Exam 1 NCLEX Questions

A client who is recovering from benzodiazepine dependence says, "I've lost so many people. First, my brother dies of cancer; then my husband leaves me for a 20-year-old. I wish I had 1 of those pills right now." Which statement by the nurse would be therapeutic? 1. "Can you tell me what you think the pills can do for you?" 2. "It sounds as if you feel that all of this has just happened to you." 3. "It must have been a terrible loss for you when your brother died." 4. "How did your husband's interest in a younger woman make you feel?"

1. "Can you tell me what you think the pills can do for you?"

The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response? 1. "I cannot discuss any client situation with you." 2. "If you want to know about Carol, you need to ask her yourself." 3. "Only because you're worried about a friend, I'll tell you that she is improving." 4. "Being her friend, you know she is having a difficult time and deserves her privacy."

1. "I cannot discuss any client situation with you."

The nurse is caring for a client with a diagnosis of agoraphobia. Which statement made by the client would support this diagnosis? 1. "I'd be sure to have a panic attack if I left my house." 2. "I couldn't touch a public doorknob unless I wore gloves." 3. "Just the thought of getting into an elevator causes me to panic." 4. "Speaking to more than 1 or 2 people would be impossible for me."

1. "I'd be sure to have a panic attack if I left my house."

A client diagnosed with depression says to the nurse, "Things would be so much better for everyone if I just weren't around." Which response should the nurse make at this time to assess the client's state of mind? 1. "You sound very unhappy. Are you thinking of harming yourself?" 2. "Have you talked to anyone specifically about what is bothering you?" 3. "Those feelings will go away when your medication really takes effect." 4. "I know what you mean; everyone gets that way when they are depressed."

1. "You sound very unhappy. Are you thinking of harming yourself?"

A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my primary health care provider's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation? 1. An expected coping mechanism 2. An ineffective defense mechanism 3. A need to notify the hospital lawyer 4. An expression of guilt on the part of the client

1. An expected coping mechanism

A client with a history of panic disorder comes to the emergency department and states to the nurse, "Please help me. I think I'm having a heart attack." What is the priority nursing action? 1. Assess the client's vital signs. 2. Identify the client's activity during the pain. 3. Assess for signs related to a panic disorder. 4. Determine the client's use of relaxation techniques.

1. Assess the client's vital signs.

A client admitted voluntarily for treatment of an anxiety problem demands to be released from the hospital. Which action should the nurse take initially? 1. Contact the client's primary health care provider (PHCP). 2. Call the client's family to arrange for transportation. 3. Attempt to persuade the client to stay "for only a few more days." 4. Tell the client that leaving would likely result in an involuntary commitment.

1. Contact the client's primary health care provider (PHCP).

A client diagnosed with an anxiety disorder is prescribed buspirone orally. The client tells the nurse that it is difficult to swallow the tablets. Which is the best instruction to provide the client? 1. Crush the tablets before taking them. 2. Mix the tablet uncrushed in apple sauce. 3. Purchase the liquid preparation with the next refill. 4. Call the primary health care provider for a change in medication.

1. Crush the tablets before taking them.

When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client? 1. Monitor closely for harm to self or others. 2. Assist in completing an application for admission. 3. Supply the client with written information about her or his mental health problem. 4. Provide an opportunity for the family to discuss why they felt the admission was needed.

1. Monitor closely for harm to self or others.

A client comes into the emergency department in a severe state of anxiety after a car crash. Which is the best nursing intervention at this time? 1. Remain with the client. 2. Put the client in a quiet room. 3. Teach the client deep breathing. 4. Encourage the client to talk about his or her feelings and concerns.

1. Remain with the client.

A woman is seen in the emergency department in a severe state of anxiety following assault and battery. Which nursing action should the nurse place highest priority on at this time? 1. Remaining with the client 2. Teaching the client deep-breathing techniques 3. Encouraging the client to talk about her feelings 4. Putting the client in a quiet room, away from other clients

1. Remaining with the client

The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply. 1. Restating 2. Active listening 3.Asking the client "Why?" 4. Maintaining neutral responses 5. Providing acknowledgment and feedback 6. Giving advice and approval or disapproval

1. Restating 2. Active listening 4. Maintaining neutral responses 5. Providing acknowledgment and feedback

A supervisor reprimands the charge nurse for not adhering to the unit budget. What behavior by the charge nurse is an example of displacement? 1. The charge nurse blames staff for wasting supplies. 2. The charge nurse claims that administration wasn't critical. 3. The charge nurse refuses to believe the supervisor's criticisms. 4. The charge nurse smiles and nods in agreement when reprimanded.

1. The charge nurse blames staff for wasting supplies.

A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that the client is coping ineffectively with the situation. Which are the most realistic goals for this client? Select all that apply. 1. The client will develop adaptive coping patterns. 2. The client will identify a realistic perception of stressors. 3. The client will cease to have negative feelings about the event. 4. The client will express and share feelings regarding the present crisis. 5. The client will identify effective coping patterns that have worked in the past.

1. The client will develop adaptive coping patterns. 2. The client will identify a realistic perception of stressors. 4. The client will express and share feelings regarding the present crisis. 5. The client will identify effective coping patterns that have worked in the past.

Which short-term initial goals would be realistic for a client who was recently sexually abused? Select all that apply. 1. The client will keep scheduled appointments. 2. The client's physical wounds will begin to heal properly. 3. The client will verbalize feelings about the abusive event. 4. The client will resolve feelings of anxiety related to the event. 5. The client will participate in the various aspects of the treatment plan.

1. The client will keep scheduled appointments. 2. The client's physical wounds will begin to heal properly. 3. The client will verbalize feelings about the abusive event. 5. The client will participate in the various aspects of the treatment plan.

The nurse recognizes that which interventions are likely to facilitate effective communication between a dying client and family? Select all that apply. 1. The nurse encourages the client and family to identify and discuss feelings openly. 2. The nurse assists the client and family in carrying out spiritually meaningful practices. 3. The nurse removes autonomy from the client to alleviate any unnecessary stress for the client. 4. The nurse makes decisions for the client and family to relieve them of unnecessary demands. 5. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.

1. The nurse encourages the client and family to identify and discuss feelings openly. 2. The nurse assists the client and family in carrying out spiritually meaningful practices. 5. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.

The nurse is developing a plan of care for a client who believes the unit's food is being poisoned. Which strategy should the nurse plan to implement that will encourage the client to discuss feelings? 1. Use open-ended questions and silence. 2. Encourage the client's family to bring in food. 3. Focus on the fact that the client's beliefs are untrue. 4. Instruct the client about the need for adequate nutrition.

1. Use open-ended questions and silence.

A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat? 1. Using open-ended questions and silence 2. Sharing personal preference regarding food choices 3. Documenting reasons why the client does not want to eat 4. Offering opinions about the necessity of adequate nutrition

1. Using open-ended questions and silence

During a nursing interview, a client says, "My daughter was murdered. I can't help wondering if her husband killed her, but he's been eliminated as a suspect." Which statement is a therapeutic nursing response? 1. "I agree. What do you want to bet he did it?" 2. "Have you shared your concerns with the police?" 3. "I don't think that you should blame yourself one little bit." 4. "It feels terrible to lose a daughter. Your suspicions are only natural."

2. "Have you shared your concerns with the police?"

A client whose wife recently died of cancer says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house." What is the therapeutic nursing response? 1. "It will take time to adjust to your terrible loss." 2. "It must be hard to accept that she has passed away." 3. "Try to focus on the fact that you and your wife loved one another for years." 4. "Focus on the fact that her suffering is over and that she had a good life with you."

2. "It must be hard to accept that she has passed away."

Which statement, made by a client who has recently experienced an emotional crisis, is most likely to assure the nurse that the client has returned to her precrisis level of functioning? 1. "My husband tells me that I'm back to my old cheerful self." 2. "My boss tells me that I'm being considered for a promotion and a raise." 3. "When I find myself getting stressed, I immediately use the relaxation techniques I've learned." 4. "I have a different perspective on life now. I'm more confident of my ability to handle any problem."

2. "My boss tells me that I'm being considered for a promotion and a raise."

The client says to the nurse, "I wish you would just be my friend." Which is the appropriate response by the nurse? 1. "I am your friend." 2. "Our relationship is a therapeutic and helping one." 3. "I can't be your friend. I'm the nurse, and you're the client." 4. "You have plenty of friends. You don't need me to be your friend, too."

2. "Our relationship is a therapeutic and helping one."

The nurse tells the client that a music therapy session has been scheduled as part of the treatment plan. The client tells the nurse, "I can't sing," and refuses to attend. Which nursing response is most likely to meet the client's needs? 1. "Why don't you want to attend? What is the real reason?" 2. "You don't have to sing. Just listen and enjoy the music." 3. "You must go. You have no choice if you want to get better." 4. "Your primary health care provider has prescribed this therapy for you."

2. "You don't have to sing. Just listen and enjoy the music."

A client who has recently lost her spouse says, "No one cares about me anymore. All the people I loved are dead." Which response demonstrates an understanding of therapeutic communication when dealing with a grieving client? 1. "I certainly care about you." 2. "You must be feeling all alone at this point." 3. "I don't believe that and neither should you." 4. "It isn't unusual to feel alone when you are grieving."

2. "You must be feeling all alone at this point."

A client whose spouse of 42 years recently died shares with the nurse, "My sister came over yesterday and started talking about how I need to move on with my life. I feel badly, but I got mad and told her to mind her own business." Which response by the nurse would be therapeutic? 1. "I know just how you feel; I lost my husband last summer." 2. "You need to grieve, and expressing anger can be part of grieving." 3. "Although she means to help, you need to do what feels right for you." 4. "Focusing on the many good years you both enjoyed together will help."

2. "You need to grieve, and expressing anger can be part of grieving."

A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic? 1. "Do you think that having asthma will kill you?" 2. "You seem very distressed over learning you have asthma." 3. "Asthma is a treatable condition when medications are taken properly, so let's practice with your inhalant." 4. "It will be difficult to work with you if you can't view this as a challenge rather than a nail in your coffin."

2. "You seem very distressed over learning you have asthma."

A client is experiencing anxiety about being hospitalized. What therapeutic communication techniques should the nurse use while interacting with the client? Select all that apply. 1. Turn the client's favorite TV show on. 2. Ask the client to identify how he or she feels. 3. Help the client identify the cause of the anxiety. 4. Lean against the wall casually with arms crossed.

2. Ask the client to identify how he or she feels. 3. Help the client identify the cause of the anxiety.

A client admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially? 1. Call the client's family to arrange for transportation. 2. Contact the client's primary health care provider (PHCP). 3. Attempt to persuade the client to stay "for only a few more days." 4. Tell the client that leaving would likely result in an involuntary commitment.

2. Contact the client's primary health care provider (PHCP).

Buspirone hydrochloride is prescribed for a client with an anxiety disorder. The nurse plans to include which teaching point when reviewing this medication with the client? 1. The medication is addicting. 2. Dizziness and nervousness may occur. 3. Tolerance can develop with this medication. 4. The medication can produce a sedating effect.

2. Dizziness and nervousness may occur.

A home care nurse suspects that a client's spouse is experiencing caregiver strain. Which nursing action will assist in supporting the nurse's suspicion? 1. Obtaining feedback from the client about the coping abilities of the caregiver 2. Gathering subjective and objective assessment from the caregiver and the client 3. Making a referral to the home care agency social worker to complete the assessment 4. Interviewing family members regarding their concerns for the health and well-being of the caregiver

2. Gathering subjective and objective assessment from the caregiver and the client

When planning the discharge of a client with chronic anxiety, which is the most appropriate maintenance goal? 1. Suppressing feelings of anxiety 2. Identifying anxiety-producing situations 3. Continuing contact with a crisis counselor 4. Eliminating all anxiety from daily situations

2. Identifying anxiety-producing situations

The nurse is preparing to create a care plan for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. The nurse should plan to include which component as a priority in the plan of care? 1. The medical diagnosis of the client 2. Individualized goals and objectives 3. Attendance at group therapy sessions 4. Self-care measures to improve hygiene

2. Individualized goals and objectives

The psychiatric home care nurse visits a client diagnosed with a phobia that triggers panic attacks. When teaching the client to use paradoxical intention, which intervention will the nurse demonstrate? 1. Having the client confront the anxiety-provoking stimulus and providing support during the episode 2. Instructing the client to do what the client fears and, if possible, to exaggerate the outcome of this exposure to the point of humor 3. Presenting the anxiety-provoking stimulus without any preparation of the client and having him or her remain exposed until the anxiety subsides 4. Using progressive relaxation toward the client's individual anxiety hierarchy, increasing the level of difficulty, and pairing relaxation with the gradual exposure to reduce his or her anxiety

2. Instructing the client to do what the client fears and, if possible, to exaggerate the outcome of this exposure to the point of humor

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicates effective coping? Select all that apply. 1. Neglecting personal grooming 2. Looking at old snapshots of family 3. Participating in a senior citizens program 4. Visiting the spouse's grave once a month 5. Decorating a wall with the spouse's pictures and awards received

2. Looking at old snapshots of family 3. Participating in a senior citizens program 4. Visiting the spouse's grave once a month 5. Decorating a wall with the spouse's pictures and awards received

Clients with which diagnoses are commonly prescribed interventions to manage anxiety? Select all that apply. 1. Dementia 2. Panic disorder 3. Multiple personality disorder 4. Post-traumatic stress disorder 5. Obsessive-compulsive disorder

2. Panic disorder 4. Post-traumatic stress disorder 5. Obsessive-compulsive disorder

An anxious client is experiencing respiratory alkalosis from hyperventilation caused by anxiety. The nurse should take which action to help the client experiencing this acid-base disorder? 1. Put the client in a supine position. 2. Provide emotional support and reassurance. 3. Withhold all sedative or antianxiety medications. 4. Tell the client to breathe very deeply but more slowly.

2. Provide emotional support and reassurance.

A client who has been taking buspirone for 1 month returns to the clinic for a follow-up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred? 1. Paranoid thought process 2. Rapid heartbeat or anxiety 3. Alcohol withdrawal symptoms 4. Thought broadcasting or delusions

2. Rapid heartbeat or anxiety

The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, distracted, tremulous, and bewildered at times. How should the nurse interpret these behaviors? 1. Signs of depression 2. Reactions to a devastating event 3. Evidence that the client is a high suicide risk 4. Indicative of the need for hospital admission

2. Reactions to a devastating event

A client who has a history of being sexually assaulted is found sucking her thumb while rocking in her bed and does not respond to verbal communication. The nurse should recognize that this behavior demonstrates which coping mechanism? 1. Fantasy 2. Regression 3. Displacement 4. Compensation

2. Regression

During an admission assessment, the nurse notes that the client's diagnosis is documented as obsessive-compulsive disorder. The nurse plans care knowing that the client is most likely to experience which type of compulsive behavior? 1. An unreasonable fear of something 2. Repetitive actions to manage anxiety 3. Misinterpretation of common events 4. Recurring thoughts that are intrusive

2. Repetitive actions to manage anxiety

The nurse gathers data from the client who was prescribed buspirone hydrochloride 1 month ago. The nurse interprets that the medication is effective when the client reports an absence of which event? 1. Delusions 2. Severe anxiety 3. Alcohol cravings 4. Paranoid thoughts

2. Severe anxiety

What is an appropriate short-term outcome for a client grieving the recent loss of a spouse? 1. The client reports 3 additional coping strategies. 2. The client verbalizes stages of grief and plans to attend a community grief group. 3. The client verbalizes connections between significant losses and low self-esteem. 4. The client verbalizes decreased desire for self-harm and discusses 2 alternatives to suicide.

2. The client verbalizes stages of grief and plans to attend a community grief group.

A client with a history of anxiety appears to be in the second phase of crisis response. The nurse prepares for which client behavior? 1. The client will show the initial signs that coping methods are failing. 2. The client will employ new coping methods that will resolve the problem. 3. The client will experience severe anxiety as a result of failed coping methods. 4. The client will begin to implement coping methods that have been successful in the past.

2. The client will employ new coping methods that will resolve the problem.

A client arrives in the emergency department in a crisis state demonstrating signs of profound anxiety. What should the initial nursing assessment focus on? 1. The object of the crisis 2. The client's physical condition 3. The client's coping mechanisms 4. The presence of support systems

2. The client's physical condition

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event? 1. Witnessing a murder 2. The death of a loved one 3. A fire that destroyed the client's home 4. A recent rape episode experienced by the client

2. The death of a loved one

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. "If it's any help, everyone is nervous before surgery." 2. "I will be happy to explain the entire surgical procedure to you." 3. "Can you share with me what you've been told about your surgery?" 4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

3. "Can you share with me what you've been told about your surgery?"

The husband of an alcohol-dependent wife says, "If anyone had said I'd be henpecked, I'd have called them a liar, but now I realize that I'm codependent." Which statement by the nurse would be therapeutic? 1. "Did you know that more people identify with just what you are saying?" 2. "Which of the features that describe codependence caused you to recognize that?" 3. "Can you tell me more about that? You see yourself as being codependent with your wife?" 4. "Have you discussed your feelings with your wife? What does your wife think about what you've said?"

3. "Can you tell me more about that? You see yourself as being codependent with your wife?"

A battered wife says, "My husband is a bully and a womanizer and certainly doesn't provide for his family, but he's never beat me up, so I don't think I can say he's abusive." Which response by the nurse is therapeutic? 1. "Don't be so gullible. Your husband is an abuser." 2. "How is it that he can maneuver you like he has?" 3. "Do you believe that there are other forms of abuse besides the physical kind?" 4. "Most emotionally battered spouses begin to heal once they start to identify the abusive behaviors."

3. "Do you believe that there are other forms of abuse besides the physical kind?"

A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern? 1. "I don't believe this is true." 2. "The guards are not out to kill you." 3. "Do you feel afraid that people are trying to hurt you?" 4. "What makes you think the guards were sent to hurt you?"

3. "Do you feel afraid that people are trying to hurt you?"

A hospitalized client experiencing delusions reports to the nurse, "I know that the doctor is talking to the top man in the mob to get rid of me." Which response should the nurse make to the client? 1. "I don't believe this is true." 2. "The doctor is not talking to the mob." 3. "Do you feel afraid that people are trying to hurt you?" 4. "What makes you think the doctor wants to get rid of you?"

3. "Do you feel afraid that people are trying to hurt you?"

A client with terminal cancer arrives at the emergency department dead on arrival (DOA). After an autopsy is prescribed, the client's family requests that no autopsy be performed. Which response to the family is most appropriate? 1. "The decision is made by the medical examiner." 2. "An autopsy is mandatory for any client who is DOA." 3. "I will contact the medical examiner regarding your request." 4. "It is required by federal law. Tell me why you don't want the autopsy done."

3. "I will contact the medical examiner regarding your request."

Which statement by the client best reflects the development of an effective coping response style and effective processing of information for a hospitalized client participating in Alcoholics Anonymous (AA)? 1. "I know I'm ready to be discharged. I feel like I can say no and leave a group of friends if they are drinking. No problem." 2. "I'll keep all my appointments and go to all my AA groups; I'll do everything I'm supposed to. Nothing will go wrong that way." 3. "I'm looking forward to leaving here. I will miss all of you. So, I'm happy and I'm sad, I'm excited, and I'm scared. I know that I have to work hard to be strong and that not everyone will be as helpful as you people." 4. "This group has really helped a lot. I know it will be different when I go home. But I'm sure that my family and friends will all help me like the people in this group have. They'll all help me. I know they will. They won't let me go back to old ways."

3. "I'm looking forward to leaving here. I will miss all of you. So, I'm happy and I'm sad, I'm excited, and I'm scared. I know that I have to work hard to be strong and that not everyone will be as helpful as you people."

The nurse is caring for an older client whose husband died approximately 6 weeks ago. The client says, "There is no one left who cares about me. Everyone that I have loved is now gone." Which nursing response allows for continued communication about the client's state of mind? 1. "That doesn't sound like the real you talking!" 2. "I'm sure you have someone if you think hard enough." 3. "It sounds as though you are feeling all alone right now." 4."I don't believe that, and I really don't think you do either."

3. "It sounds as though you are feeling all alone right now."

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response? 1. "You need to try to be realistic. The rape did not just occur." 2. "It will take some time to get over these feelings about your rape." 3. "Tell me more about the incident that causes you to feel like the rape just occurred." 4. "What do you think that you can do to alleviate some of your fears about being raped again?"

3. "Tell me more about the incident that causes you to feel like the rape just occurred."

A client states that she was raped a few weeks ago but still feels "as if it just happened to me." Which response should the nurse make to the client? 1. "It is very, very hard to get over these types of feelings after being raped." 2. "What do you think you should do to reduce the likelihood that you will be raped again?" 3. "Tell me more about what happened and what causes you to feel like the rape just occurred." 4. "It's hard, but try to keep a sense of perspective. After all, it's been a while since the rape occurred.

3. "Tell me more about what happened and what causes you to feel like the rape just occurred."

The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which response by the nurse addresses the spouse's concerns? 1. "This is not a good time to make that decision." 2. "What would your spouse think about your decision?" 3. "What aspects of this situation are the most difficult for you?" 4. "You seem to have a good grip on this situation. You probably should get out."

3. "What aspects of this situation are the most difficult for you?"

The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question? 1. "With whom do you live?" 2. "Who is available to help you?" 3. "What leads you to seek help now?" 4. "What do you usually do to feel better?"

3. "What leads you to seek help now?"

A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic? 1. "Have you shared your feelings with your family?" 2. "I think we should talk more about your anger with your family." 3. "You're feeling angry that your family continues to hope for you to be cured?" 4. "You are probably very depressed, which is understandable with such a diagnosis."

3. "You're feeling angry that your family continues to hope for you to be cured?"

The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication? 1. "I see." 2. "Really?" 3. "You're having difficulty sleeping?" 4. "Sometimes I have trouble sleeping too."

3. "You're having difficulty sleeping?"

Which behavior would the nurse anticipate a client diagnosed with nyctophobia to demonstrate? 1. Declines an invitation to walk around the park 2. Never takes an elevator but rather climbs the stairs 3. Always turns on the overhead light before entering a darkened room 4. Refuses to engage in conversations when in the presence of more than 2 to 3 people

3. Always turns on the overhead light before entering a darkened room

The nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. The nurse should assign priority to which assessment finding? 1. Tearful, self-isolated 2. Affect bland, withdrawn 3. Fist clenched, pounding table, fearful 4. Temperature 98.4º F (36.8º C); respirations 18 breaths/min

3. Fist clenched, pounding table, fearful

The nurse suspects that a client prescribed clomipramine hydrochloride has been noncompliant with taking the medication as prescribed. Which client behavior would support the nurse's suspicion? 1. Tired, fatigued appearance 2. Complaints of hunger and fatigue 3. Frequently checking for the car key 4. Slight dizziness when standing up quickly

3. Frequently checking for the car key

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." How should the nurse plan to respond to the client's statement? 1. Reassure the client that things will get better. 2. Tell the client that this is not true and that we all have a purpose in life. 3. Identify recent behaviors or accomplishments that demonstrate the client's skills. 4. Remain with the client and sit in silence; this will encourage the client to verbalize feelings.

3. Identify recent behaviors or accomplishments that demonstrate the client's skills.

Soon after an assault, a client is assessed in the emergency department with behavior that is associated with severe anxiety. Which client behaviors support this level of anxiety? 1. Believes the attacker is in the emergency department 2. Detached, requiring gentle probing to respond to questions 3. Is pacing while describing the situation using a rapid speech pattern 4. Talks about being "panic stricken" that something else "bad" will happen

3. Is pacing while describing the situation using a rapid speech pattern

The nurse is creating a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client? 1. Anxiety 2. Unrealistic outlook 3. Lack of ability to cope effectively 4. Disturbances in thoughts and ideas

3. Lack of ability to cope effectively

A client diagnosed with anxiety is starting therapy with lorazepam. Which factor in the client's history should prompt the nurse to consult with the primary health care provider before administering the medication? 1. Hypothyroidism 2. Diabetes mellitus 3. Narrow-angle glaucoma 4. Coronary artery disease

3. Narrow-angle glaucoma

A homeless shelter has sustained severe damage as a result of a fire, and most of the structure and people's belongings were destroyed. Ten of the individuals who are being displaced have a history of chronic mental illness. The mental health team coordinating support initially should focus their efforts on which action? 1. Assessing the clients' need for supportive therapy 2. Evaluating the clients for signs of stress overload 3. Providing the clients with shelter, clothing, and food 4. Planning means for the clients to receive their medications

3. Providing the clients with shelter, clothing, and food

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? 1. Begin to teach relaxation techniques. 2. Encourage the client to discuss the assault. 3. Remain with the client until the anxiety decreases. 4. Place the client in a quiet room alone to decrease stimulation.

3. Remain with the client until the anxiety decreases.

Immediately after an assault, the client is extremely agitated, trembling, and hyperventilating. What is the appropriate initial nursing action? 1. Begin to teach relaxation techniques. 2. Encourage the client to discuss the assault. 3. Remain with the client until the anxiety decreases. 4. Place the client in a quiet room alone to decrease stimulation.

3. Remain with the client until the anxiety decreases.

The mother of a teenage client states that her daughter, diagnosed with an anxiety disorder, "eats nothing but junk food, has never liked going to school, and hangs out with the wrong crowd." What discharge instruction will be most effective in helping the mother to manage her daughter's condition? 1. Restrict the daughter's socializing time with her friends. 2. Keep her daughter out of school until her anxiety is well managed. 3. Restrict the amount of chocolate and caffeine products in the home. 4. Consider taking time off from work to help her daughter learn to manage the anxiety.

3. Restrict the amount of chocolate and caffeine products in the home.

Community mental health teams recognize that in the immediate postdisaster period, the most effective means of identifying individuals experiencing difficulty coping psychologically with the disaster is to take which action? 1. Establish a centrally located mental health disaster center. 2. Ask for referrals from local health care providers and clergy. 3. Station mental health professionals at established assistance centers. 4. Distribute fliers identifying the availability of psychological counseling.

3. Station mental health professionals at established assistance centers.

The client who is actively hallucinating is fearful that the voices will direct him to kill himself. Which therapeutic statement should the nurse make at this time? 1. "I can hear the voices too, but ignore them and just go to bed now." 2. "I know whose voices you are hearing, and I told them not to hurt you." 3. "I know you believe they are going to cause you harm, but it's not true." 4. "I don't hear them, but it must be frightening to hear voices that others can't hear."

4. "I don't hear them, but it must be frightening to hear voices that others can't hear."

The nurse is working with a client who is demonstrating delusional thinking. The client says to the nurse, "The leaders of a religious cult are being sent to assassinate me." Which is the best response by the nurse? 1. "I don't believe that what you are telling me is true." 2. "There are no religious cults in this area that are going to kill you." 3. "What makes you think that cult members are being sent to hurt you?" 4. "I don't know about a religious cult. Are you afraid that people are trying to hurt you?"

4. "I don't know about a religious cult. Are you afraid that people are trying to hurt you?"

The home health nurse visits an agoraphobic client who experiences panic attacks. Which statement by the client would indicate a therapeutic response to behavioral and pharmacological treatment? 1. "I took an extra pill for anxiety and got through the funeral fairly well." 2. "I worry that if I don't take my anxiety pill on time, I'll have one of those attacks." 3. "Taking my anxiety pills before I leave has helped me to cross the bridge and go to work every morning." 4. "I went to the movies with my family and stayed through the whole film by sitting in a seat along the aisle."

4. "I went to the movies with my family and stayed through the whole film by sitting in a seat along the aisle."

Laboratory work is prescribed for a client who has been experiencing delusions. When the nurse approaches the client to obtain a specimen of blood, the client begins to shout, "You're all vampires. Let me out of here!" Which nursing response addresses the client's anxiety? 1. "What makes you think that I am a vampire?" 2. "I'll leave and come back later for the specimen." 3. "Do you remember discussing the lab work earlier?" 4. "It must be frightening to think that others want to hurt you."

4. "It must be frightening to think that others want to hurt you."

A client admitted to the inpatient unit is being considered for electroconvulsive therapy (ECT). While the client is calm, the daughter anxiously tells the nurse, "My mother's brain will be shocked with electricity. How can the doctor even think about doing this to her?" Which response by the nurse will best address the daughter's concerns? 1. "I think you need to speak directly to the psychiatrist." 2. "Maybe you'll feel better if you see the ECT room and speak to the staff." 3. "Your mother has decided to have this treatment. You should support her." 4. "It sounds as though you are very concerned. Let's discuss the procedure."

4. "It sounds as though you are very concerned. Let's discuss the procedure."

An older resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." Which is the appropriate response by the nurse? 1. "I need you to sign a form before leaving." 2. "You will get sick if you go out in the rain." 3. "How old are you? Your father must no longer be living." 4. "Let's have a cup of coffee, and you can tell me about your father."

4. "Let's have a cup of coffee, and you can tell me about your father."

The nurse determines that the client understands the basis of the diagnosis of obsessive-compulsive disorder after making which statement? 1. "Inner voices tell me to perform my rituals." 2. "My behavior is a conscious attempt to punish myself." 3. "I'm demonstrating control when I engage in my rituals." 4. "My rituals are ways for me to control unpleasant thoughts or feelings."

4. "My rituals are ways for me to control unpleasant thoughts or feelings."

The nurse should interpret which comment by a client diagnosed with battered wife syndrome as being consistent with the presence of low self-esteem? 1. "I'm lucky to be married to a man who really loves me the way that he does." 2. "I stay because there's enough in it for me. I don't have to work full-time this way." 3. "I told him that this is his last chance. I'm sure he will do better if he believes I'll leave." 4. "Things would be fine at home if I just could do better. He has a lot of pressures on him at work."

4. "Things would be fine at home if I just could do better. He has a lot of pressures on him at work."

A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? 1. "This form of therapy can be applied to new situations." 2. "An advantage of this technique is that change is likely to last." 3. "Talking to oneself is a basic component of this form of therapy." 4. "This form of therapy provides a negative reinforcement when the stimulus is produced."

4. "This form of therapy provides a negative reinforcement when the stimulus is produced."

The client asks the nurse, "Could you ask my psychiatrist to let me have a pass for the weekend?" Which response is appropriate and assists the client in achieving the goal of optimal personal functioning? 1. "You have to ask your psychiatrist for the pass; I can't get it for you." 2. "When your psychiatrist comes in, I will ask for a pass for the weekend." 3. "You are not ready for such a pass, and I'm sure that your psychiatrist will say no." 4. "When your psychiatrist arrives on the unit, I will let them know that you have a question."

4. "When your psychiatrist arrives on the unit, I will let them know that you have a question."

A client states to the nurse, "My life has been such a failure. Nothing I do turns out right." Which response by the nurse will best address the client's low sense of self-esteem? 1. "You can't really believe that about yourself." 2. "I know just how you feel. I have those days myself once in a while." 3. "I disagree with you; we all have some value and accomplishments in life." 4. "You seem very discouraged. Let's identify something that you are proud of doing."

4. "You seem very discouraged. Let's identify something that you are proud of doing."

A client with a diagnosis of depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response by the nurse demonstrates therapeutic communication? 1. "You have everything to live for." 2. "Why do you see yourself as a failure?" 3. "Feeling like this is all part of being depressed." 4. "You've been feeling like a failure for a while?"

4. "You've been feeling like a failure for a while?"

The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor? 1. A crisis state indicates that the client has a mental illness. 2. A crisis state indicates that the client has an emotional illness. 3. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis. 4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior? 1. Fearfulness regarding treatment measures 2. Anger and aggressiveness directed toward others 3. An understanding of the pathology and symptoms of the diagnosis 4. A willingness to participate in the planning of the care and treatment plan

4. A willingness to participate in the planning of the care and treatment plan

Which is the best therapeutic approach for the nurse to use in crisis counseling? 1. Reassuring 2. Passive listening 3. Exploration of early life experiences 4. Active, with focus on the current situation

4. Active, with focus on the current situation

When a client is consistently 15 to 20 minutes late for weekly therapy sessions, the nurse attempts to best manage this behavior by implementing which intervention? 1. Ignoring the client's behavior 2. Telling the client that the sessions will be terminated 3. Arriving 15 minutes later than the scheduled time also 4. Asking the client if she or he is dealing with some new stressor

4. Asking the client if she or he is dealing with some new stressor

Which is the primary goal of crisis intervention therapy? 1. Introduce new, effective coping methods to the client. 2. Assess the client to identify the causative stressors. 3. Establish a sustainable therapeutic nurse-client relationship. 4. Assist the client in returning to the level of precrisis functioning.

4. Assist the client in returning to the level of precrisis functioning.

The nurse is developing a plan of care for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. What is the nurse's priority in the plan of care? 1. Monitor for repetitive behavior. 2. Demand active participation in care. 3. Educate the client about self-care needs. 4. Establish a trusting nurse-client relationship.

4. Establish a trusting nurse-client relationship.

A client gives the home health nurse a bottle of clomipramine. The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication? 1. Complaints of insomnia 2. Complaints of hunger and fatigue 3. A pulse rate less than 60 beats per minute 4. Frequent hand washing with hot, soapy water

4. Frequent hand washing with hot, soapy water

The nurse is working with a client who, despite making a heroic effort, was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship? 1. Exploring the client's ability to function 2. Exploring the client's potential for self-harm 3. Inquiring about the client's perception or appraisal of why the rescue was unsuccessful 4. Inquiring about and examining the client's feelings for any that may block adaptive coping

4. Inquiring about and examining the client's feelings for any that may block adaptive coping

An anxious preoperative client is at risk for developing respiratory alkalosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? 1. Headache and tachypnea 2. Hyperactivity and dyspnea 3. Muscle twitches and cyanosis 4. Lightheadedness and paresthesias

4. Lightheadedness and paresthesias

The client tells the nurse that she cannot leave home without checking numerous times that "everything electrical has been shut off." The client's statement supports which mental health diagnosis? 1. A phobia 2. Generalized anxiety disorder 3. Post-traumatic stress disorder 4. Obsessive-compulsive disorder

4. Obsessive-compulsive disorder

The nurse is planning a stress management seminar for clients in an ambulatory care setting. Which concept should the nurse plan to include in the content of the seminar? 1. Biofeedback has the advantage of using no equipment at all. 2. Guided imagery is a helpful technique but requires video equipment for its use. 3. Confrontation is a useful method for solving potentially stressful conflicts with others. 4. Progressive muscle relaxation techniques are useful for easing tension from many causes.

4. Progressive muscle relaxation techniques are useful for easing tension from many causes.

The nurse preparing to admit a client with a diagnosis of obsessive-compulsive disorder to the mental health unit should expect to note which behaviors in the client? 1. Sad and tearful 2. Suspicious and hostile 3. Frightened and delusional 4. Rigidness in thought and inflexibility

4. Rigidness in thought and inflexibility

A client's phobia is being treated with systematic desensitization. Which modality is the focus of this therapy? 1. Daily medication therapy 2. Involvement with a support group 3. Intense stress management training 4. Short exposure to the phobic object

4. Short exposure to the phobic object

Which client behavior demonstrates denial of a sexual abuse event? 1. Pacing while mumbling profanities 2. Minimizing the severity of the event 3. Being confused about the details of the event 4. Sitting quietly and calmly reading a magazine

4. Sitting quietly and calmly reading a magazine

What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? 1. Ask the client to leave the group for this session only. 2. Refer the client to another group that includes other manic clients. 3. Tell the client to stop monopolizing in a firm but compassionate manner. 4. Thank the client for the input, but inform the client that others now need a chance to contribute.

4. Thank the client for the input, but inform the client that others now need a chance to contribute.

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm (72 mmol/L), and HCO3− = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make? 1. The client has acidotic blood. 2. The client is probably overreacting. 3. The client is fluid volume overloaded. 4. The client is probably hyperventilating.

4. The client is probably hyperventilating.

The nurse in the postpartum unit is observing the mother-infant bonding process in a client. Which observation, if made by the nurse, indicates the potential for a maladaptive interaction? 1. The mother is observed talking to the newborn. 2. The mother performs cord care for the newborn. 3. The mother verbalizes discomfort with the new role of motherhood. 4.The mother requests that the nurse feed the newborn because she is feeling fatigued.

4. The mother requests that the nurse feed the newborn because she is feeling fatigued.