1. A client is admitted with Wernicke’s encephaiopathy. The nurse anticipates that the first physician’s order will include: a. Ordering an MRI b. Administering a steroid medication, such as Decadron c. Giving thiamine 100 mg IM STAT d. Ordering an EEG 2. Which of the following statements, if made by a four year old child whose brother just died of cancer, would be age-appropriate? a. “I know i will never see my mother again.” b. “I’m glad my mother isn’t crying anymore.” c. “I can’t wait to go get pizza with my brother.” d. “i know where my brother is buried.” 3. A patient who has AIzheimer’s disease is told by the nurse to brush his teeth. He shouts angrily, “Tomato soup!” Which of the following actions by the nurse would be correct? a. Focusing on the emotional reaction b. Clarifying the meaning of his statement c. Giving him step-by-step directions d. Doing the procedure for him 4. A nurse should teach a patient who is taking chlorpromazine (Thorazine) to avoid: a. Exposure to the sun b. Swimming in a chlorinated pool c. Drinking fluids high in sodium d. Eating foods such as chocolate and aged cheese 5. in caring for a psychotic patient who is experiencing hallucinations, which of the following interventions is considered critical? a. Setting fewer limits in order to allow for more expressions of feeling b. Maintaining constant observation. c. Providing more frequent opportunities for interaction with others. d. Constantly negating the patient’s hallucinatory Ideations. 6. A 22-year-old client is being admitted with a diagnosis of brief psychotic disorder. Two weeks ago, his girlfriend broke off their engagement and cancelled the wedding. Given the Diagnosis and Statistical Manual of Mental Disorders, edition, text’ revised (DSM- IV-TR) criteria for this disorder the nurse expects to find which of the following data during the interview with the client? a. Current treatment for pneumonia b. Regular use of alcohol and marijuana c. Evidence of delusions and hallucinations d. A history of chronic depression 7. A set of monozygotic twins who are 23 years old have begun attending groups at mental health center. One twin is diagnosed with schizophrenia. Her twin has no diagnoses but has been experiencing significant anxiety since becoming engaged. In counseling the engaged twin, it would be crucial to include which of the following tacts? a. Her future children will be at risk for developing schizophrenia b. She may have a predisposition for schizophrenia c. One of her parents may develop schizophrenia later in life d. It is unlikely that she wil! develop schizophrenia, at her age
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1. A client is admitted with Wernicke’s encephaiopathy. The nurse anticipates that the first
physician’s order will include:
a. Ordering an MRI
b. Administering a steroid medication, such as Decadron
c. Giving thiamine 100 mg IM STAT
d. Ordering an EEG
2. Which of the following statements, if made by a four year old child whose brother just died of
cancer, would be age-appropriate?
a. “I know i will never see my mother again.”
b. “I’m glad my mother isn’t crying anymore.”
c. “I can’t wait to go get pizza with my brother.”
d. “i know where my brother is buried.”
3. A patient who has AIzheimer’s disease is told by the nurse to brush his teeth. He shouts
angrily, “Tomato soup!” Which of the following actions by the nurse would be correct?
a. Focusing on the emotional reaction
b. Clarifying the meaning of his statement
c. Giving him step-by-step directions
d. Doing the procedure for him
4. A nurse should teach a patient who is taking chlorpromazine (Thorazine) to avoid:
a. Exposure to the sun
b. Swimming in a chlorinated pool
c. Drinking fluids high in sodium
d. Eating foods such as chocolate and aged cheese
5. in caring for a psychotic patient who is experiencing hallucinations, which of the following
interventions is considered critical?
a. Setting fewer limits in order to allow for more expressions of feeling
b. Maintaining constant observation.
c. Providing more frequent opportunities for interaction with others.
d. Constantly negating the patient’s hallucinatory Ideations.
6. A 22-year-old client is being admitted with a diagnosis of brief psychotic disorder. Two weeks
ago, his girlfriend broke off their engagement and cancelled the wedding. Given the Diagnosis
and Statistical Manual of Mental Disorders, edition, text’ revised (DSM-IV-TR) criteria for this
disorder the nurse expects to find which of the following data during the interview with the
client?
a. Current treatment for pneumonia
b. Regular use of alcohol and marijuana
c. Evidence of delusions and hallucinations
d. A history of chronic depression
7. A set of monozygotic twins who are 23 years old have begun attending groups at mental
health center. One twin is diagnosed with schizophrenia. Her twin has no diagnoses but has
been experiencing significant anxiety since becoming engaged. In counseling the engaged twin,
it would be crucial to include which of the following tacts?
a. Her future children will be at risk for developing schizophrenia
b. She may have a predisposition for schizophrenia
c. One of her parents may develop schizophrenia later in life
d. It is unlikely that she wil! develop schizophrenia, at her age
8. A client tells the nurse that her co-workers are sabotaging the computer. When the nurse
asks questions, the client becomes argumentative. This behavior shows personality traits
associated with which of the following personality disorders?
a. Antisocial
b. Histrionic
c. Paranoid
d. Schizotypal
9. Which of the following types of behavior is expected from a client diagnosed with paranoid
personality disorder?
a. Eccentric
b. Exploitative
c. Hypersensitive
d. Seductive
10. A nurse is reviewing the serum laboratory test results for a client with sickle cell anemia. The
nurse finding that which of the following values is elevated?
a. Hemoglobin F
b. Hemoglobin S
c. Hemoglobin C
d. Hemoglobin a
11. A parent with a daughter with bulimia nervosa asks a nurse, “How can my child have an
eating disorder when she isn’t underweight?” Which of the following responses is best?
a. “A person with bulimia nervosa can maintain a normal weight.”
b. It’s hard to face this type of problem in a person you love.”
c. “At first there is no weight loss; it comes later In the disease.”
d. “This is a serious problem even though there is no weight loss.”
12. A nurse is assessing an adolescent girl recently diagnosed with an eating disorder and
symptoms of bulimia nervosa. Which of the following findings is expected based on laboratory
test results?
a. Hypocalcemia
b. Hypoglycemia
c. Hypokalemia
d. Hypophosphatemia
13. Which of the following complications of bulimia nervosa Is life threatening?
a. Amenorrhea
b. Bradycardia
c. Electrolyte Imbalance
d. Yellow skin
14. A nurse is talking to a client with bulimia nervosa about the complications of Laxative abuse.
Which of the following complications should be included?
a. Loss of taste
b. Swollen glands
c. Dental problems
d. Malabsorption of nutrients
15. A nurse is assessing a client to determine the distress experienced after binge eating.
Which of the following symptoms are typical after bingeing?
a. Ageusia
b. Headache
c. Pain
d. Sore throat
16. Which of the following difficulties are frequently found in families with a member who has
bulimia nervosa?
a. Mental Illness
b. Multiple losses
c. Chronic anxiety
d. Substance abuse
17. A client with anorexia nervosa tells a nurse, “My parents never hug me or say I’ve done
anything right.” Which of the following Interventions is the best to use with this family?
a. Teach the family principles of assertive behavior.
b. Discuss the difficulties the family has in social situations.
c. Help the family convey a positive attitude toward the client.
d. Explore the family’s ability to express affection appropriately.
18. A client with anorexia nervosa tells a nurse she always feels fat. Which of the following
interventions is the best for this client?
a. Talk about how important the client is.
b. Encourage her to look at herself in a mirror.
c. Address the dynamics of the disorder.
d. Talk about how she’s different from her peers.
Ms. J.K. is a 24-year old woman admitted to the neurosurgery floor 2 days following a
hypophysectomy for a pituitary tumor. She is alert, oriented, and eager to return to her job as an
executive to the hospital director. She is alert, oriented and eager to return to her job as an
executive assistant to the hospital director. She calls the nurse to her room to express her
concern about the frequency of urination she is experiencing, as well as the feeling of weakness
that began this morning.
19. The most likely cause of her chief complaint this morning is
a. A decrease in postoperative stress causing polyuria
b. The onset of diabetes mellitus, an unusual complication
c. An expected result of the removal of the pituitary gland
d. A frequent complication of the hypophysectomy
20. Following hypophysectomy, patients require extensive teaching regarding this major
alteration in their lifestyle
a. Abnormal distribution of body hair
b. Lifetime dependency on hormone replacement
c. The need to drink many fluids to replace those lost
d. The need to undergo repeat surgical procedures
21. The Glasgow coma scale is used to .evaluate the level of consciousness in the neurological
and neurological patients. The three assessment factors included in this scale are:
a. pupil size, response to pain, motor responses
b. Pupil size, verbal response, motor response
c. Eye opening, verbal response, motor response
d. Eye opening, response to pain, motor response
J.E, is an 18-year old freshman admitted to the ICU following a motor vehicle accident in which
he sustained multiple trauma including a ruptured spleen, myocardial contusion, fractured
pelvis, and fractured right femur. He had a mild contusion, but is alert and oriented. His vital
signs BP 120/80, pulse 84, respirations 12, and temperature 99 F orally.
22. The nurse will monitor J.E. for the following signs and symptoms:
a. Change in the level of consciousness, tachypnea, tachycardia, petechiae
b. Onset of chest pain, tachycardia, diaphoresis, nausea and vomiting
c. Loss of consciousness, bradycardia, petechiae, and severe leg pain
d. Change in level of consciousness, bradycardia, chest pain and oliguria
23. Appropriate nursing interventions for J.E. would be
a. Skin care and position q2h and prn; maintain alignment of extremities; respiratory exercises
b. Skin care/bathe daily; passive leg exercises daily; respiratory therapy for intermittent positive
pressure breathing therapy
c. Skin care and position q2h; teach use of overhead trapeze; respiratory exercises, and
intermittent positive pressure breathing q2h
d. Skin care q2h; teach use of overhead trapeze; respiratory exercises; use pressure relief
devices
Ms. J., a 34-year old white female, is admitted via the emergency room complaining of
abdominal pain, fatigue, anorexia, muscle cramping, and nausea. She is a diabetic who been
managed at 30 U NPH insulin every AM and a 1200-calorie ADA diet. Her glucose in ER 700
mg/dL. Regular insulin 30 U was given and a repeat glucose were drawn. Results were not
avaiIable upon transfer to the unit.
24. Given the above Information, which nursing activities should be highest priority?
a. Monitoring vita i signs
b. Obtaining blood glucose results
c. Assessing neurological status
d. Assessing pedal pulses and feet
25. The nurse received the lab results from the blood sample drawn in ER. Her glucose is now-
100. However, her WBC count is 25,000. What conclusion can the nurse draw basing on this
information?
a. Lab results are within normal limits, no action Is necessary
b. Her diabetes is out of control
c. insulin administration increase WBC count
d. Infection has increased her insulin needs
26. Later that evening, Ms. J’s abdominal pain increased in intensity. A diagnosis of appendicitis
is made and Ms. J is scheduled for surgery in the morning. The physician has written the
following orders:
NPO after midnight
At 6 AM starting IVF of D5W to be infused at 250 ml/hr
15 U NPH insulin at 6AM
Draw FBS prior to initiating iV fluids
The statement that best describe the rationale for these orders Is:
a. To provide calories to offset the patient being NPO
b. To prevent a hypoglycemic reaction
c. To prevent a fluid volume deficit
d. To assist with the body’s response to stress
27. When ambulating a client following surgical removal of a protruded
intervertebral lumbar disc, the nurse would do which of the following?
a. Maintain proper body alignment
b. Administer analgesia after walking
c. Provide a cane for support
d. Immobilize the head and neck
28. Which of the following point scores on the post anesthesia chart, indicates that the client has
fulfilled minimal criteria for discharge from the PACU?
a. One point In each of the five areas .for a total score of 5.
b. One point in at least three areas” respiratory, circulatory, and consciousness – for a total of 3
c. A total score for the five areas of 7 or.above.
d. Two points each in each of the five areas for a total score of 10.
29. Which of the following statements would be the nurse’s response to a family member asking
questions about a client’s transient ischemic attack (TIA)?
a. “I think you should ask the doctor. Would you like me to call him for you?”
b. ” The blood supply to the brain has decreased causing permanent brain damage.”
c. “It Is a temporary interruption in the blood flow to the brain.”
d. “TIA means a transient ischemic attack.”
30. While receiving radiation therapy for the treatment of breast cancer, a client complains of
dysphagia and skin texture changes, at the radiation site. Which of the following instructions
would be most appropriate to suggest to minimize the risk of complications, and promote
healing?
a. Wash the radiation site vigorously with soap and water to remove dead cells.
b. Eat a diet high in protein and calories to optimize tissue repair.
c. Apply coo! compresses to the radiation site to reduce edema,
d. Drink warm fluids throughout the day to relieve discomfort in swallowing.
31. A client using an over-the counter nasal decongestant spray reports unrelieved and
worsening nasal congestion. The nurse should instruct the client to do which of the following?
a. Switch to a stronger dosage of the medication.
b. Discontinue the medication for a few weeks
c. Use the spray more frequently
d. Combine the spray with an oral decongestant.
32. Following a thyroidectomy, the client experiences hemorrhage. The nurse would prepare for
which of the following emergency interventions?
a. intravenous administration of calcium
b. insertion of an oral airway
c. Creation of a tracheostomy
d. Intravenous administration of thyroid hormone
33. After a client signs the form, giving informed consent for surgery and the physician !eaves
the room, the client asks the nurse, “When will this hotel bring me some food?” After confirming
that the client is confused, which of the following would be the nurse’s priority action?
a. Reporting that the consent has been obtained from a confused client.
b. Teaching preoperative moving, coughing, and deep-breathing,exercises.
c. Inserting a bladder catheter to urine output.
d. Administering preoperative medication immediately ,
34. At 16 weeks gestation, no fetal heart rate was detected during assessment of a pregnant
patient. An ultrasound confirmed a hydatidiform molar pregnancy. Which of the following actions
should the nurse tell the patient to expect during her one-year follow-up?
a. Multiple serum chorionic gonadotropin levels will be drawn
b. An Intrauterine device will be used to decrease vaginal bleeding
c. Pregnancy will be restricted for another year
d. Oral contraceptives will not be prescribed because they will increase the risk’ of cancer
35. Thirty minutes after the nurse removes a nasogastric tube that has been In place for seven
days, the patient experiences epistaxis (nosebleed). Which of the following nursing actions is
most appropriate to control the bleeding?
a. Apply pressure by pinching the anterior portion of the for five to ten minutes
b. Place the patient in a sitting position with the neck hyperextended
c. Pack the nostrils with gauze and keep the gauze in place for four to five days
d. Apply ice compresses to the patient’s forehead and back of the neck
36. The staff nurse calls a physician regarding an order to administer digoxin (Lanoxin) to a
patient with a pulse of 55 and a serum potassium level of 2.9 mEq/L The physician says to give
the medication, as ordered . The staff nurse’s best response would be
a. “I’ll give the medication but you will still be responsible if anything happens to the patient.”
b. “I will not give this medication.”
c. ‘”I think we should discuss this with the nursing supervisor.”
d. “I’m sorry, but if you want the medication given, you will have to give it yourself.”
37. During the night, shift report, the charge nurse learns that an elderly patient has become
very confused and is shouting obscenities and undressing himself. Which of the following
actions is the most appropriate Initial nursing response?
a. Restrain the patient with a Posey jacket
b. Medicate the patient with haloperidol (Haldol) as ordered.
c. Notify the physician
d. Complete a nursing assessment of the patient
38. When a woman is 10 weeks pregnant which of the following hematology test results would
need further Investigation?
a. Hemoglobin level of 9 mg/dL
b. white blood cell count of 15,000/cu mm
c. platelet count of 200,000/cu mm
d. red blood cell count of 4,200,000/ cu mm
39. Which of the following techniques would a nurse use when interviewing a 94-year-old
patient?
a. Using a low-pitched voice
b. Enunciating each word .slowly
c. Varying voice intonations
d. Reinforcing the words with pictures .
40. A patient who is receiving total parenteral nutrition has an elevated blood glucose eve! and
is to be administered intravenous insulin. Which of the following types of insulin should a nurse
has available?
a. Isophane insulin (NPH)
b. Regular insulin (Humulin R)
c. Insulin zinc suspension (Lente)
d. Semi-Lente Insulin (Semiterd)
41. A nurse is taking history from a patient who has just been admitted to the hospital withl an
acute myocardia! infarction. Which of the following questions would be most important for the
nurse to ask?
a. “At what time did the pain start?”
b. “When did you eat your last meal?”
c. “Have you experienced a pounding headache?”
d. “Did you feel fluttering in your chest”
42. An infant who weighs 11 lbs. is to receive 750 mg of an antibiotic in a 24-hour period. The
liquid antibiotic comes in a concentration of 125 mg/5ml. If the antibiotic were to be given three
times each day. how many ml would the nurse administer with each dose?
a. 2
b. 5
c. 6.25
d. 10
43. Spasm of the neck muscles developed in a patient who is taking phenothiazine (Nemazine).
Which of the following medications should the nurse administer?
a. Vistaril
b. Acetaminophen (Tyienol)
c. Acetylsalicylic acid (Aspirin)
d. Benztropine mesyiate (Cogentin)
Mr. Anthony Malailinelii is a 54-year old truck driver. He is admitted for possible gastric ulcer, He
is a heavy smoker.
44. When discussing his smoking habits with Mr. Martinelli. the nurse should advise him to:
a. Smoke low-tar, filter cigarettes
b. Smoke cigars instead
c. Smoke only right after meals
d. Chew gum instead
45. As the nurse preparing Ivlr. Martinelii for gastric analysis. You should know which of the
following Is not.correct concerning this test
a. The patient Is fasting 12 hours prior to test
b. Gastric contents are aspirated via a tube
c. Smoking for 8 hours prior to test is not allowed
d. Various position changes are necessary during the test
46. Mr. Martinelli had an Hgb of 9.8. You would not find which of the following assessments in a
patient with severe anemia?
a. Pallor
b. Cold sensitivity
c. Fatigue
d. Dyspnea only on exertion
47. When you report on duty, your team leader tells you that Mr. MartineHi accidentally received
1000 ml of fluids in 2 hours and that you are to be alert for signs of circulatory overload. Which
of the following signs would not be likely to occur?
a. moist gurgling respirations
b. Weak, slow pulse
c. Distended neck veins
d. Dyspnea and coughing
48. A new staff nurse is on an orientation tour with the head nurse. A client approaches her and
says, “I don’t belong here. Please try to get me out.” The staff nurse’s best response would be:
a. “What would you do if you were out of the hospital?”
b. “I am a. new staff member, and I’m on a tour. I’ll come back and talk with you later.”
c. “I think you should talk to the head nurse about that.’
d. “I can’t do anything about that.”
49. A 50 year-old male client has a history of many hospitalizations for schizophrenic disorder.
He has been on long-term phenothiazines (Thorazine), 400 mg/day. The nurse assessing this
client observes that he demonstrates a shuffling gait, drooling and exhibits general dystonic
symptoms.. From these symptoms and his history, the nurse concludes that the client has
developed:
a. Tardive dyskinesia
b. Parkinsonism
c. Dystonia
d. Akathisia
50. A client with antisocial personality disorder tells a nurse “Life has been full of problems since
childhood.” Which of the following situations or conditions would the nurse explore in the
assessment?
a. Birth defects
b. Distracted easily
c. Hypoactive behavior
d. Substance abuse
51. A client with antisocial personality disorder is trying to manipulate the healthcare team.
Which of the following strategies is important for the staff to use?
a. Focus on how to teach the client more effective behaviors for meeting basic needs.
b. Help the client verbalize underlying feelings of hopelessness and learn coping skills.
c. Remain calm and don’t emotionally respond to the client’s manipulative actions.
d. Help the client eliminate the intense desire to have everything in life turn out perfectly.
52. A client with antisocial personality disorder is beginning to practice several socially
acceptable behaviors in the group setting. Which of the following outcomes will result from this
change?
a. Fewer panic attacks
b. Acceptance of reality
c. Improved self-esteem
d. decreased physical symptoms
53. Which of the following discharge instructions would be most accurate to provide to a female
client who has suffered a spinal cord injury at the C4 level?
a. After a spinal cord injury, women usually remain fertile; therefore, you may consider
contraception if you don’t want to become pregnant.
b. After a spinal cord injury, women usually are unable to conceive a child.
c. Sexual intercourse shouldn’t be different for you.
d. After a spinal cord injury, menstruation usually stops.
54.A client with chronic obstructive pulmonary disease (COPD) tells the nurse, “I no longer have
enough energy to make love to my husband.” Which of the following nursing interventions would
be most appropriate?
a. Refer the couple to a sex therapist.
b. Advise the woman to seek a gynecologic consult
c. Suggest methods and measures that facilitate sexual activity.
d. Tell the client, “if you talk this over with your husband, he will understand.
55. A client tells the nurse she is having her menstrual period every 2 weeks and it lasts for 1
week. Which of the following conditions is best defined by this menstrual pattern?
a. Amenorrhea
b. Dyspareunia
c. Oligorrhagia
d. menororrhagia
Answers & Rationale
1. c. Giving thiamine 100 mg IM STAT
2. c. ”I can’t wait to go get pizza with my brother.”
3. c. Giving him step-by-step directions
4. a. Exposure to the sun
5. b. Maintaining constant observation.
6. c. Evidence of delusions and hallucinations
7. b. She may have a predisposition for schizophrenia
8. c. Paranoid
9. c. Hypersensitive
10. b. Hemoglobin S
11. a. ”A person with bulimia nervosa can maintain a normal weight.”
12. c. Hypokalemia
13. c. Electrolyte Imbalance
14. d. Malabsorption of nutrients
15. c. Pain
16. b. Multiple losses
17. d. Explore the family’s ability to express affection appropriately.
18. c. Address the dynamics of the disorder.
19. c. An expected result of the removal of the pituitary gland
20. b. Lifetime dependency on hormone replacement
21. c. Eye opening, verbal response, motor response
22. a. Change in the level of consciousness, tachypnea, tachycardia, petechiae
23. a. Skin care and position q2h and prn; maintain alignment of extremities; respiratory
exercises
24. b. Obtaining blood glucose results
25. d. Infection has increased her insulin needs
26. b. To prevent a hypoglycemic reaction
27. a. Maintain proper body alignment
28. c. A total score for the five areas of 7 or.above.
29. c. ”It Is a temporary interruption in the blood flow to the brain.”
30. b. Eat a diet high in protein and calories to optimize tissue repair.
31. b. Discontinue the medication for a few weeks
32. c. Creation of a tracheostomy
33. a. Reporting that the consent has been obtained from a confused client.
34. a. Multiple serum chorionic gonadotropin levels will be drawn
35. a. Apply pressure by pinching the anterior portion of the for five to ten minutes
36. b. ”I will not give this medication.”
37. d. Complete a nursing assessment of the patient
38. a. Hemoglobin level of 9 mg/dL
39. a. Using a low-pitched voice
40. b. Regular insulin (Humulin R)
41. a. ”At what time did the pain start?”
42. c. 6.25
43. d. Benztropine mesyiate (Cogentin)
44. c. Smoke only right after meals
45. d. Various position changes are necessary during the test
46. d. Dyspnea only on exertion
47. b. Weak, slow pulse
48. b. ”I am a. new staff member, and I’m on a tour. I’ll come back and talk with you later.”
49. a. Tardive dyskinesia
50. d. Substance abuse
51. c. Remain calm and don’t emotionally respond to the client’s manipulative actions.
52. c. Improved self-esteem
53. a. After a spinal cord injury, women usually remain fertile; therefore, you may consider
contraception if you don’t want to become pregnant.
54. c. Suggest methods and measures that facilitate sexual activity.
55. d. menorrhagia
1. Nurse Tony should first discuss terminating the nurse-client relationship with a
client during the:
a. Termination phase when discharge plans are being made.
b. Working phase when the client shows some progress.
c. Orientation phase when a contract is established.
d. Working phase when the client brings it up.
2. Malou is diagnosed with major depression spends majority of the day lying in bed
with the sheet pulled over his head. Which of the following approaches by the nurse
would be the most therapeutic?
a. Question the client until he responds
b. Initiate contact with the client frequently
c. Sit outside the clients room
d. Wait for the client to begin the conversation
3. Joe who is very depressed exhibits psychomotor retardation, a flat affect and
apathy. The nurse in charge observes Joe to be in need of grooming and hygiene.
Which of the following nursing actions would be most appropriate?
a. Waiting until the client’s family can participate in the client’s care
b. Asking the client if he is ready to take shower
c. Explaining the importance of hygiene to the client
d. Stating to the client that it’s time for him to take a shower
4. When teaching Mario with a typical depression about foods to avoid while taking
phenelzine(Nardil), which of the following would the nurse in charge include?
a. Roasted chicken
b. Fresh fish
c. Salami
d. Hamburger
5. When assessing a female client who is receiving tricyclic antidepressant therapy,
which of the following would alert the nurse to the possibility that the client is
experiencing anticholinergic effects?
a. Urine retention and blurred vision
b. Respiratory depression and convulsion
c. Delirium and Sedation
d. Tremors and cardiac arrhythmias
6. For a male client with dysthymic disorder, which of the following approaches
would the nurse expect to implement?
a. ECT
b. Psychotherapeutic approach
c. Psychoanalysis
d. Antidepressant therapy
7. Danny who is diagnosed with bipolar disorder and acute mania, states the nurse,
“Where is my daughter? I love Louis. Rain, rain go away. Dogs eat dirt.” The nurse
interprets these statements as indicating which of the following?
a. Echolalia
b. Neologism
c. Clang associations
d. Flight of ideas
8. Terry with mania is skipping up and down the hallway practically running into
other clients. Which of the following activities would the nurse in charge expect to
include in Terry’s plan of care?
a. Watching TV
b. Cleaning dayroom tables
c. Leading group activity
d. Reading a book
9. When assessing a male client for suicidal risk, which of the following methods of
suicide would the nurse identify as most lethal?
a. Wrist cutting
b. Head banging
c. Use of gun
d. Aspirin overdose
10. Jun has been hospitalized for major depression and suicidal ideation. Which of
the following statements indicates to the nurse that the client is improving?
a. “I’m of no use to anyone anymore.”
b. “I know my kids don’t need me anymore since they’re grown.”
c. “I couldn’t kill myself because I don’t want to go to hell.”
d. “I don’t think about killing myself as much as I used to.”
11. Which of the following activities would Nurse Trish recommend to the client who
becomes very anxious when thoughts of suicide occur?
a. Using exercise bicycle
b. Meditating
c. Watching TV
d. Reading comics
12. When developing the plan of care for a client receiving haloperidol, which of the
following medications would nurse Monet anticipate administering if the client
developed extra pyramidal side effects?
a. Olanzapine (Zyprexa)
b. Paroxetine (Paxil)
c. Benztropine mesylate (Cogentin)
d. Lorazepam (Ativan)
13. Jon a suspicious client states that “I know you nurses are spraying my food with
poison as you take it out of the cart.” Which of the following would be the best
response of the nurse?
a. Giving the client canned supplements until the delusion subsides
b. Asking what kind of poison the client suspects is being used
c. Serving foods that come in sealed packages
d. Allowing the client to be the first to open the cart and get a tray
14. A client is suffering from catatonic behaviors. Which of the following would the
nurse use to determine that the medication administered PRN have been most
effective?
a. The client responds to verbal directions to eat
b. The client initiates simple activities without direction
c. The client walks with the nurse to her room
d. The client is able to move all extremities occasionally
15. Nurse Hazel invites new client’s parents to attend the psycho educational
program for families of the chronically mentally ill. The program would be most likely
to help the family with which of the following issues?
a. Developing a support network with other families
b. Feeling more guilty about the client’s illness
c. Recognizing the client’s weakness
d. Managing their financial concern and problems
16. When planning care for Dory with schizotypal personality disorder, which of the
following would help the client become involved with others?
a. Attending an activity with the nurse
b. Leading a sing a long in the afternoon
c. Participating solely in group activities
d. Being involved with primarily one to one activities
17. Which statement about an individual with a personality disorder is true?
a. Psychotic behavior is common during acute episodes
b. Prognosis for recovery is good with therapeutic intervention
c. The individual typically remains in the mainstream of society, although he has problems
in social and occupational roles
d. The individual usually seeks treatment willingly for symptoms that are personally
distressful.
18. Nurse John is talking with a client who has been diagnosed with antisocial
personality about how to socialize during activities without being seductive. Nurse
John would focus the discussion on which of the following areas?
a. Discussing his relationship with his mother
b. Asking him to explain reasons for his seductive behavior
c. Suggesting to apologize to others for his behavior
d. Explaining the negative reactions of others toward his behavior
19. Tina with a histrionic personality disorder is melodramatic and responds to
others and situations in an exaggerated manner. Nurse Trish would recommend
which of the following activities for Tina?
a. Baking class
b. Role playing
c. Scrap book making
d. Music group
20. Joy has entered the chemical dependency unit for treatment of alcohol
dependency. Which of the following client’s possession will the nurse most likely
place in a locked area?
a. Toothpaste
b. Shampoo
c. Antiseptic wash
d. Moisturizer
21. Which of the following assessment would provide the best information about the
client’s physiologic response and the effectiveness of the medication prescribed
specifically for alcohol withdrawal?
a. Sleeping pattern
b. Mental alertness
c. Nutritional status
d. Vital signs
22. After administering naloxone (Narcan), an opioid antagonist, Nurse Ronald
should monitor the female client carefully for which of the following?
a. Respiratory depression
b. Epilepsy
c. Kidney failure
d. Cerebral edema
23. Which of the following would nurse Ronald use as the best measure to determine
a client’s progress in rehabilitation?
a. The way he gets along with his parents
b. The number of drug-free days he has
c. The kinds of friends he makes
d. The amount of responsibility his job entails
24. A female client is brought by ambulance to the hospital emergency room after
taking an overdose of barbiturates is comatose. Nurse Trish would be especially alert
for which of the following?
a. Epilepsy
b. Myocardial Infarction
c. Renal failure
d. Respiratory failure
25. Joey who has a chronic user of cocaine reports that he feels like he has
cockroaches crawling under his skin. His arms are red because of scratching. The
nurse in charge interprets these findings as possibly indicating which of the
following?
a. Delusion
b. Formication
c. Flash back
d. Confusion
Psychiatric Nursing Exams: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | All
26. Jose is diagnosed with amphetamine psychosis and was admitted in the
emergency room. Nurse Ronald would most likely prepare to administer which of the
following medication?
a. Librium
b. Valium
c. Ativan
d. Haldol
27. Which of the following liquids would nurse Leng administer to a female client who
is intoxicated with phencyclidine (PCP) to hasten excretion of the chemical?
a. Shake
b. Tea
c. Cranberry Juice
d. Grape juice
28. When developing a plan of care for a female client with acute stress disorder who
lost her sister in a car accident. Which of the following would the nurse expect to
initiate?
a. Facilitating progressive review of the accident and its consequences
b. Postponing discussion of the accident until the client brings it up
c. Telling the client to avoid details of the accident
d. Helping the client to evaluate her sister’s behavior
29. The nursing assistant tells nurse Ronald that the client is not in the dining room
for lunch. Nurse Ronald would direct the nursing assistant to do which of the
following?
a. Tell the client he’ll need to wait until supper to eat if he misses lunch
b. Invite the client to lunch and accompany him to the dining room
c. Inform the client that he has 10 minutes to get to the dining room for lunch
d. Take the client a lunch tray and let the client eat in his room
30. The initial nursing intervention for the significant-others during shock phase of a
grief reaction should be focused on:
a. Presenting full reality of the loss of the individuals
b. Directing the individual’s activities at this time
c. Staying with the individuals involved
d. Mobilizing the individual’s support system
31. Joy’s stream of consciousness is occupied exclusively with thoughts of her
father’s death. Nurse Ronald should plan to help Joy through this stage of grieving,
which is known as:
a. Shock and disbelief
b. Developing awareness
c. Resolving the loss
d. Restitution
32. When taking a health history from a female client who has a moderate level of
cognitive impairment due to dementia, the nurse would expect to note the presence
of:
a. Accentuated premorbid traits
b. Enhance intelligence
c. Increased inhibitions
d. Hyper vigilance
33. What is the priority care for a client with a dementia resulting from AIDS?
a. Planning for remotivational therapy
b. Arranging for long term custodial care
c. Providing basic intellectual stimulation
d. Assessing pain frequently
34. Jerome who has eating disorder often exhibits similar symptoms. Nurse Lhey
would expect an adolescent client with anorexia to exhibit:
a. Affective instability
b. Dishered, unkempt physical appearance
c. Depersonalization and derealization
d. Repetitive motor mechanisms
35. The primary nursing diagnosis for a female client with a medical diagnosis of
major depression would be:
a. Situational low self-esteem related to altered role
b. Powerlessness related to the loss of idealized self
c. Spiritual distress related to depression
d. Impaired verbal communication related to depression
36. When developing an initial nursing care plan for a male client with a Bipolar I
disorder (manic episode) nurse Ron should plan to?
a. Isolate his gym time
b. Encourage his active participation in unit programs
c. Provide foods, fluids and rest
d. Encourage his participation in programs
37. Grace is exhibiting withdrawn patterns of behavior. Nurse Johnny is aware that
this type of behavior eventually produces feeling of:
a. Repression
b. Loneliness
c. Anger
d. Paranoia
38. One morning a female client on the inpatient psychiatric service complains to
nurse Hazel that she has been waiting for over an hour for someone to accompany
her to activities. Nurse Hazel replies to the client “We’re doing the best we can. There
are a lot of other people on the unit who needs attention too.” This statement shows
that the nurse’s use of:
a. Defensive behavior
b. Reality reinforcement
c. Limit-setting behavior
d. Impulse control
39. A nursing diagnosis for a male client with a diagnosed multiple personality
disorder is chronic low self-esteem probably related to childhood abuse. The most
appropriate short term client outcome would be:
a. Verbalizing the need for anxiety medications
b. Recognizing each existing personality
c. Engaging in object-oriented activities
d. Eliminating defense mechanisms and phobia
40. A 25 year old male is admitted to a mental health facility because of inappropriate
behavior. The client has been hearing voices, responding to imaginary companions
and withdrawing to his room for several days at a time. Nurse Monette understands
that the withdrawal is a defense against the client’s fear of:
a. Phobia
b. Powerlessness
c. Punishment
d. Rejection
41. When asking the parents about the onset of problems in young client with the
diagnosis of schizophrenia, Nurse Linda would expect that they would relate the
client’s difficulties began in:
a. Early childhood
b. Late childhood
c. Adolescence
d. Puberty
42. Jose who has been hospitalized with schizophrenia tells Nurse Ron, “My heart
has stopped and my veins have turned to glass!” Nurse Ron is aware that this is an
example of:
a. Somatic delusions
b. Depersonalization
c. Hypochondriasis
d. Echolalia
43. In recognizing common behaviors exhibited by male client who has a diagnosis
of schizophrenia, nurse Josie can anticipate:
a. Slumped posture, pessimistic out look and flight of ideas
b. Grandiosity, arrogance and distractibility
c. Withdrawal, regressed behavior and lack of social skills
d. Disorientation, forgetfulness and anxiety
44. One morning, nurse Diane finds a disturbed client curled up in the fetal position
in the corner of the dayroom. The most accurate initial evaluation of the behavior
would be that the client is:
a. Physically ill and experiencing abdominal discomfort
b. Tired and probably did not sleep well last night
c. Attempting to hide from the nurse
d. Feeling more anxious today
45. Nurse Bea notices a female client sitting alone in the corner smiling and talking to
herself. Realizing that the client is hallucinating. Nurse Bea should:
a. Invite the client to help decorate the dayroom
b. Leave the client alone until he stops talking
c. Ask the client why he is smiling and talking
d. Tell the client it is not good for him to talk to himself
46. When being admitted to a mental health facility, a young female adult tells Nurse
Mylene that the voices she hears frighten her. Nurse Mylene understands that the
client tends to hallucinate more vividly:
a. While watching TV
b. During meal time
c. During group activities
d. After going to bed
47. Nurse John recognizes that paranoid delusions usually are related to the defense
mechanism of:
a. Projection
b. Identification
c. Repression
d. Regression
48. When planning care for a male client using paranoid ideation, nurse Jasmin
should realize the importance of:
a. Giving the client difficult tasks to provide stimulation
b. Providing the client with activities in which success can be achieved
c. Removing stress so that the client can relax
d. Not placing any demands on the client
49. Nurse Gerry is aware that the defense mechanism commonly used by clients who
are alcoholics is:
a. Displacement
b. Denial
c. Projection
d. Compensation
50. Within a few hours of alcohol withdrawal, nurse John should assess the male
client for the presence of:
a. Disorientation, paranoia, tachycardia
b. Tremors, fever, profuse diaphoresis
c. Irritability, heightened alertness, jerky movements
d. Yawning, anxiety, convulsions
Answers & Rationale
1. C. When the nurse and client agree to work together, a contract should be established,
the length of the relationship should be discussed in terms of its ultimate termination.
2. B. The nurse should initiate brief, frequent contacts throughout the day to let the client
know that he is important to the nurse. This will positively affect the client’s self-esteem.
3. D. The client with depression is preoccupied, has decreased energy, and is unable to
make decisions. The nurse presents the situation, “It’s time for a shower”, and assists
the client with personal hygiene to preserve his dignity and self-esteem.
4. C. Foods high in tyramine, those that are fermented, pickled, aged, or smoked must be
avoided because when they are ingested in combination with MAOIs a hypertensive
crisis will occur.
5. A. Anticholinergic effects, which result from blockage of the parasympathetic
(craniosacral) nervous system including urine retention, blurred vision, dry mouth &
constipation.
6. B. Dysthymia is a less severe, chronic depression diagnosed when a client has had a
depressed mood for more days than not over a period of at least 2 years. Client with
dysthymic disorder benefit from psychotherapeutic approaches that assist the client in
reversing the negative self image, negative feelings about the future.
7. D. Flight of ideas is speech pattern of rapid transition from topic to topic, often without
finishing one idea. It is common in mania.
8. B. The client with mania is very active & needs to have this energy channeled in a
constructive task such as cleaning or tidying the room.
9. C. A crucial factor is determining the lethality of a method is the amount of time that
occurs between initiating the method & the delivery of the lethal impact of the method.
10. D. The statement “I don’t think about killing myself as much as I used to.” Indicates a
lessening of suicidal ideation and improvement in the client’s condition.
11. A. Using exercise bicycle is appropriate for the client who becomes very anxious when
thoughts of suicidal occur.
12. C. The drug of choice for a client experiencing extra pyramidal side effects from
haloperidol (Haldol) is benztropine mesylate (cogentin) because of its anti cholinergic
properties.
13. D. Allowing the client to be the first to open the cart & take a tray presents the client with
the reality that the nurses are not touching the food & tray, thereby dispelling the
delusion.
14. B. Although all the actions indicate improvement, the ability to initiate simple activities
without directions indicates the most improvement in the catatonic behaviors.
15. A. Psychoeducational groups for families develop a support network. They provide
education about the biochemical etiology of psychiatric disease to reduce, not increase
family guilt.
16. C. Attending activity with the nurse assists the client to become involved with others
slowly. The client with schizotypal personality disorder needs support, kindness & gentle
suggestion to improve social skills & interpersonal relationship.
17. C. An individual with personality disorder usually is not hospitalized unless a coexisting
Axis I psychiatric disorder is present. Generally, these individuals make marginal
adjustments and remain in society, although they typically experience relationship and
occupational problems related to their inflexible behaviors. Personality disorders are
chronic lifelong patterns of behavior; acute episodes do not occur. Psychotic behavior is
usually not common, although it can occur in either schizotypal personality disorder or
borderline personality disorder. Because these disorders are enduring and evasive and
the individual is inflexible, prognosis for recovery is unfavorable. Generally, the individual
does not seek treatment because he does not perceive problems with his own behavior.
Distress can occur based on other people’s reaction to the individual’s behavior.
18. D. The nurse would explain the negative reactions of others towards the client’s
behaviors to make the clients aware of the impact of his seductive behaviors on others.
19. B. The nurse would use role-playing to teach the client appropriate responses to others
and in various situations. This client dramatizes events, drawn attention to self, and is
unaware of and does not deal with feelings. The nurse works to help the client clarify
true feelings & learn to express them appropriately.
20. C. Antiseptic mouthwash often contains alcohol & should be kept in locked area, unless
labeling clearly indicates that the product does not contain alcohol.
21. D. Monitoring of vital signs provides the best information about the client’s overall
physiologic status during alcohol withdrawal & the physiologic response to the
medication used.
22. A. After administering naloxone (Narcan) the nurse should monitor the client’s
respiratory status carefully, because the drug is short acting & respiratory depression
may recur after its effects wear off.
23. B. The best measure to determine a client’s progress in rehabilitation is the number of
drug- free days he has. The longer the client is free of drugs, the better the prognosis is.
24. D. Barbiturates are CNS depressants; the nurse would be especially alert for the
possibility of respiratory failure. Respiratory failure is the most likely cause of death from
barbiturate over dose.
25. B. The feeling of bugs crawling under the skin is termed as formication, and is
associated with cocaine use.
26. D. The nurse would prepare to administer an antipsychotic medication such as Haldol to
a client experiencing amphetamine psychosis to decrease agitation & psychotic
symptoms, including delusions, hallucinations & cognitive impairment.
27. C. An acid environment aids in the excretion of PCP. The nurse will definitely give the
client with PCP intoxication cranberry juice to acidify the urine to a ph of 5.5 & accelerate
excretion.
28. A. The nurse would facilitate progressive review of the accident and its consequence to
help the client integrate feelings & memories and to begin the grieving process.
29. B. The nurse instructs the nursing assistant to invite the client to lunch & accompany him
to the dinning room to decrease manipulation, secondary gain, dependency and
reinforcement of negative behavior while maintaining the client’s worth.
30. C. This provides support until the individuals coping mechanisms and personal support
systems can be immobilized.
31. C. Resolving a loss is a slow, painful, continuous process until a mental image of the
dead person, almost devoid of negative or undesirable features emerges.
32. A. A moderate level of cognitive impairment due to dementia is characterized by
increasing dependence on environment & social structure and by increasing psychologic
rigidity with accentuated previous traits & behaviors.
33. C. This action maintains for as long as possible, the clients intellectual functions by
providing an opportunity to use them.
34. A. Individuals with anorexia often display irritability, hospitality, and a depressed mood.
35. D. Depressed clients demonstrate decreased communication because of lack of psychic
or physical energy.
36. C. The client in a manic episode of the illness often neglects basic needs, these needs
are a priority to ensure adequate nutrition, fluid, and rest.
37. B. The withdrawn pattern of behavior presents the individual from reaching out to others
for sharing the isolation produces feeling of loneliness.
38. A. The nurse’s response is not therapeutic because it does not recognize the client’s
needs but tries to make the client feel guilty for being demanding.
39. B. The client must recognize the existence of the sub personalities so that interpretation
can occur.
40. D. An aloof, detached, withdrawn posture is a means of protecting the self by
withdrawing and maintaining a safe, emotional distance.
41. C. The usual age of onset of schizophrenia is adolescence or early childhood.
42. A. Somatic delusion is a fixed false belief about one’s body.
43. C. These are the classic behaviors exhibited by clients with a diagnosis of schizophrenia.
44. D. The fetal position represents regressed behavior. Regression is a way of responding
to overwhelming anxiety.
45. B. This provides a stimulus that competes with and reduces hallucination.
46. D. Auditory hallucinations are most troublesome when environmental stimuli are
diminished and there are few competing distractions.
47. A. Projection is a mechanism in which inner thoughts and feelings are projected onto the
environment, seeming to come from outside the self rather than from within.
48. B. This will help the client develop self-esteem and reduce the use of paranoid ideation.
49. B. Denial is a method of resolving conflict or escaping unpleasant realities by ignoring
their existence.
50. C. Alcohol is a central nervous system depressant. These symptoms are the body’s
neurologic adaptation to the withdrawal of alcohol.
1. Flumazenil (Romazicon) has been ordered for a client who has overdosed on
oxazepam (Serax). Before administering the medication, the nurse should be
prepared for which common adverse effect?
A. Seizures
B. Shivering
C. Anxiety
D. Chest pain
2. The nurse is caring for a client diagnosed with bulimia. The most appropriate
initial goal for a client diagnosed with bulimia is to:
A. avoid shopping for large amounts of food.
B. control eating impulses.
C. identify anxiety-causing situations.
D. eat only three meals per day.
3. A client who’s at high risk for suicide needs close supervision. To best ensure
the client’s safety, the nurse should:
A. check the client frequently at irregular intervals throughout the night.
B. assure the client that the nurse will hold in confidence anything the client says.
C. repeatedly discuss previous suicide attempts with the client.
D. disregard decreased communication by the client because this is common in suicidal
clients.
4. Which of the following drugs should the nurse prepare to administer to a client
with a toxic acetaminophen (Tylenol) level?
A. deferoxamine mesylate (Desferal)
B. succimer (Chemet)
C. flumazenil (Romazicon)
D. acetylcysteine (Mucomyst)
5. A client is admitted to the substance abuse unit for alcohol detoxification.
Which of the following medications is the nurse most likely to administer to
reduce the symptoms of alcohol withdrawal?
A. naloxone (Narcan)
B. haloperidol (Haldol)
C. magnesium sulfate
D. chlordiazepoxide (Librium)
6. During postprandial monitoring, a client with bulimia nervosa tells the nurse, “You
can sit with me, but you’re just wasting your time. After you sat with me yesterday, I
was still able to purge. Today, my goal is to do it twice.” What is the nurse’s best
response?
A. “I trust you not to purge.”
B. “How are you purging and when do you do it?”
C. “Don’t worry. I won’t allow you to purge today.”
D. “I know it’s important for you to feel in control, but I’ll monitor you for 90 minutes
after you eat.”
7. A client admitted to the psychiatric unit for treatment of substance abuse says to
the nurse, “It felt so wonderful to get high.” Which of the following is the most
appropriate response?
A. “If you continue to talk like that, I’m going to stop speaking to you.”
B. “You told me you got fired from your last job for missing too many days after taking drugs
all night.”
C. “Tell me more about how it felt to get high.”
D. “Don’t you know it’s illegal to use drugs?”
8. For a client with anorexia nervosa, which goal takes the highest priority?
A. The client will establish adequate daily nutritional intake.
B. The client will make a contract with the nurse that sets a target weight.
C. The client will identify self-perceptions about body size as unrealistic.
D. The client will verbalize the possible physiological consequences of self-
starvation.
9. When interviewing the parents of an injured child, which of the following is the
strongest indicator that child abuse may be a problem?
A. The injury isn’t consistent with the history or the child’s age.
B. The mother and father tell different stories regarding what happened.
C. The family is poor.
D. The parents are argumentative and demanding with emergency department
personnel.
10. For a client with anorexia nervosa, the nurse plans to include the parents in
therapy sessions along with the client. What fact should the nurse remember to be
typical of parents of clients with anorexia nervosa?
A. They tend to overprotect their children.
B. They usually have a history of substance abuse.
C. They maintain emotional distance from their children.
D. They alternate between loving and rejecting their children.
11. In the emergency department, a client with facial lacerations states that her
husband beat her with a shoe. After the health care team repairs her lacerations, she
waits to be seen by the crisis intake nurse, who will evaluate the continued threat of
violence. Suddenly the client’s husband arrives, shouting that he wants to “finish the
job.” What is the first priority of the health care worker who witnesses this scene?
A. Remaining with the client and staying calm
B. Calling a security guard and another staff member for assistance
C. Telling the client’s husband that he must leave at once
D. Determining why the husband feels so angry
12. The nurse is caring for a client with bulimia. Strict management of dietary intake
is necessary. Which intervention is also important?
A. Fill out the client’s menu and make sure she eats at least half of what is on her
tray.
B. Let the client eat her meals in private. Then engage her in social activities for at
least 2 hours after each meal.
C. Let the client choose her own food. If she eats everything she orders, then stay
with her for 1 hour after each meal.
D. Let the client eat food brought in by the family if she chooses, but she should
keep a strict calorie count.
13. The nurse is assigned to care for a suicidal client. Initially, which is the nurse’s
highest care priority?
A. Assessing the client’s home environment and relationships outside the hospital
B. Exploring the nurse’s own feelings about suicide
C. Discussing the future with the client
D. Referring the client to a clergyperson to discuss the moral implications of suicide
14. A client with anorexia nervosa tells the nurse, “When I look in the mirror, I hate
what I see. I look so fat and ugly.” Which strategy should the nurse use to deal with
the client’s distorted perceptions and feelings?
A. Avoid discussing the client’s perceptions and feelings.
B. Focus discussions on food and weight.
C. Avoid discussing unrealistic cultural standards regarding weight.
D. Provide objective data and feedback regarding the client’s weight and
attractiveness.
15. The nurse is caring for a client being treated for alcoholism. Before initiating
therapy with disulfiram (Antabuse), the nurse teaches the client that he must read
labels carefully on which of the following products?
A. Carbonated beverages
B. Aftershave lotion
C. Toothpaste
D. Cheese
16. The nurse is developing a plan of care for a client with anorexia nervosa. Which
action should the nurse include in the plan?
A. Restrict visits with the family until the client begins to eat.
B. Provide privacy during meals.
C. Set up a strict eating plan for the client.
D. Encourage the client to exercise, which will reduce her anxiety.
17. Victims of domestic violence should be assessed for what important information?
A. Reasons they stay in the abusive relationship (for example, lack of financial
autonomy and isolation)
B. Readiness to leave the perpetrator and knowledge of resources
C. Use of drugs or alcohol
D. History of previous victimization
18. A client is hospitalized with fractures of the right femur and right humerus
sustained in a motorcycle accident. Police suspect the client was intoxicated at the
time of the accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dl).
The client later admits to drinking heavily for years. During hospitalization, the client
periodically complains of tingling and numbness in the hands and feet. The nurse
realizes that these symptoms probably result from:
A. acetate accumulation.
B. thiamine deficiency.
C. triglyceride buildup.
D. a below-normal serum potassium level
19. A parent brings a preschooler to the emergency department for treatment of a
dislocated shoulder, which allegedly happened when the child fell down the stairs.
Which action should make the nurse suspect that the child was abused?
A. The child cries uncontrollably throughout the examination.
B. The child pulls away from contact with the physician.
C. The child doesn’t cry when the shoulder is examined.
D. The child doesn’t make eye contact with the nurse.
20. When planning care for a client who has ingested phencyclidine (PCP), which of
the following is the highest priority?
A. Client’s physical needs
B. Client’s safety needs
C. Client’s psychosocial needs
D. Client’s medical needs
21. Which outcome criteria would be appropriate for a child diagnosed with
oppositional defiant disorder?
A. Accept responsibility for own behaviors.
B. Be able to verbalize own needs and assert rights.
C. Set firm and consistent limits with the client.
D. Allow the child to establish his own limits and boundaries.
22. A client is found sitting on the floor of the bathroom in the day treatment clinic
with moderate lacerations on both wrists. Surrounded by broken glass, she sits
staring blankly at her bleeding wrists while staff members call for an ambulance. How
should the nurse approach her initially?
A. Enter the room quietly and move beside her to assess her injuries.
B. Call for staff back-up before entering the room and restraining her.
C. Move as much glass away from her as possible and sit next to her quietly.
D. Approach her slowly while speaking in a calm voice, calling her name, and
telling her that the nurse is here to help her.
23. A client with anorexia nervosa describes herself as “a whale.” However, the
nurse’s assessment reveals that the client is 5′ 8″ (1.7 m) tall and weighs only 90 lb
(40.8 kg). Considering the client’s unrealistic body image, which intervention should
be included in the plan of care?
A. Asking the client to compare her figure with magazine photographs of women her age
B. Assigning the client to group therapy in which participants provide realistic feedback
about her weight
C. Confronting the client about her actual appearance during one-on-one sessions,
scheduled during each shift
D. Telling the client of the nurse’s concern for her health and desire to help her make
decisions to keep her healthy
24. Eighteen hours after undergoing an emergency appendectomy, a client with a
reported history of social drinking displays these vital signs: temperature, 101.6° F
(38.7° C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood
pressure, 140/96 mm Hg. The client exhibits gross hand tremors and is screaming for
someone to kill the bugs in the bed. The nurse should suspect:
A. a postoperative infection.
B. alcohol withdrawal.
C. acute sepsis.
D. pneumonia.
25. Clonidine (Catapres) can be used to treat conditions other than hypertension. For
which of the following conditions might the drug be administered?
A. Phencyclidine (PCP) intoxication
B. Alcohol withdrawal
C. Opiate withdrawal
D. Cocaine withdrawal
26. One of the goals for a client with anorexia nervosa is that the client will
demonstrate increased individual coping by responding to stress in constructive
ways. Which of the following actions is the best indicator that the client is working
toward meeting the goal?
A. The client drinks 4 L of fluid per day.
B. The client paces around the unit most of the day.
C. The client keeps a journal and discusses it with the nurse.
D. The client talks almost constantly with friends by telephone.
27. The nurse in the substance abuse unit is trying to encourage a client to attend
Alcoholics Anonymous meetings. When the client asks the nurse what he must do to
become a member, the nurse should respond:
A. “You must first stop drinking.”
B. “Your physician must refer you to this program.”
C. “Admit you’re powerless over alcohol and that you need help.”
D. “You must bring along a friend who will support you.”
28. An attorney who throws books and furniture around the office after losing a case
is referred to the psychiatric nurse in the law firm’s employee assistance program.
The nurse knows that the client’s behavior most likely represents the use of which
defense mechanism?
A. Regression
B. Projection
C. Reaction-formation
D. Intellectualization
29. After completing chemical detoxification and a 12-step program to treat crack
addiction, a client is being prepared for discharge. Which remark by the client
indicates a realistic view of the future?
A. “I’m never going to use crack again.”
B. “I know what I have to do. I have to limit my crack use.”
C. “I’m going to take 1 day at a time. I’m not making any promises.”
D. “I will substitue crack for something else”
30. The nurse is assessing a client on admission to the chemical dependency unit for
alcohol detoxification. When the nurse asks about alcohol use, this client is most
likely to:
A. accurately describe the amount consumed.
B. underestimate the amount consumed.
C. overestimate the amount consumed.
D. deny any consumption of alcohol.
31. The nurse is assessing a 15-year-old female who’s being admitted for treatment
of anorexia nervosa. Which clinical manifestation is the nurse most likely to find?
A. Tachycardia
B. Warm, flushed extremities
C. Parotid gland tenderness
D. Coarse hair growth
32. A 38-year-old client is admitted for alcohol withdrawal. The most common early
sign or symptom that this client is likely to experience is:
A. impending coma.
B. manipulating behavior.
C. suppression.
D. perceptual disorders.
33. The nurse is caring for an adolescent female who reports amenorrhea, weight
loss, and depression. Which additional assessment finding would suggest that the
woman has an eating disorder?
A. Wearing tight-fitting clothing
B. Increased blood pressure
C. Oily skin
D. Excessive and ritualized exercise
34. A client with a history of polysubstance abuse is admitted to the facility. She
complains of nausea and vomiting 24 hours after admission. The nurse assesses the
client and notes piloerection, pupillary dilation, and lacrimation. The nurse suspects
that the client is going through which of the following withdrawals?
A. Alcohol withdrawal
B. Cannibis withdrawal
C. Cocaine withdrawal
D. Opioid withdrawal
35. A client is admitted to the psychiatric unit with a diagnosis of anorexia nervosa.
Although she is 5′ 8″ (1.7 m) tall and weighs only 103 lb (46.7 kg), she talks
incessantly about how fat she is. Which measure should the nurse take first when
caring for this client?
A. Teach the client about nutrition, calories, and a balanced diet.
B. Establish a trusting relationship with the client.
C. Discuss cultural stereotypes regarding thinness and attractiveness.
D. Explore the reasons why the client doesn’t eat.
36. A client is admitted for an overdose of amphetamines. When assessing this
client, the nurse should expect to see:
A. tension and irritability.
B. slow pulse.
C. hypotension.
D. constipation.
37. Which of the following drugs may be abused because of tolerance and
physiologic dependence.
A. lithium (Lithobid) and divalproex (Depakote).
B. verapamil (Calan) and chlorpromazine (Thorazine)
C. alprazolam (Xanax) and phenobarbital (Luminal)
D. clozapine (Clozaril) and amitriptyline (Elavil)
38. Which of the following groups are considered to be at highest risk for suicide?
A. Adolescents, men over age 45, and persons who have made previous suicide
attempts
B. Teachers, divorced persons, and substance abusers
C. Alcohol abusers, widows, and young married men
D. Depressed persons, physicians, and persons living in rural areas
39. Tourette syndrome is characterized by the presence of multiple motor and vocal
tics. A vocal tic that involves repeating one’s own sounds or words is known as:
A. echolalia.
B. palilalia.
C. apraxia.
D. aphonia.
40. A client is admitted to the psychiatric unit with a diagnosis of borderline
personality disorder. The nurse expects the assessment to
reveal:
A. unpredictable behavior and intense interpersonal relationships.
B. inability to function as a responsible parent.
C. somatic symptoms.
D. coldness, detachment, and lack of tender feelings.
41. A client with disorganized type schizophrenia has been hospitalized for the past 2
years on a unit for chronic mentally ill clients. The client’s behavior is labile and
fluctuates from childishness and incoherence to loud yelling to slow but appropriate
interaction. The client needs assistance with all activities of daily living. Which
behavior is characteristic of disorganized type schizophrenia?
A. Extreme social impairment
B. Suspicious delusions
C. Waxy flexibility
D. Elevated affect
42. The nurse is providing care for a female client with a history of schizophrenia
who’s experiencing hallucinations. The physician orders 200 mg of haloperidol
(Haldol) orally or I.M. every 4 hours as needed. What is the nurse’s best action?
A. Administer the haloperidol orally if the client agrees to take it.
B. Call the physician to clarify whether the haloperidol should be given orally or
I.M.
C. Call the physician to clarify the order because the dosage is too high.
D. Withhold haloperidol because it may worsen hallucinations.
43. A client receiving haloperidol (Haldol) complains of a stiff jaw and difficulty
swallowing. The nurse’s first action is to:
A. reassure the client and administer as needed lorazepam (Ativan) I.M.
B. administer as needed dose of benztropine (Cogentin) I.M. as ordered.
C. administer as needed dose of benztropine (Cogentin) by mouth as ordered.
D. administer as needed dose of haloperidol (Haldol) by mouth.
44. A 24-year-old client is experiencing an acute schizophrenic episode. He has vivid
hallucinations that are making him agitated. The nurse’s best response at this time
would be to:
A. take the client’s vital signs.
B. explore the content of the hallucinations.
C. tell him his fear is unrealistic.
D. engage the client in reality-oriented activities.
45. Which medication can control the extrapyramidal effects associated with
antipsychotic agents?
A. perphenazine (Trilafon)
B. doxepin (Sinequan)
C. amantadine (Symmetrel)
D. clorazepate (Tranxene)
46. A client with paranoid schizophrenia has been experiencing auditory
hallucinations for many years. One approach that has proven to be effective for
hallucinating clients is to:
A. take an as-needed dose of psychotropic medication whenever they hear
voices.
B. practice saying “Go away” or “Stop” when they hear voices.
C. sing loudly to drown out the voices and provide a distraction.
D. go to their room until the voices go away.
47. A dystonic reaction can be caused by which of the following medications?
A. diazepam (Valium)
B. haloperidol (Haldol)
C. amitriptyline (Elavil)
D. clonazepam (Klonopin)
48. While pacing in the hall, a client with paranoid schizophrenia runs to the nurse
and says, “Why are you poisoning me? I know you work for central thought control!
You can keep my thoughts. Give me back my soul!” How should the nurse respond
during the early stage of the therapeutic process?
A. “I’m a nurse. I’m not poisoning you. It’s against the nursing code of ethics.”
B. “I’m a nurse, and you’re a client in the hospital. I’m not going to harm you.”
C. “I’m not poisoning you. And how could I possibly steal your soul?”
D. “I sense anger. Are you feeling angry today?”
49. A client is admitted to the inpatient unit of the mental health center with a
diagnosis of paranoid schizophrenia. He’s shouting that the government of France is
trying to assassinate him. Which of the following responses is most appropriate?
A. “I think you’re wrong. France is a friendly country and an ally of the United
States. Their government wouldn’t try to kill you.”
B. “I find it hard to believe that a foreign government or anyone else is trying to
hurt you. You must feel frightened by this.”
C. “You’re wrong. Nobody is trying to kill you.”
D. “A foreign government is trying to kill you? Please tell me more about it.”
RATIONALE
1. A. Seizures
Rationale: Seizures are the most common serious adverse effect of using flumazenil to
reverse benzodiazepine overdose. The effect is magnified if the client has a combined
tricyclic antidepressant and benzodiazepine overdose. Less common adverse effects
include shivering, anxiety, and chest pain.
2. C. identify anxiety-causing situations.
Rationale: Bulimic behavior is generally a maladaptive coping response to stress and
underlying issues. The client must identify anxiety-causing situations that stimulate the
bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping
for large amounts of food isn’t a goal early in treatment. Managing eating impulses and
replacing them with adaptive coping mechanisms can be integrated into the plan of care
after initially addressing stress and underlying issues. Eating three meals per day isn’t a
realistic goal early in treatment.
3. A. check the client frequently at irregular intervals throughout the night.
Rationale: Checking the client frequently but at irregular intervals prevents the client from
predicting when observation will take place and altering behavior in a misleading way at
these times. Option B may encourage the client to try to manipulate the nurse or seek
attention for having a secret suicide plan. Option C may reinforce suicidal ideas. Decreased
communication is a sign of withdrawal that may indicate the client has decided to commit
suicide; the nurse
shouldn’t disregard it (option D
4.D. acetylcysteine (Mucomyst)
Rationale: The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion
of toxic metabolites to nontoxic metabolites. Deferoxamine mesylate is the antidote for iron
intoxication. Succimer is an antidote for lead poisoning. Flumazenil reverses the sedative
effects of benzodiazepines.
5. D. chlordiazepoxide (Librium)
Rationale: Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of
alcohol withdrawal. Haloperidol (Haldol) may be given to treat clients with psychosis, severe
agitation, or delirium. Naloxone (Narcan) is administered for narcotic overdose. Magnesium
sulfate and other anticonvulsant medications are only administered to treat seizures if they
occur during withdrawal.
6. D. “I know it’s important for you to feel in control, but I’ll monitor you for 90 minutes after
you eat.”
Rationale: This response acknowledges that the client is testing limits and that the nurse is
setting them by performing postprandial monitoring to prevent self-induced emesis. Clients
with bulimia nervosa need to feel in control of the diet because they feel they lack control
over all other aspects of their lives. Because their therapeutic relationships with caregivers
are less important than their need to purge, they don’t fear betraying the nurse’s trust by
engaging in the activity. They commonly plot purging and rarely share their secrets about it.
An authoritarian or challenging response may trigger a power struggle between the nurse
and client.
7. B. “You told me you got fired from your last job for missing too many days after taking
drugs all night.”
Rationale: Confronting the client with the consequences of substance abuse helps to break
through denial. Making threats (option A) isn’t an effective way to promote self-disclosure or
establish a rapport with the client. Although the nurse should encourage the client to
discuss feelings, the discussion should focus on how the client felt before, not during, an
episode of substance abuse (option C). Encouraging elaboration about his experience while
getting high may reinforce the abusive behavior. The client undoubtedly is aware that drug
use is illegal; a reminder to this effect (option D) is unlikely to alter behavior.
8. A. The client will establish adequate daily nutritional intake.
Rationale: According to Maslow’s hierarchy of needs, all humans need to meet basic
physiological needs first. Because a client with anorexia nervosa eats little or nothing, the
nurse must first plan to help the client meet this basic, immediate physiological need. The
nurse may give lesser priority to goals that address long-term plans (as in option B), self-
perception (as in option C), and potential complications (as in option D).
9. A. The injury isn’t consistent with the history or the child’s age.
Rationale: When the child’s injuries are inconsistent with the history given or impossible
because of the child’s age and developmental stage, the emergency department nurse
should be suspicious that child abuse is occurring. The parents may tell different stories
because their perception may be different regarding what happened. If they change their
story when different health care workers ask the same question, this is a clue that child
abuse may be a problem. Child abuse occurs in all socioeconomic groups. Parents may
argue and be demanding because of the stress of having an injured child.
10.A. They tend to overprotect their children.
Rationale: Clients with anorexia nervosa typically come from a family with parents who are
controlling and overprotective. These clients use eating to gain control of an aspect of their
lives. The characteristics described in options B, C, and D aren’t typical of parents of
children with anorexia.
11. B. Calling a security guard and another staff member for assistance
Rationale: The health care worker who witnesses this scene must take precautions to
ensure personal as well as client safety, but shouldn’t attempt to manage a physically
aggressive person alone. Therefore, the first priority is to call a security guard and another
staff member. After doing this, the health care worker should inform the husband what is
expected, speaking in concise statements and maintaining a firm but calm demeanor. This
approach makes it clear that the health care worker is in control and may diffuse the
situation until the security guard arrives. Telling the husband to leave would probably be
ineffective because of his agitated and irrational state. Exploring his anger doesn’t take
precedence over safeguarding the client and staff.
12. C. Let the client choose her own food. If she eats everything she orders, then stay with
her for 1 hour after each meal.
Rationale: Allowing the client to select her own food from the menu will help her feel some
sense of control. She must then eat 100% of what she selected. Remaining with the client
for at least 1 hour after eating will prevent purging. Bulimic clients should only be allowed to
eat food provided by the dietary department.
13. B. Exploring the nurse’s own feelings about suicide
Rationale: The nurse’s values, beliefs, and attitudes toward self-destructive behavior
influence responses to a suicidal client; such responses set the overall mood for the nurse-
client relationship. Therefore, the nurse initially must explore personal feelings about suicide
to avoid conveying negative feelings to the client. Assessment of the client’s home
environment and relationships may reveal the need for family therapy; however, conducting
such an assessment isn’t
a nursing priority. Discussing the future and providing anticipatory guidance can help the
client prepare for future stress, but this isn’t a priority. Referring the client to a clergyperson
may increase the client’s trust or alleviate guilt; however, it isn’t the highest priority.
14. D. Provide objective data and feedback regarding the client’s weight and attractiveness.
Rationale: By focusing on reality, this strategy may help the client develop a more realistic
body image and gain self-esteem. Option A is inappropriate because discussing the client’s
perceptions and feeling wouldn’t help her to identify, accept, and work through them.
Focusing discussions on food and weight would give the client attention for not eating,
making option B incorrect. Option C is inappropriate because recognizing unrealistic cultural
standards wouldn’t help the client establish more realistic weight goals.
15. B. Aftershave lotion
Rationale: Disulfiram may be given to clients with chronic alcohol abuse who wish to curb
impulse drinking. Disulfiram works by blocking the oxidation of alcohol, inhibiting the
conversion of acetaldehyde to acetate. As acetaldehyde builds up in the blood, the client
experiences noxious and uncomfortable symptoms. Even alcohol rubbed onto the skin can
produce a reaction. The client receiving disulfiram must be taught to read ingredient labels
carefully to avoid products containing alcohol such as aftershave lotions. Carbonated
beverages, toothpaste, and cheese don’t contain alcohol and don’t need to be avoided by
the
client.
16. C. Set up a strict eating plan for the client.
Rationale: Establishing a consistent eating plan and monitoring the client’s weight are
important for this disorder. The family should be included in the client’s care. The client
should be monitored during meals — not given privacy. Exercise must be limited and
supervised.
17. B. Readiness to leave the perpetrator and knowledge of resources
Rationale: Victims of domestic violence must be assessed for their readiness to leave the
perpetrator and their knowledge of the resources available to them. Nurses can then
provide the victims with information and options to enable them to leave when they are
ready. The reasons they stay in the relationship are complex and can be explored at a later
time. The use of drugs or alcohol is irrelevant. There is no evidence to suggest that previous
victimization results in a
person’s seeking or causing abusive relationships.
18.B. thiamine deficiency.
Rationale: Numbness and tingling in the hands and feet are symptoms of peripheral
polyneuritis, which results from inadequate intake of vitamin B1 (thiamine) secondary to
prolonged and excessive alcohol intake. Treatment includes reducing alcohol intake,
correcting nutritional deficiencies through diet and vitamin supplements, and preventing
such residual disabilities as foot and wrist drop. Acetate accumulation, triglyceride buildup,
and a below-normal serum
potassium level are unrelated to the client’s symptoms.19. C. The child doesn’t cry when
the shoulder is examined.
Rationale: A characteristic behavior of abused children is lack of crying when they undergo
a painful procedure or are examined by a health care professional. Therefore, the nurse
should suspect child abuse. Crying throughout the examination, pulling away from the
physician, and not making eye contact with the nurse are normal behaviors for
preschoolers.
20. B. Client’s safety needs
Rationale: The highest priority for a client who has ingested PCP is meeting safety needs of
the client as well as the staff. Drug effects are unpredictable and prolonged, and the client
may lose control easily. After safety needs have been met, the client’s physical,
psychosocial, and medical needs can be met.
21. A. Accept responsibility for own behaviors.
Rationale: Children with oppositional defiant disorder frequently violate the rights of others.
They are defiant, disobedient, and blame others for their actions. Accountability for their
actions would demonstrate progress for the oppositional child. Options C and D aren’t
outcome criteria but interventions. Option B is incorrect as the oppositional child usually
focuses on his own needs.
22. D. Approach her slowly while speaking in a calm voice, calling her name, and telling her
that the nurse is here to help her.
Rationale: Ensuring the safety of the client and the nurse is the priority at this time.
Therefore, the nurse should approach the client cautiously while calling her name and
talking to her in a calm, confident manner. The nurse should keep in mind that the client
shouldn’t be startled or overwhelmed. After explaining that the nurse is there to help, the
nurse should observe the client’s response carefully. If the client shows signs of agitation or
confusion or poses a threat, the nurse should retreat and request assistance. The nurse
shouldn’t attempt to sit next to the client or examine injuries without first announcing the
nurse’s presence and assessing the dangers of the situation.
23. D. Telling the client of the nurse’s concern for her health and desire to help her make
decisions to keep her healthy
Rationale: A client with anorexia nervosa has an unrealistic body image that causes
consumption of little or no food. Therefore, the client needs assistance with making
decisions about health. Instead of protecting the client’s health, options A, B, and C may
serve to make the client defensive and more entrenched in her unrealistic body image.
24. B. alcohol withdrawal.
Rationale: The client’s vital signs and hallucinations suggest delirium tremens or alcohol
withdrawal syndrome. Although infection, acute sepsis, and pneumonia may arise as
postoperative complications, they wouldn’t cause this client’s signs and symptoms and
typically would occur later in the postoperative course.
25. C. Opiate withdrawal
Rationale: Clonidine is used as adjunctive therapy in opiate withdrawal. Benzodiazepines,
such as chlordiazepoxide (Librium), and neuropleptic agents, such as haloperidol, are used
to treat alcohol withdrawal. Benzodiazepines and neuropleptic agents are typically used to
treat PCP intoxication. Antidepressants and medications with dopaminergic activity in the
brain, such as fluoxotine (Prozac), are used to treat cocaine withdrawal.
26.C. The client keeps a journal and discusses it with the nurse.
Rationale: The client is moving toward meeting the goal because recording and discussing
feelings is a constructive way to manage stress. Although physical activity can reduce
stress, the anorexic client is more likely to use pacing to burn calories and lose weight.
Although talks with friends can decrease stress, constant talking is more likely a way of
avoiding dealing with problems. Increased fluid intake may be an attempt by the client to
curb her appetite and artificially increase her weight.
27. C. “Admit you’re powerless over alcohol and that you need help.”
Rationale: The first of the “Twelve Steps of Alcoholics Anonymous” is admitting that an
individual is powerless over alcohol and that life has become unmanageable. Although
Alcoholics Anonymous promotes total abstinence, a client will still be accepted if he drinks.
A physician referral isn’t necessary to join. New members are assigned a support person
who may be called upon when the client has the urge to drink.
28. A. Regression
Rationale: An adult who throws temper tantrums, such as this one, is displaying regressive
behavior, or behavior that is appropriate at a younger age. In projection, the client blames
someone or something other than the source. In reaction formation, the client acts in
opposition to his feelings. In intellectualization, the client overuses rational explanations or
abstract thinking to decrease the significance of a feeling or event.
29. C. “I’m going to take 1 day at a time. I’m not making any promises.”
Rationale: Twelve-step programs focus on recovery 1 day at a time.Such programs
discourage people from claiming that they will never again use a substance, because
relapse is common. The belief that one may use a limited amount of an abused substance
indicates denial. Substituting one abused substance for another predisposes the client to
cross-addiction.
30. B. underestimate the amount consumed.
Rationale: Most people who abuse substances underestimate their consumption in an
attempt to conform to social norms or protect themselves. Few accurately describe or
overestimate consumption; some may deny it. Therefore, on admission, quantitative and
qualitative toxicology screens are done to validate information obtained from the client.
31. C. Parotid gland tenderness
Rationale: Frequent vomiting causes tenderness and swelling of the parotid glands. The
reduced metabolism that occurs with severe weight loss produces bradycardia and cold
extremities. Soft, downlike hair (called lanugo) may cover the extremities, shoulders, and
face of an anorexic client.
32. D. perceptual disorders.
Rationale: Perceptual disorders, especially frightening visual hallucinations, are very
common with alcohol withdrawal. Coma isn’t an immediate consequence. Manipulative
behaviors are part of the alcoholic client’s personality but aren’t signs of alcohol withdrawal.
Suppression is a conscious effort to conceal unacceptable thoughts, feelings, impulses, or
acts and serves as a coping mechanism for most alcoholics.
33.D. Excessive and ritualized exercise
Rationale: A client with an eating disorder will normally exercise to excess in an effort to
burn as many calories as possible. The client will usually wear loose-fitting clothing to hide
what she considers to be a fat body. Skin and nails become dry and brittle and blood
pressure and body temperature drop from excessive weight loss.
34. D. Opioid withdrawal
Rationale: The symptoms listed are specific to opioid withdrawal. Alcohol withdrawal would
show elevated vital signs. There is no real withdrawal from cannibis. Symptoms of cocaine
withdrawal include depression, anxiety, and agitation.
35. B. Establish a trusting relationship with the client.
Rationale: A client with an eating disorder may be secretive and unwilling to admit that a
problem exists. Therefore, the nurse first must establish a trusting relationship to elicit the
client’s feelings and thoughts. The anorexic client may spend long hours discussing nutrition
or handling and preparing food in an effort to stall or avoid eating food; the nurse shouldn’t
reinforce her preoccupation with food, as in option A. Although cultural stereotypes may
play a prominent
role in anorexia nervosa, discussing these factors isn’t the first action the nurse should take.
Exploring the reasons why the client doesn’t eat would increase her emotional investment in
food and eating.
36. A. tension and irritability.
Rationale: An amphetamine is a nervous system stimulant that is subject to abuse because
of its ability to produce wakefulness and euphoria. An overdose increases tension and
irritability. Options B and C are incorrect because amphetamines stimulate norepinephrine,
which increases the heart rate and blood flow. Diarrhea is a common adverse effect, so
option D is incorrect.
37. C. alprazolam (Xanax) and phenobarbital (Luminal)
Rationale: Both benzodiazepines, such as alprazolam, and barbiturates, such as
phenobarbital, are addictive, controlled substances. All the other drugs listed aren’t
addictive substances.
38. A. Adolescents, men over age 45, and persons who have made previous suicide
attempts
Rationale: Studies of those who commit suicide reveal the following high-risk groups:
adolescents; men over age 45; persons who have made previous suicide attempts;
divorced, widowed, and separated persons; professionals, such as physicians, dentists, and
attorneys; students; unemployed persons; persons who are depressed, delusional, or
hallucinating; alcohol or substance abusers; and persons who live in urban areas. Although
more women attempt suicide than
men, they typically choose less lethal means and therefore are less likely to succeed in their
attempts.
39. B. palilalia.
Rationale: Palilalia is defined as the repetition of sounds and words. Echolalia is the act of
repeating the words of others. Apraxia is the inability to carry out motor activities, and
aphonia is the inability to speak
40. A. unpredictable behavior and intense interpersonal relationships.
Rationale: A client with borderline personality disorder displays a pervasive pattern of
unpredictable behavior, mood, and self-image. Interpersonal relationships may be intense
and unstable and behavior may be inappropriate and impulsive. Although the client’s
impaired ability to form relationships may affect parenting skills, inability to function as a
responsible parent is more typical of antisocial personality disorder. Somatic symptoms
characterize avoidant personality disorder. Coldness, detachment, and lack of tender
feelings typify schizoid and schizotypal personality disorders.
41. A. Extreme social impairment
Rationale: Disorganized type schizophrenia (formerly called hebephrenia) is characterized
by extreme social impairment, marked inappropriate affect, silliness, grimacing, posturing,
and fragmented delusions and hallucinations. A client with a paranoid disorder typically
exhibits suspicious delusions, such as a belief that evil forces are after him. Waxy flexibility,
a condition in which the client’s limbs remain fixed in uncomfortable positions for long
periods, characterizes
catatonic schizophrenia. Elevated affect is associated withschizoaffective disorder.
42. C. Call the physician to clarify the order because the dosage is too high.
Rationale: The dosage is too high (normal dosage ranges from 5 to 10 mg daily). Options A
and B may lead to an overdose. Option D is incorrect because haloperidol helps with
symptoms of hallucinations.
43. B. administer as needed dose of benztropine (Cogentin) I.M. as ordered.
Rationale: The client is most likely suffering from muscle rigidity due to haloperidol. I.M.
benztropine should be administered to prevent asphyxia or aspiration. Lorazepam treats
anxiety, not extrapyramidal effects. Another dose of haloperidol would increase the severity
of the reaction.
44. B. explore the content of the hallucinations.
Rationale: Exploring the content of the hallucinations will help the nurse understand the
client’s perspective on the situation. The client shouldn’t be touched, such as in taking vital
signs, without telling him exactly what is going to happen. Debating with the client about his
emotions isn’t therapeutic. When the client is calm, engage him in reality-based activities.
45. C. amantadine (Symmetrel)
Rationale: Amantadine is an anticholinergic drug used to relieve drug-induced
extrapyramidal adverse effects, such as muscle weakness, involuntary muscle movement,
pseudoparkinsonism, and tardive dyskinesia. Other anticholinergic agents used to control
extrapyramidal reactions include benztropine mesylate (Cogentin), trihexyphenidyl (Artane),
biperiden (Akineton), and diphenhydramine (Benadryl). Perphenazine is an antipsychotic
agent; doxepin, an antidepressant; and chlorazepate, an antianxiety agent. Because these
medications have no anticholinergic or neurotransmitter effects, they don’t alleviate
extrapyramidal reactions.
46. B. practice saying “Go away” or “Stop” when they hear voices.
Rationale: Researchers have found that some clients can learn to control bothersome
hallucinations by telling the voices to go away or stop. Taking an as needed dose of
psychotropic medication whenever the voices arise may lead to overmedication and put the
client at risk for adverse effects. Because the voices aren’t likely to go away permanently,
the client must learn to deal with the hallucinations without relying on drugs. Although
distraction is helpful, singing loudly may upset other clients and would be socially
unacceptable after the client is discharged. Hallucinations are most bothersome in a quiet
environment when the client is alone, so sending the client to his room would increase,
rather than decrease, the hallucinations.
47. B. haloperidol (Haldol)
Rationale: Haloperidol is a phenothiazine and is capable of causing dystonic reactions.
Diazepam and clonazepam are benzodiazepines, and amitriptyline is a tricyclic
antidepressant. Benzodiazepines don’t cause dystonic reactions; however, they can cause
drowsiness, lethargy, and hypotension. Tricyclic antidepressants rarely cause severe
dystonic reactions; however, they can cause a decreased level of consciousness,
tachycardia, dry mouth, and dilated pupils.
48. B. “I’m a nurse, and you’re a client in the hospital. I’m not going to harm you.”
Rationale: The nurse should directly orient a delusional client to reality, especially to place
and person. Options A and C may encourage further delusions by denying poisoning and
offering information related to the delusion. Validating the client’s feelings, as in option D,
occurs during a later stage in the therapeutic process.
49. B. “I find it hard to believe that a foreign government or anyone else is trying to hurt you.
You must feel frightened by this.”
Rationale: Responses should focus on reality while acknowledging the client’s feelings.
Arguing with the client or denying his belief isn’t therapeutic. Arguing can also inhibit
development of a trusting relationship. Continuing to talk about delusions may aggravate
the psychosis. Asking the client if a foreign government is trying to kill him may increase his
anxiety level and can reinforce his delusions.
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