PSYCH FINAL PRACTICE
11. A nurse should identify topiramate (Topamax) as the drug of choice for which of the following conditions? (Select all that apply.) 1. Binge eating with a diagnosis of obesity 2. Bingeing and purging with a diagnosis of bulimia nervosa 3. Weight loss with a diagnosis of anorexia nervosa 4. Amenorrhea with a diagnosis of anorexia nervosa 5. Emaciation with a diagnosis of bulimia nervosa
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16. Which of the following are behavior assessment categories in the Broset Violence Checklist? (Select all that apply.) 1. Confusion 2. Paranoia 3. Boisterousness 4. Panic 5. Irritability
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10. A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurses rationale for this intervention? 1. To assess for emotional strength 2. To assess for Wernicke-Korsakoff syndrome 3. To assess for tachycardia 4. To assess for fine tremors
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1. A kindergarten student is frequently violent toward other children. A school nurse notices bruises and burns on the childs face and arms. What other symptom should indicate to the nurse that the child may have been physically abused? 1. The child shrinks at the approach of adults. 2. The child begs or steals food or money. 3. The child is frequently absent from school. 4. The child is delayed in physical and emotional development.
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1. What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal? 1. Risk for injury R/T central nervous system stimulation 2. Disturbed thought processes R/T tactile hallucinations 3. Ineffective coping R/T powerlessness over alcohol use 4. Ineffective denial R/T continued alcohol use despite negative consequences
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11. An aggressive client has been placed in restraints after all other interventions have failed. Which protocol would apply in this situation? 1. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 1 hour of the initiation of the restraints. 2. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 2 hours of the initiation of the restraints. 3. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 3 hours of the initiation of the restraints. 4. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 4 hours of the initiation of the restraints.
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12. By which biological mechanism does EMDR achieve its therapeutic effect? 1. EMDR achieves its therapeutic effect, but the exact biological mechanism is unknown. 2. EMDR achieves its therapeutic effect by causing a decrease in imagery vividness. 3. EMDR achieves its therapeutic effect by causing an increase in memory access. 4. EMDR achieves its therapeutic effect by decreasing trauma associated anxiety.
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13. Which assessment data should a school nurse recognize as a sign of physical neglect? 1. The child is often absent from school and seems apathetic and tired. 2. The child is very insecure and has poor self-esteem. 3. The child has multiple bruises on various body parts. 4. The child has sophisticated knowledge of sexual behaviors.
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14. A nurse would recognize which treatment as most commonly used for AD and its appropriate rationale? 1. Psychotherapy; to examine the stressor and confront unresolved issues 2. Fluoxetine (Prozac); to stabilize mood and resolve symptoms 3. Eye movement desensitization therapy; to reprocess traumatic events 4. Lorazepam (Ativan); a first-line treatment to address symptoms of anxiety
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16. A client diagnosed with major depressive episode and substance use disorder has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions? 1. Sedative-hypnotics are potentially addictive, and their effectiveness will be compromised owing to tolerance. 2. Sedative-hypnotics are expensive and have numerous side effects. 3. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep. 4. Sedative-hypnotics are known not to be as effective in promoting sleep as antidepressant medications.
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18. A nurse is assessing a pathological gambler. What would differentiate this clients behaviors from the behaviors of a non-pathological gambler? 1. Pathological gamblers have abnormal levels of neurotransmitters, whereas non-pathological gamblers do not. 2. Pathological gambling occurs more commonly among women, whereas non-pathological gambling occurs more commonly among men. 3. Pathological gambling generally runs an acute course, whereas non-pathological gambling runs a chronic course. 4. Pathological gambling is not related to stress relief, whereas non-pathological gambling is related to stress relief.
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2. Which factors differentiate the diagnosis of PTSD from the diagnosis of adjustment disorder (AD)? 1. PTSD results from exposure to an extreme traumatic event, whereas AD results from exposure to normal daily events. 2. AD results from exposure to an extreme traumatic event, whereas PTSD results from exposure to normal daily events. 3. Depressive symptoms occur in PTSD and not in AD. 4. Depressive symptoms occur in AD and not in PTSD.
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21. A nursing instructor is teaching nursing students about cirrhosis of the liver. Which of the following statements about the complications of hepatic encephalopathy should indicate to the nursing instructor that further student teaching is needed? (Select all that apply.) 1. A diet rich in protein will promote hepatic healing. 2. This condition results from a rise in serum ammonia, leading to impaired mental functioning. 3. In this condition, an excessive amount of serous fluid accumulates in the abdominal cavity. 4. Neomycin and lactulose are used in the treatment of this condition. 5. This condition is caused by the inability of the liver to convert ammonia to urea.
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3. A nurse is counseling a client diagnosed with bulimia nervosa about the symptom of tooth enamel deterioration. Which explanation for this complication of bulimia nervosa, should the nurse provide? 1. The emesis produced during purging is acidic and corrodes the tooth enamel. 2. Purging causes the depletion of dietary calcium. 3. Food is rapidly ingested without proper mastication. 4. Poor dental and oral hygiene leads to dental caries.
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3. A nursing instructor is developing a lesson plan to teach about domestic violence. Which information should be included? 1. Power and control are central to the dynamic of domestic violence. 2. Poor communication and social isolation are central to the dynamic of domestic violence. 3. Erratic relationships and vulnerability are central to the dynamic of domestic violence. 4. Emotional injury and learned helplessness are central to the dynamic of domestic violence.
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5. A lonely, depressed divorce has been self-medicating with small amounts of cocaine for the past year. Which term should a nurse use to best describe this individuals situation? 1. Psychological addiction 2. Physical addiction 3. Substance induced disorder 4. Social induced disorder
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5. After threatening to jump off of a bridge, a client is brought to an emergency department by police. To assess for suicide potential, which question should a nurse ask first? 1. Are you currently thinking about harming yourself? 2. Why do you want to harm yourself? 3. Have you thought about the consequences of your actions? 4. Who is your emergency contact person?
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7. A client diagnosed with chronic alcohol addiction is being discharged from an inpatient treatment facility after detoxification. Which client outcome, related to AA, would be most appropriate for a nurse to discuss with the client during discharge teaching? 1. After discharge, the client will immediately attend 90 AA meetings in 90 days. 2. After discharge, the client will rely on an AA sponsor to help control alcohol cravings. 3. After discharge, the client will incorporate family in AA attendance. 4. After discharge, the client will seek appropriate deterrent medications through AA.
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8. A college student was sexually assaulted when out on a date. After several weeks of crisis intervention therapy, which client statement should indicate to a nurse that the student is handling this situation in a healthy manner? 1. I know that it was not my fault. 2. My boyfriend has trouble controlling his sexual urges. 3. If I dont put myself in a dating situation, I wont be at risk. 4. Next time I will think twice about wearing a sexy dress.
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8. A morbidly obese client is prescribed an anorexiant medication. The nurse should expect to teach the client about which medication? 1. Phentermine (Mirapront) 2. Dexfenfluramine (Redux) 3. Sibutramine (Meridia) 4. Pemoline (Cylert)
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9. A client diagnosed with AD has been assigned the nursing diagnosis of anxiety R/T divorce. Which correctly written outcome addresses this clients problem? 1. Rates anxiety as 4 out of 10 by discharge. 2. States anxiety level has decreased by day one. 3. Accomplishes activities of daily living independently. 4. Demonstrates ability for adequate social functioning by day three.
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9. A nurse is attempting to differentiate between the symptoms of anorexia nervosa and the symptoms of bulimia. Which statement delineates the difference between these two disorders? 1. Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not. 2. Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not. 3. Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not. 4. Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not.
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16. Which of the following nursing diagnoses are typically appropriate for an adult survivor of incest? (Select all that apply.) 1. Low self-esteem 2. Powerlessness 3. Disturbed personal identity 4. Knowledge deficit 5. Non-adherence
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22. A family asks the nurse why their son was diagnosed with PTSD and others in the accident were not. Which of the following information should the nurse offer? (Select all that apply.) 1. An individuals religious affiliation can affect response to trauma. 2. Responses are affected by how an individual handled previous trauma. 3. Protectiveness of family and friends can help an individual deal with trauma. 4. Control over the possibility of recurrence can affect the response to trauma. 5. The time in which the trauma occurred can affect the individuals response.
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14. Which of the following nursing statements and/or questions represent appropriate communication to assess an individual in crisis? (Select all that apply.) 1. Tell me what happened. 2. What coping methods have you used, and did they work? 3. Describe to me what your life was like before this happened. 4. Lets focus on the current problem. 5. Ill assist you in selecting functional coping strategies.
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20. A client diagnosed with an adjustment disorder says to the nurse, Tell me about medications that will cure this problem. Which of the following are appropriate nursing responses? (Select all that apply.) 1. Medications can interfere with your ability to find a more permanent problem solution. 2. Medications may mask the real problem at the root of this diagnosis. 3. Adjustment disorders are not commonly treated with medications. 4. Psychoactive drugs carry the potential for physiological and psychological dependence. 5. Psychoactive drugs will be prescribed only if your problems persist for more than three months.
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21. A nurse is admitting a client who has been diagnosed with PTSD. Which of the following symptoms might the nurse expect to assess? (Select all that apply.) 1. Feelings of guilt that precipitate social isolation 2. Aggressive behavior that affects job performance 3. Relationship problems 4. High levels of anxiety 5. Escalating symptoms lasting less than one month
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15. In planning care for a woman who presents as a survivor of domestic abuse, a nurse should be aware of which of the following data? (Select all that apply.) 1. It often takes several attempts before a woman leaves an abusive situation. 2. Substance abuse is a common factor in abusive relationships. 3. Until children reach school age, they are usually not affected by abuse between their parents. 4. Women in abusive relationships usually feel isolated and unsupported. 5. Economic factors rarely play a role in the decision to stay.
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15. Which of the following interventions should a nurse use when caring for an inpatient client who expresses anger inappropriately? (Select all that apply.) 1. Maintain a calm demeanor. 2. Clearly delineate the consequences of the behavior. 3. Use therapeutic touch to convey empathy. 4. Set limits on the behavior. 5. Teach the client to avoid I statements related to expression of feelings.
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17. A nursing instructor is teaching about intimate partner violence. Which of the following student statements indicate that learning has occurred? (Select all that apply.) 1. Intimate partner violence is a pattern of abusive behavior that is used by an intimate partner. 2. Intimate partner violence is used to gain power and control over the other intimate partner. 3. Fifty-one percent of victims of intimate violence are women. 4. Women ages 25 to 34 experience the highest per capita rates of intimate violence. 5. Victims are typically young married women who are dependent housewives.
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20. Which of the following nursing statements exemplify the cognitive process that must be completed by a nurse prior to caring for clients diagnosed with a substance-related disorder? (Select all that apply.) 1. I am easily manipulated and need to work on this prior to caring for these clients. 2. Because of my fathers alcoholism, I need to examine my attitude toward these clients. 3. I need to review the side effects of the medications used in the withdrawal process. 4. Ill need to set boundaries to maintain a therapeutic relationship. 5. I need to take charge when dealing with clients diagnosed with substance disorders.
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22. A clinic nurse is about to meet with a client diagnosed with a gambling disorder. Which of the following symptoms and/or behaviors is the nurse likely to assess? (Select all that apply.) 1. Stressful situations precipitate gambling behaviors. 2. Anxiety and restlessness can only be relieved by placing a bet. 3. Winning brings about feelings of sexual satisfaction. 4. Gambling is used as a coping strategy. 5. Losing at gambling meets the clients need for self-punishment.
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23. A nurse would recognize which of the following as the best predictors of PTSD in Vietnam veterans? (Select all that apply.) 1. The severity of the stressor 2. The degree of ego strength 3. The degree of psychosocial isolation in the recovery environment 4. The attitudes of society regarding the experience 5. The presence of preexisting psychopathology
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13. Which of the following would contribute to a clients excessive weight gain? (Select all that apply.) 1. A hypothalamus lesion 2. Hyperthyroidism 3. Diabetes mellitus 4. Cushings disease 5. Low levels of serotonin
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12. A nursing instructor is teaching about the DSM-5 criteria for the diagnosis of binge-eating disorder. Which of the following student statements indicates that further instruction is needed? (Select all that apply.) 1. In this disorder, binge eating occurs exclusively during the course of bulimia nervosa. 2. In this disorder, binge eating occurs, on average, at least once a week for three months. 3. In this disorder, binge eating occurs, on average, at least two days a week for six months. 4. In this disorder, distress regarding binge eating is present. 5. In this disorder, distress regarding binge eating is absent.
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24. A nursing supervisor is offering an impaired staff member information regarding employee assistance programs. Which of the following facts should the supervisor include? (Select all that apply.) 1. A hotline number will be available in order to call for peer assistance. 2. A verbal contract detailing the method of treatment will be initiated prior to the program. 3. Peer support is provided through regular contact with the impaired nurse. 4. Contact to provide peer support will last for one year. 5. One of the program goals is to intervene early in order to reduce hazards to clients.
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25. A nursing counselor is about to meet with a client suffering from codependency. Which of the following data would further support the assessment of this dysfunctional behavior? (Select all that apply.) 1. The client has a long history of focusing thoughts and behaviors on other people. 2. The client, as a child, experienced overindulgent and overprotective parents. 3. The client is a people pleaser and does almost anything to gain approval. 4. The client exhibits helpless behaviors but actually feels very competent. 5. The client can achieve a sense of control only through fulfilling the needs of others.
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11. After a teaching session about grief, a client says to the nurse, I seem to be stuck in the anger stage of grieving over the loss of my son. How would the nurse assess this statement, and in what phase of the nursing process would this occur? 1. Assessment phase nursing actions have been successful in achieving the objectives of care. 2. Evaluation phase nursing actions have been successful in achieving the objectives of care. 3. Implementation phase nursing actions have been successful in achieving the objectives of care. 4. Diagnosis phase nursing actions have been successful in achieving the objectives of care.
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13. A client receiving EMDR therapy says, After only two sessions of my therapy, I am feeling great. Now I can stop and get on with my life. Which of the following nursing responses is most appropriate? 1. I am thrilled that you have responded so rapidly to EMDR. 2. To achieve lasting results, all eight phases of EMDR must be completed. 3. If I were you, I would complete the EMDR and comply with doctors orders. 4. How do you feel about continuing the therapy?
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14. A client diagnosed with an eating disorder experiences insomnia, nightmares, and panic attacks that occur before bedtime. She has never married or dated, and she lives alone. She states to a nurse, My father has recently moved back to town. What should the nurse suspect? 1. Possible major depressive disorder 2. Possible history of childhood incest 3. Possible histrionic personality disorder 4. Possible history of childhood physical abuse
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15. A nurse is reviewing the stat laboratory data of a client in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur? 1. 50 mg/dL 2. 100 mg/dL 3. 250 mg/dL 4. 300 mg/dL
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18. A client has been extremely nervous ever since a person died as a result of the clients drunk driving. When assessing for the diagnosis of AD, within what time frame should the nurse expect the client to exhibit symptoms? 1. To meet the DSM-5 criteria for adjustment disorder, the client should exhibit symptoms within one year of the accident. 2. To meet the DSM-5 criteria for adjustment disorder, the client should exhibit symptoms within three months of the accident. 3. To meet the DSM-5 criteria for adjustment disorder, the client should exhibit symptoms within six months of the accident. 4. To meet the DSM-5 criteria for adjustment disorder, the client should exhibit symptoms within nine months of the accident.
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19. A nursing instructor is teaching about the impaired nurse and the consequences of this impairment. Which statement by a student indicates that further instruction is needed? 1. The state board of nursing must be notified with factual documentation of impairment. 2. All state boards of nursing have passed laws that, under any circumstances, do not allow impaired nurses to practice. 3. Many state boards of nursing require an impaired nurse to successfully complete counseling treatment programs prior to a return to work. 4. After a return to practice, a recovering nurse may be closely monitored for several years.
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2. A nurse evaluates a clients patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance addiction? 1. Narcotic pain medication is contraindicated for all clients with active substance use disorders. 2. Clients who are addicted to alcohol or benzodiazepines may develop cross-tolerance to analgesics and require increased doses to achieve effective pain control. 3. There is no need to assess the client for substance addiction. There is an obvious PCA malfunction, because these clients have a higher pain tolerance. 4. The client is experiencing alcohol withdrawal symptoms and needs accurate assessment.
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2. A wife brings her husband to an emergency department after an attempt to hang himself. He is a full-time student and works 8 hours at night to support his family. He states, I cant function any longer under all this stress. Which type of crisis is the client experiencing? 1. Maturational/developmental crisis 2. Psychiatric emergency crisis 3. Anticipated life transition crisis 4. Traumatic stress crisis
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4. A client is brought to an emergency department after being violently raped. Which nursing action is appropriate? 1. Discourage the client from discussing the rape, because this may lead to further emotional trauma. 2. Remain nonjudgmental while actively listening to the clients description of the violent rape event. 3. Meet the clients self-care needs by assisting with showering and perineal care. 4. Probe for further, detailed description of the rape event.
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4. A nursing instructor is explaining the etiology of trauma-related disorders from a learning theory perspective. Which student statement indicates that learning has occurred? 1. How clients perceive events and view the world affect their response to trauma. 2. The psychic numbing in PTSD is a result of negative reinforcement. 3. The individual becomes addicted to the trauma owing to an endogenous opioid response. 4. Believing that the world is meaningful and controllable can protect an individual from PTSD.
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6. A client has been assigned a nursing diagnosis of complicated grieving related to the death of multiple family members in a motor vehicle accident. Which intervention should the nurse initially employ? 1. Encourage the journaling of feelings. 2. Assess for the stage of grief in which the client is fixed. 3. Provide community resources to address the clients concerns. 4. Encourage attending a grief therapy group.
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23. A nursing supervisor is about to meet with a staff nurse suspected of diverting client medications. Which of the following assessment data would lead the supervisor to suspect that the staff nurse is impaired? (Select all that apply.) 1. The staff nurse is frequently absent from work. 2. The staff nurse experiences mood swings. 3. The staff nurse makes elaborate excuses for behavior. 4. The staff nurse frequently uses the restroom. 5. The staff nurse has a flushed face.
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6. The family of a client diagnosed with anorexia nervosa becomes defensive when the treatment team calls for a family meeting. Which is the appropriate nursing response? 1. Tell me why this family meeting is causing you to be defensive. All clients are required to participate in two family sessions. 2. Eating disorders have been correlated to certain familial patterns without addressing these, your childs condition will not improve. 3. Family dynamics are not linked to eating disorders. The meeting is to provide your child with family support. 4. Clients diagnosed with anorexia nervosa are part of the family system, and any alteration in family processes needs to be addressed.
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8. A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 48 hours. When the nurse reports to the ED physician, which client symptom should be the nurses first priority? 1. Hearing and visual impairment 2. Blood pressure of 180/100 mm Hg 3. Mood rating of 2/10 on numeric scale 4. Dehydration
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8. A despondent client who has recently lost her husband of 30 years tearfully states, Ill feel a lot better if I sell my house and move away. Which nursing response is most appropriate? 1. Im confident you know whats best for you. 2. This may not be the best time for you to make such an important decision. 3. Your children will be terribly disappointed. 4. Tell me why you want to make this change.
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9. An inpatient client with a known history of violence suddenly begins to pace. Which additional client behavior should alert a nurse to escalating anger and aggression? 1. The client requests prn medications. 2. The client has a tense facial expression and body language. 3. The client refuses to eat lunch. 4. The client sits in group with back to peers.
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24. A client diagnosed with PTSD states, Why did my doctor prescribe an antidepressant rather than an antianxiety drug for me? Which of the following are the most appropriate nursing responses? (Select all that apply.) 1. Im not sure, because antianxiety drugs have been approved by the FDA for PTSD. 2. Antidepressants are now considered first-line treatment choice for PTSD. 3. Many people have adverse reactions to anti anxiety drugs. 4. Because of their addictive properties, antianxiety drugs are less desirable. 5. There have been no controlled studies on the effect of antianxiety drugs on PTSD.
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1. Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which statement regarding a clients home environment should a nurse associate with the development of anorexia nervosa? 1. The home environment maintains loose personal boundaries. 2. The home environment places an overemphasis on food. 3. The home environment is overprotective and demands perfection. 4. The home environment condones corporal punishment.
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10. When questioned about bruises, a woman states, It was an accident. My husband just had a bad day at work. Hes being so gentle now and even brought me flowers. Hes going to get a new job, so it wont happen again. This client is in which phase of the cycle of battering? 1. Phase I: The tension-building phase 2. Phase II: The acute battering incident phase 3. Phase III: The honeymoon phase 4. Phase IV: The resolution and reorganization phase
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11. A client presents with symptoms of alcohol withdrawal and states, I havent eaten in three days. A nurses assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) with dry mucous membranes and poor skin turgor. What should be the priority nursing diagnosis? 1. Knowledge deficit 2. Fluid volume excess 3. Imbalanced nutrition: less than body requirements 4. Ineffective individual coping
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12. A clients wife has been making excuses for her alcoholic husbands work absences. In family therapy, she states, His problems at work are my fault. Which is the appropriate nursing response? 1. Why do you assume responsibility for his behaviors? 2. I think you should start to confront his behavior. 3. Your husband needs to deal with the consequences of his drinking. 4. Do you understand what the term enabler means?
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12. A survivor of rape presents in an emergency department crying, pacing, and cursing her attacker. A nurse should recognize these client actions as which behavioral defense? 1. Controlled response pattern 2. Compounded rape reaction 3. Expressed response pattern 4. Silent rape reaction
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13. A nursing instructor is teaching about the Roberts Seven-Stage Crisis Intervention Model. Which nursing action should be identified with Stage IV? 1. Collaboratively implement an action plan. 2. Help the client identify the major problems or crisis precipitants. 3. Help the client deal with feelings and emotions. 4. Collaboratively generate and explore alternatives.
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15. A nurse has been caring for a client diagnosed with PTSD. Which realistic goal should be included in this clients plan of care? 1. The client will have no flashbacks. 2. The client will be able to feel a full range of emotions by discharge. 3. The client will not require zolpidem (Ambien) to obtain adequate sleep by discharge. 4. The client will refrain from discussing the traumatic event.
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16. A client diagnosed with PTSD is receiving paliperidone (Invega). Which symptoms should a nurse identify that would warrant the need for this medication? 1. Flat affect and anhedonia 2. Persistent anorexia and 10 lb weight loss in 3 weeks 3. Flashbacks of killing the enemy 4. Distant and guarded in relationships
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17. A client diagnosed with a gambling disorder asks the nurse about medications that may be ordered by the clients physician to treat this disorder. The nurse would give the client information on which medications? 1. Escitalopram (Lexapro) and clozapine (Clozaril) 2. Citalopram (Celexa) and olanzapine (Zyprexa) 3. Lithium carbonate (Lithobid) and sertraline (Zoloft) 4. Naltrexone (ReVia) and ziprasidone (Geodon)
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2. A clients altered body image is evidenced by claims of feeling fat, even though the client is emaciated. Which is the appropriate outcome criterion for this clients problem? 1. The client will consume adequate calories to sustain normal weight. 2. The client will cease strenuous exercise programs. 3. The client will perceive personal ideal body weight and shape as normal. 4. The client will not express a preoccupation with food.
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3. On the first day of a clients alcohol detoxification, which nursing intervention should take priority? 1. Strongly encourage the client to attend 90 Alcoholics Anonymous (AA) meetings in 90 days. 2. Educate the client about the biopsychosocial consequences of alcohol abuse. 3. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. 4. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.
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3. Which client would a nurse recognize as being at highest risk for the development of an AD? 1. A young married woman 2. An elderly unmarried man 3. A young unmarried woman 4. A young unmarried man
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4. A high school student has learned that she cannot graduate. Her boyfriend will be attending a college out of state that she planned to attend. She is admitted to a psychiatric unit after overdosing on Tylenol. Which is the priority nursing diagnosis for this client? 1. Ineffective coping R/T situational crisis AEB powerlessness 2. Anxiety R/T fear of failure 3. Risk for self-directed violence R/T hopelessness 4. Risk for low self-esteem R/T loss events AEB suicidal ideations
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5. A raped client answers a nurses questions in a monotone voice with single words, appears calm, and exhibits a blunt affect. How should the nurse interpret this clients responses? 1. The client may be lying about the incident. 2. The client may be experiencing a silent rape reaction. 3. The client may be demonstrating a controlled response pattern. 4. The client may be having a compounded rape reaction.
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5. As the sole survivor of a roadside bombing, a veteran is experiencing extreme guilt. Which nursing diagnosis would address this clients symptom? 1. Anxiety 2. Altered thought processes 3. Complicated grieving 4. Altered sensory perception
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7. A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change? 1. The client gained two pounds in one week. 2. The client focused conversations on nutritious food. 3. The client demonstrated healthy coping mechanisms that decreased anxiety. 4. The client verbalized an understanding of the etiology of the disorder.
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7. A woman comes to an emergency department with a broken nose and multiple bruises after being beaten by her husband. She states, The beatings have been getting worse, and Im afraid, next time, he will kill me. Which is the appropriate nursing response? 1. Leopards dont change their spots, and neither will he. 2. There are things you can do to prevent him from losing control. 3. Lets talk about your options so that you dont have to go home. 4. Why dont we call the police so that they can confront your husband with his behavior?
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8. Both situational and intrapersonal factors most likely contribute to an individuals stress response. Which factor would a nurse categorize as intrapersonal? 1. Occupational opportunities 2. Economic conditions 3. Degree of flexibility 4. Availability of social supports
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9. A client asks, Why does a rapist use a weapon during the act of rape? Which is the most appropriate nursing response? 1. To decrease the victimizers insecurity. 2. To inflict physical harm with the weapon. 3. To terrorize and subdue the victim. 4. To mirror learned family behavior patterns related to weapons.
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1. A new mother is concerned about her ability to perform her parental role. She is quite anxious and ambivalent about leaving the postpartum unit. To offer effective client care, a nurse should be familiar with what information about this type of crisis? 1. This type of crisis is precipitated by unexpected external stressors. 2. This type of crisis is precipitated by preexisting psychopathology. 3. This type of crisis is precipitated by an acute response to an external situational stressor. 4. This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client.
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1. A nursing instructor is teaching about trauma and stressor-related disorders. Which student statement indicates that further instruction is needed? 1. The trauma that women experience is more likely to be sexual assault and child sexual abuse. 2. The trauma that men experience is more likely to be accidents, physical assaults, combat, or viewing death or injury. 3. After exposure to a traumatic event, only 10 percent of victims develop post-traumatic stress disorder (PTSD). 4. Research shows that PTSD is more common in men than in women.
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10. A client diagnosed with a history of anorexia nervosa comes to an outpatient clinic after being medically cleared. The client states, My parents watch me like a hawk and never let me out of their sight. Which nursing diagnosis would take priority at this time? 1. Altered nutrition less than body requirements 2. Altered social interaction 3. Impaired verbal communication 4. Altered family processes
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10. Eye movement desensitization and reprocessing (EMDR) has been empirically validated for which disorder? 1. Adjustment disorder 2. Generalized anxiety disorder 3. Panic disorder 4. Post-traumatic stress disorder
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10. What is the best nursing rationale for holding a debriefing session with clients and staff after a take-down intervention has taken place on an inpatient unit? 1. Reinforce unit rules with the client population. 2. Create protocols for the future release of tensions associated with anger. 3. Process client feelings and alleviate fears of undeserved seclusion and restraint. 4. Discuss the situation that led to inappropriate expressions of anger.
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11. Which information should the nurse in an employee assistance program provide to an employee who exhibits symptoms of domestic physical abuse? 1. Have ready access to a gun and learn how to use it. 2. Research lawyers that can aid in divorce proceedings. 3. File charges of assault and battery. 4. Have ready access to the number of a safe house for battered women.
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12. A combative adolescent client has been placed in seclusion after all other interventions have failed. Which protocol would apply in this situation? 1. The physician or other licensed independent practitioner must reissue a new order for restraints every 24 hours. 2. The physician or other licensed independent practitioner must reissue a new order for restraints every 8 hours. 3. The physician or other licensed independent practitioner must reissue a new order for restraints every 3 to 4 hours. 4. The physician or other licensed independent practitioner must reissue a new order for restraints every 1 to 2 hours.
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13. Which medication orders should a nurse anticipate for a client who has a history of benzodiazepine withdrawal delirium? 1. Haloperidol (Haldol) and fluoxetine (Prozac) 2. Carbamazepine (Tegretol) and donepezil (Aricept) 3. Disulfiram (Antabuse) and lorazepam (Ativan) 4. Chlordiazepoxide (Librium) and phenytoin (Dilantin)
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14. A nurse is interviewing a client in an outpatient addiction clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish? 1. The client will identify one person to turn to for support. 2. The client will give up all old drinking buddies. 3. The client will be able to verbalize the effects of alcohol on the body. 4. The client will correlate life problems with alcohol use.
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17. A client, who recently delivered a stillborn baby, has a diagnosis of adjustment disorder unspecified. The nurse case manager should expect which client presentation that is characteristic of this diagnosis? 1. The client worries continually and appears nervous and jittery. 2. The client complains of a depressed mood, is tearful, and feels hopeless. 3. The client is belligerent, violates others rights, and defaults on legal responsibilities. 4. The client complains of many physical ailments, refuses to socialize, and quits her job.
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19. A 20-year-old client and a 60-year-old client have had drunk driving accidents and are both experiencing extreme anxiety. From a psychosocial theory perspective, which of these clients would be predisposed to the diagnosis of adjustment disorder? 1. The 60-year-old, because of memory deficits. 2. The 60-year-old, because of decreased cognitive processing ability. 3. The 20-year-old, because of limited cognitive experiences. 4. The 20-year-old, because of lack of developmental maturity.
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2. A woman presents with a history of physical and emotional abuse in her intimate relationships. What should this information lead a nurse to suspect? 1. The woman may be exhibiting a controlled response pattern. 2. The woman may have a history of childhood neglect. 3. The woman may be exhibiting codependent characteristics. 4. The woman may be a victim of incest.
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4. A nurse is teaching a client diagnosed with an eating disorder about behavior-modification programs. Why is this intervention the treatment of choice? 1. It helps the client correct a distorted body image. 2. It addresses the underlying client anger. 3. It manages the clients uncontrollable behaviors. 4. It allows clients to maintain control.
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4. Which client statement indicates a knowledge deficit related to a substance use disorder? 1. Although its legal, alcohol is one of the most widely abused drugs in our society. 2. Tolerance to heroin develops quickly. 3. Flashbacks from LSD use may reoccur spontaneously. 4. Marijuana is like smoking cigarettes. Everyone does it. Its essentially harmless.
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5. A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects insight related to this disorder? 1. Skaters need to be thin to improve their daily performance. 2. All the skaters on the team are following an approved 1200-calorie diet. 3. The exercise of skating reduces my appetite but improves my energy level. 4. I am angry at my mother. I can only get her approval when I win competitions.
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6. A client who is in a severely abusive relationship is admitted to a psychiatric inpatient unit. The client fears for her life. A staff nurse asks, Why doesnt she just leave him? Which is the nursing supervisors most appropriate response? 1. These clients dont know life any other way, and change is not an option until they have improved insight. 2. These clients have limited cognitive skills and few vocational abilities to be able to make it on their own. 3. These clients often have a lack of financial independence to support themselves and their children, and most have religious beliefs prohibiting divorce and separation. 4. These clients are paralyzed into inaction by a combination of physical threats and a sense of powerlessness.
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6. An involuntarily committed client when offered a dinner tray pushes it off the bedside table onto the floor. Which nursing intervention should a nurse implement to address this behavior? 1. Initiate forced medication protocol. 2. Help the client to explore the source of anger. 3. Ignore the act to avoid reinforcing the behavior. 4. With staff support and a show of solidarity, set firm limits on the behavior.
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6. Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during the substance induced disorder of alcohol withdrawal? 1. Antagonist therapy 2. Deterrent therapy 3. Codependency therapy 4. Substitution therapy
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7. A college student who was nearly raped while jogging, completes a series of appointments with a rape crisis nurse. At the final session, which client statement most clearly suggests that the goals of crisis intervention have been met? 1. Youve really been helpful. Can I count on your for continued support? 2. I work out in the college gym rather than jogging outdoors. 3. Im really glad I didnt go home. It would have been hard to come back. 4. I carry mace when I jog. It makes me feel safe and secure.
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7. Which clinical presentation is associated with the most commonly diagnosed adjustment disorder (AD)? 1. Anxiety, feelings of hopelessness, and worry 2. Truancy, vandalism, and fighting 3. Nervousness, worry, and jitteriness 4. Depressed mood, tearfulness, and hopelessness
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9. Which client statement demonstrates positive progress toward recovery from a substance use disorder? 1. I have completed detox and therefore am in control of my drug use. 2. I will faithfully attend Narcotic Anonymous (NA) when I cant control my cravings. 3. As a church deacon, my focus will now be on spiritual renewal. 4. Taking those pills got out of control. It cost me my job, marriage, and children.
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3. A client comes to a psychiatric clinic experiencing sudden extreme fatigue and decreased sleep and appetite. The client works 12 hours a day and rates anxiety as 8/10 on a numeric scale. What long-term outcome is realistic in addressing this clients crisis? 1. The client will change his type A personality traits to more adaptive ones by one week. 2. The client will list five positive self-attributes. 3. The client will examine how childhood events led to his overachieving orientation. 4. The client will return to previous adaptive levels of functioning by week six.
ANS: 4