question 19 Explanation:
Resolving a loss is a slow, painful, continuous process until a mental image of the dead person, almost devoid of negative or undesirable features emerges.
Question 20
When asking the parents about the onset of problems in young client with the diagnosis of schizophrenia, Nurse Linda would expect that they would relate the client’s difficulties began in:
A
Adolescence
B
Puberty
C
Late childhood
D
Early childhood
Question 20 Explanation:
The usual age of onset of schizophrenia is adolescence or early childhood.
Question 21
When assessing a female client who is receiving tricyclic antidepressant therapy, which of the following would alert the nurse to the possibility that the client is experiencing anticholinergic effects?
A
Respiratory depression and convulsion
B
Delirium and Sedation
C
Urine retention and blurred vision
D
Tremors and cardiac arrhythmias
Question 21 Explanation:
Anticholinergic effects, which result from blockage of the parasympathetic (craniosacral) nervous system including urine retention, blurred vision, dry mouth & constipation.
Question 22
For a male client with dysthymic disorder, which of the following approaches would the nurse expect to implement?
A
ECT
B
Antidepressant therapy
C
Psychoanalysis
D
Psychotherapeutic approach
Question 22 Explanation:
Dysthymia is a less severe, chronic depression diagnosed when a client has had a depressed mood for more days than not over a period of at least 2 years. Client with dysthymic disorder benefit from psychotherapeutic approaches that assist the client in reversing the negative self image, negative feelings about the future.
Question 23
After administering naloxone (Narcan), an opioid antagonist, Nurse Ronald should monitor the female client carefully for which of the following?
A
Cerebral edema
B
Respiratory depression
C
Epilepsy
D
Kidney failure
Question 23 Explanation:
After administering naloxone (Narcan) the nurse should monitor the client’s respiratory status carefully, because the drug is short acting & respiratory depression may recur after its effects wear off.
Question 24
Tina with a histrionic personality disorder is melodramatic and responds to others and situations in an exaggerated manner. Nurse Trish would recommend which of the following activities for Tina?
A
Baking class
B
Role playing
C
Music group
D
Scrap book making
Question 24 Explanation:
The nurse would use role-playing to teach the client appropriate responses to others and in various situations. This client dramatizes events, drawn attention to self, and is unaware of and does not deal with feelings. The nurse works to help the client clarify true feelings & learn to express them appropriately.
Question 25
Joy has entered the chemical dependency unit for treatment of alcohol dependency. Which of the following client’s possession will the nurse most likely place in a locked area?
A
Moisturizer
B
Toothpaste
C
Shampoo
D
Antiseptic wash
Question 25 Explanation:
Antiseptic mouthwash often contains alcohol & should be kept in locked area, unless labeling clearly indicates that the product does not contain alcohol.
Question 26
When being admitted to a mental health facility, a young female adult tells Nurse Mylene that the voices she hears frighten her.Nurse Mylene understands that the client tends to hallucinate more vividly:
A
During group activities
B
After going to bed
C
During meal time
D
While watching TV
Question 26 Explanation:
Auditory hallucinations are most troublesome when environmental stimuli are diminished and there are few competing distractions.
Question 27
When planning care for Dory with schizotypal personality disorder, which of the following would help the client become involved with others?
A
Participating solely in group activities
B
Leading a sing a long in the afternoon
C
Attending an activity with the nurse
D
Being involved with primarily one to one activities
Question 27 Explanation:
Attending activity with the nurse assists the client to become involved with others slowly. The client with schizotypal personality disorder needs support, kindness & gentle suggestion to improve social skills & interpersonal relationship.
Question 28
Nurse John recognizes that paranoid delusions usually are related to the defense mechanism of:
A
Regression
B
Identification
C
Projection
D
Repression
Question 28 Explanation:
Projection is a mechanism in which inner thoughts and feelings are projected onto the environment, seeming to come from outside the self rather than from within.
Question 29
Joe who is very depressed exhibits psychomotor retardation, a flat affect and apathy. The nurse in charge observes Joe to be in need of grooming and hygiene. Which of the following nursing actions would be most appropriate?
A
Waiting until the client’s family can participate in the client’s care
B
Explaining the importance of hygiene to the client
C
Asking the client if he is ready to take shower
D
Stating to the client that it’s time for him to take a shower
Question 29 Explanation:
The client with depression is preoccupied, has decreased energy, and is unable to make decisions. The nurse presents the situation, “It’s time for a shower”, and assists the client with personal hygiene to preserve his dignity and self-esteem.
Question 30
When taking a health history from a female client who has a moderate level of cognitive impairment due to dementia, the nurse would expect to note the presence of:
A
Enhance intelligence
B
Hyper vigilance
C
Increased inhibitions
D
Accentuated premorbid traits
Question 30 Explanation:
A moderate level of cognitive impairment due to dementia is characterized by increasing dependence on environment & social structure and by increasing psychologic rigidity with accentuated previous traits & behaviors.
Question 31
When developing the plan of care for a client receiving haloperidol, which of the following medications would nurse Monet anticipate administering if the client developed extra pyramidal side effects?
A
Olanzapine (Zyprexa)
B
Lorazepam (Ativan)
C
Paroxetine (Paxil)
D
Benztropine mesylate (Cogentin)
Question 31 Explanation:
The drug of choice for a client experiencing extra pyramidal side effects from haloperidol (Haldol) is benztropine mesylate (cogentin) because of its anti cholinergic properties.
Question 32
The initial nursing intervention for the significant-others during shock phase of a grief reaction should be focused on:
A
Staying with the individuals involved
B
Directing the individual’s activities at this time
C
Mobilizing the individual’s support system
D
Presenting full reality of the loss of the individuals
Question 32 Explanation:
This provides support until the individuals coping mechanisms and personal support systems can be immobilized.
Question 33
The nursing assistant tells nurse Ronald that the client is not in the dining room for lunch. Nurse Ronald would direct the nursing assistant to do which of the following?
A
Invite the client to lunch and accompany him to the dining room
B
Take the client a lunch tray and let the client eat in his room
C
Inform the client that he has 10 minutes to get to the dining room for lunch
D
Tell the client he’ll need to wait until supper to eat if he misses lunch
Question 33 Explanation:
The nurse instructs the nursing assistant to invite the client to lunch & accompany him to the dinning room to decrease manipulation, secondary gain, dependency and reinforcement of negative behavior while maintaining the client’s worth.
Question 34
Malou is diagnosed with major depression spends majority of the day lying in bed with the sheet pulled over his head. Which of the following approaches by the nurse would be the most therapeutic?
A
Initiate contact with the client frequently
B
Wait for the client to begin the conversation
C
Sit outside the clients room
D
Question the client until he responds
Question 34 Explanation:
The nurse should initiate brief, frequent contacts throughout the day to let the client know that he is important to the nurse. This will positively affect the client’s self-esteem.
Question 35
Jose who has been hospitalized with schizophrenia tells Nurse Ron, “My heart has stopped and my veins have turned to glass!” Nurse Ron is aware that this is an example of:
A
Depersonalization
B
Echolalia
C
Somatic delusions
D
Hypochondriasis
Question 35 Explanation:
Somatic delusion is a fixed false belief about one’s body.
Question 36
When developing an initial nursing care plan for a male client with a Bipolar I disorder (manic episode) nurse Ron should plan to?
A
Encourage his active participation in unit programs
B
Provide foods, fluids and rest
C
Isolate his gym tim
D
Encourage his participation in programs
Question 36 Explanation:
The client in a manic episode of the illness often neglects basic needs, these needs are a priority to ensure adequate nutrition, fluid, and rest.
Question 37
Jose is diagnosed withamphetamine psychosis and was admitted in the emergency room.Nurse Ronald would most likely prepare to administer which of the following medication?
A
Ativan
B
Librium
C
Haldol
D
Valium
Question 37 Explanation:
The nurse would prepare to administer an antipsychotic medication such as Haldol to a client experiencing amphetamine psychosis to decrease agitation & psychotic symptoms, including delusions, hallucinations & cognitive impairment.
Question 38
Nurse Hazel invites new client’s parents to attend the psycho educational program for families of the chronically mentally ill. The program would be most likely to help the family with which of the following issues?
A
Managing their financial concern and problems
B
Feeling more guilty about the client’s illness
C
Recognizing the client’s weakness
D
Developing a support network with other families
Question 38 Explanation:
Psychoeducational groups for families develop a support network. They provide education about the biochemical etiology of psychiatric disease to reduce, not increase family guilt.
Question 39
When teaching Mario with a typical depression about foods to avoid while taking phenelzine(Nardil), which of the following would the nurse in charge include?
A
Hamburger
B
Fresh fish
C
Salami
D
Roasted chicken
Question 39 Explanation:
Foods high in tyramine, those that are fermented, pickled, aged, or smoked must be avoided because when they are ingested in combination with MAOIs a hypertensive crisis will occur.
Question 40
When assessing a male client for suicidal risk, which of the following methods of suicide would the nurse identify as most lethal?
A
Head banging
B
Use of gun
C
Wrist cutting
D
Aspirin overdose
Question 40 Explanation:
A crucial factor is determining the lethality of a method is the amount of time that occurs between initiating the method & the delivery of the lethal impact of the method.
Question 41
Danny who is diagnosed with bipolar disorder and acute mania, states the nurse, “Where is my daughter? I love Louis. Rain, rain go away. Dogs eat dirt.” The nurse interprets these statements as indicating which of the following?
A
Clang associations
B
Echolalia
C
Neologism
D
Flight of ideas
Question 41 Explanation:
Flight of ideas is speech pattern of rapid transition from topic to topic, often without finishing one idea. It is common in mania.
Question 42
When developing a plan of care for a female client with acute stress disorder who lost her sister in a car accident. Which of the following would the nurse expect to initiate?
A
Helping the client to evaluate her sister’s behavior
B
Telling the client to avoid details of the accident
C
Facilitating progressive review of the accident and its consequences
D
Postponing discussion of the accident until the client brings it up
Question 42 Explanation:
The nurse would facilitate progressive review of the accident and its consequence to help the client integrate feelings & memories and to begin the grieving process.
Question 43
In recognizing common behaviors exhibited by male client who has a diagnosis of schizophrenia, nurse Josie can anticipate:
A
Slumped posture, pessimistic out look and flight of ideas
B
Disorientation, forgetfulness and anxiety
C
Withdrawal, regressed behavior and lack of social skills
D
Grandiosity, arrogance and distractibility
Question 43 Explanation:
These are the classic behaviors exhibited by clients with a diagnosis of schizophrenia.
Question 44
Jun has been hospitalized for major depression and suicidal ideation. Which of the following statements indicates to the nurse that the client is improving?
A
“I don’t think about killing myself as much as I used to.”
B
“I’m of no use to anyone anymore.”
C
“I couldn’t kill myself because I don’t want to go to hell.”
D
“I know my kids don’t need me anymore since they’re grown.”
Question 44 Explanation:
The statement “I don’t think about killing myself as much as I used to.” Indicates a lessening of suicidal ideation and improvement in the client’s condition.
Question 45
Joey who has a chronic user of cocaine reports that he feels like he has cockroaches crawling under his skin. His arms are red because of scratching. The nurse in charge interprets these findings as possibly indicating which of the following?
A
Flash back
B
Delusion
C
Formication
D
Confusion
Question 45 Explanation:
The feeling of bugs crawling under the skin is termed as formication, and is associated with cocaine use.
Question 46
.A female client is brought by ambulance to the hospital emergency room after taking an overdose of barbiturates is comatose. Nurse Trish would be especially alert for which of the following?
A
Respiratory failure
B
Renal failure
C
Epilepsy
D
Myocardial Infarction
Question 46 Explanation:
Barbiturates are CNS depressants; the nurse would be especially alert for the possibility of respiratory failure. Respiratory failure is the most likely cause of death from barbiturate over dose.
Question 47
Nurse John is talking with a client who has been diagnosed with antisocial personality about how to socialize during activities without being seductive. Nurse John would focus the discussion on which of the following areas?
A
Asking him to explain reasons for his seductive behavior
B
Discussing his relationship with his mother
C
Suggesting to apologize to others for his behavior
D
Explaining the negative reactions of others toward his behavior
Question 47 Explanation:
The nurse would explain the negative reactions of others towards the client’s behaviors to make the clients aware of the impact of his seductive behaviors on others.
Question 48
Which of the following assessment would provide the best information about the client’s physiologic response and the effectiveness of the medication prescribed specifically for alcohol withdrawal?
A
Nutritional status
B
Mental alertness
C
Vital signs
D
Sleeping pattern
Question 48 Explanation:
Monitoring of vital signs provides the best information about the client’s overall physiologic status during alcohol withdrawal & the physiologic response to the medication used.
Question 49
Nurse Bea notices a female client sitting alone in the corner smiling and talking to herself.Realizing that the client is hallucinating. Nurse Bea should:
A
Invite the client to help decorate the dayroom
B
Ask the client why he is smiling and talking
C
Leave the client alone until he stops talking
D
Tell the client it is not good for him to talk to himself
Question 49 Explanation:
This provides a stimulus that competes with and reduces hallucination.
Question 50
A 25 year old male is admitted to a mental health facility because of inappropriate behavior. The client has been hearing voices, responding to imaginary companions and withdrawing to his room for several days at a time. Nurse Monette understands that the withdrawal is a defense against the client’s fear of:
A
Rejection
B
Phobia
C
Punishment
D
Powerlessness
Question 50 Explanation:
An aloof, detached, withdrawn posture is a means of protecting the self by withdrawing and maintaining a safe, emotional distance.
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Exam Mode – Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam.
Psychiatric Nursing Practice Exam 2 (EM)
Choose the letter of the correct answer. You got 50 minutes to finish the exam .Good luck!
Start
Congratulations - you have completed Psychiatric Nursing Practice Exam 2 (EM).
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%%
Your answers are highlighted below.
Question 1
Which of the following liquids would nurse Leng administer to a female client who is intoxicated with phencyclidine (PCP) to hasten excretion of the chemical?
A
Cranberry Juice
B
Shake
C
Tea
D
Grape juice
Question 1 Explanation:
An acid environment aids in the excretion of PCP. The nurse will definitely give the client with PCP intoxication cranberry juice to acidify the urine to a ph of 5.5 & accelerate excretion.
Question 2
Terry with mania is skipping up and down the hallway practically running into other clients. Which of the following activities would the nurse in charge expect to include in Terry’s plan of care?
A
Watching TV
B
Reading a book
C
Leading group activity
D
Cleaning dayroom tables
Question 2 Explanation:
The client with mania is very active & needs to have this energy channeled in a constructive task such as cleaning or tidying the room.
Question 3
After administering naloxone (Narcan), an opioid antagonist, Nurse Ronald should monitor the female client carefully for which of the following?
A
Kidney failure
B
Cerebral edema
C
Epilepsy
D
Respiratory depression
Question 3 Explanation:
After administering naloxone (Narcan) the nurse should monitor the client’s respiratory status carefully, because the drug is short acting & respiratory depression may recur after its effects wear off.
Question 4
For a male client with dysthymic disorder, which of the following approaches would the nurse expect to implement?
A
Psychotherapeutic approach
B
Antidepressant therapy
C
ECT
D
Psychoanalysis
Question 4 Explanation:
Dysthymia is a less severe, chronic depression diagnosed when a client has had a depressed mood for more days than not over a period of at least 2 years. Client with dysthymic disorder benefit from psychotherapeutic approaches that assist the client in reversing the negative self image, negative feelings about the future.
Question 5
Malou is diagnosed with major depression spends majority of the day lying in bed with the sheet pulled over his head. Which of the following approaches by the nurse would be the most therapeutic?
A
Question the client until he responds
B
Sit outside the clients room
C
Wait for the client to begin the conversation
D
Initiate contact with the client frequently
Question 5 Explanation:
The nurse should initiate brief, frequent contacts throughout the day to let the client know that he is important to the nurse. This will positively affect the client’s self-esteem.
Question 6
When teaching Mario with a typical depression about foods to avoid while taking phenelzine(Nardil), which of the following would the nurse in charge include?
A
Hamburger
B
Fresh fish
C
Roasted chicken
D
Salami
Question 6 Explanation:
Foods high in tyramine, those that are fermented, pickled, aged, or smoked must be avoided because when they are ingested in combination with MAOIs a hypertensive crisis will occur.
Question 7
In recognizing common behaviors exhibited by male client who has a diagnosis of schizophrenia, nurse Josie can anticipate:
A
Disorientation, forgetfulness and anxiety
B
Slumped posture, pessimistic out look and flight of ideas
C
Withdrawal, regressed behavior and lack of social skills
D
Grandiosity, arrogance and distractibility
Question 7 Explanation:
These are the classic behaviors exhibited by clients with a diagnosis of schizophrenia.
Question 8
Jose who has been hospitalized with schizophrenia tells Nurse Ron, “My heart has stopped and my veins have turned to glass!” Nurse Ron is aware that this is an example of:
A
Depersonalization
B
Somatic delusions
C
Hypochondriasis
D
Echolalia
Question 8 Explanation:
Somatic delusion is a fixed false belief about one’s body.
Question 9
Nurse Gerry is aware that the defense mechanism commonly used by clients who are alcoholics is:
A
Displacement
B
Denial
C
Compensation
D
Projection
Question 9 Explanation:
Denial is a method of resolving conflict or escaping unpleasant realities by ignoring their existence.
Question 10
One morning, nurse Diane finds a disturbed client curled up in the fetal position in the corner of the dayroom. The most accurate initial evaluation of the behavior would be that the client is:
A
Feeling more anxious today
B
Attempting to hide from the nurse
C
Physically ill and experiencing abdominal discomfort
D
Tired and probably did not sleep well last night
Question 10 Explanation:
The fetal position represents regressed behavior. Regression is a way of responding to overwhelming anxiety.
Question 11
When taking a health history from a female client who has a moderate level of cognitive impairment due to dementia, the nurse would expect to note the presence of:
A
Enhance intelligence
B
Accentuated premorbid traits
C
Hyper vigilance
D
Increased inhibitions
Question 11 Explanation:
A moderate level of cognitive impairment due to dementia is characterized by increasing dependence on environment & social structure and by increasing psychologic rigidity with accentuated previous traits & behaviors.
Question 12
A client is suffering from catatonic behaviors. Which of the following would the nurse use to determine that the medication administered PRN have been most effective?
A
The client walks with the nurse to her room
B
The client is able to move all extremities occasionally
C
The client responds to verbal directions to eat
D
The client initiates simple activities without direction
Question 12 Explanation:
Although all the actions indicate improvement, the ability to initiate simple activities without directions indicates the most improvement in the catatonic behaviors.
Question 13
Jose is diagnosed withamphetamine psychosis and was admitted in the emergency room.Nurse Ronald would most likely prepare to administer which of the following medication?
A
Librium
B
Valium
C
Haldol
D
Ativan
Question 13 Explanation:
The nurse would prepare to administer an antipsychotic medication such as Haldol to a client experiencing amphetamine psychosis to decrease agitation & psychotic symptoms, including delusions, hallucinations & cognitive impairment.
Question 14
When asking the parents about the onset of problems in young client with the diagnosis of schizophrenia, Nurse Linda would expect that they would relate the client’s difficulties began in:
A
Adolescence
B
Late childhood
C
Puberty
D
Early childhood
Question 14 Explanation:
The usual age of onset of schizophrenia is adolescence or early childhood.
Question 15
Joe who is very depressed exhibits psychomotor retardation, a flat affect and apathy. The nurse in charge observes Joe to be in need of grooming and hygiene. Which of the following nursing actions would be most appropriate?
A
Explaining the importance of hygiene to the client
B
Asking the client if he is ready to take shower
C
Waiting until the client’s family can participate in the client’s care
D
Stating to the client that it’s time for him to take a shower
Question 15 Explanation:
The client with depression is preoccupied, has decreased energy, and is unable to make decisions. The nurse presents the situation, “It’s time for a shower”, and assists the client with personal hygiene to preserve his dignity and self-esteem.
Question 16
Jun has been hospitalized for major depression and suicidal ideation. Which of the following statements indicates to the nurse that the client is improving?
A
“I’m of no use to anyone anymore.”
B
“I don’t think about killing myself as much as I used to.”
C
“I know my kids don’t need me anymore since they’re grown.”
D
“I couldn’t kill myself because I don’t want to go to hell.”
Question 16 Explanation:
The statement “I don’t think about killing myself as much as I used to.” Indicates a lessening of suicidal ideation and improvement in the client’s condition.
Question 17
When being admitted to a mental health facility, a young female adult tells Nurse Mylene that the voices she hears frighten her.Nurse Mylene understands that the client tends to hallucinate more vividly:
A
After going to bed
B
During meal time
C
During group activities
D
While watching TV
Question 17 Explanation:
Auditory hallucinations are most troublesome when environmental stimuli are diminished and there are few competing distractions.
Question 18
Nurse John is talking with a client who has been diagnosed with antisocial personality about how to socialize during activities without being seductive. Nurse John would focus the discussion on which of the following areas?
A
Explaining the negative reactions of others toward his behavior
B
Asking him to explain reasons for his seductive behavior
C
Discussing his relationship with his mother
D
Suggesting to apologize to others for his behavior
Question 18 Explanation:
The nurse would explain the negative reactions of others towards the client’s behaviors to make the clients aware of the impact of his seductive behaviors on others.
Question 19
The primary nursing diagnosis for a female client with a medical diagnosis of major depression would be:
A
Spiritual distress related to depression
B
Situational low self-esteem related to altered role
C
Impaired verbal communication related to depression
D
Powerlessness related to the loss of idealized self
Question 19 Explanation:
Depressed clients demonstrate decreased communication because of lack of psychic or physical energy.
Question 20
When planning care for a male client using paranoid ideation, nurse Jasmin should realize the importance of:
A
Removing stress so that the client can relax
B
Providing the client with activities in which success can be achieved
C
Not placing any demands on the client
D
Giving the client difficult tasks to provide stimulation
Question 20 Explanation:
This will help the client develop self-esteem and reduce the use of paranoid ideation.
Question 21
Nurse Tony should first discuss terminating the nurse-client relationship with a client during the:
A
Working phase when the client shows some progress.
B
Termination phase when discharge plans are being made.
C
Orientation phase when a contract is established.
D
Working phase when the client brings it up.
Question 21 Explanation:
When the nurse and client agree to work together, a contract should be established, the length of the relationship should be discussed in terms of its ultimate termination.
Question 22
Joy has entered the chemical dependency unit for treatment of alcohol dependency. Which of the following client’s possession will the nurse most likely place in a locked area?
A
Shampoo
B
Antiseptic wash
C
Moisturizer
D
Toothpaste
Question 22 Explanation:
Antiseptic mouthwash often contains alcohol & should be kept in locked area, unless labeling clearly indicates that the product does not contain alcohol.
Question 23
Joey who has a chronic user of cocaine reports that he feels like he has cockroaches crawling under his skin. His arms are red because of scratching. The nurse in charge interprets these findings as possibly indicating which of the following?
A
Formication
B
Delusion
C
Flash back
D
Confusion
Question 23 Explanation:
The feeling of bugs crawling under the skin is termed as formication, and is associated with cocaine use.
Question 24
Nurse Hazel invites new client’s parents to attend the psycho educational program for families of the chronically mentally ill. The program would be most likely to help the family with which of the following issues?
A
Managing their financial concern and problems
B
Developing a support network with other families
C
Feeling more guilty about the client’s illness
D
Recognizing the client’s weakness
Question 24 Explanation:
Psychoeducational groups for families develop a support network. They provide education about the biochemical etiology of psychiatric disease to reduce, not increase family guilt.
Question 25
A nursing diagnosis for a male client with a diagnosed multiple personality disorder is chronic low self-esteem probably related to childhood abuse. The most appropriate short term client outcome would be:
A
Eliminating defense mechanisms and phobia
B
Recognizing each existing personality
C
Engaging in object-oriented activities
D
Verbalizing the need for anxiety medications
Question 25 Explanation:
The client must recognize the existence of the sub personalities so that interpretation can occur.
Question 26
Tina with a histrionic personality disorder is melodramatic and responds to others and situations in an exaggerated manner. Nurse Trish would recommend which of the following activities for Tina?
A
Scrap book making
B
Baking class
C
Music group
D
Role playing
Question 26 Explanation:
The nurse would use role-playing to teach the client appropriate responses to others and in various situations. This client dramatizes events, drawn attention to self, and is unaware of and does not deal with feelings. The nurse works to help the client clarify true feelings & learn to express them appropriately.
Question 27
Joy’s stream of consciousness is occupied exclusively with thoughts of her father’s death. Nurse Ronald should plan to help Joy through this stage of grieving, which is known as:
A
Restitution
B
Developing awareness
C
Resolving the loss
D
Shock and disbelief
Question 27 Explanation:
Resolving a loss is a slow, painful, continuous process until a mental image of the dead person, almost devoid of negative or undesirable features emerges.
Question 28
Which statement about an individual with a personality disorder is true?
A
Prognosis for recovery is good with therapeutic intervention
B
Psychotic behavior is common during acute episodes
C
The individual usually seeks treatment willingly for symptoms that are personally distressful.
D
The individual typically remains in the mainstream of society, although he has problems in social and occupational roles
Question 28 Explanation:
An individual with personality disorder usually is not hospitalized unless a coexisting Axis I psychiatric disorder is present. Generally, these individuals make marginal adjustments and remain in society, although they typically experience relationship and occupational problems related to their inflexible behaviors. Personality disorders are chronic lifelong patterns of behavior; acute episodes do not occur. Psychotic behavior is usually not common, although it can occur in either schizotypal personality disorder or borderline personality disorder. Because these disorders are enduring and evasive and the individual is inflexible, prognosis for recovery is unfavorable. Generally, the individual does not seek treatment because he does not perceive problems with his own behavior. Distress can occur based on other people’s reaction to the individual’s behavior.
Question 29
One morning a female client on the inpatient psychiatric service complains to nurse Hazel that she has been waiting for over an hour for someone to accompany her to activities. Nurse Hazel replies to the client “We’re doing the best we can. There are a lot of other people on the unit who needs attention too.” This statement shows that the nurse’s use of:
A
Limit-setting behavior
B
Reality reinforcement
C
Impulse control
D
Defensive behavior
Question 29 Explanation:
The nurse’s response is not therapeutic because it does not recognize the client’s needs but tries to make the client feel guilty for being demanding.
Question 30
Jon a suspicious client states that “I know you nurses are spraying my food with poison as you take it out of the cart.” Which of the following would be the best response of the nurse?
A
Giving the client canned supplements until the delusion subsides
B
Serving foods that come in sealed packages
C
Asking what kind of poison the client suspects is being used
D
Allowing the client to be the first to open the cart and get a tray
Question 30 Explanation:
Allowing the client to be the first to open the cart & take a tray presents the client with the reality that the nurses are not touching the food & tray, thereby dispelling the delusion.
Question 31
When developing an initial nursing care plan for a male client with a Bipolar I disorder (manic episode) nurse Ron should plan to?
A
Encourage his participation in programs
B
Isolate his gym tim
C
Provide foods, fluids and rest
D
Encourage his active participation in unit programs
Question 31 Explanation:
The client in a manic episode of the illness often neglects basic needs, these needs are a priority to ensure adequate nutrition, fluid, and rest.
Question 32
When developing the plan of care for a client receiving haloperidol, which of the following medications would nurse Monet anticipate administering if the client developed extra pyramidal side effects?
A
Lorazepam (Ativan)
B
Olanzapine (Zyprexa)
C
Benztropine mesylate (Cogentin)
D
Paroxetine (Paxil)
Question 32 Explanation:
The drug of choice for a client experiencing extra pyramidal side effects from haloperidol (Haldol) is benztropine mesylate (cogentin) because of its anti cholinergic properties.
Question 33
What is the priority care for a client with a dementia resulting from AIDS?
A
Assessing pain frequently
B
Arranging for long term custodial care
C
Providing basic intellectual stimulation
D
Planning for remotivational therapy
Question 33 Explanation:
This action maintains for as long as possible, the clients intellectual functions by providing an opportunity to use them.
Question 34
Nurse John recognizes that paranoid delusions usually are related to the defense mechanism of:
A
Repression
B
Regression
C
Projection
D
Identification
Question 34 Explanation:
Projection is a mechanism in which inner thoughts and feelings are projected onto the environment, seeming to come from outside the self rather than from within.
Question 35
Within a few hours of alcohol withdrawal, nurse John should assess the male client for the presence of:
Alcohol is a central nervous system depressant. These symptoms are the body’s neurologic adaptation to the withdrawal of alcohol.
Question 36
A 25 year old male is admitted to a mental health facility because of inappropriate behavior. The client has been hearing voices, responding to imaginary companions and withdrawing to his room for several days at a time. Nurse Monette understands that the withdrawal is a defense against the client’s fear of:
A
Powerlessness
B
Punishment
C
Rejection
D
Phobia
Question 36 Explanation:
An aloof, detached, withdrawn posture is a means of protecting the self by withdrawing and maintaining a safe, emotional distance.
Question 37
.A female client is brought by ambulance to the hospital emergency room after taking an overdose of barbiturates is comatose. Nurse Trish would be especially alert for which of the following?
A
Respiratory failure
B
Epilepsy
C
Renal failure
D
Myocardial Infarction
Question 37 Explanation:
Barbiturates are CNS depressants; the nurse would be especially alert for the possibility of respiratory failure. Respiratory failure is the most likely cause of death from barbiturate over dose.
Question 38
Which of the following would nurse Ronald use as the best measure to determine a client’s progress in rehabilitation?
A
The way he gets along with his parents
B
The kinds of friends he makes
C
The amount of responsibility his job entails
D
The number of drug-free days he has
Question 38 Explanation:
The best measure to determine a client’s progress in rehabilitation is the number of drug- free days he has. The longer the client is free of drugs, the better the prognosis is
Question 39
When planning care for Dory with schizotypal personality disorder, which of the following would help the client become involved with others?
A
Being involved with primarily one to one activities
B
Participating solely in group activities
C
Attending an activity with the nurse
D
Leading a sing a long in the afternoon
Question 39 Explanation:
Attending activity with the nurse assists the client to become involved with others slowly. The client with schizotypal personality disorder needs support, kindness & gentle suggestion to improve social skills & interpersonal relationship.
Question 40
Nurse Bea notices a female client sitting alone in the corner smiling and talking to herself.Realizing that the client is hallucinating. Nurse Bea should:
A
Leave the client alone until he stops talking
B
Tell the client it is not good for him to talk to himself
C
Ask the client why he is smiling and talking
D
Invite the client to help decorate the dayroom
Question 40 Explanation:
This provides a stimulus that competes with and reduces hallucination.
Question 41
The initial nursing intervention for the significant-others during shock phase of a grief reaction should be focused on:
A
Staying with the individuals involved
B
Presenting full reality of the loss of the individuals
C
Mobilizing the individual’s support system
D
Directing the individual’s activities at this time
Question 41 Explanation:
This provides support until the individuals coping mechanisms and personal support systems can be immobilized.
Question 42
Danny who is diagnosed with bipolar disorder and acute mania, states the nurse, “Where is my daughter? I love Louis. Rain, rain go away. Dogs eat dirt.” The nurse interprets these statements as indicating which of the following?
A
Flight of ideas
B
Clang associations
C
Echolalia
D
Neologism
Question 42 Explanation:
Flight of ideas is speech pattern of rapid transition from topic to topic, often without finishing one idea. It is common in mania.
Question 43
When assessing a female client who is receiving tricyclic antidepressant therapy, which of the following would alert the nurse to the possibility that the client is experiencing anticholinergic effects?
A
Respiratory depression and convulsion
B
Urine retention and blurred vision
C
Tremors and cardiac arrhythmias
D
Delirium and Sedation
Question 43 Explanation:
Anticholinergic effects, which result from blockage of the parasympathetic (craniosacral) nervous system including urine retention, blurred vision, dry mouth & constipation.
Question 44
When assessing a male client for suicidal risk, which of the following methods of suicide would the nurse identify as most lethal?
A
Aspirin overdose
B
Wrist cutting
C
Use of gun
D
Head banging
Question 44 Explanation:
A crucial factor is determining the lethality of a method is the amount of time that occurs between initiating the method & the delivery of the lethal impact of the method.
Question 45
Which of the following assessment would provide the best information about the client’s physiologic response and the effectiveness of the medication prescribed specifically for alcohol withdrawal?
A
Sleeping pattern
B
Nutritional status
C
Vital signs
D
Mental alertness
Question 45 Explanation:
Monitoring of vital signs provides the best information about the client’s overall physiologic status during alcohol withdrawal & the physiologic response to the medication used.
Question 46
Which of the following activities would Nurse Trish recommend to the client who becomes very anxious when thoughts of suicide occur?
A
Watching TV
B
Using exercise bicycle
C
Meditating
D
Reading comics
Question 46 Explanation:
Using exercise bicycle is appropriate for the client who becomes very anxious when thoughts of suicidal occur.
Question 47
Grace is exhibiting withdrawn patterns of behavior. Nurse Johnny is aware that this type of behavior eventually produces feeling of:
A
Paranoia
B
Anger
C
Loneliness
D
Repression
Question 47 Explanation:
The withdrawn pattern of behavior presents the individual from reaching out to others for sharing the isolation produces feeling of loneliness.
Question 48
The nursing assistant tells nurse Ronald that the client is not in the dining room for lunch. Nurse Ronald would direct the nursing assistant to do which of the following?
A
Invite the client to lunch and accompany him to the dining room
B
Take the client a lunch tray and let the client eat in his room
C
Tell the client he’ll need to wait until supper to eat if he misses lunch
D
Inform the client that he has 10 minutes to get to the dining room for lunch
Question 48 Explanation:
The nurse instructs the nursing assistant to invite the client to lunch & accompany him to the dinning room to decrease manipulation, secondary gain, dependency and reinforcement of negative behavior while maintaining the client’s worth.
Question 49
Jerome who has eating disorder often exhibits similar symptoms.Nurse Lhey would expect an adolescent client with anorexia to exhibit:
A
Depersonalization and derealization
B
Repetitive motor mechanisms
C
Affective instability
D
Dishered, unkempt physical appearance
Question 49 Explanation:
Individuals with anorexia often display irritability, hospitality, and a depressed mood.
Question 50
When developing a plan of care for a female client with acute stress disorder who lost her sister in a car accident. Which of the following would the nurse expect to initiate?
A
Telling the client to avoid details of the accident
B
Facilitating progressive review of the accident and its consequences
C
Helping the client to evaluate her sister’s behavior
D
Postponing discussion of the accident until the client brings it up
Question 50 Explanation:
The nurse would facilitate progressive review of the accident and its consequence to help the client integrate feelings & memories and to begin the grieving process.
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1. Nurse Tony should first discuss terminating the nurse-client relationship with a client during the:
Termination phase when discharge plans are being made.
Working phase when the client shows some progress.
Orientation phase when a contract is established.
Working phase when the client brings it up.
2. Malou is diagnosed with major depression spends majority of the day lying in bed with the sheet pulled over his head. Which of the following approaches by the nurse would be the most therapeutic?
Question the client until he responds
Initiate contact with the client frequently
Sit outside the clients room
Wait for the client to begin the conversation
3. Joe who is very depressed exhibits psychomotor retardation, a flat affect and apathy. The nurse in charge observes Joe to be in need of grooming and hygiene. Which of the following nursing actions would be most appropriate?
Waiting until the client’s family can participate in the client’s care
Asking the client if he is ready to take shower
Explaining the importance of hygiene to the client
Stating to the client that it’s time for him to take a shower
4. When teaching Mario with a typical depression about foods to avoid while taking phenelzine(Nardil), which of the following would the nurse in charge include?
Roasted chicken
Fresh fish
Salami
Hamburger
5. When assessing a female client who is receiving tricyclic antidepressant therapy, which of the following would alert the nurse to the possibility that the client is experiencing anticholinergic effects?
Urine retention and blurred vision
Respiratory depression and convulsion
Delirium and Sedation
Tremors and cardiac arrhythmias
6. For a male client with dysthymic disorder, which of the following approaches would the nurse expect to implement?
ECT
Psychotherapeutic approach
Psychoanalysis
Antidepressant therapy
7. Danny who is diagnosed with bipolar disorder and acute mania, states the nurse, “Where is my daughter? I love Louis. Rain, rain go away. Dogs eat dirt.” The nurse interprets these statements as indicating which of the following?
Echolalia
Neologism
Clang associations
Flight of ideas
8. Terry with mania is skipping up and down the hallway practically running into other clients. Which of the following activities would the nurse in charge expect to include in Terry’s plan of care?
Watching TV
Cleaning dayroom tables
Leading group activity
Reading a book
9. When assessing a male client for suicidal risk, which of the following methods of suicide would the nurse identify as most lethal?
Wrist cutting
Head banging
Use of gun
Aspirin overdose
10. Jun has been hospitalized for major depression and suicidal ideation. Which of the following statements indicates to the nurse that the client is improving?
“I’m of no use to anyone anymore.”
“I know my kids don’t need me anymore since they’re grown.”
“I couldn’t kill myself because I don’t want to go to hell.”
“I don’t think about killing myself as much as I used to.”
11. Which of the following activities would Nurse Trish recommend to the client who becomes very anxious when thoughts of suicide occur?
Using exercise bicycle
Meditating
Watching TV
Reading comics
12. When developing the plan of care for a client receiving haloperidol, which of the following medications would nurse Monet anticipate administering if the client developed extra pyramidal side effects?
Olanzapine (Zyprexa)
Paroxetine (Paxil)
Benztropine mesylate (Cogentin)
Lorazepam (Ativan)
13. Jon a suspicious client states that “I know you nurses are spraying my food with poison as you take it out of the cart.” Which of the following would be the best response of the nurse?
Giving the client canned supplements until the delusion subsides
Asking what kind of poison the client suspects is being used
Serving foods that come in sealed packages
Allowing the client to be the first to open the cart and get a tray
14. A client is suffering from catatonic behaviors. Which of the following would the nurse use to determine that the medication administered PRN have been most effective?
The client responds to verbal directions to eat
The client initiates simple activities without direction
The client walks with the nurse to her room
The client is able to move all extremities occasionally
15. Nurse Hazel invites new client’s parents to attend the psycho educational program for families of the chronically mentally ill. The program would be most likely to help the family with which of the following issues?
Developing a support network with other families
Feeling more guilty about the client’s illness
Recognizing the client’s weakness
Managing their financial concern and problems
16. When planning care for Dory with schizotypal personality disorder, which of the following would help the client become involved with others?
Attending an activity with the nurse
Leading a sing a long in the afternoon
Participating solely in group activities
Being involved with primarily one to one activities
17. Which statement about an individual with a personality disorder is true?
Psychotic behavior is common during acute episodes
Prognosis for recovery is good with therapeutic intervention
The individual typically remains in the mainstream of society, although he has problems in social and occupational roles
The individual usually seeks treatment willingly for symptoms that are personally distressful.
18. Nurse John is talking with a client who has been diagnosed with antisocial personality about how to socialize during activities without being seductive. Nurse John would focus the discussion on which of the following areas?
Discussing his relationship with his mother
Asking him to explain reasons for his seductive behavior
Suggesting to apologize to others for his behavior
Explaining the negative reactions of others toward his behavior
19. Tina with a histrionic personality disorder is melodramatic and responds to others and situations in an exaggerated manner. Nurse Trish would recommend which of the following activities for Tina?
Baking class
Role playing
Scrap book making
Music group
20. Joy has entered the chemical dependency unit for treatment of alcohol dependency. Which of the following client’s possession will the nurse most likely place in a locked area?
Toothpaste
Shampoo
Antiseptic wash
Moisturizer
21. Which of the following assessment would provide the best information about the client’s physiologic response and the effectiveness of the medication prescribed specifically for alcohol withdrawal?
Sleeping pattern
Mental alertness
Nutritional status
Vital signs
22. After administering naloxone (Narcan), an opioid antagonist, Nurse Ronald should monitor the female client carefully for which of the following?
Respiratory depression
Epilepsy
Kidney failure
Cerebral edema
23. Which of the following would nurse Ronald use as the best measure to determine a client’s progress in rehabilitation?
The way he gets along with his parents
The number of drug-free days he has
The kinds of friends he makes
The amount of responsibility his job entails
24. A female client is brought by ambulance to the hospital emergency room after taking an overdose of barbiturates is comatose. Nurse Trish would be especially alert for which of the following?
Epilepsy
Myocardial Infarction
Renal failure
Respiratory failure
25. Joey who has a chronic user of cocaine reports that he feels like he has cockroaches crawling under his skin. His arms are red because of scratching. The nurse in charge interprets these findings as possibly indicating which of the following?
Delusion
Formication
Flash back
Confusion
26. Jose is diagnosed with amphetamine psychosis and was admitted in the emergency room. Nurse Ronald would most likely prepare to administer which of the following medication?
Librium
Valium
Ativan
Haldol
27. Which of the following liquids would nurse Leng administer to a female client who is intoxicated with phencyclidine (PCP) to hasten excretion of the chemical?
Shake
Tea
Cranberry Juice
Grape juice
28. When developing a plan of care for a female client with acute stress disorder who lost her sister in a car accident. Which of the following would the nurse expect to initiate?
Facilitating progressive review of the accident and its consequences
Postponing discussion of the accident until the client brings it up
Telling the client to avoid details of the accident
Helping the client to evaluate her sister’s behavior
29. The nursing assistant tells nurse Ronald that the client is not in the dining room for lunch. Nurse Ronald would direct the nursing assistant to do which of the following?
Tell the client he’ll need to wait until supper to eat if he misses lunch
Invite the client to lunch and accompany him to the dining room
Inform the client that he has 10 minutes to get to the dining room for lunch
Take the client a lunch tray and let the client eat in his room
30. The initial nursing intervention for the significant-others during shock phase of a grief reaction should be focused on:
Presenting full reality of the loss of the individuals
Directing the individual’s activities at this time
Staying with the individuals involved
Mobilizing the individual’s support system
31. Joy’s stream of consciousness is occupied exclusively with thoughts of her father’s death. Nurse Ronald should plan to help Joy through this stage of grieving, which is known as:
Shock and disbelief
Developing awareness
Resolving the loss
Restitution
32. When taking a health history from a female client who has a moderate level of cognitive impairment due to dementia, the nurse would expect to note the presence of:
Accentuated premorbid traits
Enhance intelligence
Increased inhibitions
Hyper vigilance
33. What is the priority care for a client with a dementia resulting from AIDS?
Planning for remotivational therapy
Arranging for long term custodial care
Providing basic intellectual stimulation
Assessing pain frequently
34. Jerome who has eating disorder often exhibits similar symptoms. Nurse Lhey would expect an adolescent client with anorexia to exhibit:
Affective instability
Dishered, unkempt physical appearance
Depersonalization and derealization
Repetitive motor mechanisms
35. The primary nursing diagnosis for a female client with a medical diagnosis of major depression would be:
Situational low self-esteem related to altered role
Powerlessness related to the loss of idealized self
Spiritual distress related to depression
Impaired verbal communication related to depression
36. When developing an initial nursing care plan for a male client with a Bipolar I disorder (manic episode) nurse Ron should plan to?
Isolate his gym time
Encourage his active participation in unit programs
Provide foods, fluids and rest
Encourage his participation in programs
37. Grace is exhibiting withdrawn patterns of behavior. Nurse Johnny is aware that this type of behavior eventually produces feeling of:
Repression
Loneliness
Anger
Paranoia
38. One morning a female client on the inpatient psychiatric service complains to nurse Hazel that she has been waiting for over an hour for someone to accompany her to activities. Nurse Hazel replies to the client “We’re doing the best we can. There are a lot of other people on the unit who needs attention too.” This statement shows that the nurse’s use of:
Defensive behavior
Reality reinforcement
Limit-setting behavior
Impulse control
39. A nursing diagnosis for a male client with a diagnosed multiple personality disorder is chronic low self-esteem probably related to childhood abuse. The most appropriate short term client outcome would be:
Verbalizing the need for anxiety medications
Recognizing each existing personality
Engaging in object-oriented activities
Eliminating defense mechanisms and phobia
40. A 25 year old male is admitted to a mental health facility because of inappropriate behavior. The client has been hearing voices, responding to imaginary companions and withdrawing to his room for several days at a time. Nurse Monette understands that the withdrawal is a defense against the client’s fear of:
Phobia
Powerlessness
Punishment
Rejection
41. When asking the parents about the onset of problems in young client with the diagnosis of schizophrenia, Nurse Linda would expect that they would relate the client’s difficulties began in:
Early childhood
Late childhood
Adolescence
Puberty
42. Jose who has been hospitalized with schizophrenia tells Nurse Ron, “My heart has stopped and my veins have turned to glass!” Nurse Ron is aware that this is an example of:
Somatic delusions
Depersonalization
Hypochondriasis
Echolalia
43. In recognizing common behaviors exhibited by male client who has a diagnosis of schizophrenia, nurse Josie can anticipate:
Slumped posture, pessimistic out look and flight of ideas
Grandiosity, arrogance and distractibility
Withdrawal, regressed behavior and lack of social skills
Disorientation, forgetfulness and anxiety
44. One morning, nurse Diane finds a disturbed client curled up in the fetal position in the corner of the dayroom. The most accurate initial evaluation of the behavior would be that the client is:
Physically ill and experiencing abdominal discomfort
Tired and probably did not sleep well last night
Attempting to hide from the nurse
Feeling more anxious today
45. Nurse Bea notices a female client sitting alone in the corner smiling and talking to herself. Realizing that the client is hallucinating. Nurse Bea should:
Invite the client to help decorate the dayroom
Leave the client alone until he stops talking
Ask the client why he is smiling and talking
Tell the client it is not good for him to talk to himself
46. When being admitted to a mental health facility, a young female adult tells Nurse Mylene that the voices she hears frighten her. Nurse Mylene understands that the client tends to hallucinate more vividly:
While watching TV
During meal time
During group activities
After going to bed
47. Nurse John recognizes that paranoid delusions usually are related to the defense mechanism of:
Projection
Identification
Repression
Regression
48. When planning care for a male client using paranoid ideation, nurse Jasmin should realize the importance of:
Giving the client difficult tasks to provide stimulation
Providing the client with activities in which success can be achieved
Removing stress so that the client can relax
Not placing any demands on the client
49. Nurse Gerry is aware that the defense mechanism commonly used by clients who are alcoholics is:
Displacement
Denial
Projection
Compensation
50. Within a few hours of alcohol withdrawal, nurse John should assess the male client for the presence of:
C. When the nurse and client agree to work together, a contract should be established, the length of the relationship should be discussed in terms of its ultimate termination.
B. The nurse should initiate brief, frequent contacts throughout the day to let the client know that he is important to the nurse. This will positively affect the client’s self-esteem.
D. The client with depression is preoccupied, has decreased energy, and is unable to make decisions. The nurse presents the situation, “It’s time for a shower”, and assists the client with personal hygiene to preserve his dignity and self-esteem.
C. Foods high in tyramine, those that are fermented, pickled, aged, or smoked must be avoided because when they are ingested in combination with MAOIs a hypertensive crisis will occur.
A. Anticholinergic effects, which result from blockage of the parasympathetic (craniosacral) nervous system including urine retention, blurred vision, dry mouth & constipation.
B. Dysthymia is a less severe, chronic depression diagnosed when a client has had a depressed mood for more days than not over a period of at least 2 years. Client with dysthymic disorder benefit from psychotherapeutic approaches that assist the client in reversing the negative self image, negative feelings about the future.
D. Flight of ideas is speech pattern of rapid transition from topic to topic, often without finishing one idea. It is common in mania.
B. The client with mania is very active & needs to have this energy channeled in a constructive task such as cleaning or tidying the room.
C. A crucial factor is determining the lethality of a method is the amount of time that occurs between initiating the method & the delivery of the lethal impact of the method.
D. The statement “I don’t think about killing myself as much as I used to.” Indicates a lessening of suicidal ideation and improvement in the client’s condition.
A. Using exercise bicycle is appropriate for the client who becomes very anxious when thoughts of suicidal occur.
C. The drug of choice for a client experiencing extra pyramidal side effects from haloperidol (Haldol) is benztropine mesylate (cogentin) because of its anti cholinergic properties.
D. Allowing the client to be the first to open the cart & take a tray presents the client with the reality that the nurses are not touching the food & tray, thereby dispelling the delusion.
B. Although all the actions indicate improvement, the ability to initiate simple activities without directions indicates the most improvement in the catatonic behaviors.
A. Psychoeducational groups for families develop a support network. They provide education about the biochemical etiology of psychiatric disease to reduce, not increase family guilt.
C. Attending activity with the nurse assists the client to become involved with others slowly. The client with schizotypal personality disorder needs support, kindness & gentle suggestion to improve social skills & interpersonal relationship.
C. An individual with personality disorder usually is not hospitalized unless a coexisting Axis I psychiatric disorder is present. Generally, these individuals make marginal adjustments and remain in society, although they typically experience relationship and occupational problems related to their inflexible behaviors. Personality disorders are chronic lifelong patterns of behavior; acute episodes do not occur. Psychotic behavior is usually not common, although it can occur in either schizotypal personality disorder or borderline personality disorder. Because these disorders are enduring and evasive and the individual is inflexible, prognosis for recovery is unfavorable. Generally, the individual does not seek treatment because he does not perceive problems with his own behavior. Distress can occur based on other people’s reaction to the individual’s behavior.
D. The nurse would explain the negative reactions of others towards the client’s behaviors to make the clients aware of the impact of his seductive behaviors on others.
B. The nurse would use role-playing to teach the client appropriate responses to others and in various situations. This client dramatizes events, drawn attention to self, and is unaware of and does not deal with feelings. The nurse works to help the client clarify true feelings & learn to express them appropriately.
C. Antiseptic mouthwash often contains alcohol & should be kept in locked area, unless labeling clearly indicates that the product does not contain alcohol.
D. Monitoring of vital signs provides the best information about the client’s overall physiologic status during alcohol withdrawal & the physiologic response to the medication used.
A. After administering naloxone (Narcan) the nurse should monitor the client’s respiratory status carefully, because the drug is short acting & respiratory depression may recur after its effects wear off.
B. The best measure to determine a client’s progress in rehabilitation is the number of drug- free days he has. The longer the client is free of drugs, the better the prognosis is.
D. Barbiturates are CNS depressants; the nurse would be especially alert for the possibility of respiratory failure. Respiratory failure is the most likely cause of death from barbiturate over dose.
B. The feeling of bugs crawling under the skin is termed as formication, and is associated with cocaine use.
D. The nurse would prepare to administer an antipsychotic medication such as Haldol to a client experiencing amphetamine psychosis to decrease agitation & psychotic symptoms, including delusions, hallucinations & cognitive impairment.
C. An acid environment aids in the excretion of PCP. The nurse will definitely give the client with PCP intoxication cranberry juice to acidify the urine to a ph of 5.5 & accelerate excretion.
A. The nurse would facilitate progressive review of the accident and its consequence to help the client integrate feelings & memories and to begin the grieving process.
B. The nurse instructs the nursing assistant to invite the client to lunch & accompany him to the dinning room to decrease manipulation, secondary gain, dependency and reinforcement of negative behavior while maintaining the client’s worth.
C. This provides support until the individuals coping mechanisms and personal support systems can be immobilized.
C. Resolving a loss is a slow, painful, continuous process until a mental image of the dead person, almost devoid of negative or undesirable features emerges.
A. A moderate level of cognitive impairment due to dementia is characterized by increasing dependence on environment & social structure and by increasing psychologic rigidity with accentuated previous traits & behaviors.
C. This action maintains for as long as possible, the clients intellectual functions by providing an opportunity to use them.
A. Individuals with anorexia often display irritability, hospitality, and a depressed mood.
D. Depressed clients demonstrate decreased communication because of lack of psychic or physical energy.
C. The client in a manic episode of the illness often neglects basic needs, these needs are a priority to ensure adequate nutrition, fluid, and rest.
B. The withdrawn pattern of behavior presents the individual from reaching out to others for sharing the isolation produces feeling of loneliness.
A. The nurse’s response is not therapeutic because it does not recognize the client’s needs but tries to make the client feel guilty for being demanding.
B. The client must recognize the existence of the sub personalities so that interpretation can occur.
D. An aloof, detached, withdrawn posture is a means of protecting the self by withdrawing and maintaining a safe, emotional distance.
C. The usual age of onset of schizophrenia is adolescence or early childhood.
A. Somatic delusion is a fixed false belief about one’s body.
C. These are the classic behaviors exhibited by clients with a diagnosis of schizophrenia.
D. The fetal position represents regressed behavior. Regression is a way of responding to overwhelming anxiety.
B. This provides a stimulus that competes with and reduces hallucination.
D. Auditory hallucinations are most troublesome when environmental stimuli are diminished and there are few competing distractions.
A. Projection is a mechanism in which inner thoughts and feelings are projected onto the environment, seeming to come from outside the self rather than from within.
B. This will help the client develop self-esteem and reduce the use of paranoid ideation.
B. Denial is a method of resolving conflict or escaping unpleasant realities by ignoring their existence.
C. Alcohol is a central nervous system depressant. These symptoms are the body’s neurologic adaptation to the withdrawal of alcohol.