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Question 1

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

mechanisms.

Answer 1

ANS: B

Question 2

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

Answer 2

ANS: B

Question 3

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

Answer 3

ANS: C

Question 4

wo staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, “The nurse manager had a headache the day I was interviewed.”  Which defense mechanism is evident?
a.
Introjection
c.
Projection
b.
Conversion
d.
Splitting

Answer 4

ANS: C

Question 5

.	A student says, “Before taking a test, I feel very alert and a little restless.” The nurse can correctly assess the student’s experience as:
a.
culturally influenced.
c.
trait anxiety.
b.
displacement.
d.
mild anxiety.

Answer 5

D

Question 6

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

Answer 6

ANS: C

Question 7

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

Answer 7

ANS: A

Question 8

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

Answer 8

ANS: B

Question 9

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

Answer 9

C

Question 10

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

Answer 10

ANS: D

Question 11

.	A nurse plans health teaching for a patient with generalized anxiety disorder who begins a new prescription for lorazepam (Ativan). What information should be included? Select all that apply.
a.
Caution in use of machinery
b.
Foods allowed on a tyramine-free diet
c.
The importance of caffeine restriction
d.
Avoidance of alcohol and other sedatives
e.
Take the medication on an empty stomach

Answer 11

ANS: A, C, D

Question 12

3. Which assessment questions would be most appropriate for the nurse to ask a patient with possible obsessive-compulsive disorder? Select all that apply.
   a.
   “Are there certain social situations that cause you to feel especially uncomfortable?”
   b.
   “Are there others in your family who must do things in a certain way to feel comfortable?”
   c.
   “Have you been a victim of a crime or seen someone badly injured or killed?”
   d.
   “Is it difficult to keep certain thoughts out of your awareness?”
   e.
   “Do you do certain things over and over again?”

Answer 12

ANS: B, D, E

Question 13

4.	The nurse assesses an adult who is socially withdrawn and hoards. Which nursing diagnoses most likely apply to this individual?  Select all that apply.
a.
Ineffective home maintenance
b.
Situational low self-esteem
c.
Chronic low self-esteem
d.
Disturbed body image
e.
Risk for injury

Answer 13

ANS: A, C, E

Question 14

Symptoms of withdrawal from opioids for which the nurse should assess include:
a.
dilated pupils, tachycardia, elevated blood pressure, and elation.
b.
nausea, vomiting, diaphoresis, anxiety, and hyperreflexia.
c.
mood lability, incoordination, fever, and drowsiness.
d.
excessive eating, constipation, and headache.

Answer 14

ANS: B

Question 15

What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal?
A. Risk for injury R/T central nervous system stimulation
B. Disturbed thought processes R/T tactile hallucinations
C. Ineffective coping R/T powerlessness over alcohol use
D. Ineffective denial R/T continued alcohol use despite negative consequences

Answer 15

ANS: A

Question 16

On the first day of a client’s alcohol detoxification, which nursing intervention should take priority?
A. Strongly encourage the client to attend 90 Alcoholics Anonymous meetings in 90 days.
B. Educate the client about the biopsychosocial consequences of alcohol abuse.
C. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol.
D. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

Answer 16

ANS: C

Question 17

A client diagnosed with chronic alcohol use disorder is being discharged from an inpatient treatment facility after detoxification. Which client outcome related to Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss with the client during discharge teaching?
A. After discharge, the client will immediately attend 90 AA meetings in 90 days.
B. After discharge, the client will rely on an AA sponsor to help control alcohol cravings.
C. After discharge, the client will incorporate family in AA attendance.
D. After discharge, the client will seek appropriate deterrent medications through AA.

Answer 17

ANS: A

Question 18

A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect. She has been admitted to an inpatient drug rehabilitation program. Which client statement should a nurse associate with a positive prognosis for this client?
A. “I’m not going to use heroin ever again. I know I’ve got the willpower to do it this time.”
B. “I cannot control my use of heroin. It’s stronger than I am.”
C. “I’m going to get all my children back. They need their mother.”
D. “Once I deal with my childhood physical abuse, recovery should be easy.”

Answer 18

ANS: B

Question 19

Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines?
A. Haloperidol (Haldol) and fluoxetine (Prozac)
B. Carbamazepine (Tegretol) and donepezil (Aricept)
C. Disulfiram (Antabuse) and lorazepam (Ativan)
D. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

Answer 19

ANS: D

Question 20

During group therapy, a client diagnosed with alcohol use disorder states, “I would not have boozed it up if my wife hadn’t been nagging me all the time to get a job. She never did think that I was good enough for her.” How should a nurse interpret this statement?
A. The client is using denial by avoiding responsibility.
B. The client is using displacement by blaming his wife.
C. The client is using rationalization to excuse his alcohol dependence.
D. The client is using reaction formation by appealing to the group for sympathy.

Answer 20

ANS: C

Question 21

16. A nurse is interviewing a client in an outpatient drug treatment clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish?
    A. The client will identify one person to turn to for support.
    B. The client will give up all old drinking buddies.
    C. The client will be able to verbalize the effects of alcohol on the body.
    D. The client will correlate life problems with alcohol use.

Answer 21

ANS: D

Question 22

A client has a history of daily bourbon drinking for the past 6 months. He is brought to an emergency department by family, who report that his last drink was 1 hour ago. It is now 12 midnight. When should a nurse expect this client to exhibit withdrawal symptoms?
A. Between 3 a.m. and 11 a.m.
B. Shortly after a 24-hour period
C. At the beginning of the third day
D. Withdrawal is individualized and cannot be predicted.

Answer 22

ANS: A

Question 23

19. A client diagnosed with depression and substance use disorder has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions?
    A. Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance.
    B. Sedative-hypnotics are expensive and have numerous side effects.
    C. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep.
    D. Sedative-hypnotics are not as effective to promote sleep as antidepressant medications.

Answer 23

ANS: A

Question 24

. A client with a history of insomnia has been taking chlordiazepoxide (Librium), 15 mg, at night for the past year. The client currently reports that this dose is no longer helping him fall asleep. Which nursing diagnosis appropriately documents this problem?
A. Ineffective coping R/T unresolved anxiety AEB substance abuse
B. Anxiety R/T poor sleep AEB difficulty falling asleep
C. Disturbed sleep pattern R/T Librium tolerance AEB difficulty falling asleep
D. Risk for injury R/T addiction to Librium

Answer 24

ANS: C

Question 25

A client is admitted for alcohol detoxification. During detoxification, which symptoms should the nurse expect to assess?
A. Gross tremors, delirium, hyperactivity, and hypertension
B. Disorientation, peripheral neuropathy, and hypotension
C. Oculogyric crisis, amnesia, ataxia, and hypertension
D. Hallucinations, fine tremors, confabulation, and orthostatic hypotension

Answer 25

ANS: A

Question 26

22. A recovering alcoholic relapses and drinks a glass of wine. The client presents in the emergency department (ED) experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. What may these symptoms indicate to the ED nurse? 
A. Alcohol poisoning
B. Cardiovascular accident (CVA)
C. A reaction to disulfiram (Antabuse)
D. A reaction to tannins in the red wine

Answer 26

C

Question 27

. Which is the priority nursing intervention for a client admitted for acute alcohol intoxication?
A. Darken the room to reduce stimuli in order to prevent seizures.
B. Assess aggressive behaviors in order to intervene to prevent injury to self or others.
C. Administer lorazepam (Ativan) to reduce the rebound effects on the central nervous system.
D. Teach the negative effects of alcohol on the body.

Answer 27

ANS: B

Question 28

28. The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility?
    A. By asking directly if the client has ever had a problem with alcohol
    B. By holistically assessing the client, using the CIWA scale
    C. By using a screening tool such as the CAGE questionnaire
    D. By referring the client for physician evaluation

Answer 28

ANS: C

Question 29

Which of the following nursing statements exemplify important insights that will promote effective intervention with clients diagnosed with substance use disorders? Select all that apply.
A. “I am easily manipulated and need to work on this prior to caring for these clients.”
B. “Because of my father’s alcoholism, I need to examine my attitude toward these clients.”
C. “Drinking is legal, so the diagnosis of substance use disorder is an infringement on client rights.”
D. “Opiate addicts are typically uneducated, unrefined individuals who will need a lot of education and social skills training.”
E. “I can fix clients diagnosed with substance use disorders as long as I truly care about them.”

Answer 29

ANS: A, B, D

Question 30

A nursing instructor is teaching students about cirrhosis of the liver. Which of the following student statements about the complications of hepatic encephalopathy should indicate that further student teaching is needed? Select all that apply.
A. “A diet rich in protein will promote hepatic healing.”
B. “This condition leads to a rise in serum ammonia, resulting in impaired mental functioning.”
C. “In this condition, blood accumulates in the abdominal cavity.”
D. “Neomycin and lactulose are used in the treatment of this condition.”
E. “This condition is caused by the inability of the liver to convert ammonia to urea.”

Answer 30

ANS: A, C