NP V set II

1. A 17-year-old client has a record of being absent in the class without

permission, and “borrowing” other people’s things without asking permission.
The client denies stealing; rationalizing instead that as long as no one was
using the items, there is no problem to use it by other people. It is important
for the nurse to understand that psychodynamically, the behavior of the client
may be largely attributed to a development defect related to the:

A. Oedipal complex
B. Superego
C. Id
D. Ego

2. A client tells the nurse, “Yesterday, I was planning to kill myself.” What is the
best nursing response to this cient?

A. “What are you going to do this time?”

B. Say nothing. Wait for the client’s next comment
C. “You seem upset. I am going to be here with you; perhaps you will
want to talk about it”
D. “Have you felt this way before?”

3. In crisis intervention therapy, which of the following principle that the nurse
will use to plan her/his goals?

A. Crises are related to deep, underlying problems

B. Crises seldom occur in normal people’s lives
C. Crises may go on indefinitely.
D. Crises usually resolved in 4-6 weeks.

4. The nurse enters the room of the male client and found out that the client
urinates on the floor. The client hides when the nurse is about to talk to him.
Which of the following is the best nursing intervention?
 A. Place restriction on the client’s activities when his behavior occurs.
B. Ask the client to clean the soiled floor.
C. Take the client to the bathroom at regular intervals.
D. Limit fluid intake.

5. A young lady with a diagnosis of schizophrenic reaction is admitted to the

psychiatric unit. In the past two months, the client has poor appetite,
experienced difficulty in sleeping, was mute for long periods of time, just
stayed in her room, grinning and pointing at things. What would be the initial
nursing action on admitting the client to the unit?

A. Assure the client that “ You will be well cared for.”

B. Introduce the client to some of the other clients.
C. Ask “Do you know where you are?”
D. Take the client to the assigned room.

6. A 16-year-old girl was diagnosed with anorexia. What would be the first
assessment of the nurse?

A. What food she likes.

B. Her desired weight.
C. Her body image.
D. What causes her behavior.

7. On an adolescent unit, a nurse caring to a client was informed that her

client’s closest roommate dies at night. What would be the most appropriate
nursing action?

A. Do not bring it up unless the client asks.

B. Tell the client that her roommate went home.
C. Tell the client, if asked, “You should ask the doctor.”
D. Tell the client that her closest roommate died.
8. A woman gave birth to an unhealthy infant, and with some body defects.
The nurse should expect the woman’s initial reactions to include:

A. Depression
B. Withdrawal
C. Apathy
D. Anger

9. A client in the psychiatric unit is shouting out loud and tells the nurse,
“Please, help me. They are coming to get me.” What would be the appropriate
nursing response?

A. “ I won’t let anyone get you.”

B. “Who are they?”
C. “I don’t see anyone coming.”
D. “You look frightened.”

10. A client who is severely obese tells the nurse, “My therapist told me that I
eat a lot because I didn’t get any attention and love from my mother. What
does the therapist mean?” What is the best nursing response?

A. “What do you think is the connection between your not getting

enough love and overeating?”
B. “Tell me what you think the therapist means.”
C. “You need to ask your therapist.”
D. “ We are here to deal with your diet, not with your psychological
problems.”

11. After the discussion about the procedure the physician scheduled the
client for mastectomy. The client tells the nurse, “If my breasts will be
removed, I’m afraid my husband will not love me anymore and maybe he will
never touch me.” What should the nurse’s response?

A. “I doubt that he feels that way.”

 B. “What makes you feel that way?”
C. “Have you discussed your feelings with your husband?”
D. Ask the husband, in front of the wife, how he feels about this.

12. The child is brought to the hospital by the parents. During assessment of
the nurse, what parental behavior toward a child should alert the nurse to
suspect child abuse?

A. Ignoring the child.

B. Flat affect.
C. Expressions of guilt.
D. Acting overly solicitous toward the child

13. A nurse is caring to a client with manic disorder in the psychiatric ward. On
the morning shift, the nurse is talking with the client who is now exhibiting a
manic episode with flight of ideas. The nurse primarily needs to:

A. Focus on the feelings conveyed rather than the thoughts expressed.

B. Speak loudly and rapidly to keep the client’s attention, because the
client is easily distracted.
C. Allow the client to talk freely.
D. Encourage the client to complete one thought at a time.

14. The nurse is caring to an autistic child. Which of the following play
behavior would the nurse expect to see in a child?

A. competitive play
B. nonverbal play
C. cooperative play
D. solitary play

15. The client is telling the nurse in the psychiatric ward, “I hate them.” Which
of the following is the most appropriate nursing response to the client?
 A. “Tell me about your hate.”
B. “I will stay with you as long as you feel this way.”
C. “For whom do you have these feelings?”
D. “I understand how you can feel this way.”

16. The mother visits her son with major depression in the psychiatric unit.
After the conversation of the client and the mother, the nurse asks the mother
how it is talking to her son. The mother tells the nurse that it was a stressful
time. During an interview with the client, the client says, “we had a marvelous
visit.” Which of the following coping mechanism can be described to
thestatement of the client?

A. Identification.
B. Rationalization.
C. Denial.
D. Compensation.

17. A male client is quiet when the physician told him that he has stage IV
cancer and has 4 months to live. The nurse determines that this reaction may
be an example of:

A. Indifference
B. Denial
C. Resignation
D. Anger

18. A nurse is caring to a female client with five young children. The family
member told the client that her ex-husband has died 2 days ago. The reaction
of the client is stunned silence, followed by anger that the ex-husband left no
insurance money for their young children. The nurse should understand that:

A. The children and the injustice done to them by their father’s death
are the woman’s main concern.
 B. To explain the woman’s reaction, the nurse needs more information
about the relationship and breakup.
C. The woman is not reacting normally to the news.
D. The woman is experiencing a normal bereavement reaction.

19. A client who is manic comes to the outpatient department. The nurse is
assigning an activity for the client. What activity is best for the nurse to
encourage for a client in a manic phase?

A. Solitary activity, such as walking with the nurse, to decrease

stimulation.
B. Competitive activity, such as bingo, to increase the client’s
self-esteem.
C. Group activity, such as basketball, to decrease isolation.
D. Intellectual activity, such as scrabble, to increase concentration.

20. The nurse is about to administer Imipramine HCI (Tofranil) to the client,
the client says, “Why should I take this?” The doctor started me on this 10days
ago; it didn’t help me at all.” Which of the following is the best nursing
response:

A. “What were you expecting to happen?”

B. “It usually takes 2-3 weeks to be effective.”
C. “Do you want to refuse this medication? You have the right.”
D. “That’s a long time wait when you feel so depressed.”

21. Which of the following drugs the nurse should choose to administer to a
client to prevent pseudoparkinsonism?

A. Isocarboxazid (Marplan)
B. Chlorpromazine HCI (Thorazine)
C. Trihexyphenidyl HCI (Artane)
D. Trifluoperazine HCI (Stelazine)
22. The nurse is caring to an 80-year-old client with dementia? What is the
most important psychosocial need for this client?

A. Focus on the there-and-then rather the here-and-now.

B. Limit in the number of visitors, to minimize confusion.
C. Variety in their daily life, to decrease depression.
D. A structured environment, to minimize regressive behaviors.

23. A client tells the nurse, “I don’t want to eat any meals offered in this
hospital because the food is poisoned.” The nurse is aware that the client is
expressing an example of:

A. Delusion.
B. Hallucination.
C. Negativism.
D. Illusion.

24. A client is admitted in the hospital. On assessment, the nurse found out
that the client had several suicidal attempts. Which of the following is the
most important nursing action?

A. Ignore the client as long as he or she is talking about suicide,

because suicide attempt is unlikely.
B. Administer medication.
C. Relax vigilance when the client seems to be recovering from
depression.
D. Maintain constant awareness of the client’s whereabouts.

25. The nurse suspects that the client is suffering from depression. During
assessment, what are the most characteristic signs and symptoms of
depression the nurse would note?

A. Constipation, increased appetite.

B. Anorexia, insomnia.
 C. Diarrhea, anger.
D. Verbosity, increased social interaction.

26. The client in the psychiatric unit states that, “The goodas are coming! I
must be ready.” In response to this neologism, the nurse’s initial response is
to:

A. Acknowledge that the word has some special meaning for the client.
B. Try to interpret what the client means.
C. Divert the client’s attention to an aspect of reality.
D. State that what the client is saying has not been understood and
then divert attention to something that is really bound.

27. A male client diagnosed with depression tells the nurse, “I don’t want to
look weak and I don’t even cry because my wife and my kids can’t bear it.” The
nurse understands that this is an example of:

A. Repression.
B. Suppression.
C. Undoing.
D. Rationalization.

28. A female client tells the nurse that she is afraid to go out from her room
because she thinks that the other client might kill her. The nurse is aware that
this behavior is related to:

A. Hallucination.
B. Ideas of reference.
C. Delusion of persecution.
D. Illusion.

29. A female client is taking Imipramine HCI (Tofranil) for almost 1 week and
shows less awareness of the physical body. What problem would the nurse be
most concerned?
 A. Nausea.
B. Gait disturbances.
C. Bowel movements.
D. Voiding.

30. A 6-year-old client dies in the nursing unit. The parents want to see the
child. What is the most appropriate nursing action?

A. Give the parents time alone with the body.

B. Ask the physician for permission.
C. Complete the postmortem care and quietly accompany the family to
the child’s room.
D. Suggest the parents to wait until the funeral service to say
“good-bye.”

31. A 20-year-old female client is diagnosed with anxiety disorder. The

physician prescribed Flouxetine (Prozac). What is the most important side
effects should a nurse be concerned?

A. Tremor, drowsiness.
B. Seizures, suicidal tendencies.
C. Visual disturbance, headache.
D. Excessive diaphoresis, diarrhea.

32. A nurse is assigned to activate a client who is withdrawn, hears voices and
negativistic. What would be the best nursing approach?

A. Mention that the “voices” would want the client to participate.

B. Demand that the client must join a group activity.
C. Give the client a long explanation of the benefits of activity.
D. Tell the client that the nurse needs a partner for an activity.

33. A nurse is going to give a rectal suppository as a preoperative medication

to a 4-year-old boy. The boy is very anxious and frightened. Which of the
following statement by the nurse would be most appropriate to gain the
child’s cooperation?

A. “Be a big kid! Everyone’s waiting for you.”

B. “Lie still now and I’ll let you have one of your presents before you
even have your operation.”
C. “Take a nice, big, deep breath and then let me hear you count to five.”
D. “You look so scared. Want to know a secret? This won’t hurt a bit!”

34. A depressed client is on an MAO inhibitor? What should the nurse watch
out for?

A. Hypertensive crisis.
B. Diet restrictions.
C. Taking medication with meals.
D. Exposure to sunlight.

35. A 16-year-old girl is admitted for treatment of a fracture. The client shares
to the nurse caring to her that her step-father has made sexual advances to
her. She got the chance to tell it to her mother but refuses to believe. What is
the most therapeutic action of the nurse would be:

A. Tell the client to work it out with her father.

B. Tell the client to discuss it with her mother.
C. Ask the father about it.
D. Ask the mother what she thinks.

36. A client with a diagnosis of paranoid disorder is admitted in the psychiatric

hospital. The client tells the nurse, “the FBI is following me. These people are
plotting against me.” With this statement the nurse will need to:

A. Acknowledge that this is the client’s belief but not the nurse’s belief.
B. Ask how that makes the client feel.
C. Show the client that no one is behind.
 D. Use logic to help the client doubt this belief.

37. A nurse is completing the routine physical examination to a healthy

16-year-old male client. The client shares to the nurse that he feels like killing
his girlfriend because he found out that her girlfriend had another boyfriend.
He then laughs, and asks the nurse to keep this a secret just between the two
of them. The nurse reviews his chart and notes that there is no previously
history of violence or psychiatric illness. Which of the following would be the
best action of the nurse to take at this time?

A. Suggest the teen meet with a counselor to discuss his feelings

about his girlfriend.
B. Tell the teen that his feelings are normal, and recommend that he
find another girlfriend to take his mind off the problem.
C. Recall the teenage boys often say things they really do not mean and
ignore the comment.
D. Regard the comment seriously and notify the teen’s primary health
care provider and parents

38. Which of the following person will be at highest risk for suicide?

A. A student at exam time

B. A married woman, age 40, with 6 children.
C. A person who is an alcoholic.
D. A person who made a previous suicide attempt.

39. A male client is repetitively doing the handwashing every time he touches
things. It is important for a nurse to understand that the client’s behavior is
probably an attempt to:

A. Seek attention from the staff.

B. Control unacceptable impulses or feelings.
C. Do what the voices the patient hears tell him or her to do.
D. Punish himself or herself for guilt feeling.
40. In a mental health settings, the basic goal of nursing is to:

A. Advance the science of psychiatry by initiating research and

gathering data for current statistics on emotional illness.
B. Plan activity programs for clients.
C. Understand various types of family therapy and psychological tests
and how to interpret them.
D. Maintain a therapeutic environment.

41. A 3-year-old boy is brought to the emergency department. After an hour,

the boy dies of respiratory failure. The mother of the boy becomes upset,
shouting and abusive, saying to the nurse, “If it had been your son, they would
have done more to save it. “What should the nurse say or do?

A. Touch her and tell her exactly what was done for her baby.
B. Allow the mother to continue her present behavior while sitting
quietly with her.
C. “No, all clients are given the same good care.”
D. “Yes, you’re probably right. Your son did not get better care.”

42. The nurse is interacting to a client with an antisocial personality disorder.

What would be the most therapeutic approach of the nurse to an antisocial
behavior?

A. Gratify the client’s inner needs.

B. Give the client opportunities to test reality.
C. Provide external controls.
D. Reinforce the client’s self-concept.

43. A 55-year-old male client tells the nurse that he needs his glasses and
hearing aid with him in the recovery room after the surgery, or he will be upset
for not granting his request. What is the appropriate nursing response?

A. “Do you get upset and confused often?”

 B. “You won’t need your glasses or hearing aid. The nurses will take
care of you.”
C. “I understand. You will be able to cooperate best if you know what is
going on, so I will find out how I can arrange to have your glasses
and hearing aid available to you in the recovery room.”
D. I understand you might be more cooperative if you have your aid and
glasses, but that is just not possible. Rules, you know.”

44. The male client had fight with his roommates in the psychiatric unit. The
client agitated client is placed in isolation for seclusion. The nurse knows it is
essential that:

A. A staff member has frequent contacts with the client.

B. Restraints are applied.
C. The client is allowed to come out after 4 hours.
D. All the furniture is removed form the isolation room.

45. A medical representative comes to the hospital unit for the promotion of a
new product. A female client, admitted for hysterical behavior, is found
embracing him. What should the nurse say?

A. “Have you considered birth control?”

B. “This isn’t the purpose of either of you being here.”
C. “I see you’ve made a new friend.”
D. “Think about what you are doing.”

46. A client with dementia is for discharge. The nurse is providing a discharge
instruction to the family member regarding safety measures at home. What
suggestion can the nurse make to the family members?

A. Avoid stairs without banisters.

B. Use restraints while the client is in bed to keep him or her from
wandering off during the night.
 C. Use restraints while the client is sitting in a chair to keep him or her
from wandering off during the day.
D. Provide a night-light and a big clock.

47. A 30-year-old married woman comes to the hospital for treatment of

fractures. The woman tells the nurse that she was physically abused by her
husband. The woman receives a call from her husband telling her to get home
and things will be different. He felt sorry of what he did. What can the nurse
advise her?

A. “Do you think so?”

B. “It’s not likely.”
C. “What will be different?”
D. “I hope so, for your sake.”

48. A female client was diagnosed with breast cancer. It is found to be stage
IV, and a modified mastectomy is performed. After the procedure, what
behaviors could the nurse expects the client to display?

A. Denial of the possibility of carcinoma.

B. Signs of grief reaction.
C. Relief that the operation is over.
D. Signs of deep depression.

49. A client is withdrawn and does not want to interact to anybody even to the
nurse. What is the best initial nursing approach to encourage communication
with this client?

A. Use simple questions that call for a response.

B. Encourage discussion of feelings.
C. Look through a photo album together.
D. Bring up neutral topics.
50. Which of the following nursing approach is most important in a client with
depression?

A. Deemphasizing preoccupation with elimination, nourishment, and

sleep.
B. Protecting against harm to others.
C. Providing motor outlets for aggressive, hostile feelings.
D. Reducing interpersonal contacts.

Set III

1. Marco approached Nurse Trish asking for advice on how to deal with his
alcohol addiction. Nurse Trish should tell the client that the only effective
treatment for alcoholism is:

A. Psychotherapy
B. Alcoholics anonymous (A.A.)
C. Total abstinence
D. Aversion Therapy

2. Nurse Hazel is caring for a male client who experience false sensory
perceptions with no basis in reality. This perception is known as:

A. Hallucinations
B. Delusions
C. Loose associations
D. Neologisms

3. Nurse Monet is caring for a female client who has suicidal tendency. When
accompanying the client to the restroom, Nurse Monet should…

A. Give her privacy

B. Allow her to urinate
C. Open the window and allow her to get some fresh air
 D. Observe her

4. Nurse Maureen is developing a plan of care for a female client with

anorexia nervosa. Which action should the nurse include in the plan?

A. Provide privacy during meals

B. Set-up a strict eating plan for the client
C. Encourage client to exercise to reduce anxiety
D. Restrict visits with the family

5. A client is experiencing anxiety attack. The most appropriate nursing

intervention should include?

A. Turning on the television

B. Leaving the client alone
C. Staying with the client and speaking in short sentences
D. Ask the client to play with other clients

6. A female client is admitted with a diagnosis of delusions of GRANDEUR.

This diagnosis reflects a belief that one is:

A. Being Killed
B. Highly famous and important
C. Responsible for evil world
D. Connected to client unrelated to oneself

7. A 20 year old client was diagnosed with dependent personality disorder.

Which behavior is not likely to be evidence of ineffective individual coping?

A. Recurrent self-destructive behavior

B. Avoiding relationship
C. Showing interest in solitary activities
D. Inability to make choices and decision without advise
8. A male client is diagnosed with schizotypal personality disorder. Which
signs would this client exhibit during social situation?

A. Paranoid thoughts
B. Emotional affect
C. Independence need
D. Aggressive behavior

9. Nurse Claire is caring for a client diagnosed with bulimia. The most
appropriate initial goal for a client diagnosed with bulimia is?

A. Encourage to avoid foods

B. Identify anxiety causing situations
C. Eat only three meals a day
D. Avoid shopping plenty of groceries

10. Nurse Tony was caring for a 41 year old female client. Which behavior by
the client indicates adult cognitive development?

A. Generates new levels of awareness

B. Assumes responsibility for her actions
C. Has maximum ability to solve problems and learn new skills
D. Her perception are based on reality

11.A neuromuscular blocking agent is administered to a client before ECT

therapy. The Nurse should carefully observe the client for?

A. Respiratory difficulties
B. Nausea and vomiting
C. Dizziness
D. Seizures
12.A 75 year old client is admitted to the hospital with the diagnosis of
dementia of the Alzheimer’s type and depression. The symptom that is
unrelated to depression would be?

A. Apathetic response to the environment

B. “I don’t know” answer to questions
C. Shallow of labile effect
D. Neglect of personal hygiene

[Link] Trish is working in a mental health facility; the nurse priority nursing
intervention for a newly admitted client with bulimia nervosa would be to?

A. Teach client to measure I & O

B. Involve client in planning daily meal
C. Observe client during meals
D. Monitor client continuously

[Link] Patricia is aware that the major health complication associated with
intractable anorexia nervosa would be?

A. Cardiac dysrhythmias resulting to cardiac arrest

B. Glucose intolerance resulting in protracted hypoglycemia
C. Endocrine imbalance causing cold amenorrhea
D. Decreased metabolism causing cold intolerance

[Link] Anna can minimize agitation in a disturbed client by?

A. Increasing stimulation
B. limiting unnecessary interaction
C. increasing appropriate sensory perception
D. ensuring constant client and staff contact
16.A 39 year old mother with obsessive-compulsive disorder has become
immobilized by her elaborate hand washing and walking rituals. Nurse Trish
recognizes that the basis of O.C. disorder is often:

A. Problems with being too conscientious

B. Problems with anger and remorse
C. Feelings of guilt and inadequacy
D. Feeling of unworthiness and hopelessness

[Link] is complaining to other clients about not being allowed by staff to

keep food in his room. Which of the following interventions would be most
appropriate?

A. Allowing a snack to be kept in his room

B. Reprimanding the client
C. Ignoring the clients behavior
D. Setting limits on the behavior

[Link] with borderline personality disorder who is to be discharge soon

threatens to “do something” to herself if discharged. Which of the following
actions by the nurse would be most important?

A. Ask a family member to stay with the client at home temporarily

B. Discuss the meaning of the client’s statement with her
C. Request an immediate extension for the client
D. Ignore the clients statement because it’s a sign of manipulation

[Link] a client with antisocial personality disorder belches loudly. A staff

member asks Joey, “Do you know why people find you repulsive?” this
statement most likely would elicit which of the following client reaction?

A. Depensiveness
B. Embarrassment
C. Shame
 D. Remorsefulness

[Link] of the following approaches would be most appropriate to use with

a client suffering from narcissistic personality disorder when discrepancies
exist between what the client states and what actually exist?

A. Rationalization
B. Supportive confrontation
C. Limit setting
D. Consistency

[Link] is experiencing alcohol withdrawal exhibits tremors, diaphoresis and

hyperactivity. Blood pressure is 190/87 mmhg and pulse is 92 bpm. Which of
the medications would the nurse expect to administer?

A. Naloxone (Narcan)
B. Benzlropine (Cogentin)
C. Lorazepam (Ativan)
D. Haloperidol (Haldol)

[Link] of the following foods would the nurse Trish eliminate from the diet
of a client in alcohol withdrawal?

A. Milk
B. Orange Juice
C. Soda
D. Regular Coffee

[Link] of the following would Nurse Hazel expect to assess for a client
who is exhibiting late signs of heroin withdrawal?

A. Yawning & diaphoresis

B. Restlessness & Irritability
C. Constipation & steatorrhea
 D. Vomiting and Diarrhea

[Link] establish open and trusting relationship with a female client who has
been hospitalized with severe anxiety, the nurse in charge should?

A. Encourage the staff to have frequent interaction with the client

B. Share an activity with the client
C. Give client feedback about behavior
D. Respect client’s need for personal space

25. Nurse Monette recognizes that the focus of environmental (MILIEU)

therapy is to:

A. Manipulate the environment to bring about positive changes in

behavior
B. Allow the client’s freedom to determine whether or not they will be
involved in activities
C. Role play life events to meet individual needs
D. Use natural remedies rather than drugs to control behavior

[Link] Trish would expect a child with a diagnosis of reactive attachment

disorder to:

A. Have more positive relation with the father than the mother
B. Cling to mother & cry on separation
C. Be able to develop only superficial relation with the others
D. Have been physically abuse

[Link] teaching parents about childhood depression Nurse Trina should

say?

A. It may appear acting out behavior

B. Does not respond to conventional treatment
C. Is short in duration & resolves easily
 D. Looks almost identical to adult depression

[Link] Perry is aware that language development in autistic child

resembles:

A. Scanning speech
B. Speech lag
C. Shuttering
D. Echolalia

29.A 60 year old female client who lives alone tells the nurse at the
community health center “I really don’t need anyone to talk to”. The TV is my
best friend. The nurse recognizes that the client is using the defense
mechanism known as?

A. Displacement
B. Projection
C. Sublimation
D. Denial

[Link] working with a male client suffering phobia about black cats, Nurse
Trish should anticipate that a problem for this client would be?

A. Anxiety when discussing phobia

B. Anger toward the feared object
C. Denying that the phobia exist
D. Distortion of reality when completing daily routines

[Link] is pacing the floor and appears extremely anxious. The duty nurse
approaches in an attempt to alleviate Linda’s anxiety. The most therapeutic
question by the nurse would be?

A. Would you like to watch TV?

B. Would you like me to talk with you?
 C. Are you feeling upset now?
D. Ignore the client

[Link] Penny is aware that the symptoms that distinguish post traumatic
stress disorder from other anxiety disorder would be:

A. Avoidance of situation & certain activities that resemble the stress

B. Depression and a blunted affect when discussing the traumatic
situation
C. Lack of interest in family & others
D. Re-experiencing the trauma in dreams or flashback

[Link] Benjie is communicating with a male client with substance-induced

persisting dementia; the client cannot remember facts and fills in the gaps
with imaginary information. Nurse Benjie is aware that this is typical of?

A. Flight of ideas
B. Associative looseness
C. Confabulation
D. Concretism

[Link] Joey is aware that the signs & symptoms that would be most
specific for diagnosis anorexia are?

A. Excessive weight loss, amenorrhea & abdominal distension

B. Slow pulse, 10% weight loss & alopecia
C. Compulsive behavior, excessive fears & nausea
D. Excessive activity, memory lapses & an increased pulse

35.A characteristic that would suggest to Nurse Anne that an adolescent may
have bulimia would be:

A. Frequent regurgitation & re-swallowing of food

B. Previous history of gastritis
 C. Badly stained teeth
D. Positive body image

[Link] Monette is aware that extremely depressed clients seem to do best

in settings where they have:

A. Multiple stimuli
B. Routine Activities
C. Minimal decision making
D. Varied Activities

[Link] further assess a client’s suicidal potential. Nurse Katrina should be

especially alert to the client expression of:

A. Frustration & fear of death

B. Anger & resentment
C. Anxiety & loneliness
D. Helplessness & hopelessness

38.A nursing care plan for a male client with bipolar I disorder should include:

A. Providing a structured environment

B. Designing activities that will require the client to maintain contact
with reality
C. Engaging the client in conversing about current affairs
D. Touching the client provide assurance

[Link] planning care for a female client using ritualistic behavior, Nurse
Gina must recognize that the ritual:

A. Helps the client focus on the inability to deal with reality

B. Helps the client control the anxiety
C. Is under the client’s conscious control
D. Is used by the client primarily for secondary gains
40.A 32 year old male graduate student, who has become increasingly
withdrawn and neglectful of his work and personal hygiene, is brought to the
psychiatric hospital by his parents. After detailed assessment, a diagnosis of
schizophrenia is made. It is unlikely that the client will demonstrate:

A. Low self esteem

B. Concrete thinking
C. Effective self boundaries
D. Weak ego

41.A 23 year old client has been admitted with a diagnosis of schizophrenia
says to the nurse “Yes, its march, March is little woman”. That’s literal you
know”. These statement illustrate:

A. Neologisms
B. Echolalia
C. Flight of ideas
D. Loosening of association

42.A long term goal for a paranoid male client who has unjustifiably accused
his wife of having many extramarital affairs would be to help the client
develop:

A. Insight into his behavior

B. Better self control
C. Feeling of self worth
D. Faith in his wife

43.A male client who is experiencing disordered thinking about food being
poisoned is admitted to the mental health unit. The nurse uses which
communication technique to encourage the client to eat dinner?

A. Focusing on self-disclosure of own food preference

B. Using open ended question and silence
 C. Offering opinion about the need to eat
D. Verbalizing reasons that the client may not choose to eat

[Link] Nina is assigned to care for a client diagnosed with Catatonic

Stupor. When Nurse Nina enters the client’s room, the client is found lying on
the bed with a body pulled into a fetal position. Nurse Nina should?

A. Ask the client direct questions to encourage talking

B. Rake the client into the dayroom to be with other clients
C. Sit beside the client in silence and occasionally ask open-ended
question
D. Leave the client alone and continue with providing care to the other
clients

[Link] Tina is caring for a client with delirium and states that “look at the
spiders on the wall”. What should the nurse respond to the client?

A. “You’re having hallucination, there are no spiders in this room at all”

B. “I can see the spiders on the wall, but they are not going to hurt you”
C. “Would you like me to kill the spiders”
D. “I know you are frightened, but I do not see spiders on the wall”

[Link] Jonel is providing information to a community group about violence

in the family. Which statement by a group member would indicate a need to
provide additional information?

A. “Abuse occurs more in low-income families”

B. “Abuser Are often jealous or self-centered”
C. “Abuser use fear and intimidation”
D. “Abuser usually have poor self-esteem”

[Link] electroconvulsive therapy (ECT) the client receives oxygen by mask

via positive pressure ventilation. The nurse assisting with this procedure
knows that positive pressure ventilation is necessary because?
 A. Anesthesia is administered during the procedure
B. Decrease oxygen to the brain increases confusion and disorientation
C. Grand mal seizure activity depresses respirations
D. Muscle relaxations given to prevent injury during seizure activity
depress respirations.

[Link] planning the discharge of a client with chronic anxiety, Nurse Chris
evaluates achievement of the discharge maintenance goals. Which goal
would be most appropriately having been included in the plan of care requiring
evaluation?

A. The client eliminates all anxiety from daily situations

B. The client ignores feelings of anxiety
C. The client identifies anxiety producing situations
D. The client maintains contact with a crisis counselor

[Link] Tina is caring for a client with depression who has not responded to
antidepressant medication. The nurse anticipates that what treatment
procedure may be prescribed.

A. Neuroleptic medication
B. Short term seclusion
C. Psychosurgery
D. Electroconvulsive therapy

[Link] is admitted to the emergency room with drug-included anxiety

related to over ingestion of prescribed antipsychotic medication. The most
important piece of information the nurse in charge should obtain initially is
the:

A. Length of time on the med.

B. Name of the ingested medication & the amount ingested
C. Reason for the suicide attempt
D. Name of the nearest relative & their phone number