Kaplan Psychiatric Nursing A, B, and C

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1. Which nursing approach is best when caring for a client diagnosed with conversion reaction paralysis?

1. Give special attention to the paralyze limb.
2. Point out to the client the paralysis reflects anxiety.
3. Minimize the sick role and secondary gains.
4. Attempt to have the client move periodically.

Answer: 3. Minimize the sick role and secondary gains.

2. One morning at a group therapy session, several clients begin to pick on another client for their passive behavior. The nurse leader says that the client is a very sensitive person who has problems, and they should stop picking on the client. Which is the most likely affect of the statement?

1. The client’s isolation from the group will decrease.
2. The client’s insight into the group behavior will increase.
3. The client’s isolation from the group will increase.
4. The client’s participation in the group will increase.

Answer: 3. The client’s isolation from the group will increase.

3. The nurse assist a terminally ill elderly patient with the morning bath routine. The patient says to the nurse, "why do you bother with me?" Which response by the nurse is best?

1. Would you preferred to be alone right now?
2. I care about you and how you are doing.
3. I understand how you feel.
4. This is a difficult disease, isn’t it?

Answer: 2. I care about you and how you are doing.

4. A psychiatric nurse is presented with a group of patients in the ER. Which of the following patients requires immediate attention?

1. A 24-year-old male who failed medical school and says, "my pain will be over soon."
2. A 30-year-old female who is unable to talk in front of other people due to symptoms of anxiety.
3. A 45-year-old male who hears voices telling him to harm others.
4. A 50-year-old male who is anxious after witnessing a murder.

Answer: 1. A 24-year-old male who failed medical school and says, "my pain will be over soon."

5. The nurse admits a client with a diagnosis of schizophrenia to the unit. The patient’s needs are best met by which of the following group?

1. Give the client a brief orientation and staying with the client for a while.
2. Offer the client a description of ward activities and introducing the client to other patients.
3. Introduce the client to another client and ask the other client to give a short unit tour.
4. Sit with the client in a quiet room and waiting until the hallucinations stop.

1. Give the client a brief orientation and staying with the client for a while.

6. An adolescent is admitted to the psychiatric hospital. The adolescent reports that during the previous weekend the adolescent hit a sibling during an argument. After the argument, the clients arm became paralyzed. The nurse anticipates the client will react in which way about the paralysis?

1. The client appears calm about the paralysis.
2. Client expresses anxiety about permanent damage.
3. The client improves with a passive arm exercises.
4. The client recognizes the symptoms are not real.

Answer: 1. The client appears calm about the paralysis.

7. The nurse is seeing patients in the adolescent psychiatric clinic. Which of the following patients should the nurse see first?

1. A 13-year-old with complaints of impulsivity and poor attention span.
2. A 14-year-old who often uses his temper and argues with his teachers.
3. A 15-year-old who wants to be a model and only drinks water and eat vegetables.
4. A 16-year-old who bullies, threatened, and intimidates others and initiates physical fights.

Answer: 3. A 15-year-old who wants to be a model and only drinks water and eats vegetables.

8. The RN has assessed patients on the psychiatric unit. Which of the following activities is appropriate for the nurse to delegate to a nursing assistant on a psychiatric unit?

1. Perform 30 minute check on each patient.
2. Teen lithium level on a patient who may be toxic.
3. Lead a group on anger management with eight patients.
4. Administer fluoxetine (Prozac) to the patient as ordered.

Answer: 1. Perform 30 minute check on each patient.

9. During the period of elation for the client diagnosed with bipolar disorder, which approach should the nurse plan to use frequently?

1. Point out the effect a client’s behavior has on others.
2. Attempt to distract and redirect the client.
3. Encourage the client to express himself.
4. Provide opportunities for the client to socialize.

Answer: 2. Attempt to distract and redirect the client.

10. The nurse understands that the primary problem experienced by a patient diagnosed with schizophrenia is

1. A split personality.
2. Compulsive behavior patterns.
3. Difficulty in forming relationships.
4. Acting out behavior patterns.

Answer: 3. Difficulty in forming relationships.

11. The client responds incorrectly when a nurse asks the date and day of the week. The nurse best describes the client’s mental state by which term?

1. Euphoric.
2. Ambivalent.

3. Incoherent.
4. Disoriented

Answer: 4. Disoriented.

12. A young man is brought to the emergency department by a friend. The patient is agitated and is screaming, "I can’t stop seeing things. Help me, I’m going crazy." His friend reports to the nurse that he took some LSD earlier in the day. It is most important for the nurse to take which of the following actions?

1. Give the patient reflected feedback.

2. Stay with the patient and quietly attempt to talk the patient down.

3. Set limits on the patient’s behavior.
4. Place patient in a well lighted room close to the nurse’s station.

Answer: 2. Stay with the patient and quietly attempt to talk the patient down.

13. The nurse instructs the patient’s spouse about how to cope with the patient’s anxiety. The nurse determines teaching is successful if the spouse makes which of the following statements?

1. Anxiety is a conscious means of resolving conflict.

2. Anxiety represents an unconscious conflict of needs.

3. It is important to confront my spouse during periods of anxiety.

4. Anxiety is increased by using defense mechanisms.

Answer: 2. Anxiety represents an unconscious conflict of needs.

14. The nurse volunteers in a homeless shelter. The nurse notices that another volunteer develops an overly close relationship with the older women in the shelter. During conversation, the volunteer relates to the nurse that several years before the volunteer’s mother died, they refused to let their mother live in the volunteer’s home. The nurse understands that the volunteer is using which defense mechanism?

1. Substitution.

2. Undoing.

3. Compensation.

4. Denial.

Answer: 2. Undoing.

15. A nurse reviews the patient care given by another RN to a group of psychiatric patients. The nurse identifies this type of review is which of the following?

1. Peer review.
2. Quality review.
3. Performance appraisal.
4. Risk review.

Answer: 1. Peer review.

16. A patient is slumped on the floor with a razor blade in hand; blood pours from the wrist. A nurse finds the patient. What is most important for the nurse to do?

1. Find out why the patient tried to commit suicide.
2. Telephone the doctor to explain the situation.
3. Ask a nurses assistant to hold his wrist while the nurse called the doctor.
4. Call another nurse for help; stay with the patient.

Answer: 4. Call another nurse for help; stay with the patient

17. The nurse plans care for a patient diagnosed with antisocial personality disorder. The nurse understands that the purpose of group therapy for this patient is to

1. Provide extra time to explore the patient’s past.
2. Demonstrate acceptance of the patient and his behavior.
3. Set limits on the patient in a nonpunitive manner.
4. Encourage sublimation of the patient’s leadership potential.

Answer: 3. Set limits on the patient in a nonpunitive manner.

18. A client comes to the community mental health center with symptoms of overwhelming anxiety related to job loss, impending move, and sister being diagnosed with cancer. The client states "I used to use alcohol to cope, but ever since I’ve been going to those AA meetings two years now I have been able to remain sober." The nurse anticipates the physician will order which of the following medications for this client?

1. Chlordiazepixide (Librium)
2. Buspirone (BuSpar)
3. Alprazolam (Xanax)
4. Diazepam (Valium)

Answer: 2. Buspirone (BuSpar)

19. The nurse instructs the client about phenelzine sulfate. Which client statement indicates to the nurse that further teaching is necessary?

1. I can’t wait to eat a hotdog with sauerkraut.
2. I’m going to have to get some polycarbophil when I get home.
3. I will be playing double tennis with my neighbors.
4. When I get home, I’m going to take my car out for a road trip.

Answer: 1. I can’t wait to eat a hotdog with sauerkraut. Rational MAOI; client should avoid foods high in tyramine (such as aged cheese, beer, red wine, dry sausage, sauerkraut, liver) because it may precipitate a hypertensive crisis.

20. The client is admitted to the hospital with a diagnosis of paranoid schizophrenia. The spouse states that client has not slept in three nights. Which nursing goal takes priority?

1. Increase a sense of responsibility.
2. Increase independence.
3. Promote trust.
4. Promote rest.

Answer: 3. Promote trust.

21. The nurse cares for patients in the child psychiatric clinic which of the following patients should the nurse see first?

1. A child with auditory hallucinations.
2. A child expressing worry about leaving his mother to go to school.
3. A child receiving haloperidol (Haldol) experiencing blurry vision and dry mouth.
4. A child with a lithium level of 0.5 mEq/L.

Answer: 1. A child with auditory hallucinations.

22. The nurse cares for a client receiving venlafaxine for two months. The client tells the nurse that he is unable to maintain an erection and wants to stop taking the medication to see if this is causing the problem. Which response by the nurse is most appropriate?

1. Venlafaxine does not cause sexual side effects.
2. I’ll contact the healthcare provider so that he can gradually reduce the dosage of medication.
3. The sexual side effects will decrease with time.
4. Your inability to maintain an erection is due to anxiety.

Answer: 2. I’ll contact the healthcare provider so that he can gradually reduce the dosage of medication.

23. The nurse orients the client to the unit. The nurse observes the client is pacing, talking rapidly, and has elevated respirations. Which action by the nurse is best?

1. Provide an informational booklet.
2. Keep the explanation simple.
3. Delay the orientation until the anxiety has eased.
4. Stress the positive aspects of the unit.

Answer: 2. Keep the explanation simple.

24. The nurse knows which statement is true regarding anorexia nervosa?

1. Adolescent males are most affected.
2. 5 to 20% of clients diagnosed with anorexia nervosa die.
3. Client diagnosed with anorexia nervosa see themselves as emaciated.
4. Clients diagnosed with anorexia nervosa are self-indulgent.

Answer: 2. 5 to 20% of clients diagnosed with anorexia nervosa die.

25. The nurse cares for patients in the psychiatric ER. Which of the following patient should the nurse see the first?
1. A patient receiving haloperidol (Haldol) experiencing and oculogyric crisis.
2. A patient receiving thioridazine (Mellaril) experiencing akathisia.
3. A patient receiving risperidone (Risperdal) experiencing blurry vision.
4. A patient receiving fluphenazine (Prolixin) experiencing sedation

Answer: 1. A patient receiving haloperidol (Haldol) experiencing and oculogyric crisis. Rational: 1. A patient receiving haloperidol (Haldol) experiencing and oculogyric crisis. – eyes are locked upward; acute dystonic reaction; notify physician and physician will order an anticholinergic agent to correct this reaction.

26. The healthcare provider prescribes lithium carbonate for a client. The nurse understands which medication is contraindicated for this client?

1. Diuretics
2. MAOIs..
3. Tricyclic antidepressants.
4. Antibiotics.

Answer: 1. Diuretics Rational: 1. Diuretics – lithium causes sodium depletion; diuretics are contraindicated for clients on lithium 2. MAOIs – side effects include postural hypotension, hypertensive crisis if foods with tyramine ingested, potentiates alcohol..

27. The nurse anticipates which group of symptoms when caring for a client with disorientation due to dementia?

1. Judgment alterations, memory deficit, irritability.
2. Anorexia and weight loss, fatigue, hopelessness.
3. Confusion, delirium, hallucinations.
4. Impaired motor skills, lack of coordination, mood changes.

Answer: 1. Judgment alterations, memory deficit, irritability.

28. The nurse cares for patient diagnosed with an obsessive-compulsive disorder. The nurse observes that the patient has difficulty getting to meals on time because of a handwashing ritual. Which of the following statements by the nurse is best?
1. Starting tomorrow, you can eat in your room.
2. I know you’re feeling anxious, but is important to eat properly.
3. Tomorrow, I will call you 15 minutes earlier to help you get ready.
4. It is important that you discuss this with your doctor

Answer: 3. Tomorrow, I will call you 15 minutes earlier to help you get ready.

29. One morning the nurse finds a patient crying and approaches him. The patient says, "what do you want? Go away, you can’t help me. I hate you and I hate myself." Which of the following responses by the nurse is best?

1. Why is it that you dislike me and yourself?
2. I’ll come back later when you feel in a better mood.
3. It’s difficult for me to communicate with you when you talk this way.
4. You seem to be in pain, I’ll stay with you for a while.

Answer: 4. You seem to be in pain, I’ll stay with you for a while.

30. The nurse cares for a patient with depression who attempts suicide. The nurse understands which of the following is the most likely reason that a patient attempts suicide?

1. The patient is suspicious and mistrustful.
2. The patient consciously wishes to manipulate others.
3. The patient feels overwhelmed and helpless.
4. The patient wants to gain attention.

Answer: 3. The patient feels overwhelmed and helpless.

31. The nurse cares for client in the mental health clinic. A client diagnosed with obsessive-compulsive disorder tells the nurse that they are afraid of contracting AIDS. The client reports spending much of the day washing hands and spraying disinfectant in the room. The nurse understands that this handwashing behavior represents which statement?

1. A drive that needs to be denied.
2. A dissociative response to trauma.
3. A hidden wish to become ill and disabled.
4. A symbolic expression of conflict and guilt.

Answer: 4. A symbolic expression of conflict and guilt. Rational: dissociation – disconnects one part of memory from another; repetitive behavior – is an attempt to control anxiety; accept client’s ritualistic behavior, structure environment, offer alternative activities, especially ones using the hands.

32. The nurse knows that disulfiram is most likely prescribed for which client?

1. An obese client.
2. A dying client.
3. A client who is anorexic.
4. A client abusing alcohol.

Answer: 4. A client abusing alcohol.

33. An RN from the pediatric unit is assigned to the psychiatric unit. Which of the following patient assignments is the most appropriate for the reassigned nurse?

1. A psychotic patient who hears the double telling him to kill himself.
2. A suicidal patient who had a plan to jump off the bridge today.
3. A patient diagnosed with depression with a decreased appetite.
4. And adolescent who vomited every day for three months because she wants to be thin.

Answer: 3. A patient diagnosed with depression with a decreased appetite. Rational – most stable patient for RN new to unit.

34. A patient on a psychiatric unit continually complains to the nurse that his stomach is missing. Which of the following responses by the nurse is most appropriate?

1. That’s not possible, you wouldn’t be able to eat anything.
2. I am here to help you with this problem.
3. It sounds as if you feel very empty and alone.
4. This is a common response to depression.

Answer: 3. It sounds as if you feel very empty and alone.

35. The nurse prepares a patient for surgery to remove a malignant tumor from the large intestines. The patient appears calm and relaxed and remarks to the nurse, "my health is fine. My physician is a pessimist." The nurse identifies that the statement is an example of

1. Sublimation.
2. Denial.
3. Displacement.
4. Intellectualization.

Answer: 2. Denial.

36. The nurse cares for clients in an inpatient psychiatric unit and leads an adolescent social/support group to discuss the difficulties of growing up in today’s society. The nurse knows that the therapeutic benefit of this group is based on which concept?

1. The group’s ability to evaluate their behavior.
2. The phase of the group’s interaction.
3. The leader’s skill in promoting progress.
4. The group members’ sense of belonging.

Answer: 4. The group members’ sense of belonging.

37. Nursing care for the client diagnosed with substance abuse is based on which principle?

1. The client has difficulty making decisions.
2. The client expects too much of himself.
3. The client attempts to appease others at all costs.
4. The client has limited ability to tolerate anxiety.

Answer: 4. The client has limited ability to tolerate anxiety.

38. The client diagnosed with schizophrenia is placed on haloperidol 5 mg bid. The nurse should observe the client for which symptoms?

1. Constipation and dry mouth.
2. Vomiting and diarrhea.
3. Diuresis and sodium loss.
4. Hypertension and insomnia.

Answer: 1. Constipation and dry mouth. – traditional antipsychotic of high potency; high incidence of extrapyarmidal side effects

39. The nurse interacts with a patient diagnosed with depression. The nurse expects the patient to express which of the following thoughts?

1. I’m embarrassed that everyone has to take care of me.
2. Once my depression is over, I’ll be able to get on with life.
3. I like being taken care of from time to time.
4. I’m glad that I came for helping time.

Answer: 1. I’m embarrassed that everyone has to take care of me. Rational – patients diagnosed with depression usually have feelings of guilt and unworthiness, and have difficulty accepting help from others because of these feelings; while depressed patients may be dependent and demanding, they often feel unworthy of the attention they receive and are embarrassed by their feelings of helplessness.

40. The nurse cares for the client who has taken tricyclic antidepressant for 12 days. Which behavior(s) should the nurse be alert for in this client?

1. Anger and sarcasm.
2. Suicidal behaviors.
3. Withdrawal from reality.
4. Early morning waking.

Answer: 2. Suicidal behaviors. Rational – tricyclic antidepressants begin to take effect about 10 to 14 days after treatment is started; at that time, patients may have enough physical and emotional energy to act upon their suicidal thoughts.

41. The nurse cares for the client diagnosed with conversion reaction. The nurse identifies that this client utilizes which defense mechanisms?

1. Interjection and denial.
2. Projection and displacement.
3. Identification and rationalization.
4. Repression and symbolization.

Answer: 4. Repression and symbolization. – instinctive drives and their accompanying anxiety are repressed by the client with conversion reaction and converted into physical symptom that has symbolic meaning; paralysis of a hand means the individual cannot carry out the unacceptable activity, which is guilt provoking.

42. The nurse in the mental health clinic understands that which of the following foods should be avoided by clients taking Phenelzine sulfate (Nardil)? Select all that apply.

1. Aged cheeses.
2. Lunch meats.
3. Nuts.
4. Leafy green vegetables.
5. Tofu.
6. Chocolate.

1. Aged cheeses, 2. Lunchmeats, 5. Tofu, 6. Chocolate

43. The client is told by the healthcare provider that the client’s cancer is inoperable. The nurse enters the room a short time later and find client crying. Which action should the nurse take first?

1. Acknowledge this is a sad time.
2. Quietly leave the room.
3. Call the chaplain or spiritual leader at the hospital.
4. Stress what can be done in the time remaining.

Answer: 1. Acknowledge this is a sad time.

44. The nurse overhears the client diagnosed with dementia tell a story about something that the nurse knows is not true. Which action by the nurse is best?

1. Correct the information as presented.
2. Allow the client to continue the story.
3. Refer the client for reminiscence therapy.
4. Orient the client to person, place, and time.

Answer: 2. Allow the client to continue the story. Rational: supports a positive self-image; confabulation serves as a defense against memory impairment; avoiding confrontation over fabricated stories will alleviate factors affecting dementia, and avoid increasing demands on the client’s coping mechanisms.

45. The nurse knows that, according to Maslow’s hierarchy of needs, which means our most basic to any clients health maintenance plan?

1. Love and belonging.
2. Esteem and recognition.
3. Safety and security.
4. Self actualization.

Answer: 3. Safety and security.

46. The client is placed on escitalopram 10 mg daily. Which side effects to the nurse instruct family to observe for?

1. Photophobia.
2. Dizziness.
3. Epistaxis. – nose bleeds
4. Hypertensive crisis.

Answer: 2. Dizziness.

47. The nurse cares for a patient receiving sertraline (Zoloft). Which of the following statements is most important for the nurse to make?

1. It would not have any effect on your sleeping patterns.
2. You don’t have to worry about interactions with other medications.
3. You can drink beer and wine but not mixed drinks, while taking this drug.
4. It might take four weeks for you to reach full therapeutic effect.

Answer: 4. It might take four weeks for you to reach full therapeutic effect.

48. Chlordiazepixide (Librium) 10 mg PO bid is prescribed for a patient. The nurse should assess the patient for which of the following?

1. Skeletal muscle spasms and insomnia.
2. Anorexia and dry mouth.
3. Diarrhea and euphoria.
4. Drowsiness and confusion.

Answer: 4. Drowsiness and confusion.

50. A graduate nurse fails an examination and accuses the psychiatric instructor of being an unfit teacher and causing the failure. The nurse identifies this as an example of

1. Conversion.
2. Acting out.
3. Compensation.
4. Projection.

Answer: 4. Projection. Rational: 4. Projection. – unable to accept her sense of failure and resulting poor self-esteem, the student projects the failure onto the instructor, thereby saving face but coping ineffectively.

51. The nurse is interacting with a patient diagnosed with an obsessive-compulsive personality disorder. The patient says to the nurse, "I don’t understand what is wrong with rules, regulations, and schedules." The nurse understands that the patient uses defense mechanisms in order to

1. Apply a logical approach to a need
2. Provide a feeling of safety and protect the person sense of self-worth.
3. Fragment the personality causing mental illness.
4. Bring suppressed material into awareness

Answer: 2. Provide a feeling of safety and protect the person sense of self-worth.

52. A middle-age client is admitted to the hospital with a diagnosis of terminal lung cancer. The client’s spouse reports to the nurse that the client did not want to come to the hospital and "refuses to slow down." The nurse should give priority to which measure?

1. Promote rest and relaxation.
2. Encourage the client to participate in planning care.
3. Encourage the client to except help from others.
4. Set limits on excessive activities.

Answer: 2. Encourage the client to participate in planning care.

53. The nurse understands that in a psychiatric inpatient setting, milieu therapy is best understood as
1. Providing a therapeutic physical and social environment.
2. Manipulation of the environment anyway that makes the patient feel at home.
3. Establishing therapeutic communication with numerous staff members.
4. Setting limits on behavior

Answer: 1. Providing a therapeutic physical and social environment.

. A client diagnosed with schizophrenia is referred for family therapy at a mental health clinic. In the first session, the client’s mother monopolizes the discussion. Which of the following actions should the nurse take first?

1. Politely asked the mother to be quiet to allow other family members to talk.
2. Allow the mother to ventilate since she has a need to do so.
3. Discuss the mothers monopolizing behavior with her privately after the session.
4. Ask the rest of the family how they feel about the mothers talking.

Answer: 4. Ask the rest of the family how they feel about the mothers talking.

54. The nurses seeing patients in the psychiatric clinic. Which of the following patients should the nurse see first?

1. A 15-year-old male brought in by police because he threatened to jump off a bridge and has access to a gun.
2. A 20-year-old female who lost 2 pounds this week and only eats two meals a day.
3. A 45-year-old male with a history of depression he states he is out of Prozac.
4. A 75-year-old male whose wife passed away two weeks ago and is experiencing insomnia and irritability.

Answer: 1. A 15-year-old male brought in by police because he threatened to jump off a bridge and has access to a gun.

55. The home care nurse makes an initial visit for a client diagnosed with myocardial infarction. The client’s spouse states that she is having difficulty coping with the clients "obsessive-compulsive" tendencies. Which of the following statements, if made by the client to the nurse, is consistent with obsessive-compulsive disorder?

1. I have difficulty making decisions and adjusting to change.
2. I am sure I am being followed by someone from work.
3. All of my life I’ve had problems with being unkept.
4. I spend money excessively, which upsets my wife.

Answer: 1. I have difficulty making decisions and adjusting to change

56. When intervening with a violent client, the nurse should take which action?

1. Tell the client that they have no control over their behavior.
2. Point out that the client is making others anxious.
3. Identify the nurse to client and remain calm.
4. Touch the client gently to offer reassurance.

Answer: 3. Identify the nurse to client and remain calm.

57. The nurse cares for clients in the mental health clinic. A client with depression joins an ongoing therapy group. What is the goal of group therapy?

1. To introduce the client to other clients.
2. To communicate acceptance to the client.
3. To encourage decision-making.
4. To increase the client’s sense of responsibility.

Answer: 2. To communicate acceptance to the client.

58. The nurse finds the client diagnosed with schizophrenia standing in the day room of the psychiatric inpatient unit completely undressed. Which measure by the nurse is best?

1. Cover the client with a towel or sheet and send the client to get dressed.
2. Lead the client back to their room and help the client get dressed.
3. Asked client why they seem to need extra attention this morning.
4. Take the client back to room and privately reprimand them.

Answer: 2. Lead the client back to their room and help the client get dressed.

59. The nurse knows that chlorpromazine hydrochloride (Thorazine) is most likely to be prescribed for which of the following patients?

1. A patient diagnosed with thoracic outlet syndrome.
2. A patient diagnosed with schizophrenia.
3. A patient diagnosed with asthma.
4. A patient diagnosed with acne.

Answer: 2. A patient diagnosed with schizophrenia.

60. During group therapy on the unit, one participant seldom speaks. One morning, the participant listens intensely and maintains eye contact with another patient who speaks about depression, but the client still doesn’t speak. Which response by the nurse is most appropriate?

1. You are both sad now, but it is better to have a positive you to share.
2. Why are you looking that way? You seem very upset.
3. Express yourself verbally, so the group understands you.
4. It seems as if you have some feelings about what’s being said.

Answer: 4. It seems as if you have some feelings about what’s being said.

61. Which of the following signs and symptoms would the nurse observe in a patient who has recently taken heroin?
1. Constricted pupils, depressed respirations.
2. Dilated pupils, increased respirations.
3. Vomiting and hypertension.
4. Agitation and tachycardia

Answer: 1. Constricted pupils, depressed respirations.

62. The client diagnosed with a phobic disorder joins a group meeting with a psychiatric nurse leader. During the first meeting, the client states: "I know my feeling of being terrified of close spaces is dumb. It doesn’t make any sense. I just can’t seem to do anything about it. Right now I get nervous and scared just thinking about it." Which response by the nurse is best?

1. Having her stay with you in a closed space could help you overcome your fear.
2. Knowing that your fears don’t make sense doesn’t always help you feel better.
3. Participating in several of our ward activities may make you feel better.
4. Being frightened as a child by some particular incident probably cause these fears.

Answer: 2. Knowing that your fears don’t make sense doesn’t always help you feel better.

63. The client is brought to the emergency room by family members after taking an overdose of diazepam. The family reports the client has become increasingly depressed and withdrawn during the previous month. Which question is most important for the nurse to ask during the initial interview?
1. Why did you do this to yourself?
2. Can you elaborate on what is bothering you?
3. Exactly what, how much, and when did you take the medication?
4. Did you seriously think of killing yourself?

Answer: 3. Exactly what, how much, and when did you take the medication?

64. The home care nurse visits a client living in a dependent living facility. The client is receiving risperidone (Risperdal). The nurse notes the client has a shuffling gait and trembles when reaching for reading glasses. The nurse did not notice these behaviors on the previous visit. Which action by the nurse is most appropriate?

1. Re-educate the staff about the importance of administering the medication on time.
2. Contact the client’s physician.
3. Counseled the client about the importance of not mixing medication and alcohol.
4. Record the observation in the client’s record.

Answer: 2. Contact the client’s physician.

65. During the second session of individual therapy, a client sits quietly with arms folded and eyes cast down. Which approach by the nurse is best?

1. You small talk to keep the conversation going.
2. Ask the client why is having difficulty talking.
3. Ask concrete, direct questions that require simple answers.
4. Use broad openings and leads to encourage discussion.

Answer: 4. Use broad openings and leads to encourage discussion.

66. The client who had a hysterectomy six months ago suddenly developed an intense fear of elevators. When a client approaches the building elevator, the client becomes panicky and cannot get on. The nurse knows that this client’s fear of elevators is caused by which occurrence?

1. A projection of anxiety onto a neutral object.
2. A common post op phenomenon in females.
3. An attempt to undo her traumatic hospital experience.
4. A conversion reaction to emotional stress.

Answer: 1. A projection of anxiety onto a neutral object.

67. The nurse cares for a patient diagnosed with antisocial personality disorder. Which of the following statements, if made by the patient to the nurse, best indicates improvement in the patient’s condition?

1. I get into trouble because I don’t think before I act.
2. My parents have difficulty accepting my independence.
3. I’ve spent very little time actually enjoying life.
4. It’s sad that others don’t recognize my potential.

Answer: 1. I get into trouble because I don’t think before I act.

68. The nurse observes that a patient develops a strong attachment to another patient who repeatedly insults him. The nurse understands that this is an example of which of the following?

1. Reaction formation.
2. Undoing.
3. Displacement.
4. Introjection.

Answer: 1. Reaction formation.

69. The nurse cares for a patient diagnosed with depression and encourages the patient to join in an activity. Which of the following approaches by the nurse is best?

1. Offer several appealing choices to the patient.
2. Tell the patient it is part of the physician’s orders.
3. Describe the activity in detail to the patient.
4. Invite the patient to join in.

Answer: 4. Invite the patient to join in.

70. The parent of two school-age children tells the nurse that the spouse has recently become unemployed and the client reports feeling depressed. The nurse understands which statement to be true?

1. The spouse’s unemployment is a significant potential stressor.
2. The spouse’s unemployment is irrelevant.
3. Unemployment is mainly a factor in development crises.
4. The client is using the spouse’s unemployment to avoid their own problems.

Answer: 1. The spouse’s unemployment is a significant potential stressor

71. Four clients in the ER are complaining of side effects from the medication. Which of the following clients shouldn’t nurse see first?

1. A client receiving clozapine and experiencing flulike symptoms.
2. A client receiving valorous acid and experiencing tremors.
3. A client receiving lorazepam and experiencing abdominal discomfort.
4. A client receiving methylphenidate who lost 5 pounds in four weeks.

Answer: 1. A client receiving clozapine and experiencing flulike symptoms.

72. A patient diagnosed with paranoid schizophrenia tells the nurse, "I have a feeling of numbness in my legs. They feel like they don’t belong to me, and I think someone on TV is controlling my walking." Which response by the nurse is best?

1. That must be an unpleasant experience for you. Have you had these feelings before?
2. I know that you are frightened now, but soon the medication will ease your symptoms.
3. Part of your sickness is an imaginary world. In reality, television does not control people.
4. Tell me more about these feelings.

Answer: 1. That must be an unpleasant experience for you. Have you had these feelings before?

73. The parent comes to the mental health clinic seeking help to cope with an oppositional/defiant teenager who is abusing alcohol and drugs which question should the nurse ask first?

1. What seems to be the problem?
2. What do you think you can do?
3. You must feel very angry about this.
4. Help is available for you.

Answer: 1. What seems to be the problem?

74. In the day unit of an outpatient mental health program, the nurse finds the client diagnosed with undifferentiated schizophrenia dancing alone next to the radio. Suddenly, the client stops dancing and stares at the nurse in a menacing manner. Which action by the nurse is best?

1. Leave for short time promising to return soon.
2. Remain silent and standstill until the client speaks.
3. Start talking to the client about a neutral topic.
4. Point out that the client has stopped dancing and seems upset.

Answer: 4. Point out that the client has stopped dancing and seems upset.

75. One day the mother of the patient diagnosed with antisocial personality disorder says to the nurse, "my son seems much better. I feel he is finally going to grow up and assume responsibility." The nurse should anticipate that the prognosis for this client is probably

1. Good because there is no evidence of psychotic behavior.
2. Doubtful because psychotherapy will cause regression.
3. Good because with medication and psychotherapy, the underlying problem will be resolved.
4. Doubtful because antisocial patients have little, if any, motivation for change.

Answer: 4. Doubtful because antisocial patients have little, if any, motivation for change.

77. The client comes to the local clinic reporting dizziness and a racing heart. The client’s physical exam is normal. The client reports that the client’s company recently lost a large sum of money, and the client feels responsible. The client tells the nurse that the client is extremely anxious. Which response by the nurse is best?

1. When did you first notice that you were feeling anxious?
2. Have you shared this information with a loved one?
3. Are you worried about having to visit the healthcare provider?
4. Would you like to discuss it with me?

Answer: 1. When did you first notice that you were feeling anxious?

78. When intervening with a patient who is in a state of crisis, which of the following statements by the nurse most effectively help the patient to cope?
1. Why is it that you feel so upset in this situation?
2. What have you done when you felt this anxious before?
3. There was no way to prevent this from happening.
4. It seems as if the situation is very stressful for you

Answer: 2. What have you done when you felt this anxious before?

79. One of the nursing assistive personnel on the unit is critical of a client admitted after an accidental overdose. The assistant says, "the client’s family worries about the client but the client doesn’t seem to care how anybody feels." Which response by the nurse to the assistant is best?

1. If we can make the client realize this, perhaps the client will get better.
2. Sometimes it’s difficult to see how anxious the clients really are.
3. Perhaps the clients family has caused the patient pain.
4. Being critical of the client is not going to help the client improve.

Answer: 2. Sometimes it’s difficult to see how anxious the clients really are.

76. The nurse instructs a client diagnosed with bipolar disorder receiving lithium 300 mg tid. The nurse determines that teaching is effective if the client states which of the following?

1. I can still have my coffee.
2. I should not increase my level of exercise.
3. I should not sit in a hot tub.
4. I will eat a moderate amount of sodium.

Answer: 4. I will eat a moderate amount of sodium.

80. Fluphenizene (Prolixin) is ordered for a patient. If the client develops tardive dyskinesia the nurse expects the patient to exhibit which of the following?

1. Tremors and an unsteady gait.
2. Tingling sensations in the extremities and stiffness.
3. Shuffling and pacing.
4. Bizzarre facial movements and difficulty in swallowing.

Answer: 4. Bizzarre facial movements and difficulty in swallowing.

81. The nurse expects which of the following medications to be ordered for a patient experiencing alcohol withdrawal delirium?
1. Phenobarbital and chlordiazepixide (Librium).
2. Disulfiram (Antabuse) and chlorpromazine (Thorazine).
3. Disulfiram (Antabuse) and barbiturates.
4. Tricyclics and sedatives

Answer: 1. Phenobarbital and chlordiazepixide (Librium).

82. The nurse observes a patient for signs of Korsakoff’s psychosis. The nurse expects the patient to exhibit which?

1. Seizures.
2. Diplopia.
3. Nystagmus.
4. Confabulation.

Answer: 4. Confabulation.

83. The nurse cares for clients on the medical/surgical unit. The nurse admits a client for possible appendicitis. During the admission interview the client states, "most days I drink about 1 pint of vodka." The nurse knows that which is the most likely time for the client to develop alcohol withdrawal delirium?

1. 6-12 hours after cessation of drinking.
2. 12-18 hours after cessation of drinking.
3. 48-72 hours after cessation of drinking.
4. 4 days after cessation of drinking.

Answer: 3. 48-72 hours after cessation of drinking

84. A patient diagnosed with bipolar depression is hospitalized in the elation phase of the illness. The patient says to the nurse, "I just bought myself a home computer and a large screen TV for the family." Which of these interpretations by the nurse is most accurate?

1. The patient wants to impress the nurse with his generosity toward the family.
2. The patient is insecure about his self-worth and needs to manipulate electronic devices.
3. The patient has completely lost contact with reality and his thought patterns are disturbed.
4. The patient has a mood disturbance and his judgment is poor at this time.

Answer: 4. The patient has a mood disturbance and his judgment is poor at this time.

85. Which of the following statements, it’s made by an alcoholic patient to the nurse, indicates that the patient has an accurate understanding of the problem?

1. When I can learn to stop after one drink, I will have my problems beat.
2. When my family and work problems go away, I won’t need alcohol anymore.
3. I can’t seem to cope with my problems without drinking.
4. In my business, most people work hard and drink too much.

Answer: 3. I can’t seem to cope with my problems without drinking.

86. The nurse plans care for the client with a history of substance abuse. It is most important for the nurse to select which approach?

1. A structured but permissive setting.
2. And environment that increases reality testing.
3. A structured, nonpermissive setting.
4. An environment that decreases stimuli and redirects behavior.

Answer: 3. A structured, nonpermissive setting.

87. The nurse prepares to lead a group session for clients with a dependence on alcohol. The nurse knows that an alcoholic client drinks because of which reason?

1. The alcoholic enjoys the feeling of being intoxicated.
2. The alcoholic uses alcohol to escape from problems.
3. The alcoholic has a greater alcohol tolerance than most people.
4. The alcoholic performs more efficiently when drinking.

Answer: 2. The alcoholic uses alcohol to escape from problems.

88. The 29-year-old woman told by the healthcare provider that she cannot have children subsequently forms a close attachment to her niece and nephew. The nurse understands that this is an example of which defense mechanism?

1. Sublimation.
2. Projection.
3. Undoing.
4. Rationalization.

Answers: 1. Sublimation. Rational: sublimation – client’s desire to be a mother through a close attachment to her niece and nephew; by using sublimation, she can satisfy some of her unmet maternal instincts; she will still have to work through the issues of loss ande the mourning process that usually accompany infertility. Projection – attributing to others one’s own feelings, impulses, thoughts, or wishes; saying that someone you are angry with dislikes you

89. A client newly diagnosed with paranoid schizophrenia tells the nurse, "there are really strange people in the corner of my room laughing at me and saying horrible things." Which response by the nurse is most appropriate?

1. I don’t see anything, and you really have nothing to be afraid of.
2. I don’t hear any voices, but I know this is frightening for you.
3. What are they saying to you?
4. Sometimes when people are upset, their imaginations plays tricks on them.

Answer: 2. I don’t hear any voices, but I know this is frightening for you.

90. When caring for a patient after electroconvulsive therapy it is most important for the nurse to take which of the following actions?

1. Encourage the patient to turn from side to side.
2. Remind patient that memory loss is temporary.
3. Examine the patient carefully for fractures.
4. Tell the patient the seizure was very short.

Answer: 2. Remind patient that memory loss is temporary.

91. A patient diagnosed with depression is scheduled to begin a series of electroconvulsive therapy treatments. It is most important for the nurse to notify the physician about which of the following?

1. The patient is being treated for glaucoma.
2. The father of the patient had seizures during an episode of meningitis.
3. The patient has one dentures for 10 years.
4. The patient is allergic to shellfish.

Answer: 1. The patient is being treated for glaucoma.

92. The nurse meets with a patient on the psychiatric unit when another patient diagnosed with antisocial personality disorder walks into the room and sits down. Which of the following responses by the nurse is best?

1. This patient and I are talking. If you’d like to sit with us for a while, you’ll have to remain quiet.
2. How do you feel about another patient joining us?
3. Do you have something you’d like to discuss?
4. Right now we are talking. Please return to the ward and I’ll talk to you later.

Answer: 4. Right now we are talking. Please return to the ward and I’ll talk to you later.

93. The client is brought to the hospital by the spouse. The client is boisterous, quarrelsome, and unusually energetic. The spouse reports that in the past week the client has not slept more than three hours a night, and has been buying extravagant items that they cannot afford. Which understanding is basic to the care of the client with episodes of elation and depression?

1. The client has non-specific fears.
2. The client is easily stimulated by the surroundings.
3. The client has recurring unwanted thoughts.
4. The client has a well organized delusional system.

Answer: 2. The client is easily stimulated by the surroundings.

94. The client with a diagnosis of antisocial personality disorder fails to arrive on time for scheduled appointment with the nurse. The nurse contacts the client to remind them of the appointment, and the client states, "I would rather meet between 12 and one." Which response by the nurse is best?

1. Perhaps we can make that change the next time.
2. Is there something you are having trouble discussing?
3. I would have to discuss any changes with the team first.
4. Are you having some difficulty with the time you agreed to?

Answer: 4. Are you having some difficulty with the time you agreed to?

95. The mother of two delivers a newborn with a cleft palate. The parents visit the baby in the newborn nursery. Which statement by the nurse to the parents is best?

1. Sit in that rocking chair so that you can hold your baby.
2. We feed the infants every four hours.
3. I’ll hold your baby while you look at him.
4. You can watch the nurse give your baby a bath.

Answer: 1. Sit in that rocking chair so that you can hold your baby.

96. The nurse cares for clients in the pediatric clinic. The parent of the younger child asks the nurse why the child is involved in play therapy. Which statement by the nurse is best?

1. Young children have difficulty verbalizing emotions.
2. Children hesitate to confide in anyone but their parents.
3. Play is an enjoyable form of therapy for children.
4. Play therapy is helpful in preventing regression.

Answer: 1. Young children have difficulty verbalizing emotions.

97. The nurse cares for clients in the pediatric clinic. The nurse understands according to Erikson’s stages of psychosocial development, trust and significant early attachments develop during which year of life?
1. Birth – 18 months.
2. 18 months – 3 years.
3. 3-6 years
4. 6-12 years

Answer: 1. Birth – 18 months.

98. The client diagnosed with inoperable cancer has difficulty walking after chemotherapy. When the nurse comes to assist the client to the bathroom, the client says, "Leave me alone. You treat me like a child." Which interpretation of the client’s behavior, by the nurse, is most justifiable?

1. The client is frightened about falling.
2. The client is entering a regressive phase.
3. The client wants to maintain independence.
4. The client is angry at the nurse’s interference.

Answer: 3. The client wants to maintain independence.

99. The nurse cares for a patient diagnosed with a terminal illness. It is most important for the nurse to take which of the following actions?

1. Let the patient know he is not alone.
2. Attempt to promote hope in the patient.
3. Be helpful to the patient at all times.
4. Discourage denial in the patient.

Answer: 1. Let the patient know he is not alone.

100. A patient appears angry and demanding following a below-the-knee amputation. Which of these interpretations by the nurse of this patient’s behavior is most justifiable?

1. The patient is seeking attention to compensate for the loss.
2. The patient is placing the blame for her difficulties on others.
3. The patient is having difficulty accepting her body image.
4. The patient feels alienated by the hospital staff.

Answer: 3. The patient is having difficulty accepting her body image.

101. The woman is admitted to the hospital for a possible mastectomy. On the evening before his wife’s scheduled surgery, the husband appears tense and paces up and down the hall. Which comment by the nurse to the husband is best?

1. We will do everything we can to help your wife.
2. This is an upsetting experience for you and your wife.
3. You will feel relieved once the surgery is over.
4. I think it might help you if we discussed your wife’s surgery.

Answer: 2. This is an upsetting experience for you and your wife.

102. A terminal patient dies quietly in his sleep. The nurse should take which of the following actions?

1. Provide a private place for family members.
2. Explain that the patient is in heaven now.
3. Notify the family members individually.
4. Shield the family from viewing the patient.

Answer: 1. Provide a private place for family members.

103. A client in the hypertension clinic expresses worry to the nurse that his wife has been unemployed for more than six months, and that he is afraid that soon they will be unable to pay the rent. Which of these responses by the nurse is most appropriate?

1. These things always seem worse than they really are.
2. It’s important for your blood pressure that you not worry too much about that.
3. You’re worried that you won’t be able to pay the rent?
4. I will refer you to a social worker.

Answer: 3. You’re worried that you won’t be able to pay the rent?

104. When caring for a person diagnosed with a peptic ulcer, which of the following nursing measures is indicated?

1. Identify stress factors in the person’s environment.
2. Avoid giving the person choices to make.
3. Encourage the person to become angry.
4. Avoid discussing the person’s symptoms.

Answer: 1. Identify stress factors in the person’s environment.

105. The spouse of a phobic patient is troubled by his wife’s sudden fear of cars. He asks the nurse, "What should I do when she gets frightened? The nurse should urge the husband to

1. Ride with his wife in a car.
2. Encourage his wife to go for a ride in a car.
3. Allow his wife to avoid cars.
4. Encourage his wife to discuss her fears.

Answer: 3. Allow his wife to avoid cars. Rational: well-meaning friends and family often encourage a patient to encounter the feared object; this only increases apprehension and anger on the part of the patient, by allowing his wife to avoid the car, her husband accepts her position while therapy is under way.

106. The nurse cares for clients in the outpatient clinic. A client relates to the nurse, "I travel only by train because I am terrified of flying." The nurse understands that the phobic client is most likely to respond to which of the following?

1. Major tranquilizers.
2. Insight-oriented therapy
3. Crisis intervention.
4. Systemic desensitization

Answer: 4. Systemic desensitization

107. The nurse finds one patient screaming at the roommate, "You are always meddling in my side of the room and snooping around my property. I can’t stand you anymore." The nurse should take which of the following actions?

1. Address both patients, saying, "You both seem very upset with each other."
2. Address the patient who is shouting and say, "You sound as if you are very angry with your roommate."
3. Tell both patients, "We will have to make a plan to avoid this kind of bickering between you."
4. Tell the angry patient, "You must leave the room immediately because you are out of control."

Answer: 2. Address the patient who is shouting and say, "You sound as if you are very angry with your roommate."

108. The nurse cares for a patient who has been raped. Which of the following actions should the nurse perform first?

1. Focus on the here and now.
2. Refer the patient for crisis counseling.
3. Determine how the rape occurred.
4. Assess how the patient has previously responded to trauma.

Answer: 1. Focus on the here and now.

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