(N129) Practice Exam

Which client may have concerns related to sexuality when hospitalized with a chronic illness? 1. An 8-year-old 2. A 10-year-old 3. A 12-year-old 4. An 18-year-old

4 Rationale: An 18-year-old client is an adolescent, which is the stage of development where concerns about sexuality may occur when hospitalized with a chronic illness. The other clients are not developmentally characterized as adolescents; therefore, the nurse would not anticipate an 8-year-old, 10-year-old, or 12-year-old to have this concern.

The night nurse reports that a young client with paranoid schizophrenia has been awake for several nights. The day nurse reviews the client's record and finds that this client did not have an interrupted sleep pattern disorder before transfer from a private room to a four-bed room 3 days ago. What factor should the nurse identify as most likely related to the client's sleeplessness? 1.Fear of the other clients 2. Concern about family at home 3. Watching for an opportunity to escape 4. Trying to work out emotional problems

1 Rationale: Because the client has paranoid feelings that other people are out to do harm, assignment to a four-bed room may be threatening. Concern about family at home seems unlikely, because the disruption appears to have started with the transfer to a four-bed room. Watching for an opportunity to escape is possible but unlikely; planning an escape is usually not part of a schizophrenic pattern of behavior. Trying to work out emotional problems is possible but not likely; clients with schizophrenia have difficulty solving problems.

A client is diagnosed as having expressive aphasia. Which type of impairment does the nurse expect the client to exhibit? 1. Speaking or writing 2. Following specific instructions 3. Understanding speech or writing 4. Recognizing words for familiar objects

1 Rationale: Damage to the Broca area, located in the posterior frontal region of the dominant hemisphere, causes problems in the motor aspect of speech, like speaking and writing. Impairments such as following specific instructions, understanding speech or writing, and recognizing words for familiar objects are associated with receptive aphasia, not expressive aphasia; receptive aphasia is associated with disease of the Wernicke area of the brain.

During an interview of a client with a diagnosis of bipolar I disorder, manic episode, what does the nurse expect the client to demonstrate? 1. Flight of ideas 2. Ritualistic behaviors 3. Associative looseness 4. Auditory hallucinations

1 Rationale: Flight of ideas is a fragmented, pressured, nonsequential pattern of speech typically used during a manic episode. Ritualistic behaviors are repetitive, purposeful, and intentional behaviors that are carried out in a stereotyped fashion; they are found in clients with obsessive-compulsive disorders. Associative looseness is the pattern of speech found in clients with schizophrenia; usual connections between words and phrases are lost to the listener and meaningful only to the speaker. Hallucinations are false perceptions generated by internal stimuli; they are found in clients with the diagnosis of schizophrenia.

A female client with obsessive-compulsive disorder has become immobilized by her elaborate handwashing and walking rituals. Which feelings does the nurse recall are often the basis of obsessive-compulsive disorder? 1. Anxiety and guilt 2. Anger and hostility 3. Embarrassment and shame 4. Hopelessness and powerlessness

1 Rationale: Ritualistic behavior seen in this disorder is aimed at controlling feelings of anxiety and guilt by maintaining an absolute set pattern of action. Although the person with an obsessive-compulsive disorder may be angry and hostile, the feelings of anger and hostility do not precipitate the rituals. Although the person with an obsessive-compulsive disorder may be embarrassed and ashamed by the ritual or feel hopeless and powerless to the ritual, the basic feelings precipitating the rituals are usually anxiety and guilt.

The nurse identifies that a client who had extensive abdominal surgery appears depressed. Which nursing action is the most appropriate? 1. Talking with the client and encouraging exploration of feelings 2. Asking the client's primary healthcare provider to prescribe an antidepressant medication 3. Understanding that the client's depression is an expected response to surgery 4. Reassuring the client that feelings of depression will lift after returning home

1 Rationale: The nurse must first explore the client's feelings; an honest discussion with emphasis on concerns helps promote adjustment. Asking the client's healthcare provider to prescribe an antidepressant medication may be necessary if the depression continues. Postoperative depression is not an expected response to surgery. Reassuring the client that feelings of depression will lift after returning home is false reassurance because there is no guarantee that the depression will lift at home.

A client exhibits blurred and double vision and muscular weakness, and diagnostic tests are prescribed. The client is informed that a diagnosis of multiple sclerosis (MS) has been made. The client becomes visibly upset. How should the nurse respond? 1. "That must have really shocked you. Tell me what the healthcare provider told you about it." 2. "You should see a psychiatrist who will help you cope with this overwhelming news." 3. "Don't worry; early treatment often alleviates symptoms of the disease." 4. "You should be glad that we caught it early so it can be cured."

1 Rationale: The response "That must have really shocked you. Tell me what the healthcare provider told you about it" acknowledges the effect of the diagnosis on the client and explores what is known. There is no evidence of ineffective coping, so a referral to a psychiatrist is not necessary. The statement "Don't worry; early treatment often alleviates symptoms of the disease" provides false reassurance. The statement "You should be glad we caught it early so it can be cured" does not address the client's current emotional state, and it is inaccurate; MS is a chronic autoimmune disease.

What is true about psychosocial changes observed in adolescents? Select all that apply. 1. "They search for personal identity." 2. "They develop their own ethical systems." 3. "They consider themselves invincible." 4. "They think of their parents as materialistic." 5. "They get emotionally dependent on their parents."

1, 2 Rationale: An adolescent tends to search for his or her personal identity and develop his or her own ethical system during psychosocial development. During cognitive development, adolescents consider themselves invincible and consider their parents materialistic. Adolescents work at becoming emotionally independent from their parents while retaining family ties.

A nurse is preparing a teaching plan to educate a relative of a client with schizophrenia about the early signs of relapse. What signs should the nurse plan to include? Select all that apply. 1. Appearing disheveled 2. Socializing with peers 3. Staying alone in the house 4. Joining a local church singing group 5. Exhibiting indifference to family activities

1, 3, 5 Rationale: Appearing disheveled, a negative sign, may indicate schizophrenic relapse, because the individual does not have the interest or energy to complete the activities of daily living. Staying at home alone can be a sign of mental illness relapse, because the individual is becoming isolated and not socializing. Indifference to family activities may indicate mental illness relapse, because it may reflect feelings of apathy or a lack of emotional energy to become involved with others. Socializing with peers is a sign of mental health, because the individual is interacting with others; humans are highly social beings. Joining a church singing group indicates mental health, because the individual is interacting with others and is interested in an activity.

How does an individual overcome conflicting thoughts that arise during an Electra complex? 1. By getting proper toilet training process 2. By identifying with the parent of the same sex 3. By indulging in educational and social activities 4. By having physical and emotional availability of the parents

2 Rationale: A child with an Electra complex fantasizes about the parent of the opposite sex as his or her first love interest. This conflicting thought is overcome by identifying with the parent of the same sex as a way to win recognition and acceptance. Toilet training is related to the anal stage. During the latency stage, a child indulges in education and social activities. Physical and emotional availability of the parents is needed during the oral stage.

Which age should the nurse anticipate that a toddler-age client will begin to develop awareness of ownership? 1. 15 months 2. 18 months 3. 24 months 4. 30 months

2 Rationale: A toddler-age client begins to be aware of ownership at the age of 18 months. The nurse would not expect this to begin at 15 months, 24 months, or 30 months.

An Asian client arrives at the mental health clinic with symptoms of anxiety and panic. While speaking with the client, the nurse notes that the client makes very little eye contact. What does this assessment data suggest? 1. Shyness 2. Cultural variation 3. Symptom of depression 4. Shame regarding treatment

2 Rationale: As a show of respect, people in Asian cultures tend to make little eye contact, particularly with people perceived as authority figures. A lack of eye contact may connote shyness in some clients, but further assessment is needed. A lack of eye contact may suggest a depressed mood; however, there is no indication of depression in this client. A lack of eye contact may indicate shame or low self-esteem in the American culture; however, it is important not to make this same interpretation of behavior for someone from another culture.

A client who is to undergo dilation and curettage and conization of the cervix for cancer appears tense and anxious. What is the best approach for the nurse to support the client emotionally? 1. Explaining that these procedures are considered minor surgery 2. Asking whether something is troubling the client and whether she'd like to talk about it 3. Stating that the procedures are routine and asking what the client is really worried about 4. Explaining that everybody is fearful before the surgery even though there is little reason to worry

2 Rationale: Asking whether the client wants to talk about what's troubling her acknowledges that the client is anxious and, by means of indirect questioning, helps facilitate communication. Saying that these procedures are considered minor surgery denies the client's feelings. The client has not indicated that she is upset, and she may be unaware of or unable to verbalize the actual cause of the emotions. Saying that there is little reason to worry is false reassurance and cuts off communication.

What is most important for the nurse to do when caring for a client who is experiencing a paranoid delusion? 1. Touch the client's arm gently to convey concern. 2. Maintain eye contact when talking with the client. 3. Attempt to disprove the client's delusional thoughts. 4. Speak softly when talking with others near the client.

2 Rationale: Eye contact focuses the client's attention on the nurse; it also conveys caring and tells the client that the nurse considers the client important. The nurse should respect the client's personal space; touching the client, particularly without warning, may reinforce suspicious thoughts or precipitate agitation. Attempting to disprove the client's delusional thoughts is useless, because a delusion is real to the client. Whispering or laughing in the presence of a paranoid delusional client may reinforce the delusional state and further agitate the client.

A nurse is caring for a hyperactive, manic client who exhibits flight of ideas and is not eating. What may be the reason why the client is not eating? 1. Feeling undeserving of the food 2. Too busy to take the time to eat 3. Wishes to avoid others in the dining room 4. Believes that there is no need for food at this time

2 Rationale: Hyperactive clients frequently will not take the time to eat because they are overinvolved with everything in their environment. Feeling undeserving of the food is characteristic of a depressive episode. The client is unable to sit long enough with the other clients to eat a meal; this is not conscious avoidance. The client probably gives no thought to food because of overinvolvement with the activities in the environment.

A nurse is conducting the Mini-Mental Status examination on an older client. What should the nurse ask the client to do when testing short-term memory? 1. Subtract serial sevens from 100. 2. Copy one simple geometric figure. 3. State three random words mentioned earlier in the exam. 4. Name two common objects when the nurse points to them.

2 Rationale: Stating three random words mentioned earlier in the examination is a test of the client's ability to recall from short-term memory. Subtracting serial sevens from 100 is a test of the ability to calculate and pay attention. Copying one simple geometric figure is a test of visual comprehension. Naming two common objects when the nurse points to them is a test of verbal skills to identify aphasia.

Which statement describes stage 4 of Kohlberg's theory? Select all that apply. 1. Child recognizes that there is more than one right view. 2. Child shows respect for authority and maintains the social order. 3. Adolescents choose to avoid a party where they know beer will be served. 4. Individual wants to win approval and maintain the expectations of one's immediate group. 5. Child's response to a moral dilemma is in terms of absolute obedience to authority and rules.

2, 3 Rationale: According to stage 4 of Kohlberg's theory, adolescents show respect for authority and maintain the social order. They choose not to attend a party where beer will be served because they know this is wrong. During stage 2, the child recognizes that there is more than one right view. Stage 3 states that an individual wants to win approval and maintain the expectations of one's immediate group. During stage 1, the child's response to a moral dilemma is in terms of absolute obedience to authority and rules.

Identify factors associated with an increased incidence of abuse within a family. Select all that apply. 1. Acute illness 2. Pregnancy 3. Drug abuse 4. Chronic illness 5. Sexual orientation

2, 3, 5 Rationale: Pregnancy, drug abuse, and sexual orientation are associated with an increased incidence of abuse within a family. Acute and chronic illness may place stress on the family, but these factors are not specifically linked to a higher incidence of violence.

How does group identity aid psychosocial development in adolescents? Select all that apply. 1. It helps them evaluate their own health. 2. It helps them feel a sense of admiration and approval. 3. It helps them develop decision-making and budgeting skills. 4. It provides them the opportunity to learn acceptable behavior. 5. It helps them lessen the feeling that they are different from their peers.

2, 4 Rationale: Group identity helps the adolescent feel a sense of admiration and approval. Peer groups provide the adolescent with a sense of belonging, approval, and the opportunity to learn acceptable behavior. Health identity helps the adolescent evaluate his or her own health. Family identity helps adolescents develop decision-making and budgeting skills. Sexual identity helps adolescents assuage the fear that they are different from peers.

While awaiting the biopsy report before removal of a bone tumor, the client reports being afraid of a diagnosis of cancer. How should the nurse respond? 1. "Worrying is not going to help the situation." 2. "Let's wait until we hear what the biopsy report says." 3. "It is very upsetting to have to wait for a biopsy report." 4. "Operations are not performed unless there are no other options."

3 Rationale: "It is very upsetting to have to wait for a biopsy report" addresses the fact that the client's feelings of anxiety are valid. Stating "Worrying is not going to help the situation" or "Let's wait until we hear what the biopsy report says" does not address the client's concerns and may inhibit the expression of feelings. Telling the client that operations are not performed unless there are no other options is irrelevant and does not address the client's concerns.

A nurse is counseling clients who are attending an alcohol rehabilitation program. Which substance poses the greatest risk of addiction for these clients? 1.Heroin 2. Cocaine 3. Nicotine 4. Marijuana

3 Rationale: Although polysubstance abuse is common, clients undergoing rehabilitation from alcohol dependence are more likely to use or develop a dependence on nicotine, another legal substance, than on an illegal substance such as heroin, cocaine, or marijuana.

What is most important for a nurse to do when initially helping clients resolve a crisis situation? 1. Encourage socialization. 2. Meet dependency needs. 3. Support coping behaviors. 4. Involve them in a therapy group.

3 Rationale: In a crisis situation, the individual frequently just needs support to regroup and re-establish the ability to cope. Socialization is part of recovery; this is not done during the initial stage of a crisis. Meeting dependency needs is not possible or realistic. Involving clients in a therapy group may have the effect of increasing anxiety, thereby making the crisis situation worse.

Which should the nurse anticipate, according to Erikson, when assessing a preschool-age child? 1. Being engaged in tasks 2. Questioning sexual identity 3. Having highly imaginative thoughts 4. Wanting to participate in organized activities

3 Rationale: The nurse would anticipate that a preschool-age child would have highly imaginative thoughts, according to Erikson. Being engaged in tasks and wanting to participate in organized activities is expected for the school-age child. Questioning sexual identity is expected for the adolescent.

A new mother said to the nurse, "I would like to care for my baby independently rather than depending on the baby's grandparents." What does the nurse infer from this information? 1. The client is of Asian culture. 2. The client is of African culture. 3. The client is of North American culture. 4. The client is of Latin American culture

3 Rationale: The people who belong to United States and Western Europe culture possess individualistic characteristics. The people who belong to Asia, Africa, and Latin America do not possess individualistic characteristics; instead, they have a collectivistic approach. The new mother who belongs to any of these cultures other than the North American culture may depend on elder family members for child-rearing.

Before discharge of an anxious client, the nurse should teach the family that anxiety can be recognized as what? 1. A totally unique feeling 2. Fears specifically related to the total environment 3. Consciously motivated actions, thoughts, and wishes 4. A pattern of emotional and behavioral responses to stress

4 Rationale: Anxiety is a human response consisting of both physical and emotional changes that everyone experiences when faced with stressful situations. Anxiety is experienced to a greater or lesser degree by every person. The fear may be related to a specific aspect of the environment rather than the total environment. Anxiety does not operate from the conscious level.

A client who suspects that she is 6 weeks pregnant appears mildly anxious as she is waiting for her first obstetric appointment. What symptom of mild anxiety does the nurse expect this client to experience? 1. Dizziness 2. Breathlessness 3. Abdominal cramps 4. Increased alertness

4 Rationale: Increased alertness is an expected common behavior that occurs in new or different situations when a person is mildly anxious. Dizziness, breathlessness, and abdominal cramps are all common signs of moderate to severe anxiety.

A client with an obsessive-compulsive disorder continually walks up and down the hall, touching every other chair. When unable to do this, the client becomes upset. What should the nurse do? 1. Distract the client, which will help the client forget about touching the chairs 2. Encourage the client to continue touching the chairs as long as the client wants until fatigue sets in 3. Remove chairs from the hall, thereby relieving the client of the necessity of touching every other one 4. Allow the behavior to continue for a specified time, letting the client help set the time limits to be imposed

4 Rationale: It is important to set limits on the behavior, but it is also important to involve the client in the decision-making. Distracting the client, which will help the client forget about touching the chairs, is nontherapeutic; rarely can a client be distracted from a ritual when anxiety is high. Encouraging the client to continue touching the chairs for as long he desires until fatigue sets in is a nontherapeutic approach; some limits must be set by the client and nurse together. Removing chairs from the hall, thereby relieving the client of the necessity of touching every other one, will increase the client's anxiety because the client uses the ritual as a defense against anxiety.

The nurse is caring for a client who is suspected of having a brain tumor and is scheduled for a computed tomography (CT) scan. The nurse expects that the preprocedure plan of care will include which component? 1. Withholding routine medications 2. Administering the prescribed sedative 3. Explaining that all metal must be removed 4. Telling the client about what to expect during the examination

4 Rationale: Knowing what to expect decreases anxiety. Routine medications are not withheld. A sedative is not necessary for a CT scan. Removing metal is for a magnetic resonance imaging (MRI) test.

After several years of unprotected sex, a client is diagnosed as having acquired immunodeficiency syndrome (AIDS). The client states, "I'm not worried because they have a cure for AIDS." What is the best response by the nurse? 1. "Repeated phlebotomies may be able to rid you of the virus." 2. "You may be cured of AIDS after prolonged pharmacologic therapy." 3. "Perhaps you should have worn condoms to prevent contracting the virus." 4. "There is no cure for AIDS, but there are drugs that can slow down the virus."

4 Rationale: Stating "There is no cure for AIDS, but there are drugs that can slow down the virus" is an honest response that corrects the client's misconception about the effectiveness of the current antiviral medications. Phlebotomy is not the treatment used to remove the virus from the client's body. Current pharmacologic treatment does not eliminate the virus from the body; it can slow its progress and may even effect a remission (although the medications are never discontinued), but there is no known cure. Stating "Perhaps you should have worn condoms to prevent contracting the virus" is a nontherapeutic, judgmental response that can alienate the client and precipitate feelings of guilt.

A nurse is assessing a middle-aged client whose children have left home in search of work. The client is trying to adjust to these family changes. Which family life-cycle stage is the client going through? 1. Family in later life 2. Family with adolescents 3. Unattached young adult 4. Launching children and moving on

4 Rationale: The client is adjusting to a reduction in family size after the adult children have left home in search of work. The client is going through the launching children and moving on stage of the family life-cycle stage. An individual going through the family in later life stage deals with retirement and the loss of a spouse, siblings, or other peers. The family in the adolescents stage of the family lifecycle involves establishing flexible boundaries to accommodate the growing child's independence. An individual experiencing the unattached young adult stage begins to differentiate themselves from his or her family of origin. The young adult establishes him or herself at work while the young adult's parents experience the launching children and moving on stage.

A client has relocated to a new city for work. The client is unable to continue the practice of walking for 30 minutes daily and exercising five days a week. Which stage of the transtheoretical model of health behavior change is the client experiencing? 1.Action 2. Preparation 3. Maintenance 4. Precontemplation

4 Rationale: The client is experiencing a relapse while attempting to make behavioral changes to his or her lifestyle. When relapse occurs, the client returns to the contemplation or precontemplation stage before attempting to change again. The action stage lasts for up to six months during which the client is actively engaged in strategies to change behavior. During the preparation stage, the client begins to believe that advantages outweigh disadvantages of behavior change. The maintenance stage begins six months after the change has started and continues indefinitely.

Which nursing action indicates that the nurse is actively listening to the client? 1.The nurse states his or her own opinions when the client is speaking. 2. The nurse refrains from telling his or her own story to the client. 3. The nurse reads the client's health record during the conversation. 4. The nurse interprets what the client is saying and reiterates in his or her own words.

4 Rationale: The nurse is listening actively if he or she is able to take in what the client says. A nurse who is listens attentively interprets and reiterates what the client is saying in his or her own words. A nurse who states his or her own opinions when the client is speaking is being judgmental. A good listener should be able to reach out by exchanging his or her own stories with the client. If a nurse reads the client's health record during the conversation, it is an indication that the nurse is not really interested in the conversation.

Which school-age client should the nurse assess for symptoms related to burnout? 1. 7-year-old 2. 8-year-old 3. 9-year-old 4. 10-year-old

4 Rationale: The school-age client between the ages of 10 to 12 years often becomes overinvolved with activities leading to burnout; therefore, the nurse should assess the 10-year-old client for clinical manifestations associated with burnout. The other school-age clients (7 years, 8 years, and 9 years) do not often become overinvolved in activities leading to burnout.

A nurse is assisting with the administration of electroconvulsive therapy (ECT) to a severely depressed client. What side effect of the therapy should the nurse anticipate? 1. Loss of appetite 2. Postural hypotension 3. Total memory loss 4. Confusion immediately after the treatment

4 Rationale: The electrical energy passing through the cerebral cortex during ECT results in a temporary state of confusion after treatment. Loss of appetite, postural hypotension, and total memory loss are not usual or expected side effects. Memory loss is usually restored after a few months of treatment.

Before effectively responding to a sexually abused victim on the phone, it is essential that the nurse in the rape crisis center do what? 1. Get the client's full name and address. 2. Call for assistance from the psychiatrist. 3. Know some myths and facts about sexual assault. 4. Be aware of any personal bias about sexual assault.

4 Rationale: If nurses are unaware of their biases about sexual assault, they will be unprepared to evaluate objectively and meet the client's needs. Getting the client's full name and address may interrupt communication; information can be solicited later. The nurse should be able to help this client without assistance. Although knowing some myths and facts about sexual assault may be important, it is not the priority.

The nurse observes that a child fails to make eye contact and has poor impulse control. Upon further assessment, the nurse finds that the parent is an alcoholic and often neglects the child. What can be said about the child? 1. The child needs to be screened for autism. 2. The child is experiencing separation anxiety. 3. The child feels solitary because of the parent's behavior. 4. The child has developed reactive attachment disorder (RAD).

4 Rationale: RAD is a psychological and developmental disorder that occurs in children who are neglected by their primary caregivers. Children with RAD are not cuddly with parents and fail to make eye contact. They also exhibit poor impulse control and may be destructive to themselves and others. Poor eye contact is seen in autistic children as well, but in this case, there is parental neglect that indicates RAD. Separation anxiety is indicated by crying and screaming when the parent leaves the child. Feelings of solitariness do not result in poor impulse control or eye contact.