NP V

Question 0

1. A young man was running along an ocean pier; tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, “He was unconscious briefly and then became alert and behaved as though nothing had happend.” Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client’s ICP is increasing, the nurse would expect to observe which of the following signs first?

A. Pupillary asymmetry
B. Irregular breathing pattern
C. Abnormal posturing
D. Declining LOC

Answer 0

D. Declining LOC

RATIONALE
Earliest sign: Altered LOC

A, B, and C are late signs.

Question 1

2. A 50 year old construction worker is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:

A. Reactive pupils
B. A depressed fontanel
C. Bruising on the mastoid bone
D. An elevated temperature

Answer 1

C. Bruising on the mastoid bone

RATIONALE
Battle sign which indicates Basal skull fracture.

A Normal
B For newborn with DHN
D Problem with hypothalamus; not life threatening

Question 2

3. A client arrives at the emergency department after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?

A. Subdural hematoma
B. Subarachnoid hemorrhage
C. Epidural hematoma
D. Contusion

Answer 2

C. Epidural hematoma

RATIONALE
A Between dura mater and arachnoid
B Between arachnoid and pia mater
D Bruising of brain

Question 3

4. The nurse is aware that the most common manifestation of a ruptured cerebral aneurysm would be:

A. Tonic-clonic seizures
B. Decerebrate posturing
C. Narrowed pulse pressure
D. Sudden severe headache

Answer 3

D. Sudden severe headache

Question 4

5. Which of the following is TRUE regarding ICP?

A. Usually presents with headache when diminished
B. Valsalva is recommended in order to decrease ICP
C. Elevated in patients with acute bacterial meningitis
D. Patient’s position has no effect on ICP

Answer 4

C. Elevated in patients with acute bacterial meningitis

RATIONALE
A ⬆️ICP = headache
B Not recommended
D ⬆️HOB = ⬇️ICP ; ⬇️HOB = ⬆️ICP

Question 5

6. A client has a sustained ICP of 20 mmHg. The nurse should position the client:

A. With the HOB elevated 30 - 45 degrees
B. In trendelenburg position
C. In left Sim’s position
D. With the HOB elevated on two pillows

Answer 5

A. With the HOB elevated 30 - 45 degrees

RATIONALE
Position: LF - SF (30 - 45 degrees)
Best: LF (to prevent herniation)

B and C don’t decrease ICP
D is LF but flexes the neck which should be center, midline and neutral in position

Question 6

7. If a client with increased ICP demonstrates decorticate posturing, the nurse will observe:

A. Flexion of both upper and lower extremities
B. Extension of elbows and knees, plantar flexion of feet, flexion of the wrists
C. Flexion of elbows, extension of the knees, plantar flexion of the feet
D. Extension of upper extremities, flexion of lower extremities

Answer 6

C. Flexion of elbows, extension of the knees, plantar flexion of the feet

Question 7

8. The least serious form of brain trauma, characterized by a brief loss of consciousness and period of confusion, is called:

A. Contussion
B. Concussion
C. Basilar skull fracture
D. Cerebral aneurysm

Answer 7

B. Concussion

RATIONALE
No brain damage.

A Bruising of brain which may cause brain damage; serious form of brain trauma
C #2 dangerous
D #1 dangerous

Question 8

9. A client is receiving infusion of Mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?

A. Decreased level of consciousness
B. Increased urine output
C. Elevated BP
D. Decreased heart rate

Answer 8

B. Increased urine output

Question 9

10. A 23-year old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing intervention should be done first?

A. Position the client flat in bed
B. Instruct client to blow his nose
C. Suction the nose to maintain airway patency
D. Insert nasal and ear packing with sterile gauze

Answer 9

D. Insert nasal and ear packing with sterile gauze

RATIONALE
There may be a skull fracture causing CSF leakage; patient is risk for infection. Management should include prevention of meningitis.

A, B, and C exacerbates the already high ICP.

Question 10

11. A client has a diagnosis of a stroke versus transient ischemic attack. Which if the following statements shows the difference between a TIA and a stroke?

A. TIAs typically resolve within 24 hours
B. TIAs may be hemorrhagic in origin
C. TIAs may cause a permanent motor deficit
D. TIAs may predispose the client to MI

Answer 10

A. TIAs typically resolve within 24 hours

RATIONALE
TIA is a mild stroke and resolves within 24 hours

B Correct: Ischemic in origin
C Correct: Temporary only
D Correct: Predisposes to CVA

Question 11

12. A client with thrombotic CVA experiences periods of emotional lability. The client alternately laughs and cries and intermittently becomes irritable and demanding. The nurse interprets that this behavior indicates that the:

A. Problem is likely to get worse before it gets better
B. Client is experiencing the usual sequel of CVA
C. Client is not adapting well to the disability
D. Client is experiencing side effects of the prescribed anticoagulants

Answer 11

B. Client is experiencing the usual sequel of CVA

RATIONALE
Patients with CVA manifest emotional lability or mood swing.

Question 12

13. A client with a stroke has right sided hemianopsia. The nurse plans to do which of the following to help the client adapt to his visual deficit?

A. Place all objects within the left visual field
B. Patch the client’s eye
C. Ensure that the family brings the client’s eyeglasses to the hospital
D. Teach the client to scan the environment

Answer 12

D. Teach the client to scan the environment

Question 13

14. For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication?

A. Speaking loudly
B. Give client a pen and a paper
C. Writing direction so the client can read them
D. Use gestures without speaking

Answer 13

B. Give client a pen and a paper

Question 14

15. The nurse is teaching the family of the client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies is inappropriate?

A. Maintain an upright position
B. Restricting the diet to liquid until swallowing improves
C. Introducing foods on the unaffected side of the mouth
D. Assess gag reflex before feeding

Answer 14

B. Restricting the diet to liquid until swallowing improves

RATIONALE
Risk for aspiration.

Question 15

16. A nurse is caring for a client who sustained a spinal cord injury. While the nurse is administering morning care, the client develops S/Sx of autonomic dysreflexia. The initial nursing action would be to:

A. Place the client in the prone position
B. Elevate the head of the bed
C. Digitally examine the rectum
D. Assess the client’s blood pressure

Answer 15

B. Elevate the head of the bed

RATIONALE
Decreases BP and prevents stroke.

Question 16

17. After a MVA, a client is admitted to the medical surgical unit with a cervical collar in place. The cervical spinal X-ray has not been read, so the nurse doesn’t know whether the client has a cervical spinal injury. When such an injury is ruled out, the nurse should restrict this client to which position?

A. Flat, with pillows under the knee
B. Supine, with the head of the bed elevated 30 degrees
C. Flat, except for logrolling as needed
D. A head elevation of 90 degrees to prevent cerebral swelling

Answer 16

C. Flat, except for logrolling as needed

Question 17

18. Which of the following clients on the rehabilitation unit is most likely to develop autonomic dysreflexia?

A. A client with brain injury
B. A client with herniated nucleus pulposus
C. A client with a high cervical spine injury
D. A client with a stroke

Answer 17

C. A client with a high cervical spine injury

Question 18

19. A client is admitted with a spinal cord injury at the level of T12. He has limited movement of the upper extremities. Which of the following medications would be used to control edema of the spinal cord?

A. Acetazolamide
B. Furosemide
C. Methylprednisolone
D. Sodium bicarbonate

Answer 18

C. Methylprednisolone

RATIONALE
It is anti-inflammatory.

Question 19

20. A client is admitted with a cervical spine injury sustained during driving accident. When planning the client’s care. The nurse should assign highest priority to which nursing diagnosis?

A. Airway patency
B. Impaired mobility
C. Ineffective breathing pattern
D. Dressing or grooming self-care deficit

Answer 19

C. Ineffective breathing pattern

RATIONALE
In the situation, there is possible injury of the diaphragm which may cause respiratory paralysis.

A Not a nursing diagnosis
B and D are irrelevant

Question 20

21. A hospitalized client had a tonic-clonic seizure while walking in the hall. During the seizure, the nurse’s priority should be:

A. Hold the client’s arms and legs firmly
B. Place the client immediately to soft surface
C. Protect the client’s head from injury
D. Attempt to insert a tongue depressor between the client’s teeth

Answer 20

C. Protect the client’s head from injury

Question 21

22. The nurse obtains a history from the father of a six year old boy with a history of epilepsy admitted with uncontrolled seizures. It is MOST important for the nurse to ask which of the following questions?

A. “What part of the body was affected by the seizure?”
B. “Is there a family history of seizure disorders?”
C. “What was your son been doing before the seizure?”
D. “How long has it been since his last episode of seizures?”

Answer 21

C. “What was your son been doing before the seizure?”

RATIONALE
Assesses what have triggered the onset of seizure.

Question 22

23. Which of this should the nurse not refrain from doing if a patient is having seizure?

A. Suction her PRN
B. Apply restraint to both arms
C. Raise the bedside rails
D. Put mouth gag in her mouth

Answer 22

C. Raise the bedside rails

Tip: Process of elimination.

Question 23

24. A client with epilepsy is having seizure. During the active seizure phase, the nurse should:

A. Place the client on his back, remove dangerous objects, and insert a bite block
B. Place the client on his side, remove dangerous objects and insert a bite block
C. Place the client on his back, remove dangerous objects, and hold down his arms
D. Place the client on his side, remove dangerous objects, and protect his head

Answer 23

D. Place the client on his side, remove dangerous objects, and protect his head

Tip: Process of elimination.

Question 24

25. The patient was diagnosed of having Grand Mal Seizure (tonic-clonic). As part of seizure precaution, which of the following is the initial action to do?

A. Remove sharp objects
B. Facilitate dimming of light
C. Pad the side rails
D. Protect the patient’s head

Answer 24

B. Facilitate dimming of light

RATIONALE
Prevents triggering seizure.

A, C, and D prevents injury of an active seizure.

Question 25

26. To limit triggering the pain associated with Trigeminal neuralgia, the nurse should instruct the client to:

A. Drink iced liquids
B. Avoid oral hygiene
C. Apply warm compress
D. Chew on unaffected side

Answer 25

D. Chew on unaffected side

Question 26

27. A nurse is caring for a client with Trigeminal Neuralgia (Tic doloureux). The client asks for a snack and something to drink. The nurse determines that the most appropriate choice for this client to meet nutritional needs is:

A. Hot herbal tea with graham crackers
B. Iced coffee and peanut butter and crackers
C. Vanilla wafers and room temperature water
D. Cocoa with honey and toast

Answer 26

C. Vanilla wafers and room temperature water

RATIONALE
Tip: Process of elimination.

A Hot is incorrect.
B Iced is incorrect.
D Toast is hard.

Question 27

28. The nurse would expect a client with tic douloureux to exhibit?

A. Multiple petechiae
B. Unilateral facial muscle weakness
C. Excruciating facial and head pain
D. Uncontrollable tremors in the eyelid

Answer 27

C. Excruciating facial and head pain

Question 28

29. The nurse has given the client with Bell’s Palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client stated to:

A. Expose the face to cold and drafts
B. Massage the face with a gentle-upward motion
C. Wrinkle the forehead, blow-out the cheeks, and whistle
D. NOTA

Answer 28

A. Expose the face to cold and drafts

RATIONALE
Triggers pain.

Question 29

30. Nursing care of a client with Bell’s Palsy includes:

A. Managing incontinence
B. Assisting with ambulation
C. Preventing corneal damage
D. Maintaining seizure precautions

Answer 29

C. Preventing corneal damage

RATIONALE
In Bell’s Palsy, there is incomplete eye closure.

Question 30

31. The nurse is completing an admission interview for a client with Parkinson’s disease. Which question will provide additional information about manifestations the client is likely to experience?

A. “Have you ever experienced any paralysis of your arms or legs?”
B. “Do you experience trembling of your hands when trying to reach for something?”
C. “Have you ever been “frozen” in one spot, unable to move?”
D. “Do you have headaches, especially one with throbbing pain?”

Answer 30

C. “Have you ever been “frozen” in one spot, unable to move?”

RATIONALE
Asking for akinesia, a sign of Parkinson’s disease.

A and D are irrelevant
C Intentional tremors refer to MS, PD has resting tremors

Question 31

32. A client with Parkinson’s disease is on Levodopa - Carbidopa (Sinemet) therapy. Which of the following should be included in health teachings to the client?
33. Instruct the client to avoid aged cheese, wine, chocolate, and liver
34. Advise the client to change position slowly
35. Reassure the client that this medication may be discontinued as his condition improves
36. Explain to the client that the medication improves muscle flexibility
37. Inform client that his urine will be reddish
38. Advise the client to avoid taking Vitamin B6 supplement

A. 12345
B. 12456
C. 23456
D. 12346

Answer 31

B. 12456

RATIONALE
6 Avoid Vit B6 because it is antagonist.

3 Correct: For life

Question 32

33. Which goal is the most realistic and appropriate for a client diagnosed with Parkinson’s disease?

A. To cure the disease
B. To stop the progression of the disease
C. To begin preparation for terminal care
D. To maintain optimal body function

Answer 32

D. To maintain optimal body function

Question 33

34. Which of the following will the nurse interpret that the patient with Parkinson’s disease has developed micrographia?

A. Patient can only swallow little amounts
B. Patient stands with the head bent forward and walks with a propulsive gait
C. Patient’s writing becomes slow with tiny letters
D. Patient has excessive, uncontrolled sweating

Answer 33

C. Patient’s writing becomes slow with tiny letters

RATIONALE
A Dysphagia
B Shuffling gait
D Diaphoresis

Question 34

35. Two days after starting therapy with benztropine mesylate (Cogentin), a client complains of a dry mouth. Which of the following nursing interventions would best relieve the client’s dry mouth?

A. Offer the client ice chips and frequent sips of water
B. Withhold the drug and notify the physician
C. Change the client’s diet to clear liquid until the symptoms subside
D. Encourage the use of supplemental puddings and shakes to maintain weight

Answer 34

A. Offer the client ice chips and frequent sips of water

Question 35

36. A client with myasthenia gravis is taking neostigmine bromide (Prostigmin). The nurse determines that the client is gaining a therapeutic effect from the medication if which of the following is noted?

A. Improved swallowing
B. Increased heart rate
C. Bradycardia
D. Decrease in BP

Answer 35

A. Improved swallowing

RATIONALE
Prostigmine increases muscle strength relieving patient from dysphagia.

Question 36

37. Karnina, a client with myasthenia gravis is to receive immunosuppressive therapy. The nurse understands that this therapy is effective because it:

A. Promotes the removal of antibodies that impair the transmission of impulses
B. Stimulates the production of acetylcholine at the neuromuscular junction
C. Decreases the production of antibodies that attack the acetylcholine receptors
D. Inhibits the breakdown of acetylcholine at the neuromuscular junction

Answer 36

C. Decreases the production of antibodies that attack the acetylcholine receptors

RATIONALE
Immunosuppressive therapies such as corticosteroids suppresses the immune system.

Question 37

38. A client with suspected myasthenia gravis is to undergo a tensilon test. Tensilon is used to diagnose - but not treat - myasthenia gravis. Why isn’t it used for treatment?

A. It isn’t available in oral form
B. With repeated use, immunosuppression may occur
C. Dry mouth and abdominal cramps may be intolerable adverse effects
D. The duration of tensilon makes it impractical for long term use

Answer 37

D. The duration of tensilon makes it impractical for long term use

RATIONALE
The exact duration of effect of Tensilon is only 3-5 minutes.

Question 38

39. A client with myasthenia gravis has been receiving Neostigmine (Prostigmin). This drug acts by:

A. Stimulating the cerebral cortex
B. Blocking the action of cholinesterase
C. Replacing deficient neurotransmitters
D. Accelerating transmission along neural swaths

Answer 38

B. Blocking the action of cholinesterase

RATIONALE
In MG, there is abnormal attacking of acetylcholine receptors by the cholinesterase. Prostigmine blocks the action of these cholinesterase.

Question 39

40. The nurse is teaching the client with MG about prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by:

A. Doing all chores early in the day while less fatigued
B. Taking medications on time to maintain therapeutic blood level
C. Doing muscle strengthening exercises
D. Eating large, well balanced meals

Answer 39

B. Taking medications on time to maintain therapeutic blood level

Question 40

41. Which of the following pathophysiologic processes are involved in multiple sclerosis?

A. Destruction of linea nigra
B. Degeneration of optic nerve
C. Chronic inflammation of axon
D. Development of demyelination of the myelin sheath

Answer 40

D. Development of demyelination of the myelin sheath

RATIONALE
In MS, there is demyelination of CNS.

Question 41

42. Which of the following measures would be included in teaching for the client with MS to avoid exacerbation of the disease?

A. Patching the affected eye
B. Taking hot baths for relaxation
C. Sleeping 8 hours each night
D. Drinking 1.5 to 2 L of fluid daily

Answer 41

C. Sleeping 8 hours each night

RATIONALE
Resting counteracts exacerbation of MS which include:
• Fatigue
• Infection
• Temp. extremes
• Stress

Question 42

43. Which of the following clients would be most likely to develop multiple sclerosis?

A. A 20-year old soccer player
B. A 35-year old female teacher
C. A 45-year old, type A, male smoker
D. A 50-year old Black female with HPN

Answer 42

B. A 35-year old female teacher

RATIONALE
Risk factors for MS:
• Young adults (20-40 yo)
• Women
• Genetics
• Stress

In the problem, patient has 2 counts: Age and stress

A 1 count: Age
C 1 count: stress (type A personality)
D No risk

Question 43

44. Which of the following symptoms usually occurs with exacerbation in MS?

A. Diplopia
B. Hemiparesis
C. Grief
D. Recent memory loss

Answer 43

A. Diplopia

Question 44

45. What instruction should the nurse include in the discharge teaching plan of a client who has been diagnosed with MS?

A. It is very important to engage in a progressive exercise program to build strength and endurance
B. It is important with the disease to relax muscles; a hot tub spa is a good form of relaxation
C. It is important to engage in social activity and volunteering to read to schoolchildren will keep you active
D. It is very important to develop a daily schedule that reduces fatigue and conserves energy

Answer 44

D. It is very important to develop a daily schedule that reduces fatigue and conserves energy

RATIONALE
Prevents exacerbation of MS (FITS).

A Promotes fatigue
B Temp. Extremes exacerbate MS
C Stressful activity

Question 45

46. What is the most dangerous complication of GBS?

A. Respiratory depression
B. Respiratory failure
C. Respiratory paralysis
D. Acute respiratory distress syndrome

Answer 45

C. Respiratory paralysis

RATIONALE
GBS has classic ascending paralysis.

Question 46

47. A client is admitted with a possible medical diagnosis of GBS. Which question is most important for the nurse to ask the client?

A. Have you had an MMR immunization?
B. Have you had a recent upper respiratory infection?
C. Have you had any recent travel to Great Britain?
D. Have you been to China in the last two weeks?

Answer 46

B. Have you had a recent upper respiratory infection?

RATIONALE
Risk factors of GBS include:
• Male (16-25; 45-60 yo)
• History of infection (viral)

Question 47

48. The client recently diagnosed with GBS is drooling and having difficulty swallowing secretions. When the family asks why this occurs, the nurse indicates that the cause is

A. Obstructed blood flow to the midbrain
B. Demyelination of cranial nerves responsible for swallowing and gag reflex
C. Enlargement of the parotid and salivary glands
D. Deficiency in the thiamine and pyridoxine in the central nervous system

Answer 47

B. Demyelination of cranial nerves responsible for swallowing and gag reflex

RATIONALE
In GBS, there is demyelination of PNS.

Question 48

49. The nurse knows that which of the following symptoms would be supportive of a diagnosis of GBS?

A. Hemiplegia, HPN, tachycardia
B. Respiratory failure, flaccid paralysis, urinary retention
C. Peripheral edema, HPN, pulmonary congestion
D. Diminished reflexes, pain, paresthesia

Answer 48

B. Respiratory failure, flaccid paralysis, urinary retention

Question 49

50. A client is hospitalized with GBS. Which nursing assessment finding is most significant?

A. Warm, dry skin
B. Soft, non-distended abdomen
C. Urine output of 40 cc/hr
D. Even, non-labored respirations

Answer 49

D. Even, non-labored respirations

RATIONALE
Indicates that GBS has not reached to its complication which is respiratory paralysis.

Question 50

1. An anxious teenage girl is brought to the interviewing room of a crisis shelter, sobbing and saying that she thinks she is pregnant but does not know what to do. Which of the following interventions would be most appropriate at this time?

A. Ask the client about the type of things that she had thought of doing.
B. Give the client some ideas about what to expect to happen next
C. Recommend a pregnancy test after acknowledging the client’s distress
D. Question the client about her feelings and possible parental reactions

Answer 50

C. Recommend a pregnancy test after acknowledging the client’s distress

Question 51

2. A potentially pregnant 14-year-old client says that she and her boyfriend have engaged in mostly “heavy petting and necking.” Which of the following response by the nurse would be BEST initially?

A. “You mean you have had sexual intercourse?”
B. “Describe what you mean by heavy petting and necking.”
C. “I think we need to talk about what’s involved in sexual intercourse.”
D. “All you have been doing with your boyfriend is heavy petting and necking.”

Answer 51

B. “Describe what you mean by heavy petting and necking.”

Question 52

3. The nurse is assessing the client’s method of coping. A client who is being abused would be LEAST likely to demonstrate which of the following?

A. Assertiveness
B. Alcohol abuse
C. Self-blame
D. Suicidal thoughts

Answer 52

A. Assertiveness

Question 53

4. During the third session with the nurse, a client who is being abused states, “I don’t know what to do anymore. He doesn’t want me to go anywhere while he’s at work, not even to visit my friends.” Which of the following nursing diagnoses would the nurse formulate in respect to this information?

A. Risk for violence related to abusive husband, as evidenced by victim’s statement of being battered
B. Low self-esteem related to victimization, as evidenced by not being able to leave the house
C. Powerlessness related to abusive husband, as evidenced by inability to make decisions
D. Ineffective coping related to victimization, as evidenced by crying

Answer 53

C. Powerlessness related to abusive husband, as evidenced by inability to make decisions

Question 54

5. In working with any rape victim, which of the following would be most important?

A. Continuing to encourage the client to report the rape to the legal authorities
B. Recommending that the client resume sexual relations with her partner as soon as possible
C. Periodically reminding the client that she did not deserve and did not cause the rape
D. Telling the client that the rapist will eventually be caught, put on trial, and jailed

Answer 54

C. Periodically reminding the client that she did not deserve and did not cause the rape

Question 55

6. Which of the following symptoms common in individuals experiencing a crisis would a nurse expect to assess?

A. Feeling of depersonalization, loose association, flat affect
B. Lack of regard to social norms, apathy, hallucinations
C. Mood swings, feeling of boundless energy, grandiose beliefs
D. Somatic complaints, difficulty performing roles in life, poor concentration

Answer 55

D. Somatic complaints, difficulty performing roles in life, poor concentration

Question 56

7. A 40-year-old client says she would “rather die than be pregnant.” Which of the following responses by the nurse would be MOST helpful?

A. “Try not to worry until after the pregnancy test.”
B. “You know, pregnancy is a normal event.”
C. “You are only 40 years old and not too old to have a baby.”
D. “I see you’re upset. Take some deep breaths to relax a little.”

Answer 56

D. “I see you’re upset. Take some deep breaths to relax a little.”

Question 57

8. After the results of the pregnancy test for a 15-year old client are found to be negative, the nurse teaches her about sexual intercourse contraception. At the end of the teaching session, the client states, “No more fooling around for me!” Which of the following replies by the nurse would be most appropriate?

A. “Just in case, why don’t you try the pills for a while?”
B. “The last person who said that ended up having a baby.”
C. “It’s your decision, but if you change your mind, we’re here to help you.”
D. “Aren’t you being a little bit overconfident about it, as attractive as you are?”

Answer 57

C. “It’s your decision, but if you change your mind, we’re here to help you.”

Question 58

9. The family members of the victims of a three-car accident have arrived at the ER. A wife of one of the victims in the accident is sitting away from the others and crying. Which of the following actions by the nurse would be first?

A. Leave the wife alone to cry
B. Sit next to the wife and offer her some tissues
C. Call the physician for a sedative
D. Ask the wife if she would like to speak to the social worker

Answer 58

B. Sit next to the wife and offer her some tissues

Question 59

10. The nurse is employed at a crisis shelter that has several clients each day in a state of severe disorganization. An anxious teenage girl is brought to the interviewing room, sobbing and saying that she thinks she is pregnant but does not know what to do. Which of the following nursing interventions would be most appropriate at this time?

A. Ask the client what she had thought of doing
B. Give the client some ideas about what to do next
C. Summarize what the nurse heard and ask the client to confirm the nurse’s perceptions
D. Question the client in more detail about her feelings and about what her parents’ reactions are likely to be

Answer 59

C. Summarize what the nurse heard and ask the client to confirm the nurse’s perceptions

Question 60

11. When developing the plan of care for a client with personality disorder, the nurse expects to assist the client primarily with which of the following?

A. Specific dysfunctional behaviors
B. Examination of developmental conflicts
C. Psychopharmacologic compliance
D. Manipulation of the environment

Answer 60

A. Specific dysfunctional behaviors

Question 61

12. A client with Axis II diagnosis of antisocial personality disorder has been stealing equipment from his place of employment. He states, “It’s not a big deal. My boss can afford a few missing pieces. He doesn’t like me.” The nurse interprets the client’s behavior as indicative of problems in which if the following stage of growth and development defined by Erickson?

A. Trust vs. Mistrust
B. Initiative vs. Guilt
C. Autonomy vs. Shame and doubt
D. Industry vs. Inferiority

Answer 61

B. Initiative vs. Guilt

Question 62

13. Which of the following approaches would the nurse expect to include in the plan of care for a client with antisocial personality disorder who has a history of stealing and jail time?

A. Helping the client develop a conscience
B. Teaching the client consequences of her actions
C. Assisting the client with understanding right from wrong
D. Using strategies to help the client become passive

Answer 62

B. Teaching the client consequences of her actions

Question 63

14. The nurse is planning the care of a 30-year old man admitted to the psychiatric unit for court-mandated treatment for alcohol dependence. The client has a diagnosis of antisocial personality disorder as documented in previous court-mandated psychiatric evaluations. The nurse recognizes that an important part of this client’s plan will be to:

A. Encourage him to set limits on his own behavior
B. Establish clear, consistent limits on acting-out behaviors
C. Minimize peer interactions
D. Expect full family participation in effective treatment

Answer 63

B. Establish clear, consistent limits on acting-out behaviors

Question 64

15. A client who had been living with her family after her boyfriend of 4 weeks told her to her to leave is admitted to the substance unit complaining of feeling empty and lonely, being unable to sleep, hardly eating for the past week. Her arms are scarred from frequent mutilation. The nurse interprets these findings as indicated which of the following personality disorders?

A. Antisocial personality disorder
B. Borderline personality disorder
C. Avoidant personality disorder
D. Compulsive personality disorder

Answer 64

B. Borderline personality disorder

RATIONALE
Borderline personality disorder is suicidal and splitting.

Question 65

16. When planning care for a client with schizotypal personality disorder, which of the following would help the client become involve with others?

A. Participating solely in group activities
B. Leading a sing-a-long in the afternoon
C. Being involved with primarily one-to-one activities
D. Attending an activity with the nurse

Answer 65

D. Attending an activity with the nurse

Question 66

17. Clients with an Axis II diagnosis of antisocial personality disorder have a potential for violence and aggressive behavior. Which of the following client outcomes to be accomplished in the short term would be MOST appropriate for the nurse to include in the plan of care?

A. Use humor when expressing anger
B. Ask the nurse for medication when upset
C. Discuss feelings of anger with staff
D. Use indirect behaviors to express anger

Answer 66

C. Discuss feelings of anger with staff

RATIONALE
Promotes verbalization.

Question 67

18. The nurse is conducting the first one-on-one therapy session with a client who has an antisocial personality disorder. Identify the most important measure during this session.

A. Ignore bad behavior
B. Set limits on inappropriate behaviors
C. Isolate the client when aggressiveness occurs
D. Offer client diversional activities

Answer 67

B. Set limits on inappropriate behaviors

Question 68

19. A hospitalized client with an antisocial personality disorder stole money from an elderly client on the unit. Which of the following is the most appropriate for a nurse to say to this client?

A. “Bakit mo naman kinuha ang pera?”
B. “Sige, okay lang yun.”
C. “Ang ginawa mo ay may kaakibat na pagkawalang prebilihiyo sa unit.”
D. “Walang kalaban laban ang matanda sa iyo.”

Answer 68

C. “Ang ginawa mo ay may kaakibat na pagkawalang prebilihiyo sa unit.”

Question 69

20. A client is in treatment at the day hospital. This is her seventh admission. She has been unable to hold even part-time jobs and has had four abortions in the last 4 years. She is now living with her family after being evicted from her apartment. She complains of feeling empty and lonely, and her arms are scarred from frequent self-mutilation. Which nursing diagnosis would not apply to this client at this time?

A. High risk for mutilation
B. Identity disturbance
C. Self-esteem disturbance
D. Sensory/perceptual alteration

Answer 69

D. Sensory/perceptual alteration

Higlight: WOULD NOT APPLY

Question 70

21. The nurse has been working with a depressed male client for one week. This morning, the client comes to the dining room with hair uncombed and shirt unbuttoned. Which of these actions should the nurse take first?

A. Approach the client and offer to help him finish getting dressed
B. Ignore the client’s appearance and help him find his place at the table
C. Sit with the client and help him eat the food
D. Walk with the client until he notices that his shirt is unbuttoned

Answer 70

A. Approach the client and offer to help him finish getting dressed

Question 71

22. Following suicide, the family needs help in expressing grief. In which way would the nurse be of least assistance?

A. Help them talk together about their individual feelings
B. Allow them to relive some past experiences and identify how the adolescent may have masked true feelings
C. Encourage them to allow siblings to talk about what happened
D. Ask them what they think they did wrong in responding to the teenager

Answer 71

D. Ask them what they think they did wrong in responding to the teenager

Highlight: OF LEAST ASSISTANCE

Question 72

23. A community nurse is following up on a client with depressive disorder, not otherwise specified. In reviewing the client’s chart, the nurse notes that the client has a diagnosis of dependent personality disorder. Which of the following behavior would the nurse anticipate in this client?

A. Difficulty making decisions, lack of self-confidence
B. Grandiose thinking, attention-seeking behaviors
C. Odd mannerisms, speech, and behaviors
D. Unstable moods and impulsive behaviors

Answer 72

A. Difficulty making decisions, lack of self-confidence

RATIONALE
Dependent personality disorder patients can’t stand alone.

Question 73

24. A client has been given the nursing diagnosis “social isolation related to fear of rejection.” The nursing assessment documentation includes, “No eye contact, verbally uncommunicative, refuses to leave bedroom.” Which is the best outcome criterion for determining if the goal of care for this client has been met?

A. Client performs own self-care
B. Client remains free of hallucinations or delusions
C. Client smiles at nurse when nurse enters room
D. Client goes to nurses’ station for medication

Answer 73

D. Client goes to nurses’ station for medication

Question 74

25. When teaching the client with atypical depression about foods to avoid while taking phenelzine (Nardil), which of the following would the nurse note?

A. Cream cheese
B. Banana
C. Avocado
D. Spinach

Answer 74

C. Avocado

RATIONALE
Nardil is a MAOI drug. Health teaching for this drug includes avoid taking Tyramin-rich foods to prevent Hypertensive crisis. 
Foods that are rich in Tyramine:
• Avocado
• Banana (overripe)
• Papaya
• Processed foods
• Cheese (except cottage, cream, and ricotta)

Question 75

26. The nurse is leading a group about mood disorders. A client in a group is monopolizing the session to the extent that the other clients can hardly participate. The nurse would intervene which of the following?

A. “Mr. Roberts, you’ve been taking up too much of the group’s time. Let’s move on.”
B. “Mr. Roberts, you seem to have quite a lot to say today.”
C. “Mr. Roberts, you’ve done well today, but I like to hear from the others.”
D. “Mr. Roberts, it’s certainly isn’t hard for you to talk in a group.”

Answer 75

C. “Mr. Roberts, you’ve done well today, but I like to hear from the others.”

Question 76

27. The family of a client in the manic phase of a bipolar disorder consults the nurse regarding how to handle the client’s aggressive behavior. What is the most appropriate response?

A. Ignore the behavior. The client would’t hurt a family member.
B. If the client threats you, call for help
C. Physically restrain the client
D. Direct the client to the room in a calm, firm voice

Answer 76

D. Direct the client to the room in a calm, firm voice

Question 77

28. The husband apologizes to the nurse for his wife’s demanding behavior. Which of the following possible replies by the nurse would be best?

A. “I’m sure she is doing the best she can.”
B. “It’s alright. We have been treated worst.”
C. “It must be hard for you to see her like this.”
D. “I understand. What happen to set her off like this?”

Answer 77

C. “It must be hard for you to see her like this.”

Question 78

29. The nurse notes that the client is too busy investigating the unit and overseeing the activities of other client to eat dinner. To help the client obtain sufficient nourishment, which of the following plans would be best?

A. Serve foods that she can carry with her
B. Allow her to send out for her favorite foods
C. Serve food in small, attractively arranged portions
D. Allow her to enter the unit’s kitchen for extra food as necessary

Answer 78

A. Serve foods that she can carry with her

Question 79

30. A lack of dietary salt intake can have which of the following effects on lithium levels?

A. Decrease
B. Increase
C. Increase then decrease
D. No effect at all

Answer 79

B. Increase

RATIONALE
⬇️sodium = ⬇️water = risk for lithium toxicity

Question 80

31. In planning care for the client with Schizophrenia who has negative symptoms, the nurse would anticipate a problem with?

A. Auditory hallucinations
B. Bizarre behaviors
C. Ideas of reference
D. Motivation for activities

Answer 80

D. Motivation for activities

RATIONALE
Negative symptoms include:
• Avolition [(-) motivation]
• Anhedonia [(-) pleasure]
• Alogia [(-) words]

Question 81

32. Laboratory work is prescribed for a client who has been experiencing delusions. When the nurse approaches the client to obtain a specimen of the client’s blood, the client begins to shout, “You are all vampires. Let me out of here!” The appropriate nursing response is which of the following?

A. “What makes you think that I am a vampire?”
B. “I leave and come back later for your blood.”
C. “I am not going to hurt you. I am going to help you.”
D. “It must be frightening to think that others want to hurt you.”

Answer 81

D. “It must be frightening to think that others want to hurt you.”

Question 82

33. The wife of a child diagnosed with paranoid schizophrenia visits two days after her husband’s admission and states to the nurse, “Why isn’t he eating? He’s still talking about his food being poisoned.” Which of the following appraisals by the nurse would be MOST accurate?

A. The wife’s inquiry is reasonable
B. Her expectations of her husband are realistic
C. Education about her husband’s illness is needed
D. An increase in the client’s medication is indicated

Answer 82

C. Education about her husband’s illness is needed

Question 83

34. When developing the plan of care for a client who is isolating himself in his room because he perceives that staff wants to harm him, which of the following outcomes would be most appropriate?

A. Within 2 days, the client will complete his ADL
B. Within 3 days, the client will participate in recreation with other clients
C. Within 4 days, the client would demonstrate an absence of verbal aggression
D. Within 5 days, the client will seek out staff to talk his feelings

Answer 83

D. Within 5 days, the client will seek out staff to talk his feelings

RATIONALE
Most realistic.

Question 84

35. A client is sitting in the corner of the day room locking his head to one side as if he is hearing something, but no one is nearby. The nurse suspects he is having auditory hallucinations. Which of the following questions would the nurse ask FIRST?

A. “Are you seeing someone near you besides me?”
B. “What is going on with you right now?”
C. “What are you hearing right now?”
D. “Do you want to go to the recreation room?”

Answer 84

C. “What are you hearing right now?”

Question 85

36. Which of the following would be effective nursing intervention for a hallucinating patient?

A. Agree with the patient about the reality of the voices
B. Deny that the patient does not actually hear the voices
C. Agree with the patient about the voices that he hears
D. Discredit the reality of the voices

Answer 85

D. Discredit the reality of the voices

Question 86

37. A client who is receiving a phenothiazine medication has become restless and fidgety, and has paced the hallway continuously for the past hour. This behavior suggests that the client is having?

A. Dystonia
B. Akathisia
C. Parkinsonian effects
D. Tardive dyskinesia

Answer 86

B. Akathisia

Question 87

38. When asked about herself during the admission interview, the client stares blankly at the nurse and mutters unintelligibly, the nurse would best chart this behavior as:

A. “Not able to answer questions at this time.”
B. “Uncooperative during admission procedure.”
C. “Responded to questions with a blank look and incomprehensible mumble.”
D. “Stared when asked questions and was disoriented and incoherent.”

Answer 87

C. “Responded to questions with a blank look and incomprehensible mumble.”

RATIONALE
Document only what is seen or observed on the patient, not what you think about the patient.

Question 88

39. Which of the following actions would increase the client’s anxiety and suspiciousness?

A. Informing the client of schedule schanges
B. Whispering with others where the client can observe
C. Gently informing the client that the nurse does not share the client’s interpretation of an event
D. Inviting the client to join in leisure activities

Answer 88

B. Whispering with others where the client can observe

Question 89

40. A client brought to the hospital by her husband is wearing a wrinkled dress with stains on the front. Her hair is disheveled, and she has an unpleasant body odor. She looks confused, exhibits a flat affect, and moves slowly and hesitantly. The initial goal of the nurse who admits the client should be focused on:

A. Making the client feel safe and accepted
B. Helping the client get acquainted with others
C. Giving the client information about the program
D. Providing the client with clean comfortable clothes

Answer 89

A. Making the client feel safe and accepted

Question 90

1. Psychiatric nursing is:

A. Assessment of needs, determination and evaluation of care to be given to patients with mental disorders only
B. Concerned with prevention, case finding, intervention and rehabilitation of patients physical disorder
C. Therapeutic use of self in order to advise patient adjust effectively
D. Actual nursing measures to help patient regain mental health

Answer 90

D. Actual nursing measures to help patient regain mental health

RATIONALE
Tip: Process of elimination.

A and B Correct: With mental disorders and healthy people with potential risks
C Nurses don’t advise

Question 91

2. The statement that would best describe the practice of psychiatric nursing would be:

A. Helping people with present or potential mental health problems
B. Ensuring client’s legal and ethical rights by acting as a client advocate
C. Focusing interpersonal skills on people with physical or emotional problems
D. Acting in a therapeutic way with people diagnosed as having a mental disorder

Answer 91

A. Helping people with present or potential mental health problems

Question 92

3. For most nurses the most difficult part of psychiatric nursing is:

A. Remaining therapeutic and professional at all times
B. Being able to understand and accept the client’s behavior
C. Developing an awareness of self and the professional role in the relationship
D. Accepting responsibility in identifying and evaluating the real needs of the client

Answer 92

C. Developing an awareness of self and the professional role in the relationship

Question 93

4. In psychiatric nursing, the most important tool the nurse brings to a helping relationship:

A. Oneself and a desire to help
B. Advance communication skills
C. Knowledge of psychopathology
D. Years of experience in milieu management

Answer 93

A. Oneself and a desire to help

Question 94

5. In an attempt to remain objective and support a client, the nurse uses imagination and determination to project the self into the client’s emotions. The nurse accomplishes this by using a technique known as:

A. Empathy
B. Sympathy
C. Understanding
D. Self-awareness

Answer 94

A. Empathy

Question 95

6. Which principle of the psychoanalytic model is particularly useful to psychiatric nurses?

A. All behavior has meaning
B. Behavior that is reinforced will be perpetuated
C. The first 6 years of a person’s life determine personality
D. Behavioral deviations result from an incongruence between verbal and nonverbal communication

Answer 95

A. All behavior has meaning

Question 96

7. The nurse treats clients who have dual diagnoses to a community mental health center. Which of the following clients would be included in the nurse’s caseload? The client with:

A. Axis I Schizophrenia
B. Axis I Antisocial Personality Disorders
C. Axis I Anxiety with Hypertension
D. Axis I Mental Retardation

Answer 96

A. Axis I Schizophrenia

RATIONALE
Axis I major disorders except PD and MR

B Axis II
C Axis III
D Axis II

Question 97

8. The primary purpose of psychiatric rehabilitation is to:

A. Control psychiatric symptoms
B. Promote the recovery process
C. Manage client’s medications
D. Reduce hospital readmissions

Answer 97

B. Promote the recovery process

Question 98

9. Which of the following would the nurse judge to be the primary goal of milieu management?

A. Facilitation of client’s growth, rehabilitation, and health restoration
B. Successful achievement of the needs of the staff members
C. Provision of sanctuary for helpless clients
D. Implementation of physician’s orders

Answer 98

A. Facilitation of client’s growth, rehabilitation, and health restoration

Question 99

10. The nurse determines that the client would benefit from the family therapy. What factor is most important to the successful outcome of therapy?

A. Ideally, sessions should take place in the therapist’s office
B. Family therapy is successful if all members are not participating
C. Successful family therapy can occur with absence of resisting members
D. The therapist must be a psychiatrist for best outcome

Answer 99

C. Successful family therapy can occur with absence of resisting members

Question 100

11. According to Erickson, the child’s first social achievement should be to:

A. Smile when his mother and father talk to him
B. Trust his mother to meet his needs for nutrition, affection, and protection
C. Socialize with his parents and siblings
D. Utter vocal sounds to express emotional pleasure

Answer 100

B. Trust his mother to meet his needs for nutrition, affection, and protection

RATIONALE
Infancy: Trust vs Mistrust
Source: Mother

Question 101

12. The nurse plans to talk to a mother about toilet training to a toddler, knowing that the most important factor in the process of toilet training is the:

A. Child’s desire to be dry
B. Ability of the child to sit still
C. Child’s willingness to work at it
D. Approach and attitude of the parent

Answer 101

D. Approach and attitude of the parent

Question 102

13. A 15 month old girl is brought to the clinic for her well baby examination. During an interview with the mother, the nurse becomes aware that teaching regarding toddler development is needed when the mother states:

A. “She’s always trying to get out of her car seat.”
B. “I just can’t seem to get her sit on a potty chair.”
C. “Lately, she’s been crying when I leave her with the sitter.”
D. “At home, she doesn’t share toys, it is scattered everywhere.”

Answer 102

B. “I just can’t seem to get her sit on a potty chair.”

RATIONALE
Happens only during 2 years old, Toddlerhood.
Act: Toilet training

Question 103

14. A syndrome postulated by Freudian personality theory in which the child directs affectionate response towards the parent on the opposite sex, accompanied by aggressive feelings toward the parent of the same sex:

A. Fear of castration
B. Oedipus complex
C. Inferiority complex
D. Phobic reaction

Answer 103

B. Oedipus complex

Question 104

15. A healthy parent-child relationship requires:

A. Limitations that are necessary for social living
B. Physical control occassionally
C. Corporal punishment when necessary
D. Sound affection for the child and reasonable limitations on his undesirable behavior

Answer 104

D. Sound affection for the child and reasonable limitations on his undesirable behavior

Question 105

16. When assessing the social and emotional needs of a school-age child, you should focus on:

A. Psychosexual development and establishment of relationship
B. Development of self-esteem and feeling of social responsibility
C. Body image and feelings about future adult responsibility
D. Resolving role model conflict with parent of the same sex

Answer 105

B. Development of self-esteem and feeling of social responsibility

RATIONALE
School-age: Industry vs Inferiority
Source: Teacher
(+) ⬆️ self-esteem
(-) ⬇️ self-esteem

Question 106

17. Parent-adolescent conflicts are inevitable. Which is the primary reason for most of these conflicts?

A. Adolescents are basically hard-headed and negativistic
B. Adolescents do not “feel right” unless arguing with his parents
C. Adolescents are searching for how their needs and identity fit with parental expectations
D. Parents are more worried now thus they tend to tighten the rules

Answer 106

C. Adolescents are searching for how their needs and identity fit with parental expectations

Question 107

18. In order to foster the development of sense of trust in infants, which of the following measures is important?

A. The mother should always be at home
B. The infant should be fed whenever she cries
C. The infant’s needs should be met consistently
D. AOTA

Answer 107

C. The infant’s needs should be met consistently

Question 108

19. A father brings his 18 month old son to the clinic. He asks the nurse why his son is so difficult to please, has temper tantrums and annoys him by throwing food from the table. The nurse should explain that

A. Toddlers need to be disciplined at this stage to prevent the development of antisocial behaviors
B. The child is learning to assert independence, and his behavior is considered normal for his age
C. This is the usual way that the toddler expresses his needs during the initiative stage of development
D. It is best to leave the child alone in his crib after calmly telling him why his behavior is unacceptable

Answer 108

B. The child is learning to assert independence, and his behavior is considered normal for his age

Question 109

20. During the oedipal stage of growth and development, the child:

A. Loves and hates both parents
B. Loves the parent of the same sex and the parent if the opposite sex
C. Loves the parent of the opposite sex and hates the parent of the same sex
D. Loves the parent of the same sex and hates the parent of the opposite sex

Answer 109

C. Loves the parent of the opposite sex and hates the parent of the same sex

Question 110

21. A person is released from prison for selling narcotics has been rehabilitated and now works for a youth drug prevention agency. This person’s current behavior reflects which of the following defense mechanisms?

A. Undoing
B. Displacement
C. Identification
D. Sublimation

Answer 110

D. Sublimation

RATIONALE
It means changing the unacceptable.

Question 111

22. Nurse is too busy with tasks and instead of spending most of the time talking to a dying patient. This is a sample of what defense mechanism?

A. Resistance
B. Denial
C. Suppression
D. Conversion

Answer 111

A. Resistance

RATIONALE
It means avoiding anxiety or walking out.

Question 112

23. Which term refers to the primary unconscious defense mechanism that keeps intense anxiety-producing situations out of a person’s conscious awareness?

A. Conversion
B. Regression
C. Repression
D. Compensation

Answer 112

C. Repression

RATIONALE
It means unconscious forgetting.

Question 113

24. Maricel excuses herself from the hospital to go home by saying to her father, “I have to go home. I can’t stay awake anymore and I’ve been here most of the day.” Which defense mechanism is Maricel using?

A. Reaction formation
B. Rationalization
C. Sublimation
D. Intellectualization

Answer 113

B. Rationalization

RATIONALE
It means reasoning without basis.

Question 114

25. The nurse should recognize that a patient who is unable to remember being raped by her brother when she was 10 years old is using which of the following ego defense mechanism?

A. Compensation
B. Repression
C. Undoing
D. Regression

Answer 114

B. Repression

RATIONALE
It means unconscious forgetting.

Question 115

26. Each time a client is scheduled for a therapy session she develops headache and nausea. The nurse might interpret this behavior as:

A. Conversion
B. Reaction formation
C. Projection
D. Suppression

Answer 115

A. Conversion

RATIONALE
It means transferring of emotional perception to physical or body symptoms.

Question 116

27. A man is admitted to the intensive care unit with chest pain, an abnormal ECG and elevated enzymes. When the significance of this is explained to him, he says, “I can’t be having a heart attack. No way. You must be mistaken.” The nurse suspects that the client is using which defense mechanism?

A. Sublimation
B. Regression
C. Dissociation
D. Denial

Answer 116

D. Denial

RATIONALE
It means failure to admit.

Question 117

28. Incidents of child molestation are revealed years later when the victim is an adult. The nurse teaches that this can be best explained by the ego defense mechanism of

A. Repression
B. Regression
C. Rationalization
D. Reaction formation

Answer 117

A. Repression

RATIONALE
It means unconscious forgetting.

Question 118

29. A client with diabetes is able to discuss in great detail, using Lippincott, the metabolic process in diabetes while eating a piece of chocolate cake topped with butter frosting. What defense mechanism does the nurse identify when evaluating this behavior?

A. Projection
B. Dissociation
C. Displacement
D. Intellectualization

Answer 118

D. Intellectualization

RATIONALE
It means reasoning with basis.

Question 119

30. One of the following statements refers to projection:

A. “I can’t seem to recall what happened.”
B. “It’s all your fault that I was not able to catch the last train.”
C. “I don’t have time for dates. I am too busy with my hobbies.”
D. “Why should I quit smoking? Anyway, I will die the same.”

Answer 119

B. “It’s all your fault that I was not able to catch the last train.”

RATIONALE
Projection means blaming others.

Question 120

31. A client doesn’t make eye contact with the nurse during an interview. The nurse suspects that the client’s behavior has a cultural basis. What should the nurse do first?

A. Read several articles about the client’s culture
B. Ask staff members of a similar culture about the client’s behavior
C. Observe how the client and the client’s family and friends interact with one another and with other staff members
D. Accept the client’s behavior because it’s probably culturally-based

Answer 120

C. Observe how the client and the client’s family and friends interact with one another and with other staff members

Question 121

32. A nurse is assigned to a client who has a domineering and demanding attitude, similar to the nurse’s own mother. The nurse seeks out a colleague to share feelings about this situation. The nurse’s action indicates:

A. Appropriate self-awareness
B. An inability to cope effectively
C. Lack of knowledge about client’s problems
D. A need to change client assignment

Answer 121

A. Appropriate self-awareness

Question 122

33. The nurse is the leader of a client group. The members relate superficially, test each other and the group rules and competes for the nurse’s attention. This behavior is typical of which stage of group development?

A. Orientation
B. Working
C. Feedback
D. Termination

Answer 122

A. Orientation

Question 123

34. The nurse is meeting a new client on the unit. Which action by the nurse is most effective in initiating the nurse-client relationship?

A. Introduce self and explain the purpose and the plan for the relationship
B. Describe the nurse’s family and ask the client to describe his/her family
C. Wait until the client indicates a readiness to establish a relationship
D. Ask the client why she was brought to the hospital

Answer 123

A. Introduce self and explain the purpose and the plan for the relationship

Question 124

35. Which nursing action should the nurse take first to prevent medication non-compliance in a patient with schizophrenia?

A. Teach benefits of medication compliance
B. Build rapport with patient
C. Give medication in an alternate route
D. Assure the patient that medication is safe to take

Answer 124

B. Build rapport with patient

Question 125

36. An adult male has just been brought to the psychiatric unit and is pacing up and down the hall. The nurse is to admit him to the hospital. To establish a nurse-client relationship, which approach should the nurse try first?

A. Assign someone to watch him until he is calmer
B. Ask him to sit down and orient him to the nurse’s name and the need for information
C. Check his vital signs, ask him about allergies, and call the physician for sedation
D. Explain the importance of accurate assessment data to him

Answer 125

B. Ask him to sit down and orient him to the nurse’s name and the need for information

Question 126

37. Two nurses are discussing plans for the client group. What should be in the plan to promote group cohesiveness?

A. Let the group know which clients are behaving in ways approved by the nurses
B. Help the group identify group goals that are consistent with the individual members’ goals
C. Make most decisions about the group in advance and make each group member aware of the nurse’s decisions
D. Seat the most talkative members nearest the nurse where they can be more clearly heard by the group

Answer 126

B. Help the group identify group goals that are consistent with the individual members’ goals

RATIONALE
Patient-centered.

A, C, and D are nurse-centered.

Question 127

38. The nurse is beginning to establish a nurse-client relationship with a woman who was referred for help in managing her children. The woman arrives late for appointments and focuses on her busy schedule, the difficulty in parking, and other reasons for being late. The nurse best interprets this behavior as

A. Transference
B. Counter-transference
C. Identification
D. Resistance

Answer 127

D. Resistance

RATIONALE
It means avoiding anxiety or walking out.

Question 128

39. A woman has remained close to the nurse all day. When the nurse talked with other clients during dinner, the client tried to regain the nurse’s attention and then began to shout, “You’re just like my mother. You pay attention to everyone but me!” The best interpretation of this behavior is that

A. She is exhibiting resistance
B. She has been spoiled by her family
C. The nurse has failed to meet her needs
D. She is demonstrating transference

Answer 128

D. She is demonstrating transference

Question 129

40. It is common that clients ask the nurse personal questions. Anticipation of personal questions is given adequate attention during which phase of the nurse-patient relationship?

A. Orientation phase
B. Working phase
C. Pre-interaction phase
D. Termination phase

Answer 129

B. Working phase

Question 130

1. Which statement reflects the current perspective of psychiatric nursing?

A. Psychiatric nurses don’t do real nursing
B. Psychiatric nursing is a new area of interest
C. Psychiatric nursing is a specialty within nursing
D. Psychiatric nursing is the only area of nursing with standards of practice

Answer 130

C. Psychiatric nursing is a specialty within nursing

Question 131

2. When working with clients who have a diagnosis of mental illness, the nurse will explain that the societal problem of the stigma regarding mental illness:

A. Has almost disappeared due to so much new information on mental illness
B. Is less than it was in the past decade due to the mentally ill living in the community
C. Exist but is seldom a problem for those with a diagnosis of mental illness
D. Still exist today and continues to present challenges for persons with mental illness

Answer 131

D. Still exist today and continues to present challenges for persons with mental illness

Question 132

3. To meet the major developmental need of a 4 month old infant in the immediate postoperative period, the nurse should:

A. Give the infant a pacifier
B. Put a mobile over the infant’s crib
C. Provide the infant with a soft cuddly toy
D. Warm the infant’s formula before feeding

Answer 132

A. Give the infant a pacifier

RATIONALE
Infancy: Oral
Area: mouth
Act: sucking

Question 133

4. Which of the following statements best describes a child’s cognitive ability during Piaget’s concrete operations stage?

A. Behavior changes from reflexive to purposeful
B. The child is unable to put himself or herself in the place of another
C. Thought processes become more systematic and logical
D. Abstract thinking and logical conclusions are made more frequently

Answer 133

C. Thought processes become more systematic and logical

RATIONALE
A and B refer to Pre-operational stage
D Refers to Formal Operational

Question 134

5. A client is admitted to an inpatient psychiatric unit. After the assessment and admission procedures are completed, the nurse states, “I’ll try to be available to talk with you when needed and will spend time with you each morning from 10:00 until 10:30 in a specific corner of the dayroom.” What is the main rationale for communicating these planned nursing interventions?

A. To attempt to establish a trusting relationship
B. To provide an unstructured environment for the client
C. To instill hope in the client
D. To provide time for completing nursing responsibilities

Answer 134

A. To attempt to establish a trusting relationship

Question 135

6. Unresolved feelings related to loss most likely may be recognized during which phase of the therapeutic nurse-client relationship?

A. Working
B. Trusting
C. Orientation
D. Termination

Answer 135

D. Termination

Question 136

7. An adult client has been admitted with a diagnosis of paranoid schizophrenia. On the evening shift, this client is heard shouting, “Quick, get out, the electricity is going to get you.” What is the most appropriate response by the nurse?

A. “Go to your room if you can’t behave correctly.”
B. “You know there is no electricity in here; sit down and be quiet.”
C. “I don’t see or feel any electricity; tell me what you’re feeling now.”
D. “I am not going to pay any attention to you when you behave this way.”

Answer 136

C. “I don’t see or feel any electricity; tell me what you’re feeling now.”

Question 137

8. During admission to the psychiatric unit, the nurse observes that the client sits slumped over in a chair, speaks and moves slowly, and cries incessantly. When the nurse sits down next to the client, the client then states, “Hindi ka tatabi sa akin pag nalaman mo kung ano ang ginawa ko.” What is the most appropriate response by the nurse?

A. “Bakit hindi ako tatabi sa iyo?”
B. “Ano sa palagay mo ang ginawa mo?”
C. “Saan ako uupo?”
D. “Sigurado akong hindi naman masama yun.”

Answer 137

B. “Ano sa palagay mo ang ginawa mo?”

Question 138

9. The defense mechanism of “undoing” consists of a person doing or saying something to annul a previous behavior. How does this defense mechanism protect the person doing it?

A. Allows a person to overcome weakness and achieve success
B. Protects a person from behaving in irrational, impulsive ways
C. Allows a person to appease guilty feelings and atone for mistakes
D. Helps a person cope with the inability to meet goals or standards

Answer 138

C. Allows a person to appease guilty feelings and atone for mistakes

Question 139

10. A client with sleep disturbance, feelings of worthlessness, fatigue and inability to concentrate was let go from her place of employment a month ago. While interacting with the nurse, the client states, “My boss was wonderful! He was understanding and really a nice man.” The nurse interprets this statement ad indicating which of the following defense mechanisms?

A. Repression
B. Suppresion
C. Intellectualization
D. Reaction formation

Answer 139

D. Reaction formation

Question 140

11. Of the following actions, which one would be best for the nurse to take regarding a male client who must wash, rinse and dry the door handle before entering or leaving a room?

A. Explain to the client that he must control his ritualistic behavior as it interferes with his other activities
B. Disregard the client’s ritualistic behaviour, expecting him to participate in unit activities without special attention to his need
C. Limit the client to 5 minutes to complete his ritual before expecting him to comply with requests to move to another room
D. Allow time for the client to complete his ritual before expecting him to move from one area to another

Answer 140

D. Allow time for the client to complete his ritual before expecting him to move from one area to another

Question 141

12. Victims of sexual assault can experience post-traumatic stress reactions after the attack. Which of the following statements best describes symptoms associated with post-traumatic stress disorder?

A. Denial of the event
B. Anger, guilt, and humiliation
C. Fatigue and self-blame
D. Flashbacks, recurring dreams, and numbness

Answer 141

D. Flashbacks, recurring dreams, and numbness

Question 142

13. A client is treated in a mental health clinic for a phobic disorder characterized by the client’s fear of riding in an airplane. The treatment method used was systematic desensitization. The nurse would evaluate the treatment and deem it successful if:

A. The client plans a trip requiring airplane travel
B. The client rides on an airplane for a short trip
C. The client recognized the unrealistic nature of the fear of riding on airplanes
D. The client verbalizes a decreased fear about airplane trips

Answer 142

B. The client rides on an airplane for a short trip

Question 143

14. A client diagnosed with agoraphobia is suddenly forced into an open space while participating in a function at the psychiatric facility. Which symptoms are most likely to manifest in this client?

A. Purposeless activity, confusion, palpitations
B. Fast rate of speech, improved concentration, fearful look
C. Inability to communicate, daydreams, insomnia
D. Hyperactivity, emotional control, “butterflies” in the stomach

Answer 143

A. Purposeless activity, confusion, palpitations

Question 144

15. Which of the following statements is typical of a client with social phobia?

A. “Without people around, I just feel so lost.”
B. “I like to be the center of attention.”
C. “There is nothing wrong with my behavior.”
D. “I know I can’t accept that award for my brother.”

Answer 144

D. “I know I can’t accept that award for my brother.”

Question 145

16. When developing a teaching plan for a high school health class about anorexia nervosa, which of the following would the nurse include as a primary group affected by the disease?

A. Women, age at onset between 12-20 years old
B. Men, onset during college years
C. Women, onset typically after 30 years of age
D. Men, onset before 20 years of age

Answer 145

A. Women, age at onset between 12-20 years old

Question 146

17. When assessing a client with anorexia nervosa, the nurse would expect to find which of the following?

A. Hyperthermia, oliguria, bradycardia
B. Constipation, dysmennorhea, hypertension
C. Lanugo, hypothermia, and hypotension
D. Diarrhea, dry skin, and menorrhagia

Answer 146

C. Lanugo, hypothermia, and hypotension

Question 147

18. Which of the following nursing diagnoses would the nurse formulate as the priority for a client who is admitted to the mental health unit with a diagnosis of anorexia nervosa and who is 5 feet 4 inches tall and weighs only 82 pounds?

A. Low self-esteem related to feelings of inadequacy and loss of control
B. Disturbed body image related to self view of being overweight
C. Interrupted family processes related to over protectiveness and avoidance of conflict
D. Imbalanced Nutrition: Less than body requirements r/t severe restriction in intake

Answer 147

D. Imbalanced Nutrition: Less than body requirements r/t severe restriction in intake

Question 148

19. A client diagnosed with bulimia tells the nurse that she eats excessively when she is upset and then she vomits so she won’t gain of weight. Which of the following nursing diagnostic categories would be most appropriate for this client.

A. Disabled family coping
B. Imbalanced Nutrition: More than body requirements
C. Ineffective coping
D. Anxiety

Answer 148

C. Ineffective coping

Question 149

20. The nurse and a bulimic client establish a goal that the client will not engage in binge-eating. Choose the nursing intervention that is most helpful in achieving this goal:

A. Provide the client with ample privacy
B. Discourage the client from recording patterns of eating in a journal
C. Distract the client from discussion of stressful events
D. Help the client distinguish between emotions and hunger

Answer 149

D. Help the client distinguish between emotions and hunger

Question 150

21. The essential feature of mental retardation is below-average intellectual functioning accompanied by significant limitations in areas of adaptive functioning. If the child’s IQ is 20, the child is classified to have:

A. Mild retardation
B. Moderate retardation
C. Severe retardation
D. Profound retardation

Answer 150

C. Severe retardation

RATIONALE
Severe retardation: 20-34

A Mild: 59-70
B Moderate: 35-49
D Profound:

Question 151

22. One of the major behavioral characteristics of children with autism is their:

A. Overreaction to stimuli
B. Continued use of rituals
C. Retarded speech development
D. Inability to use abstract thought

Answer 151

B. Continued use of rituals

RATIONALE
Seen when children bangs their head on the wall.

Question 152

23. The mental health nurse meets with the mother of a child diagnosed with ADHD. The mother states, “I feel so guilty that he has this disease, like I did something wrong. I feel like I need to be with him constantly in order for him to get better. But still sometimes I feel like I’m going to lose control and hurt him.” Which of the following would MOST appropriate to suggest to the mother?

A. Arranging for interval care to watch the child and give herself a regular break
B. Taking a job to allow herself to feel some success because her child won’t ever improve
C. Arranging to have coffee with friend daily as a way to begin a support group
D. Considering foster care if she feels that she can’t handle her child’s problem

Answer 152

A. Arranging for interval care to watch the child and give herself a regular break

Question 153

24. An 8 year old boy is seen in a clinic for treatment of ADHD. Medication has been prescribed for the child along with family counseling. The nurse teaches the parents about the medications and discusses parenting strategies. Which of the following statements, if made by the parents, would indicate that further teaching is necessary?

A. “We will give the medication at night so it doesn’t decrease his appetite.”
B. “We will provide a regular routine for sleeping, eating, working, and playing.”
C. “We will establish firm, but reasonable limits on his behavior.”
D. “We will reduce distractions and external stimuli to help him concentrate.”

Answer 153

A. “We will give the medication at night so it doesn’t decrease his appetite.

RATIONALE
One side effect of ADHD medications is insomnia. It should be given in the morning.

Question 154

25. An 8 year old has recently been diagnosed with ADHD by his pediatrician. He and his parents come to the pediatric clinic together. Which of the following behaviors would the nurse be most likely to observe from the child?

A. Lethargy
B. Very poor verbal skills
C. Preoccupation with body parts
D. Short attention span

Answer 154

D. Short attention span

Question 155

26. A client is admitted to the emergency department after being sexually assaulted. She is accompanied by a policewoman. The nurse realizes that several important tasks should be done in sexual assault cases. Which nursing intervention should receive first priority?

A. Assisting with medical treatment
B. Collecting and preparing evidence for the police
C. Attempting to reduce the client’s anxiety from panic to a moderate level
D. Providing anticipatory guidance to the client about normal responses to sexual assault

Answer 155

C. Attempting to reduce the client’s anxiety from panic to a moderate level

Question 156

27. The nurse is intervening with a client who experienced crisis following the sudden death of a loved one. Which of the following actions would the nurse take after establishing initial rapport?

A. The nurse would ask the client to describe his social support system
B. The nurse would call the client’s family to discuss the problem
C. The nurse would encourage the client to describe in detail what happened
D. The nurse would refer the client to a bereavement support group

Answer 156

C. The nurse would encourage the client to describe in detail what happened

RATIONALE
Promotes verbalization.

Question 157

28. The school nurse receives a referral from a teacher about a sudden behavior change in a 13 year old girl. The girl has become increasingly withdrawn and uninterested in her schoolwork. Upon interviewing the girl as well as the teacher, the nurse notes that the girl’s behavioral changes correspond with a rapid onset of puberty. Which of the following types of crisis is the girl experiencing?

A. Adventitious crisis
B. Developmental crisis
C. Situational crisis
D. Natural crisis

Answer 157

B. Developmental crisis

Question 158

29. Marichu tells her friend Mario that she is distressed because she just lost her part-time job and her business. Marichu is currently experiencing a crisis. A crisis can be best defined as:

A. A way to relieve anxiety
B.. The perception of the problem by the client
C. A threat to homeostasis
D. A situation requiring help other than personal resources

Answer 158

C. A threat to homeostasis

Question 159

30. The nurse recognizes that Marichu is probably experiencing:

A. Maturational
B. A situational crisis
C. An adventitious crisis
D. A developmental crisis

Answer 159

B. A situational crisis

Question 160

31. A client with paranoid personality disorder is hospitalized for physically threatening his wife because he suspects her of having an affair with a coworker. Which of the following approaches would the nurse employ with this client?

A. Authoritarian
B. Parental
C. Matter-of-fact
D. Controlling

Answer 160

C. Matter-of-fact

Question 161

32. A client complaining to other clients about not being allowed by staff to keep food in her room. Which of the following interventions would be MOST appropriate?

A. Ignoring the client’s behavior
B. Reprimand the client
C. Setting limits on the behavior
D. Allowing the snack to be kept in her room

Answer 161

C. Setting limits on the behavior

Question 162

33. A 22 year old woman has been diagnosed with a schizoid personality disorder. Her frequent problems with family and employer have brought her to the crisis clinic. She states that her employer is a real tyrant. The nurse knows that a common characteristic of schizoid personality disorder is:

A. Lethargy
B. Two personalities
C. Sexual preoccupation
D. Tendency to withdraw from others

Answer 162

D. Tendency to withdraw from others

RATIONALE
Schizoid: loner

Question 163

34. A person with an antisocial personality disorder has difficulty relating to others because of never having learned to:

A. Count on others
B. Empathize with others
C. Be dependent on others
D. Communicate with others socially

Answer 163

B. Empathize with others

Question 164

35. A client has a diagnosis of borderline personality disorder. She has attached herself to one nurse and refuses to speak with other staff members. She tells the nurse that other nurses are mean, withhold her medication, and mistreat her. The staff is discussing this problem at their weekly conference. Which intervention would be most appropriate for the nursing staff to implement?

A. Provide an unstructured environment for the client
B. Rotate the nurses who are assigned to the client
C. Ignore the client’s behaviors
D. Bend unit rules to meet the client’s needs

Answer 164

B. Rotate the nurses who are assigned to the client

Question 165

36. A depressed client is sitting in the activities room, staring at the wall. Which nursing intervention would be most appropriate?

A. Give the client free access to the activities materials, and ask what she wants to do
B. Give the client time to select an activity, and sit with her until she gets busy
C. Give the client equipment for making a collage, and show her how to do it
D. Give the client 500-piece jigsaw puzzle, and tell her to do the best she can

Answer 165

C. Give the client equipment for making a collage, and show her how to do it

RATIONALE
Patients with depression should not be asked open-ended questions and should be given only with simple tasks.

A and B offer open ended questions
D is a complex task

Question 166

37. The nurse has been working with a depressed male client for one week. This morning, the client comes to the dining room with hair uncombed and shirt unbuttoned. Which of these actions should the nurse take first?

A. Approach the client and offer to help him finish getting dressed
B. Ignore the client’s appearance and help him find his place at the table
C. Sit with the client and help him eat the food
D. Walk with the client until he notices that his shirt is unbuttoned

Answer 166

A. Approach the client and offer to help him finish getting dressed

Question 167

38. The nurse would know that the teaching for a client receiving a monoamine oxidase inhibitor medication for treatment of depression was effective if the client states, “I should avoid…?”

A. Grilled chicken and pasta
B. Tuna
C. Aged cheeses and wine
D. Grilled fish

Answer 167

C. Aged cheeses and wine

RATIONALE
Tyramine-rich foods are contraindicated to patients taking MAOI because it could lead to hypertensive crisis. 
Food that are rich in tyramine include:
• Avocado
• Banana (overripe)
• Papaya
• Processed foods
• Alcoholic beverages
• Cheese (except cottage, cream, and ricotta)

Question 168

39. The family of a client in the manic phase of a bipolar disorder consults the nurse regarding how to handle the client’s aggressive behavior. What is the most appropriate response?

A. “Ignore the behavior. The client wouldn’t hurt a family member.”
B. “If the client threats you, call for help.”
C. “Physically restrain the client.”
D. “Direct the client to their room in a calm, firm voice.”

Answer 168

D. “Direct the client to their room in a calm, firm voice.”

Question 169

40. While taking lithium carbonate for treatment of a bipolar disorder, a client develops the following side effects. Which side effect should the nurse report to the physician?

A. Blurred vision
B. Orthostatic hypotension
C. Vomiting
D. Tinnitus

Answer 169

C. Vomiting

RATIONALE
It indicates lithium toxicity and needs to be reported.
Signs of Lithium toxicity:
• Vertigo
• Anorexia
• N/V
• Diarrhea
• Abdominal cramps
• Lethargy
• Tremors

Question 170

41. A patient is telling the nurse about his perception of his thought patterns. Which of the following statements, if made by the patient, would validate the diagnosis of schizophrenia?

A. “I can’t get the same thoughts out of my head.”
B. “I know I sometimes feel on top of the world, then suddenly down.”
C. “Sometimes, I look up and wonder where I am.”
D. “It’s clear that this is an alien laboratory and I am in charge.”

Answer 170

D. “It’s clear that this is an alien laboratory and I am in charge.”

RATIONALE
Indicates delusion, a positive sign of schizophrenia.

Question 171

42. Which of the following nursing diagnoses would the nurse identify for the client reporting thoughts of being followed by foreign guests who are his secret papers?

A. Disturbed Sensory Perception: Visual related to increased anxiety, as evidenced by inappropriate responses
B. Disturbed Thought Process related to increased anxiety as evidenced by delusional thinking
C. Impaired Verbal Communication related to disoriented thinking, as evidenced by loose associations
D. Social Isolation related to mistrust, as evidenced by withdrawal behaviors

Answer 171

B. Disturbed Thought Process related to increased anxiety as evidenced by delusional thinking

Question 172

43. A client reports that men in blue clothes keep looking in her window and talking about her. Which of the following responses by the nurse would be most appropriate?

A. “Those men in blue uniform are our groundskeepers. They probably are talking about their work, not you.”
B. “Don’t take thinks so personally. Not everyone who is talking about you.”
C. “Let’s not pay attention to the men. Let’s play card instead.”
D. “I’ll close the drapes so you can’t see the men.”

Answer 172

A. “Those men in blue uniform are our groundskeepers. They probably are talking about their work, not you.”

RATIONALE
Presents reality.

Question 173

44. When administering antipsychotics in a client with a paranoid schizophrenia, the nurse understands that the newer atypical antipsychotics such as olanzapine (Zyprexa) and resperidone (Risperdal) are more effective than the older medications in treating the negative symptoms of schizophrenia because of which of the following?

A. Serotonin and y-aminobutyric acid (GABA) levels are not affected
B. Dopamine and serotonin receptors are blocked
C. GABA and norepinephrine levels are increased
D. Norepinephrine and dopamine receptors are blocked

Answer 173

B. Dopamine and serotonin receptors are blocked

Question 174

45. Clozapine (Clozaril) therapy has been initiated for a client with schizophrenia who has been responsive to other psychotics. The client states, “Why do I have a blood test every week?” Which of the following responses by the nurse would be MOST appropriate?

A. “Weekly blood tests are necessary to determine safe dosage and to monitor the effect of the medication on the blood.”
B. “Weekly blood tests are done so that you can receive another week’s supply of the medication.”
C. “Your physician will want to know how well you are progressing with the medication therapy.”
D. “Everyone taking clozapine (Clozaril) has to go through the same procedure because it is required by the drug company.”

Answer 174

A. “Weekly blood tests are necessary to determine safe dosage and to monitor the effect of the medication on the blood.”

Question 175

1. A 15 year old adolescent looks at a mirror and cries out, “Mukha akong ibon. Hindi na ito ako.” What would be the best response by the nurse?

A. “Aling ibon?”
B. “Napakabigat ng dinaramdam mo, hindi naman nag iba ang mukha mo.”
C. “Baka dahil lang yun sa ilaw, gusto mo ba ng ibang salamin?”
D. “Bakit mo naman nasabi na nagmumukha ka nang ibon?”

Answer 175

B. “Napakabigat ng dinaramdam mo, hindi naman nag iba ang mukha mo.”

Question 176

2. The client with kidney stones refuses to eat lunch and rudely tells the nurse to get out of the room. Which of the following responses by the nurse would be MOST appropriate?

A. “I’ll leave, but you need to eat.”
B. “I’ll get something for your pain.”
C. “Your anger doesn’t bother me. I’ll be back later.”
D. “You sound angry. What is upsetting you?”

Answer 176

D. “You sound angry. What is upsetting you?”

Question 177

3. The nurse finds the client crying and saying, “Ito na naman ako, umiiyak na parang bata.” Choose the best response by the nurse.

A. “Oo nga, buti alam mo.”
B. “Dahil yan sa makulimlim na panahon.”
C. “Bakit ayaw mong sumali sa laro para sumaya ka naman?”
D. “Nahihiya ka ba dahil umiyak ka?”

Answer 177

D. “Nahihiya ka ba dahil umiyak ka?”

Question 178

4. The nurse enters the client’s room and notes that breakfast has not been touched. The client is waiting for the spouse who has been dead for several years. What is the most appropriate nursing response?

A. “In order to get well, you really do need to eat.”
B. “Don’t be silly. You know your spouse passed away years ago.”
C. “Let me help you get started. May I butter your toast for you?”
D. “I’ll have nursing assistant to come in order to feed you in a few minutes.”

Answer 178

C. “Let me help you get started. May I butter your toast for you?”

Question 179

5. One day during an interview in the psychiatric unit, a client says, “I have nothing to live for. I just can’t go on.” What is the best response by the nurse?”

A. “Are you thinking of suicide?”
B. “Don’t talk that way. You can’t mean it.”
C. “What would your husband do without you?”
D. No response, just change the subject.

Answer 179

A. “Are you thinking of suicide?”

Question 180

6. Select the most appropriate question in assessing a client’s affective response to recent hospitalization.

A. “What causes you the most anxiety about being in the hospital?”
B. “How are you adapting to the unit schedule and routine?”
C. “Have you been attending group and recreational therapy?”
D. “Who is caring for your children while you are in the hospital?”

Answer 180

A. “What causes you the most anxiety about being in the hospital?”

Question 181

7. As the nurse begins pre-op teaching for open heart surgery, the client becomes more restless, avoids eye contact, and seems distracted by outside noises. Which statement is most appropriate by the nurse?

A. “Please settle down and pay attention. This is important.”
B. “You seem anxious about your surgery.”
C. “I know you’re probably worried about this surgery — everyone feels that way.”
D. Just ignore the reaction and go on with your teaching

Answer 181

B. “You seem anxious about your surgery.”

Question 182

8. Identify the best response by the nurse when an unmarried client, who is about to be discharged from the ER, states, “Kailangan ko na namang bumalik sa lumang bahay na yun, di ba?”

A. “Ay dapat lang, bahay mo yun eh.”
B. “Bakit ayaw mong umuwi?”
C. “Uuwi ka ba o hindi (3x).”
D. “Anong gusto mong gawin?”

Answer 182

D. “Anong gusto mong gawin?”

Question 183

9. During a one-to-one interaction with the nurse, the client is silent for the last five minutes. Which response is most appropriate by the nurse?

A. “Apparently, you do not wish to talk with me. How have I made you angry?”
B. “I’ve noticed you have become quiet. Tell me what have you been thinking about.”
C. “If you don’t wish to talk, that’s OK. We will meet again tomorrow at the same time.”
D. “If you don’t use this time to solve problem with me, how will you ever get better?”

Answer 183

B. “I’ve noticed you have become quiet. Tell me what have you been thinking about.”

Question 184

10. During admission to the psychiatric unit, the nurse observes that the client sits slumped over in a chair, speaks and moves slowly, and cries incessantly. When the nurse sits down next to this client, the client then states, “You don’t want to sit next to me. You would sit with someone else if you knew what I have done.” What is the most appropriate response by the nurse?

A. “Why shouldn’t I sit next to you?”
B. “What do you think you have done?”
C. “Who should I sit by?”
D. “I’m sure whatever you have done, couldn’t be that bad.”

Answer 184

B. “What do you think you have done?”

Question 185

11. The nurse observes a client who is becoming increasingly upset. He is rapidly pacing, hyperventilating, clenching his jaw, wringing his hands and trembling. His speech is is high-pitched and random; he seems preoccupied with his thoughts. He is pounding his fist into his other hand. The nurse identifies his anxiety level as:

A. Mild
B. Moderate
C. Severe
D. Panic

Answer 185

C. Severe

Question 186

12. During a conversation with the client, the nurse observes the client shaking his leg and tapping his fingers on the table next to him. The nurse’s best statement is,

A. “I see that you’re anxious. I’ll be back later when you’re calmer.”
B. “I noticed that your leg is shaking and you’re tapping your fingers on the table. How are you feeling now?”
C. “I’ll get you something to help you feel less anxious.”
D. “I know that you feel anxious. Let’s discuss something more pleasant.”

Answer 186

B. “I noticed that your leg is shaking and you’re tapping your fingers on the table. How are you feeling now?”

Question 187

13. The nurse is caring for a 30-year-old woman admitted with a diagnosis of PTSD. Three months ago, the client had found the body of her husband, who had hung himself, in their basement. The nurse could expect her to exhibit all but which of the following behaviors:

A. Recurrent distressing dreams
B. Inability to look at husband’s picture
C. Irritability and outbursts of anger
D. Discussing plans to remedy someday

Answer 187

D. Discussing plans to remedy someday

Question 188

14. The nurse is caring for a client admitted 1 week ago with a diagnosis of PTSD. Today, he begins to describe the traumatic event that occurred in his life 6 months ago. The best response by the nurse would be to:

A. Allow the client to describe the event and listen empathically
B. Change the subject because the topic is clearly upsetting the client
C. Tell the client that the event was not as bad he remembers it
D. Encourage the client to share his experience in the therapeutic group meeting

Answer 188

A. Allow the client to describe the event and listen empathically

Question 189

15. A client is suffering from PTSD following a rape by an unknown assailant. One of the primary goals of nursing care for this client would be to:

A. Establish a safe, supportive environment
B. Control aggressive behavior
C. Deal with the client’s anxiety
D. Discuss the client’s nightmares and reactions

Answer 189

A. Establish a safe, supportive environment

Question 190

16. Which assessments of an adult suffering from PTSD are most likely to be found by the nurse?

A. Fear of disapproval, narrow focus on detail
B. Constant seeking of affirmation, need for emotional intimacy
C. Guilt, irritability, a sense of self-devaluation and nightmares
D. Changes in personality, frequent periods of “lost” time

Answer 190

C. Guilt, irritability, a sense of self-devaluation and nightmares

Question 191

17. Choose the purpose for an obsessive-compulsive client’s ritualistic behavior.

A. Response to hallucinations that tell the client of being unclean
B. Behaviors to help fulfill a need for self-punishment
C. Attempts to decrease anxiety and control the environment
D. Attempts to get increased attention from people

Answer 191

C. Attempts to decrease anxiety and control the environment

Question 192

18. In regard to monitoring rituals if a client diagnosed with an obsessive-compulsive disorder, which is the best nursing intervention?

A. Wake the client at the usual time, permit the rituals, let the client miss breakfast
B. Stop the rituals by locking the bathroom door, and escort the client to breakfast
C. Arrange an earlier rising, permit the rituals, let the client go to breakfast
D. Confront the client with the reasons for the rituals, then send the client to breakfast

Answer 192

C. Arrange an earlier rising, permit the rituals, let the client go to breakfast

Question 193

19. A nursing assistant asks the nurse why a client’s physician doesn’t just force an agoraphobic client to get out of the house to help her get over her fears. Which understanding of the treatment of phobias should the nurse’s response include?

A. People must gain a sense of control over the feared object — they cannot be forced when they’re not ready
B. People use their fears to consciously avoid taking responsibility for their lives
C. The treatment approach is intentionally slow to help the client into a sense of fearlessness
D. Forcing people into fearful situations can cause psychosis

Answer 193

A. People must gain a sense of control over the feared object — they cannot be forced when they’re not ready

Question 194

20. The nurse is caring for a 35-year old woman with agoraphobia. Which of the following behaviors would the nurse expect to observe in the client?

A. The client is afraid of talking to other people
B. The client is afraid of pain
C. The client is afraid to leave her home
D. The client is afraid of fire

Answer 194

C. The client is afraid to leave her home

Question 195

21. A 14-year-old girl is being evaluated for anorexia nervosa. Which of the following might indicate that the client has symptoms of bulimia?

A. Lack of menstruation
B. Hypertension and hyperglycemia
C. Severe weight loss due to metabolic dysfunction
D. Diaphoresis and vasodilation

Answer 195

B. Hypertension and hyperglycemia

Question 196

22. An adolescent client is admitted to the psychiatric unit for rapid weight loss associated with anorexia nervosa. She is 5 feet, 2 inches tall and weighs 70 pounds. Physical manifestations most likely be found during nursing assessment include:

A. Tachycardia, hypertension, and hyperthyroidism
B. Tachycardia, hypertension, and iron deficiency anemia
C. Hypotension, elevated serum potassium level, and Vitamin C deficiency
D. Bradycardia, hypotension, and cold sensitivity

Answer 196

D. Bradycardia, hypotension, and cold sensitivity

Question 197

23. The nurse enters the client’s room and finds her doing sit-ups. What would be the nurse’s best approach?

A. Wait until she finishes and ask her why she feels the need to exercise
B. Remind her that if she loses weight, she will lose privileges
C. Ask her to stop doing the sit-ups and direct her to a quiet activity
D. Leave the room and allow her to exercise in private

Answer 197

C. Ask her to stop doing the sit-ups and direct her to a quiet activity

Question 198

24. A 15-year-old female client with bulimia nervosa tells the nurse she does not like the other teenagers on the ward. The nurse senses the client’s disdain towards her peers. Which nursing action would be best help the teenager with peer relationships?

A. Point out to the client how she affects others
B. Ask the client why she doesn’t like her peers
C. Carefully select same-age peers to include in an activity with the client
D. Have the client choose an activity that would include herself, the nurse, and some peers as participants

Answer 198

D. Have the client choose an activity that would include herself, the nurse, and some peers as participants

Question 199

25. The client goes to the bathroom and purges after lunch. Which of the following nursing orders would be included in the client’s care plan?

A. Observe the client for 2 hours after each meal
B. Institute a one-to-one observation for the next 24 hours
C. Tell the client to write about her feelings when she has the urge to purge
D. Inform the client that an extra snack will be needed after each purging incident

Answer 199

A. Observe the client for 2 hours after each meal

Question 200

26. When caring for a client with bulimia, the best way for the nurse to determine if she has stopped purging after meals is to:

A. Observe what she does after every meal
B. Weigh her before and 2 hours after each meal
C. Monitor her electrolyte lab values
D. Not allow her to leave the unit right after meals

Answer 200

C. Monitor her electrolyte lab values

Question 201

27. A client has been referred to a nurse-led group for compulsive overeaters at the mental health clinic by her physician. It is desirable for group members to use functional roles in the group to obtain the most benefit from the group. In which of the following instances is a group role (versus an individual role) being used by one of the members? The member

A. Shows the group the latest pictures of her child
B. Insists that everyone try her favorite reducing diet
C. Makes quiet comments to the person sitting next to her
D. Proposes an alternative task to keep from thinking about food

Answer 201

D. Proposes an alternative task to keep from thinking about food

Question 202

28. The client has gained 35 pounds in 7 weeks. Before her admission to the psychiatric unit, she refused to see her friends or to leave her house. Which of the following nursing diagnoses would be most appropriate for this client?

A. Ineffective Individual coping
B. Self-esteem Disturbance
C. Diversional Activity Deficit
D. Anxiety

Answer 202

B. Self-esteem Disturbance

Question 203

29. The client has gained 35 pounds in 7 weeks. Before her admission to the psychiatric unit, she refused to see her friends or to leave her house. Which of the following nursing interventions would be least appropriate for this client?

A. Invite her to participate in an informal craft activity
B. Ask the dietician to meet with her
C. Tell her to record what she eats throughout the day
D. Explain to her that obesity can be the result of dysfunctional coping with stress

Answer 203

A. Invite her to participate in an informal craft activity

Question 204

30. An adolescent client is admitted to the psychiatric unit for rapid weight loss associated with anorexia nervosa. She is 5 feet and 2 inches tall and weighs 70 pounds. Physical manifestations most likely to be found during nursing assessment include:

A. Tachycardia, hypertension, and hyperthyroidism
B. Tachycardia, hypertension, and iron deficiency anemia
C. Hypotension, elevated serum potassium level, and Vitamin C deficiency
D. Bradycardia, hypotension, and cold sensitivity

Answer 204

D. Bradycardia, hypotension, and cold sensitivity

Question 205

31. A child scores between 55 and 68 on a standardized intelligent quotient (IQ) assessment test. The nurse is aware that this degree of intellectual impairment would be considered:

A. Mild
B. Profound
C. Severe
D. Moderate

Answer 205

A. Mild

RATIONALE
Normal IQ: 80-120

Borderline: 70-90
Mild MR: 50-70
Moderate MR: 35-49
Severe MR: 20-34
Profound MR:

Question 206

32. A 7-year-old boy is hospitalized with a diagnosis of autism. The nurse observes the child on admission. Which of the following information regarding his behavior would confirm that he is an autistic child?

A. Lack of interest in inanimate objects
B. Unresponsive to others
C. Dislike of routine
D. Below average intelligence

Answer 206

B. Unresponsive to others

RATIONALE
Child with autistic has his own world.

A Irrelevant
C Correct: Likes routine (e.g. Head banging)
D Refers to MR

Question 207

33. A 2 year old child is brought into the physician’s office by her parents who are concerned of her behavior. They state that she resists their affection, twirls around frequently, and refuses to respond to other children and adults. Based on the analysis of these behaviors, which of the following would the nurse suspect?

A. Mental retardation
B. ADHD
C. Autism
D. Schizophrenia

Answer 207

C. Autism

Question 208

34. When developing the plan of care for a child diagnosed with ADHD, the nurse would expect to include treatment MOST commonly with a combination of which of the following?

A. Anti-anxiety medication such as buspirone (Buspar) and home schooling
B. Antidepressant medication such as imipranine (Tofranil) and family therapy
C. Anticonvulsant medications such as carbamazepine (Tegretol) and monthly blood levels
D. Psychostimulants medications such as methylphenidate (Ritalin) and behavior medication

Answer 208

D. Psychostimulants medications such as methylphenidate (Ritalin) and behavior medication

Question 209

35. A 3-year-old client has been diagnosed with ADHD. Which medication is most likely to be prescribed?

A. Amitriptyline (Elavil)
B. Paroxetene (Paxil)
C. Diazepam (Valium)
D. Pemoline (Cylert)

Answer 209

D. Pemoline (Cylert)

RATIONALE
Also Ritalin and Dexedrine can be prescribed.

Question 210

36. One of the outcomes of play therapy is to enable the children to:

A. Act out feelings in a constructive manner
B. Learn to talk openly about themselves
C. Learn how to give and receive feedback
D. Learn problem-solving skills

Answer 210

A. Act out feelings in a constructive manner

Question 211

37. The nurse teaches the parents of a mentally retarded child regarding her care. The following guidelines may be taught except:

A. Hopelessness
B. Altered parenting role
C. Altered family process
D. Ineffective coping

Answer 211

A. Hopelessness

Question 212

38. A nurse may encounter children with mental disorders. Her knowledge of these various disorders is vital. When planning school interventions for a child with a diagnosis of ADHD, a guide to remember is to:

A. Provide as much structure as possible for the child
B. Ignore the child’s overactivity
C. Encourage the child to engage in any play activity to dissipate energy
D. Remove the child from the classroom when disruptive behavior occurs

Answer 212

A. Provide as much structure as possible for the child

Question 213

39. School phobia is usually treated by:

A. Returning the child to the school immediately with family support
B. Calmly explaining why attendance in school is necessary
C. Allowing the child to enter the school before the other children
D. Allowing the parent to accompany the child in the classroom

Answer 213

A. Returning the child to the school immediately with family support

Question 214

40. The nurse teaches the parents of a mentally retarded child regarding her care. The following guidelines may be taught except:

A. Overprotection of the child
B. Patience, routine, and repetition
C. Assisting the parents set realistic goals
D. Giving reasonable compliments

Answer 214

A. Overprotection of the child