Mental Health Exam 3

Question 1

A patient has had difficulty keeping a job because of arguing with co-workers and accusing
them of conspiracy. Today this patient shouts, “They’re all plotting to destroy me. Isn9t that
true?” Select the nurse’s most therapeutic response.
a. Everyone here is trying to help you. No one wants to harm you.
b. Feeling that people want to destroy you must be very frightening.
c. That is not true. People here are trying to help you if you will let them.
d. Staff members are health care professionals who are qualified to help you.

Answer 1

b. Feeling that people want to destroy you must be very frightening.

Resist focusing on content; instead, focus on the feelings the patient is expressing. This
strategy prevents arguing about the reality of delusional beliefs. Such arguments increase
patient anxiety and the tenacity with which the patient holds to the delusion. The other
options focus on content and provide opportunities for argument

Question 2

A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly
scans the environment. The patient sees two doctors talking in the hall. “They were plotting to
kill me.” The nurse may correctly assess this behavior as
a. echolalia.
b. an idea of reference.
c. a delusion of infidelity.
d. an auditory hallucination.

Answer 2

b. an idea of reference.

Question 3

A patient diagnosed with schizophrenia says, “My co-workers are out to get me. I also saw
two doctors plotting to kill me”. How does this patient perceive the environment?
a. Disorganized
b. Dangerous
c. Supportive
d. Bizarre

Answer 3

b. Dangerous

Question 4

When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol was
prescribed. The patient now says, “I stopped taking those pills. They made me feel like a
robot.” What are common side effects the nurse should validate with the patient?
a. Sedation and muscle stiffness
b. Sweating, nausea, and diarrhea
c. Mild fever, sore throat, and skin rash
d. Headache, watery eyes, and runny nose

Answer 4

a. Sedation and muscle stiffness

Question 5

Which hallucination necessitates the nurse to implement safety measures? The patient says,
a. I hear angels playing harps.
b. The voices say everyone is trying to kill me.
c. My dead father tells me I am a good person.
d. The voices talk only at night when I9m trying to sleep.

Answer 5

b. The voices say everyone is trying to kill me.

Question 6

A patient’s care plan includes monitoring for auditory hallucinations. Which assessment
findings suggest the patient may be hallucinating?
a. Detachment and overconfidence
b. Darting eyes, tilted head, mumbling to self
c. Euphoric mood, hyperactivity, distractibility
d. Foot tapping and repeatedly writing the same phrase

Answer 6

b. Darting eyes, tilted head, mumbling to self

Question 7

A patient diagnosed with schizophrenia tells the nurse, “I eat skiller. Tend to end. Easter. It
blows away. Get it?”
Select the nurse’s most therapeutic response.
a. Nothing you are saying is clear.
b. Your thoughts are very disconnected.
c. Try to organize your thoughts and then tell me again.
d. I am having difficulty understanding what you are saying.

Answer 7

d. I am having difficulty understanding what you are saying.

Question 8

A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy flexibility. The patient’s activities of daily living are severely compromised. An appropriate outcome would be that the patient will
a. demonstrate increased interest in the environment by the end of week 1.
b. perform self-care activities with coaching by the end of day 3.
c. gradually take the initiative for self-care by the end of week 2.
d. accept tube feeding without objection by day 2.

Answer 8

b. perform self-care activities with coaching by the end of day 3.

Question 9

A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon?
a. Echolalia
b. Waxy flexibility
c. Depersonalization
d. Thought withdrawal

Answer 9

b. Waxy flexibility

Question 10

A nurse leads a psychoeducational group about first-generation antipsychotic medications
with six adult men diagnosed with schizophrenia. The nurse will monitor for concerns
regarding body image with respect to which potential side effect of these medications?
a. Constipation
b. Gynecomastia
c. Visual changes
d. Photosensitivity

Answer 10

b. Gynecomastia

Question 11

A nurse leads a psychoeducational group about problem solving with six adults diagnosed
with schizophrenia. Which teaching strategy is likely to be most effective?
a. Suggest analogies that might apply to a common daily problem.
b. Assign each participant a problem to solve independently and present to the group.
c. Ask each patient to read aloud a short segment from a book about problem solving.
d. Invite participants to come up with solution to getting incorrect change for a purchase.

Answer 11

d. Invite participants to come up with solution to getting incorrect change for a purchase.

Question 12

A nurse educates a patient about the antipsychotic medication regime. Afterward, which
comment by the patient indicates the teaching was effective?
a. I will need higher and higher doses of my medication as time goes on.
b. I need to store my medication in a cool dark place, such as the refrigerator.
c. Taking this medication regularly will reduce the severity of my symptoms.
d. If I run out or stop taking my medication, I will experience withdrawal symptoms.

Answer 12

c. Taking this medication regularly will reduce the severity of my symptoms.

Question 13

A newly admitted patient diagnosed with schizophrenia says, “The voices are bothering me.
They yell and tell me I am bad. I have got to get away from them.” Select the nurse’s most
helpful reply.
a. Do you hear the voices often?
b. Do you have a plan for getting away from the voices?
c. I’ll stay with you. Focus on what we are talking about, not the voices.
d. Forget the voices and ask some other patients to play cards with you.

Answer 13

c. I’ll stay with you. Focus on what we are talking about, not the voices.

Question 14

A patient diagnosed with schizophrenia has taken fluphenazine 5 mg po bid for 3 weeks.
The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms?
a. Neuroleptic malignant syndrome
b. Hepatocellular effects
c. Pseudoparkinsonism
d. Akathisia

Answer 14

c. Pseudoparkinsonism

Question 15

A patient diagnosed with schizophrenia is very disturbed and violent. After several doses of
haloperidol, the patient is calm. Two hours later the nurse sees the patient’s head rotated to
one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is
most likely?
a. An acute dystonic reaction
b. Tardive dyskinesia
c. Waxy flexibility
d. Akathisia

Answer 15

a. An acute dystonic reaction

Question 16

An acutely violent patient diagnosed with schizophrenia received several doses of
haloperidol. Two hours later the nurse notices the patient9s head rotated to one side in a
stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the
nurse is indicated?
a. Administer diphenhydramine the prn medication administration record.
b. Reassure the patient that the symptoms will subside. Practice relaxation exercises
with the patient.
c. Give trihexyphenidyl 5 mg orally at the next regularly scheduled medication
administration time.
d. Administer atropine sulfate 2 mg subcut from the prn medication administration
record.

Answer 16

a. Administer diphenhydramine the prn medication administration record.

Question 17

A patient diagnosed with schizophrenia has received Haloperidol decanoate twice a month
for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips.
The patient9s neck and shoulders twist in a slow, snakelike motion. Which problem would
the nurse suspect?
a. Agranulocytosis
b. Tardive dyskinesia
c. Tourette9s syndrome
d. Anticholinergic effects

Answer 17

b. Tardive dyskinesia

Question 18

A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse’s most therapeutic response.
a. Why are you laughing?
b. Please share the joke with me.
c. I don9t think I said anything funny.
d. You’re laughing. Tell me what’s happening.”

Answer 18

d. You’re laughing. Tell me what’s happening.”

Question 19

The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would
the nurse regard as a negative symptom of schizophrenia?
a. Auditory hallucinations
b. Delusions of grandeur
c. Poor personal hygiene
d. Psychomotor agitation

Answer 19

c. Poor personal hygiene

Question 20

What assessment findings mark the prodromal stage of schizophrenia?
a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion
b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting
c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility
d. Loose associations, concrete thinking, and echolalia neologisms

Answer 20

a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion

Question 21

A patient diagnosed with schizophrenia says, “Contagious bacteria are everywhere. When
they get in your body, you will be locked up with other infected people.” Which problem is evident?
a. Poverty of content
b. Concrete thinking
c. Neologisms
d. Paranoia

Answer 21

d. Paranoia

Question 22

A patient diagnosed with schizophrenia begins a new prescription for ziprasidone. The patient is 5’6’’ and currently weighs 204 lbs. The patient has dry flaky skin, headaches about twice a month, and a family history of colon cancer. Which intervention has the highest
priority for the nurse to include in the patient9s plan of care?
a. Skin care techniques
b. Scheduling a colonoscopy
c. Weight management strategies
d. Teaching to limit caffeine intake

Answer 22

c. Weight management strategies

Question 23

A patient diagnosed with schizophrenia says, “It’s beat. Time to eat. No room for the cat.”
What type of verbalization is evident?
a. Neologism
b. Idea of reference
c. Thought broadcasting
d. Associative looseness

Answer 23

d. Associative looseness

Question 24

A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication
for a year. Hallucinations are present the patient continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication?
a. Haloperidol
b. clozapine
c. Chlorpromazine
d. Diphenhydramine

Answer 24

b. clozapine

Question 25

A patient diagnosed with schizophrenia has been stable for a year; however, the family now
reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating.
The patient says, “My computer is sending out infected radiation beams.” The nurse can
correctly assess this information as an indication of
a. the need for psychoeducation.
b. medication nonadherence.
c. chronic deterioration.
d. relapse.

Answer 25

d. relapse.

Question 26

A patient diagnosed with schizophrenia begins to talks about “macnabs” hiding in the
warehouse at work. The term “macnabs” should be documented as
a. a neologism.
b. concrete thinking.
c. thought insertion.
d. an idea of reference.

Answer 26

a. a neologism.

Question 27

A patient diagnosed with schizophrenia anxiously says, “I can see the left side of my body
merging with the wall, then my face appears and disappears in the mirror.” While listening,
the nurse should
a. sit close to the patient.
b. place an arm protectively around the patient’s shoulders.
c. place a hand on the patient9s arm and exert light pressure.
d. maintain a normal social interaction distance from the patient.

Answer 27

d. maintain a normal social interaction distance from the patient.

Question 28

A patient diagnosed with schizophrenia anxiously tells the nurse, “The voice is telling me to do things.” Select the nurse’s priority assessment question.
a. “How long has the voice been directing your behavior?”
b. “Does what the voice tell you to do frighten you?”
c. “Do you recognize the voice speaking to you?”
d. “What is the voice telling you to do?”

Answer 28

d. “What is the voice telling you to do?”

Question 29

A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The patient is diaphoretic. Select the nurse’s best analysis and action.
a. Agranulocytosis; institute reverse isolation.
b. Tardive dyskinesia; withhold the next dose of medication.
c. Cholestatic jaundice; begin a high-protein, high-cholesterol diet.
d. Neuroleptic malignant syndrome; notify health care provider stat

Answer 29

d. Neuroleptic malignant syndrome; notify health care provider stat

Question 30

A nurse asks a patient diagnosed with schizophrenia, “What is meant by the old saying “You can’t judge a book by looking at the cover.?” Which response by the patient indicates concrete thinking?
a. The table of contents tells what a book is about.
b. You can9t judge a book by looking at the cover.
c. Things are not always as they first appear.
d. Why are you asking me about books?

Answer 30

a. The table of contents tells what a book is about.

Question 31

The nurse is developing a plan for psychoeducational sessions for a small group of adults diagnosed with schizophrenia. Which goal is best for this group? Members will
a. gain insight into unconscious factors that contribute to their illness.
b. explore situations that trigger hostility and anger.
c. learn to manage delusional thinking.
d. demonstrate improved social skills.

Answer 31

d. demonstrate improved social skills.

Question 32

A client says, “Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist.” Select the nurse’s best initial action.
a. Tell the client, “Facebook is a safe website. You don’t need to worry about Homeland Security.”
b. Tell the client, “You are in a safe place where you will be helped.”
c. Administer a prn dose of an antipsychotic medication.
d. Tell the client, “You don’t need to worry about that.”

Answer 32

b. Tell the client, “You are in a safe place where you will be helped.”

Question 33

Which finding constitutes a negative symptom associated with schizophrenia?
a. Hostility
b. Bizarre behavior
c. Poverty of thought
d. Auditory hallucinations

Answer 33

c. Poverty of thought

Question 34

A patient insistently states, “I can decipher codes of DNA just by looking at someone.”
Which problem is evident?
a. Visual hallucinations
b. Magical thinking
c. Idea of reference
d. Thought insertion

Answer 34

b. Magical thinking

Question 35

A newly hospitalized patient experiencing psychosis says, “Red chair out town board.”
Which term should the nurse use to document this finding?
a. Word salad
b. Neologism
c. Anhedonia
d. Echolalia

Answer 35

a. Word salad

Question 36

A patient diagnosed with schizophrenia was hospitalized after arguing with co-workers and
threatening to harm them. The patient is aloof, suspicious, and says, “Two staff members I
saw talking were plotting to kill me.” Based on data gathered at this point, which nursing diagnoses relate? (Select all that apply.)
a. Risk for other-directed violence
b. Disturbed thought processes
c. Risk for loneliness
d. Spiritual distress
e. Social isolation

Answer 36

a. Risk for other-directed violence
b. Disturbed thought processes

Question 37

A nurse wants to teach alternative coping strategies to a patient experiencing severe anxiety.
Which action should the nurse perform first?
a. Verify the patient’s learning style.
b. Lower the patient’s current anxiety.
c. Create outcomes and a teaching plan.
d. Assess how the patient uses defense mechanisms.

Answer 37

b. Lower the patient’s current anxiety.

Question 38

A woman is 5’7”, 160 lbs. and wears a size 8 shoe. She says, “My feet are huge. I’ve asked
three orthopedists to surgically reduce the size”
This person tries to buy shoes to make her feet look smaller and, in social settings, conceals both feet under a table or chair. Which health problem is likely?
a. Social anxiety disorder
b. Body dysmorphic disorder
c. Separation anxiety disorder
d. Obsessive-compulsive disorder due to a medical condition

Answer 38

b. Body dysmorphic disorder

Question 39

A patient experiencing moderate anxiety says, “I feel undone.” An appropriate response for
the nurse would be:
a. “What would you like me to do to help you?”
b. “Why do you suppose you are feeling anxious?”
c. “I’m not sure I understand. Give me an example.”
d. “You must get your feelings under control before we can continue.”

Answer 39

c. “I’m not sure I understand. Give me an example.”

Question 40

A patient fearfully runs from chair to chair crying, “They’re coming! They’re coming!” The patient does not follow the staff’s directions or respond to verbal interventions. The initial nursing intervention of highest priority is to
a. provide for the patient’s safety.
b. encourage clarification of feelings.
c. respect the patient’s personal space.
d. offer an outlet for the patient’s energy.

Answer 40

a. provide for the patient’s safety.

Question 41

A patient fearfully runs from chair to chair crying, “They’re coming! They’re coming!” The
patient does not follow the staff’s directions or respond to verbal interventions. Which nursing diagnosis has the highest priority?
a. Fear
b. Risk for injury
c. Self-care deficit
d. Disturbed thought processes

Answer 41

b. Risk for injury

Question 42

A patient checks and rechecks electrical cords related to an obsessive thought that the house
may burn down. The nurse and patient explore the likelihood of an actual fire. The patient
states this event is not likely. This counseling demonstrates principles of
a. flooding.
b. desensitization.
c. relaxation technique.
d. cognitive restructuring.

Answer 42

d. cognitive restructuring.

Question 43

A patient undergoing diagnostic tests says, “Nothing is wrong with me except a stubborn chest cold.” The spouse reports the patient smokes, coughs daily, lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using?
a. Displacement
b. Regression
c. Projection
d. Denial

Answer 43

d. Denial

Question 44

A patient with an abdominal mass is scheduled for a biopsy. The patient has difficulty understanding the nurse’s comments and asks, “What do you mean? What are they going to do?” Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the patient’s level of anxiety?
a. Mild
b. Moderate
c. Severe
d. Panic

Answer 44

b. Moderate

Question 45

A patient preparing for surgery has moderate anxiety and is unable to understand preoperative
information. Which nursing intervention is most appropriate?
a. Reassure the patient that all nurses are skilled in providing postoperative care.
b. Present the information again in a calm manner using simple language.
c. Tell the patient that staff is prepared to promote recovery.
d. Encourage the patient to express feelings to family.

Answer 45

b. Present the information again in a calm manner using simple language.

Question 46

A patient is experiencing moderate anxiety. The nurse encourages the patient to talk about
feelings and concerns. What is the statement his intervention?
a. Offering hope allays and defuses the patient’s anxiety.
b. Concerns stated aloud become less overwhelming and help problem solving begin.
c. Anxiety is reduced by focusing on and validating what is occurring in the
environment.
d. Encouraging patients to explore alternatives increases the sense of control and
lessens anxiety.

Answer 46

b. Concerns stated aloud become less overwhelming and help problem solving begin

Question 47

A nurse assesses a patient with a tentative diagnosis of generalized anxiety disorder. Which question would be most appropriate for the nurse to ask?
a. Have you been a victim of a crime or seen someone badly injured or killed?
b. Do you feel especially uncomfortable in social situations involving people?
c. Do you repeatedly do certain things over and over again?
d. Do you find it difficult to control your worrying?

Answer 47

d. Do you find it difficult to control your worrying?

Question 48

A person has minor physical injuries after an auto accident. The person is unable to focus and
says, “I feel like something awful is going to happen.” This person has nausea, dizziness, tachycardia, and hyperventilation. What is the person’s level of anxiety?
a. Mild
b. Moderate
c. Severe
d. Panic

Answer 48

c. Severe

Question 49

A patient experiences a sudden episode of severe anxiety. Of these medications in the patient’s medical record, which is most appropriate to give as a prn anxiolytic?
a. buspirone
b. alprazolam
c. escitalopram
d. metoprolol

Answer 49

b. Alprazolam

Question 50

A student says, “Before taking a test, I feel very alert and a little restless.” Which nursing intervention is most appropriate to assist the student?
a. Explain that the symptoms result from mild anxiety and discuss the helpful aspects.
b. Advise the student to discuss this experience with a health care provider.
c. Encourage the student to begin antioxidant vitamin supplements
d. Listen attentively, using silence in a therapeutic way.

Answer 50

a. Explain that the symptoms result from mild anxiety and discuss the helpful aspects.

Question 51

A student says, “Before taking a test, I feel very alert and a little restless.” Which nursing intervention is most appropriate to assist the student?
a. Explain that the symptoms result from mild anxiety and discuss the helpful aspects.
b. Advise the student to discuss this experience with a health care provider.
c. Encourage the student to begin antioxidant vitamin supplements
d. Listen attentively, using silence in a therapeutic way.

Answer 51

a. Explain that the symptoms result from mild anxiety and discuss the helpful aspects.

Question 52

A cruel and abusive person often uses rationalization to explain the behavior. Which comment
demonstrates use of this defense mechanism?
a. “I don’t know why I do mean things.”
b. “I have always had poor impulse control.”
c. “That person should not have provoked me.”
d. “I’m really a coward who is afraid of being hurt.”

Answer 52

c. “That person should not have provoked me.”

Question 53

A patient experiencing panic suddenly began running and shouting, “I’m going to explode!”
Select the nurse’s best action.
a. Ask, “I’m not sure what you mean. Give me an example.”
b. Capture the patient in a basket-hold to increase feelings of control.
c. Tell the patient, “Stop running and take a deep breath. I will help you.”
d. Assemble several staff members and say, “We will take you to seclusion to help you regain control.”

Answer 53

c. Tell the patient, “Stop running and take a deep breath. I will help you.

Question 54

A person who has been unable to leave home for more than a week because of severe anxiety
says, “I know it does not make sense, but I just can’t bring myself to leave my apartment
alone.” Which nursing intervention is appropriate?
a. Help the person use online video calls to provide interaction with others.
b. Advise the person to accept the situation and use a companion.
c. Ask the person to explain why the fear is so disabling.
d. Teach the person to use positive self-talk techniques.

Answer 54

d. Teach the person to use positive self-talk techniques.

Question 55

A nurse assesses an individual who commonly experiences anxiety. Which comment by this
person indicates the possibility of obsessive-compulsive disorder?
a. I check where my car keys are eight times.
b. My legs often feel weak and spastic.
c. I’m embarrassed to go out in public.
d. I keep reliving a car accident.

Answer 55

a. I check where my car keys are eight times.

Question 56

When alprazolam is prescribed for a patient who experiences acute anxiety, health teaching should include instructions to
a. report drowsiness.
b. eat a tyramine-free diet.
c. avoid alcoholic beverages.
d. adjust dose and frequency based on anxiety level.

Answer 56

c. avoid alcoholic beverages.

Question 57

The nurse assesses a patient who complains of loneliness and episodes of anxiety. Which
statement by the patient is mostly likely if this patient also has agoraphobia?
a. <I’m sure I will get over not wanting to leave home soon. It takes time.=
b. <Being afraid to go out seems ridiculous, but I can’t go out the door.=
c. <My family says they like it now that I stay home most of the time.=
d. <When I have a good incentive to go out, I can do it.=

Answer 57

b. <Being afraid to go out seems ridiculous, but I can’t go out the door.=

Question 58

A patient diagnosed with obsessive-compulsive disorder has this nursing diagnosis: Anxiety
related to __________ as evidenced by inability to control compulsive cleaning. Which
phrase correctly completes the etiological portion of the diagnosis?
a. feelings of responsibility for the health of family members
b. approval-seeking behavior from friends and family
c. persistent thoughts about bacteria, germs, and dirt
d. needs to avoid interactions with others

Answer 58

c. persistent thoughts about bacteria, germs, and dirt

Question 59

A patient performs ritualistic hand washing. Which action should the nurse implement to help
the patient develop more effective coping?
a. Allow the patient to set a hand-washing schedule.
b. Encourage the patient to participate in social activities.
c. Encourage the patient to discuss hand-washing routines.
d. Focus on the patient’s symptoms rather than on the patient.

Answer 59

b. Encourage the patient to participate in social activities.

Question 60

For a patient experiencing panic, which nursing intervention should be implemented first?
a. Teach relaxation techniques.
b. Administer an anxiolytic medication.
c. Prepare to implement physical controls.
d. Provide calm, brief, directive communication

Answer 60

d. Provide calm, brief, directive communication

Question 61

A child was placed in a foster home after being removed from abusive parents. The child is
apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to
help the child. Which interventio btestbanks.comurse suggest? (Select all that apply.)
a. Use a calm manner and low voice.
b. Maintain simplicity in the environment.
c. Avoid repetition in what is said to the child.
d. Minimize opportunities for exercise and play.
e. Explain and reinforce reality to avoid distortions.

Answer 61

a. Use a calm manner and low voice.
b. Maintain simplicity in the environment.
e. Explain and reinforce reality to avoid distortions.

Question 62

A nurse works with a patient diagnosed with posttraumatic stress disorder (PTSD) who has
frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be
included in the plan of care?
a. Trigger flashbacks intentionally in order to help the patient learn to cope with
them.
b. Explain that the physical symptoms are related to the psychological state.
c. Encourage repression of memories associated with the traumatic event.
d. Support “numbing” as a temporary way to manage intolerable feelings.

Answer 62

b. Explain that the physical symptoms are related to the psychological state.

Question 63

Four teenagers died in an automobile accident. One week later, which behavior by the parents
of these teenagers most clearly demonstrates resilience? The parents who
a. visit their teenager’s grave daily.
b. return immediately to employment.
c. discuss the accident within the family only.
d. create a scholarship fund at their child’s high school.

Answer 63

d. create a scholarship fund at their child’s high school.

Question 64

A patient states, <I feel detached and weird all the time. It is as though I am looking at life
through a cloudy window. Everything seems unreal. It really messes up things at work and
school.= This scenario is most suggestive of which health problem?
a. Acute stress disorder
b. Dissociative amnesia
c. Depersonalization disorder
d. Disinhibited social engagement disorder

Answer 64

c. Depersonalization disorder

Question 65

A patient diagnosed with depersonalization disorder tells the nurse, “It’s starting again. I feel
as though I’m going to float away.” Which intervention would be most appropriate at this
point?
a. Notify the health care provider of this change in the patient’s behavior.
b. Engage the patient in a physical activity such as exercise.
c. Isolate the patient until the sensation has diminished.
d. Administer a prn dose of antianxiety medication

Answer 65

b. Engage the patient in a physical activity such as exercise.

Question 66

The gas pedal on a person’s car became stuck on a busy interstate highway, causing the car to
accelerate rapidly. For 20 minutes, the car was very difficult to control. In the months after
this experience, afterward, which assessment finding would the nurse expect?
a. Weight gain
b. Flashbacks
c. Headache
d. Diuresis

Answer 66

b. Flashbacks

Question 67

A soldier returns to the United States from active duty in a combat zone. The soldier is
diagnosed with PTSD. The nurse’s highest priority is to screen this soldier for
a. bipolar disorder.
b. schizophrenia.
c. depression.
d. dementia.

Question 68

A soldier returns to the United States from active duty in a combat zone. The soldier is
diagnosed with PTSD. The nurse’s highest priority is to screen this soldier for
a. bipolar disorder.
b. schizophrenia.
c. depression.
d. dementia.

Answer 68

c. depression.

Question 69

Two weeks ago, a soldier returned to the United States from active duty in a combat zone. The
soldier was diagnosed with PTSD. Which comment by the soldier requires the nurse’s
immediate attention?
a. It’s good to be home. I missed my home, family, and friends.
b. I saw my best friend get killed by a roadside bomb. I don’t understand why it wasn’t me.
c. Sometimes I think I hear bombs exploding, but it’s just the noise of traffic in my hometown.
d. I want to continue my education, but I’m not sure how I will fit in with other college students.

Answer 69

b. I saw my best friend get killed by a roadside bomb. I don’t understand why it wasn’t me.

Question 70

A soldier in a combat zone tells the nurse, <I saw a child get blown up over a year ago, and I
still keep seeing bits of flesh everywhere. I see something red, and the visions race back to my
mind.= Which phenomenon associated with PTSD is the soldier describing?
a. Reexperiencing
b. Hyperarousal
c. Avoidance
d. Psychosis

Answer 70

a. Reexperiencing

Question 71

A soldier who served in a combat zone returned to the United States. The soldier’s spouse
complains to the nurse, <We had planned to start a family, but now he won’t talk about it. He
won’t even look at children.= The spouse is describing which symptom associated with
PTSD?
a. Reexperiencing
b. Hyperarousal
c. Avoidance
d. Psychosis

Answer 71

c. Avoidance

Question 72

Which comment by the nurse would best support relationship building with a survivor of
intimate partner abuse?
a. You are feeling violated because you thought you could trust your partner.
b. I’m here for you. I want you to tell me about the bad things that happened to
you.
c. I was very worried about you. I knew you were living in a potentially violent situation.
d. Abusers often target people who are passive. I will refer you to an assertiveness class.

Answer 72

a. You are feeling violated because you thought you could trust your partner.

Question 73

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence?
a. Self-awareness enhances the nurse’s advocacy role.
b. Strong negative feelings interfere with assessment and judgment.
c. Strong positive feelings lead to healthy transference with the victim.
d. Positive feelings promote the development of sympathy for patients.

Answer 73

b. Strong negative feelings interfere with assessment and judgment.

Question 74

The parents of a 15-year-old seek to have this teen declared a delinquent because of excessive
drinking, habitually running away, and prostitution. The nurse interviewing the patient should
recognize these behaviors often occur in adolescents who
a. have been abused.
b. are attention seeking.
c. have eating disorders.
d. are developmentally delayed.

Answer 74

a. have been abused.

Question 75

What is a nurse’s legal responsibility if child abuse or neglect is suspected?
a. Discuss the findings with the child9s parent and health care provider.
b. Document the observation and suspicion in the medical record.
c. Report the suspicion according to state regulations.
d. Continue the assessment.

Answer 75

c. Report the suspicion according to state regulations.

Question 76

An 11-year-old says, <My parents don9t like me. They call me stupid and say they wish I were
never born. It doesn9t matter what they think because I already know I9m dumb.= Which
nursing diagnosis applies to this child?
a. Chronic low self-esteem related to negative feedback from parents
b. Deficient knowledge related to interpersonal skills with parents
c. Disturbed personal identity related to negative self-evaluation
d. Complicated grieving related to poor academic performance

Answer 76

a. Chronic low self-esteem related to negative feedback from parents

Question 77

An adult tells the nurse, <My partner abuses me when I make mistakes, but I always get an
apology and a gift afterward. I9ve considered leaving but haven9t been able to bring myself to
actually do it.= Which phase in the cycle of violence prevents this adult from leaving?
a. Tension-building
b. Acute battering
c. Honeymoon
d. Stabilization

Answer 77

c. Honeymoon

Question 78

A survivor of physical spousal abuse was treated in the emergency department for a broken
wrist. This patient said, <I9ve considered leaving, but I made a vow and I must keep it no
matter what happens.= Which outcome should be met before discharge? The patient will
a. facilitate counseling for the abuser.
b. name two community resources for help.
c. demonstrate insight into the abusive relationship.
d. reexamine cultural beliefs about marital commitment.

Answer 78

b. name two community resources for help.

Question 79

An older adult with Lewy body dementia lives with family. After observing multiple bruises,
the home health nurse talked with the daughter, who became defensive and said, “My mother
often wanders at night. Last night she fell down the stairs.” Which nursing diagnosis has
priority?
a. Risk for injury related to poor judgment, cognitive impairments, and inadequate
supervision
b. Wandering related to confusion and disorientation as evidenced by sleepwalking
and falls
c. Chronic confusion related to degenerative changes in brain tissue as evidenced by
nighttime wandering
d. Insomnia related to sleep disruptions associated with cognitive impairment as
evidenced by wandering at night

Answer 79

a. Risk for injury related to poor judgment, cognitive impairments, and inadequate
supervision

Question 80

An adult has a history of physicalbtestbanks.comst family when frustrated, followed byperiods of
remorse after each outburst. Which finding indicates a successful plan of care? The adult
a. expresses frustration verbally instead of physically.
b. explains the rationale for behaviors to the victim.
c. identifies three personal strengths.
d. agrees to seek counseling.

Answer 80

a. expresses frustration verbally instead of physically.

Question 81

The nurse at a university health center leads a dialogue with female freshmen about rape and
sexual assault. One student says, “If I avoid strangers or situations where I am alone outside at
night, I’ll be safe from sexual attacks.” Choose the nurse’s best response.
a. Your plan is not adequate. You could still be raped or sexually assaulted.
b. I am glad you have this excellent safety plan. Would others like to comment?
c. It’s better to walk with someone or call security when you enter or leave a building.
d. Sexual assaults are more often perpetrated by acquaintances. Let’s discuss ways to prevent that.

Answer 81

d. Sexual assaults are more often perpetrated by acquaintances. Let’s discuss ways to prevent that.

Question 82

A rape victim says to the nurse, “I always try to be so careful. I know I should not have walked to my car alone. Was this attack my fault?” Which communication by the nurse is most therapeutic?
a. Support the victim to separate issues of vulnerability from blame.
b. Emphasize the importance of using a buddy system in public places.
c. Reassure the victim that the outcome of the situation will be positive.
d. Pose questions about the rape and help the patient explore why it happened.

Answer 82

a. Support the victim to separate issues of vulnerability from blame.

Question 83

. A rape victim tells the nurse, “I should not have been out on the street alone.” Select the nurse’s most therapeutic response.
a. Rape can happen anywhere.
b. Blaming yourself increases your anxiety and discomfort.
c. You are right. You should not have been alone on the street at night.
d. You feel as though this would not have happened if you had not been alone.

Answer 83

d. You feel as though this would not have happened if you had not been alone

Question 84

The nursing diagnosis Rape-trauma syndrome applies to a rape victim in the emergency
department. Select the most appropriate outcome to achieve before discharging the patient.
a. The memory of the rape will be less vivid and less frightening.
b. The patient is able to describe feelings of safety and relaxation.
c. Symptoms of pain, discomfort, and anxiety are no longer present.
d. The patient agrees to a follow-up appointment with a rape victim advocate.

Answer 84

d. The patient agrees to a follow-up appointment with a rape victim advocate.

Question 85

A nurse works at rape telephone hotline. Communication with potential victims should focus
on
a. explaining immediate steps victims should take.
b. providing callers with a sympathetic listener.
c. obtaining information for law enforcement.
d. arranging counseling.

Answer 85

a. explaining immediate steps victims should take

Question 86

A nurse cares for a rape victim who was given a drink that contained flunitrazepam by an assailant. Which intervention has priority? Monitoring for
a. coma.
b. seizures.
c. hypotonia.
d. respiratory depression.

Answer 86

d. respiratory depression.

Question 87

Before a victim of sexual assault is discharged from the emergency department, the nurse
should
a. notify the victim’s family to provide emotional support.
b. offer to stay with the patient until stability is regained.
c. advise the patient to try not to think about the assault.
d. provide referral information verbally and in writing.

Answer 87

d. provide referral information verbally and in writing.

Question 88

A victim of a violent rape was treated in the emergency department. As discharge preparation
begins, the victim says softly, “I will never be the same again. I can’t face my friends. There
is no reason to go on.” Select the nurse’s most appropriate response.
a. Are you thinking of harming yourself?
b. It will take time, but you will feel the same as before the attack.
c. Your friends will understand when you explain it was not your fault.
d. You will be able to find meaning from this experience as time goes on.

Answer 88

a. Are you thinking of harming yourself?