behavioral final
14. A nurse identifies a nursing diagnosis of Chronic Low Self-Esteem. Which statement by a client would support this nursing diagnosis? A) "I feel so ugly." B) "No one wants to date me." C) "I'm so fat, like a cow." D) "I never do anything right."
Ans: D
12. While planning care for a child who has excoriation disorder, which of the following would be the priority NANDA? A) Hopelessness B) Dysfunctional family processes C) Ineffective role performance D) Impaired skin integrity
Ans: D
13. A client with posttraumatic stress disorder (PTSD) has begun to stay out late every night and "party" with their friends. When family members ask about when the client is going to return to work, they become extremely irritated and verbal lashes out, saying some very hurtful things. The priority NANDA for this client would be which of the following? A) Risk of relocation stress syndrome B) Ineffective activity planning C) Anxiety D) Ineffective impulse control
Ans: D
13. A nurse is assessing the parents of a child age 6 years who has died from leukemia. The nurse is integrating the dual process model for the assessment. Which of the following would the nurse identify as reflecting the parents' loss-oriented coping? A) Engaging in new activities B) Denying the grief C) Developing new relationships D) Thinking about the lost child
Ans: D
13. A son brings his mother to the clinic for an evaluation. The son's mother has moderate Alzheimer's disease without delirium. The nurse assesses the client for which of the following as the priority? A) Hearing deficits B) Mania C) Strange verbalizations D) Catastrophic reactions
Ans: D
/ 12. After teaching a class about the biochemical theories associated with panic disorder, the instructor determines a need for additional education when the students identify which neurotransmitter as being implicated? A) Dopamine B) Serotonin C) Norepinephrine D) Gamma-aminobutyric acid (GABA)
Ans: A
1. A client asks the nurse whether he needs to alter any of his activities because he is taking lithium carbonate. Which of the following responses would be most appropriate? A) "Increase your salt intake if an activity causes you to perspire heavily." B) "Wear sunscreen when you are going to be outdoors in the summer." C) "Drink less fluid than usual now that you are taking this drug." D) "No changes are necessary for strenuous activities you do outdoors."
Ans: A
1. A client is admitted to a mental health unit with a diagnosis of factitious disorder. When reviewing the client's history, which of the following would a nurse most likely find? A) Intentional self-injurious behavior B) Pain to achieve a self-serving goal C) Malingering to avoid work D) Parents who were restrictive
Ans: A
1. A client is talking to a nurse about the recent death of her grandmother. She is sad, and tears roll down her cheeks as she talks. The nurse remembers how she felt when her own grandmother died the previous summer. The nurse puts her hand on the client's shoulder and says, "This must be very difficult for you." The nurse is demonstrating empathy based on which of the following? A) The nurse's response reflects an attempt to communicate understanding of the client's feelings. B) The nurse's response and use of reassuring touch reinforce the nurse's concern for the client. C) The nurse demonstrates understanding of how the client feels because of her own grandmother's death. D) The nurse's statement expresses compassion and kindness toward the client.
Ans: A
1. A nurse is explaining advance care directives, or "living wills," to a client and the client's spouse. Which of the following would the nurse include in the description? A) The document tells what treatment is to be omitted if the client is unable to make the decision. B) It requires that the client sign the "living will" document while an attorney is present. C) The client's physician must act as a witness when the client signs the document. D) An attorney draws up the papers to be given to the client and his or her family.
Ans: A
1. A nurse is making a home visit to an adult client who is diagnosed with persistent depressive disorder. When developing this client's plan of care, which of the following would the nurse need to keep in mind? A) The client's symptoms of major depressive disorder have lasted for 2 years. B) The client's condition is considered to be of a shorter duration. C) The client typically experiences an elevated mood. D) The client experiences symptoms that are intermittent.
Ans: A
1. A nurse is planning a presentation to a group of nursing students on the topic of anxiety disorders. Which of the following would the nurse include when describing panic disorder? A) Individuals may believe they are having a heart attack when a panic attack occurs. B) People with panic attacks often have fewer attacks if they also have agoraphobia. C) Typically, individuals experience this disorder after the age of 30 years. D) Persons rarely have an underlying comorbid condition of depression.
Ans: A
14. A nurse is explaining the distinction between confidentiality and privacy. Which of the following would the nurse include as reflecting privacy? A) Part of personal life not governed by society's laws B) Ethical duty for nondisclosure C) Involvement of two individuals D) Knowledge of treatment costs and benefits
Ans: A
1. A nurse is talking to a female client who is a survivor of intimate partner violence. The woman relates that her husband has been told that he has the characteristics of an antisocial personality disorder. The woman also informs the nurse that her husband has an extensive criminal record. The nurse interprets this information and suspects that the woman's husband would most likely demonstrate which behavior? A) A risk for aggressive and assaultive violence toward people within and outside of his family B) Intermittent remorse for the violence and abuse that he commits C) Symptoms of depression along with harboring feelings of inadequacy D) Purposefully remaining socially isolated from people other than those in his family
Ans: A
1. The nurse is assessing a client who is diagnosed with borderline personality disorder. Which client statement indicates the client is at risk for self-injurious behavior? A) "I have felt so down lately. I don't enjoy doing anything anymore." B) "I do what I do because others tell me to do so." C) "When I feel extremely anxious, it is like my mind goes somewhere else." D) "It is almost as if as soon as I think of doing something, I immediately do it."
Ans: A
1. While caring for a client with anorexia nervosa, a nurse anticipates that the client would have difficulty making which of the following comments? A) "I'm mad at you because you won't let me go on a pass unless I gain weight!" B) "I need to have everything in its place and perfect." C) "If I gain a pound, I'll just keep gaining weight." D) "I am very involved in preparing my food and counting calories."
Ans: A
10. A child with autism spectrum disorder engages in a repetitive rocking behavior that does not pose a threat to the child's safety. When educating the child's family on managing this behavior, which of the following would be appropriate for the nurse to suggest? A) Ignore it B) Redirect the child C) Use positive reinforcement D) Pad the area around the child
Ans: A
10. A nurse is caring for a client diagnosed with delirium who has been brought for treatment by his son. While taking the client's history, which question would be most appropriate for the nurse to ask the client's son? A) "Has your father taken any medications recently?" B) "Are you aware of your father falling or injuring his head in any way?" C) "Has your father had a recent stroke?" D) "Has your father experienced any major losses recently?"
Ans: A
10. A nurse is reviewing the assessment data of a client diagnosed with a mental illness. The client is to be prescribed medication to treat the illness. The nurse would identify changes in which laboratory values as being the least significant? A) Hemoglobin B) Alanine aminotransferase (ALT) C) Blood urea nitrogen (BUN) D) Serum creatinine
Ans: A
10. A nurse is working as part of a community disaster response team. When responding to a community disaster, the nurse integrates understanding of individuals' responses, anticipating which of the following? A) People can become aggressive and violent when their basic needs are threatened. B) People involved in the disaster will always put the welfare of others before their own. C) Losses incurred during the disaster have little, if any, long-term effect on victims. D) The psychological distress associated with disasters is felt immediately.
Ans: A
11. A client with insomnia is prescribed zolpidem. When describing the action of this medication to the client, the nurse would incorporate information related to the medication's effect on which of the following? A) Gamma-aminobutyric acid (GABA) B) Serotonin C) Dopamine D) Norepinephrine
Ans: A
11. A group of nursing students is reviewing information about the types of crisis. The students demonstrate understanding of the information when they identify which of the following as a developmental crisis? A) Going away to college B) Obtaining a job promotion C) Loss of a pet D) Earthquake
Ans: A
11. A nurse is caring for a client with somatic symptom disorder. When assessing this client, the nurse would be especially alert for symptoms of which of the following? A) Depression B) Avoidant personality disorder C) Delirium D) Bipolar disorder
Ans: A
12. A daughter brings her mother, who has Alzheimer's disease, to the clinic. The client has been taking a cholinesterase inhibitor medication for 1 month. When assessing the client, the nurse would be alert for the possibility of which side effect? A) Gastrointestinal distress B) Mild headache C) Muscle tics D) Blurred vision
Ans: A
12. As part of a community program on crisis prevention, a nurse is describing the phases of crisis. Which of the following would the nurse identify as occurring first? A) Person has a problem that doesn't "fit" with their usual problem-solving methods B) Trial-and-error attempts to alleviate the problem C) Automatic relief behaviors take over as the "fight-or-flight" hormones dissipate D) Person has serious personality disorganization
Ans: A
12. Of the following list of nursing interventions for the patient with posttraumatic stress disorder (PTSD), place them in order of priority, with the first being the highest priority. A) Ensure that the client's physical needs are met. B) Have the client identify the original trauma that started the PTSD. C) Establish suicidal/aggressive safety measures. D) Begin intensive one-on-one counseling.
Ans: A
13. A nurse is assessing a client who is a survivor of abuse. Which of the following would be most appropriate to use when conducting a lethality assessment? A) Danger Assessment Screen B) Abuse Assessment Screen C) Burgess-Partner Abuse Scale D) Beck Depression Inventory
Ans: A
14. A client is admitted to the hospital with dementia related to Parkinson's disease. The client is being treated for a fractured tibia from a recent fall. The nurse should assess the client's history for use of which type of medication? A) Anticholinergics B) Dopamine agonists C) Anxiolytics D) Benzodiazepines
Ans: A
14. A client is brought into the emergency department because he was involved in an automobile accident. His blood alcohol level (BAL) is 0.10 mg%. Based on this finding, the nurse would expect to assess which of the following? A) Difficulty with coordination B) Stupor C) Emotional lability D) Ataxia
Ans: A
14. A client who has attempted suicide has an underlying diagnosis of depression. Which of the following would the nurse anticipate being ordered for the client? A) Selective serotonin reuptake inhibitor B) Mood stabilizer C) Tricyclic antidepressant D) Atypical antipsychotic
Ans: A
14. After teaching a group of nursing students about pharmacotherapy and attention deficit hyperactivity disorder (ADHD), the instructor determines that the education was successful when they identify which agent as the first-line choice? A) Atomoxetine B) Bupropion C) Guanfacine D) Clonidine
Ans: A
14. When a client with obsessive-compulsive disorder (OCD) has developed self-harming thoughts and actions, the emergency department nurse should expect to administer which medication to assist with the client's anxiety/panic? A) Benzodiazepines such as lorazepam B) Antipsychotics such as lithium carbonate C) Analgesics such as morphine sulfate D) Tricyclic antidepressants such as amoxapine
Ans: A
15. A child with a tic disorder is prescribed an antipsychotic agent as part of his treatment plan. Which of the following would the nurse expect to be prescribed? A) Aripiprazole B) Haloperidol C) Clonidine D) Guanfacine
Ans: A
15. A client receiving lithium therapy has a plasma concentration of 2.2 mEq/L. Which of the following would the nurse expect to assess? A) Slurred speech B) Fine resting hand tremor C) Loose stools D) Muscular weakness
Ans: A
15. A group of nursing students is role-playing situations to practice using therapeutic communication techniques. Which of the following would the students identify as verbal communication? A) Emotion underlying the words B) Gestures C) Body language D) Expressions
Ans: A
15. A nurse is interviewing a client about his sleep patterns. He tells the nurse that he goes to bed about 11 p.m. and usually falls asleep by 11:15 p.m. The nurse identifies this time period as which of the following? A) Sleep latency B) Sleep architecture C) Sleep efficiency D) Slow-wave sleep
Ans: A
15. A nurse is working with a client who will be signing a commitment to treatment statement. After teaching the client about this statement, the nurse determines the need for additional instruction when the client states which of the following? A) "Signing this statement means that I will not commit suicide." B) "I am agreeing to get emergency treatment if I have suicidal thoughts." C) "I will be open and honest about my feelings about treatment." D) "I am agreeing to participate in the necessary treatment for my condition."
Ans: A
15. While a nurse is caring for a hospitalized client in the advanced stages of Alzheimer's disease, the client begins to have a catastrophic reaction to feeding himself. Which of the following should the nurse do first? A) Remain calm and reassuring B) Restrain the client temporarily C) Draw the curtains to darken the room D) Offer to feed the client
Ans: A
15. While talking with a client who has been experiencing aggression and intense anger, a nurse identifies that the client feels isolated and anxious. Which statement by the nurse would be most appropriate? A) "This must be scary for you." B) "Once you relax, things will improve." C) "I really understand how you feel." D) "If you calm down, I can help you."
Ans: A
16. After teaching a client who is prescribed phenelzine for treatment of somatic symptom disorder, the nurse determines that additional education is needed when the client states which of the following? A) "I can take an over-the-counter medicine for my hay fever." B) "I should avoid alcohol when I take this drug." C) "I should not stop taking the drug abruptly." D) "I need to report any panic attacks or irritability."
Ans: A
16. When caring for a client with mania, which of the following would the nurse most likely assess? A) Unusual self-confidence B) Slow, repetitive speech C) Logical thinking D) Narrowed focus
Ans: A
16. Which client statement most accurately reflects the cognitive dysfunction associated with borderline personality disorder (BPD)? A) "I was a total failure at my new job." B) "Sometimes things are not always clear cut." C) "At least some good came out of my trying." D) "You need to look at things in perspective."
Ans: A
17. A client with mania is exhibiting signs of a manic episode manifested by an elevated mood. Which of the following would the nurse expect to assess? A) Feelings of being on top of the world B) Lack of restraint with feelings C) Overvalued sense of self-importance D) Indiscriminate enthusiasm for interactions
Ans: A
17. A group of nursing students is reviewing information about delirium and dementia. The students demonstrate a need for additional review when they identify which of the following as a characteristic of dementia? A) Fluctuating changes within a 24-hour period B) Possible hallucinations C) Normal psychomotor activity D) Globally impaired cognition
Ans: A
17. A nurse is reviewing the medical record of a female client diagnosed with borderline personality disorder (BPD). Which of the following would the nurse identify as one of the strongest risk factors for this disorder? A) Abuse as a child B) Parental alcohol abuse C) Poverty D) History of depression
Ans: A
17. An advanced practice psychiatric nurse is preparing to conduct a support group for psychiatric-mental health nurses who have been assaulted by clients. Which of the following would the nurse need to keep in mind with this group? A) Nurses experience a conflict between the role of caregiver and victim. B) Nurses who are victims often go on to prosecute the client attackers. C) Nurses actively express the feelings associated with client assaults. D) Nurses as victims of client assaults rarely experience guilt or shame.
Ans: A
17. When explaining kindling to a group of nursing students in their mental health rotation, which of the following would the nurse use as the best explanation of "kindling"? A) With repeated reexperiencing of the traumatic event, posttraumatic stress disorder symptoms become more easily triggered with time. B) After combat exposure a client has little or no reaction when a car backfires on the road. C) The sensitized client will no longer react to later, milder stressors that are similar to their initial exposure. D) The symptoms associated with the stressor will correlate to a decrease in dopamine activity.
Ans: A
18. A client with borderline personality disorder (BPD) tells the nurse, "You are good but the nurse on the afternoon shift is bad. The doctor is bad, too, but the therapist is good." The nurse interprets this statement as reflecting which of the following? A) Splitting B) Identity diffusion C) Dissociation D) Cognitive schema
Ans: A
18. The mother of a child age 4 years with autism spectrum disorder tells the nurse that the child rocks continuously but that "she doesn't hurt herself." Which of the following would be most appropriate for the nurse to suggest? A) Ignore the behavior. B) Tell the child to stop. C) Hold the child until she stops rocking. D) Put the child in time-out for 4 minutes.
Ans: A
18. When describing the characteristic similarities and differences between anorexia nervosa and bulimia nervosa, which of the following would the nurse identify as specific to bulimia? A) Boundary problems B) Low self-esteem C) Perfectionism D) Obsessiveness
Ans: A
19. A nurse is preparing to assess a client with a paranoid personality trait. The nurse integrates knowledge of this condition, anticipating that the client's affect and behavior will most likely be which of the following? A) Angry and hostile B) Flirtatious and seductive C) Fearful and anxious D) Friendly and open
Ans: A
19. A nurse is reading a journal article about anger and violence. Which of the following would the nurse expect to see as being linked to excessive, outwardly directed anger? A) Myocardial infarction B) Hypertension C) Arthritis D) Chronic pain
Ans: A
2. A hospitalized client diagnosed with depression asks a nurse, "Should I go home this weekend?" Which response by the nurse uses the technique of reflection? A) "Should you go home for the weekend?" B) "Home means what to you?" C) "It sounds as if you don't want to go home this weekend." D) "I doubt that you really should go home this weekend."
Ans: A
2. A nurse is caring for a young adult in the mental health clinic. The client tells the nurse that he was physically neglected as a child. The nurse should assess the client for symptoms of which of the following? A) Major depression B) Schizophrenia C) Narcissistic personality disorder D) Panic disorder
Ans: A
2. A student nurse is preparing a nursing care plan for a client who has insomnia and is experiencing sleep deprivation. Which nursing diagnosis would the nurse most likely identify as reflecting a priority care issue? A) Risk for Injury B) Ineffective Coping C) Deficient Knowledge D) Anxiety
Ans: A
2. A woman with borderline personality disorder has been admitted to the inpatient unit because she has been engaging in wrist cutting. The client's sister is visiting, and she asks the nurse to explain why the client sometimes does this to herself. Which response by the nurse would be most appropriate? A) "Sometimes the self-injurious behavior is undertaken to relieve stress." B) "Self-injurious behavior often calms and sedates people with this diagnosis." C) "Sometimes they do it to avoid the onslaught of delusional thinking." D) "The self-mutilation often slows the mood swings your sister experiences."
Ans: A
20. A nurse is caring for a client with schizoid personality trait. When developing a plan of care for the client, which of the following would a nurse most likely include? A) Social skills training B) Anger management training C) Relaxation techniques D) Coping skills training
Ans: A
23. After educating a group of nursing students on Alzheimer's disease and appropriate nursing care, the instructor determines that the education was successful when the students identify which of the following as the foundation for providing care to the client and family? A) Therapeutic relationship B) Medication therapy C) Injury prevention D) Functional independence
Ans: A
25. A client with Alzheimer's disease is admitted to an acute care facility for treatment of an infection. Assessment reveals that the client is anxious. When developing the client's plan of care, which of the following would be least appropriate for a nurse to include? A) Frequently provide reality orientation B) Simplify the client's routines C) Limit the number of choices to be made D) Establish predictable routines
Ans: A
27. A nurse is reviewing the medical record of a client diagnosed with antisocial personality disorder. The nurse notes that the client has had numerous episodes involving irritability, aggressiveness, and impulsivity, and has exhibited callousness toward others. Based on this information, which nursing diagnosis would the nurse most likely identify as a priority? A) Risk for Other-Directed Violence B) Risk for Self-Injury C) Risk for Suicide D) Risk for Self-Directed Violence
Ans: A
3. A client receives a court order for commitment. Which of the following best exemplifies the concept of "least restrictive environment"? A) Involuntary commitment to an outpatient community mental health center B) Medication administration for sedation so the client cannot get out of bed C) Placing the client in a locked, padded room in response to threats of self-harm D) Allowing the client to make the decision about whether treatment is necessary
Ans: A
3. A client tells a nurse that he is committed to trying to quit smoking. When educating the client on smoking cessation, which of the following would the nurse include? A) Success usually involves more than one type of intervention. B) Relapse is fairly rare within the first year of quitting. C) Ear acupressure is a highly proven method for quitting. D) The drug varenicline is widely used among patients with psychiatric disorders.
Ans: A
3. A client who is hospitalized with depression tells a nurse, "I don't want to take the medication because I'm afraid I'll become suicidal." Which response by the nurse would be most appropriate? A) "Have you ever thought about hurting yourself?" B) "It's important that you take this medication." C) "I agree with you. I wouldn't want to take this medication either." D) "Another client took that medication, and he really felt better."
Ans: A
3. A nurse is caring for a client in the outpatient setting who has been diagnosed with a depressive disorder. Before the client is given a prescription for a tricyclic antidepressant, assessment for which of the following would be most important? A) Suicide B) Hypersomnia C) Cardiac dysrhythmias D) Erectile dysfunction
Ans: A
3. A nurse is reviewing the medical record of a client with bipolar disorder. The nurse would most likely expect to find a history of which of the following? A) Panic disorder B) Schizophrenia C) Delusional disorder D) Posttraumatic stress disorder
Ans: A
3. A nursing instructor is preparing a class about functional neurologic symptoms. Which of the following would the instructor most likely include as an assessment finding? Select all that apply. A) Difficulty swallowing B) Spasticity C) Urinary frequency D) Aphonia E) Blindness
Ans: A, D, E
30. A nurse is interviewing a client and suspects that the client may have narcissistic personality disorder. Which statement by the client would help support the nurse's suspicions? A) "I have a very important position in life; everyone I know wants to be like me." B) "My wife is poisoning my food so she can get rid of me and marry her boss." C) "I like to work alone because then I can let my thoughts wander." D) "I'm always the life of the party, making new friends all the time."
Ans: A
32. A nurse is describing histrionic personality disorder to a group of new nurses. Which term would the nurse most likely use? A) Attention seeking B) Psychopath C) Sociopath D) Lacking empathy
Ans: A
34. After reviewing information about different personality disorders, a group of nursing students demonstrates understanding when they identify which of the following as associated with schizoid personality disorder? A) Introverted B) Overly friendly C) Highly social D) Exuberant
Ans: A
4. A nurse is assessing a client who has borderline personality disorder. Which of the following would be a priority? A) Nutrition patterns B) Personal hygiene practices C) Physical functioning D) Somatic complaints
Ans: A
4. When engaged in a nontherapeutic relationship, which of the following would a nurse identify as occurring first? A) Failure to recognize the client as a person with a need B) The client avoiding the nurse C) The nurse being perceived as rude D) The client feeling hopeless and frustrated
Ans: A
5. A nurse engaged in an interaction with a client recognizes body space zones. Which of the following would the nurse identify as the individual's personal zone? A) Beginning at the boundary of the intimate zone and ending at the social zone B) Extending outward from the border to the public zone C) Surrounding and protecting an individual from others, especially outsiders D) The most distant boundary that can be used for recognizing intruders
Ans: A
5. A staff nurse on a psychiatric unit knows that clients often have trouble sleeping because of their psychiatric conditions. Which of the following reflects a psychiatric nursing intervention to appropriately address this problem? A) Limiting amounts of evening snacks and beverages B) Involving clients in a volleyball game immediately before bedtime C) Enforcing the rule that all patients be in bed with lights out by 10:30 p.m. D) Encouraging clients to take short naps in the afternoons
Ans: A
5. Assessment of an older adult diagnosed with dementia with Lewy bodies reveals that the client is receiving psychiatric medications. The client states, "I get dizzy periodically and have trouble walking." Which of the following should the nurse do first? A) Assess for development of orthostatic hypotension. B) Instruct the client to stop taking the psychiatric medications. C) Interview the client's family about the client's coping skills and current stress level. D) Suggest the client periodically use an alcohol-based mouthwash several times a day.
Ans: A
6. A Red Cross nurse is working with tornado victims. The nurse is interviewing a woman whose house was totally destroyed during the night by the tornado. The woman's pet poodle died as a result of the tornado. Which of following would the nurse most likely expect to hear from the woman? A) "I don't know. I can't feel anything right now. Nothing seems real." B) "Devastated . . . I just feel totally devastated. I don't know how I can go on living." C) "I just want my insurance man to get here so I can file a claim. Everything I had is gone." D) "I always thought my dog would die peacefully in my arms. Now I'll never be able to hold her again."
Ans: A
6. A client who has been diagnosed with panic disorder visits the clinic and experiences a panic attack. The client tells the nurse, "I'm so nervous. My hands are shaking, and I'm sweating. I feel as if I'm having a stroke right now." What would be the priority intervention at this time? A) Stay with the client while remaining calm. B) Move the client to a safe environment. C) Tell the client that the attack will soon pass. D) Teach the client deep breathing techniques to calm her.
Ans: A
6. A client with bipolar disorder is receiving divalproex sodium as part of the treatment plan. When monitoring the client's blood concentration of this drug, which level would alert the nurse to the need to change the dosage? A) 30 ng/mL B) 55 ng/mL C) 75 ng/mL D) 115 ng/mL
Ans: A
6. A client with bulimia nervosa is scheduled for a visit to the clinic. When assessing this client, which of the following would a nurse expect to find? A) Impulsivity B) Panic C) Hyperactivity D) Delusions
Ans: A
6. A nurse is caring for a client diagnosed with borderline personality disorder. The nurse has instructed the client about using the communication triad. The nurse determines that the client has understood this technique when he states which of the following? A) "I should start by stating my feelings as an 'I' statement." B) "Maybe I should start by describing the situation that has me upset." C) "I should first tell the other person what I'd like to be different about the situation." D) "I should begin by telling the other person what has triggered my emotion."
Ans: A
6. A nurse is providing a presentation about suicide to a group of health professionals. Which of the following would the nurse address as a major contributing factor to the rising suicide rate among men? A) Substance abuse B) Media influences C) Lack of conflict resolution skills D) Parenting practices
Ans: A
7. A client has been admitted to the psychiatric unit with a diagnosis of narcolepsy. Which client statement would the nurse interpret as reflecting this condition? A) "Sometimes I fall asleep when I'm driving my car home from work." B) "I often have brief periods of intense excitement when going to sleep, and my legs won't hold still." C) "I lie there and worry all night, and it keeps me awake. I just can't relax." D) "I think my sleep pattern is messed up because I took sleeping pills when I was younger."
Ans: A
7. A client with bipolar disorder, having experienced a depressive episode, is prescribed lamotrigine. After educating the client on this medication, the nurse determines that the education was successful when the client states which of the following? A) "I need to notify my physician if I develop a skin rash." B) "I need to have my blood tested about once a month." C) "I have to watch how much salt I use every day." D) "This drug can affect my liver function."
Ans: A
7. A nurse has just completed a suicide risk assessment of a widowed man 76 years of age. In addition to documenting the presence or absence of suicidal thoughts, a suicide plan, and the client's available means, the nurse would also document which of the following? A) Use of substances 6 hours before the assessment B) Speech patterns C) Availability of support resources D) Amount of sleep in past 24 hours
Ans: A
7. A nurse is working with a client who is addicted to heroin. The nurse engages in harm reduction by educating the client about which of the following? A) Needle exchange programs B) Problem solving C) Healthy coping skills D) Proper use of naltrexone
Ans: A
7. Parents of a child who is exhibiting obsessive-compulsive disorder (OCD) may notice the child: A) Is failing classes due to a lack of concentration. B) Spending excessive amount of time in their room. C) Frequently "stares off into space." D) Is jittery and nervous all the time.
Ans: A
8. A client's psychiatrist informs her that he thinks she needs to participate in a 3-month outpatient aftercare program after her discharge. Which of the following would protect the client's right to request a second opinion before agreeing to this suggestion? A) Self-determinism B) Least restrictive environment C) Confidentiality D) Mandates to inform
Ans: A
8. A group of students is reviewing the process of verbal communication. The students demonstrate understanding of the information when they identify which of the following as the first component of the process? A) Formulation of an idea B) Message encoding C) Message transmission D) Message reception
Ans: A
8. A man 20 years of age arrives at the emergency department by ambulance. He is unconscious, with slow respirations and pinpoint pupils. There are "tracks" visible on his arms. The friend who came with him reports that the client had just "shot up" heroin when he became unconscious. Which medication would the nurse most likely expect to administer? A) Naloxone B) Naltrexone C) Bupropion D) Varenicline
Ans: A
8. A nurse is reviewing the medical history of a client diagnosed with somatic symptom disorder. Which of the following would the nurse expect to find as a comorbid condition? A) Depression B) Bipolar disorder C) Thought disorder D) Sleep disorder
Ans: A
8. A psychiatric-mental health nurse working in the community is planning an educational program for fifth- and sixth-grade teachers. Which of the following would the nurse include? A) Discussion of strategies the teachers can use to counteract the role media plays in encouraging eating disorders B) Emphasis on the need for teachers to focus their prevention efforts on female students C) Stressing the need to allow students to eat without undue attention or supervision in order to prevent inadvertently influencing eating patterns D) Clarification that peer pressure is not typically problematic in children who are in the fifth and sixth grades
Ans: A
8. After educating a group of nursing students about intellectual disability and adaptive behavior, the instructor determines that additional education is needed when the group identifies which of the following as a type of skill involved with adaptive behavior? A) Intellectual skill B) Conceptual skill C) Social skill D) Practical skill
Ans: A
8. While lecturing on the psychodynamic theory behind symptoms of obsessive-compulsive disorder (OCD), a faculty member mentions reaction formation. Which of the statements below is characteristic of this theory? A) When parents are too harsh during potty training, the child may feel dirty and ashamed. Then the child may deliberately soil his or her clothes as an act of rebellion. B) Fear in individuals with OCD will trigger a fear associated with unwashed hands that are very unlikely to cause real harm. However, they keep washing their hands frequently. C) Compulsions are rewarded by the immediate reduction of distress or anxiety. Clients carrying out the compulsive rituals never get to test out their faulty thinking that there is not a dire consequence if they make a mistake. D) Clients report their symptoms. Such report is retrospective and so may not be accurately recalled, and it yields subjective data that are vulnerable to bias and distortion.
Ans: A
9. A group of nursing students is reviewing information about maladaptive anger. The students demonstrate a need for additional study when they identify which physical condition as being linked to suppressed anger? A) Coronary heart disease B) Arthritis C) Hypertension D) Breast cancer
Ans: A
9. A home health nurse is making a home visit to a psychiatric client who was recently discharged from a mental health unit. During the visit, the nurse plans on clarifying with the client when she will return for the next home visit. During which stage would the nurse discuss the next home visit with the client? A) Closure stage B) Service implementation C) Greeting stage D) Focus establishment
Ans: A
9. After educating a group of nursing students about the neurobiologic theories of depression, the instructor determines the need for additional education when the students identify which neurotransmitter as playing a role? A) Gamma-aminobutyric acid (GABA) B) Norepinephrine C) Serotonin D) Dopamine
Ans: A
1. A nurse is caring for a client age 78 years who is taking an anticholinergic medication and complains of dry mouth. Which of the following would be most appropriate for the nurse to suggest? Select all that apply. A) Chew hard candies. B) Rinse the mouth with a glycerol mouthwash. C) Use more seasonings on food. D) Drink decaffeinated beverages often.
Ans: A, B
11. A group of nursing students is reviewing the similarities and differences between bulimia nervosa and binge-eating disorder (BED). The students demonstrate understanding when they identify which characteristics as specific to BED? Select all that apply. A) Clients typically are obese. B) Clients refrain from purging behaviors. C) Binge-eating periods are shorter. D) Clients engage in overexercising. E) Feelings of guilt do not occur after binging.
Ans: A, B
13. A nurse is developing an education plan for a client who is prescribed escitalopram. Which of the following side effects would the nurse include in this plan? Select all that apply. A) Weight gain B) Decreased sexual interest C) Sedation D) Blurred vision E) Urinary retention F) Dry mouth
Ans: A, B
20. A nursing instructor is preparing a presentation on the etiology of Alzheimer's disease (AD). When discussing the role of neurotransmitters in the course of the disease, which of the following would the instructor most likely emphasize? A) Serotonin B) Acetylcholine C) Dopamine D) Norepinephrine
Ans: B
15. A client with panic disorder who has been prescribed sertraline in conjunction with alprazolam comes to the clinic for a follow-up. The client states, "I stopped taking the alprazolam about 2 days ago. I was feeling really sleepy and tired." Which of the following would alert the nurse to suspect possible withdrawal? Select all that apply. A) Apprehension B) Irritability C) Dry, flushed skin D) Weight gain E) Muscle flaccidity
Ans: A, B
18. A client is diagnosed with bipolar I disorder. When assessing the client, the nurse would be alert for signs of other comorbidities, including which of the following? Select all that apply. A) Panic disorder B) Social phobia C) Antisocial personality disorder D) Delirium E) Somatoform disorder
Ans: A, B
20. If a client is experiencing "moderate" anxiety, a nurse will observe which of the following clinical manifestations? Select all that apply. A) The client can sustain attention on a particular focus. B) Verbally states, "For some reason, I am feeling anxious now." C) Flights of ideas and confusion are noted. D) Because of inadequacy of observed data, they make distorted inferences. E) The client may pace, run, or fight violently if asked to perform a task they do not want to perform.
Ans: A, B
29. A nurse is assessing a client diagnosed with avoidant personality disorder. Which of the following would the nurse most likely expect to find? Select all that apply. A) Shyness B) Feelings of inadequacy C) Feelings of superiority D) Perfectionism E) Detail oriented
Ans: A, B
8. Of the following items, which should the nurse discuss with the client about what the client's responsibilities are during the first meeting? Select all that apply. A) Attendance is expected for each session. B) Participation is expected during each session. C) How to make up sessions if the client doesn't feel like attending meetings. D) If the client feels anxious, they should take additional antianxiety medications. E) The client should be able to focus on the topics and not interrupt others during the session.
Ans: A, B
9. A group of nursing students is reviewing possible risk factors for development of borderline personality disorder. The students demonstrate understanding of the information when they identify which of the following as a risk factor? Select all that apply. A) Childhood sexual abuse B) Parental loss C) Substance abuse D) Family history E) Genetics
Ans: A, B
9. When a client with extremely severe obsessive-compulsive disorder (OCD) is no longer responding to intensive drug therapy or behavioral therapy, what other treatment options should the nurse prepare to educate the client/family about? Select all that apply. A) Stereotactic surgical procedures B) Deep-brain stimulation with electrical current C) Biofeedback techniques D) Service and companion dogs E) Hypnotherapy
Ans: A, B
10. A group of nursing students is preparing a class presentation on therapeutic and nontherapeutic techniques of communication. The students demonstrate understanding of the information when they select which techniques to demonstrate as therapeutic? Select all that apply. A) Confrontation B) Open-ended statements C) Reflection D) Reassurance E) Agreement F) Challenges
Ans: A, B, C
14. Which of the following features should appear when motivational interviewing is being utilized? Select all that apply. A) Eliciting and strengthening client change talk B) Negotiating change plans C) Firming up client commitment D) Trying to "stick to the plan" without adapting to the moment E) Utilizing feedback at the very last session
Ans: A, B, C
17. A child is prescribed atomoxetine to treat attention deficit hyperactivity disorder. When educating the child and parents about common side effects, which of the following would the nurse include? Select all that apply. A) Headache B) Abdominal pain C) Decreased appetite D) Nervousness E) Dyskinesias
Ans: A, B, C
18. A client has been diagnosed with obsessive-compulsive disorder (OCD). While further assessing this client, the nurse should be aware of which other mental health disorders that may be associated with OCD? Select all that apply. A) Depression B) Bipolar disease C) Mood disorder D) Schizophrenia E) Psychosis.
Ans: A, B, C
2. A client is admitted to the inpatient adult psychology unit with posttraumatic stress disorder (PTSD). When assessing the cause, the nurse can identify which of the following to be the result of psychological trauma? Select all that apply. A) Experienced abuse from a former partner B) Was raped while walking home from work one evening C) Lost their mother, with whom they had very close to relationship D) Had a car accident in which they suffered head trauma E) Regularly cuts their wrists as a form of self-inflected trauma
Ans: A, B, C
20. A client with bipolar disorder is prescribed lithium. The nurse is reviewing the client's medication history for drugs that could interact with lithium. The nurse would monitor the client's serum lithium concentrations closely for toxicity if the client's medication history included which of the following? Select all that apply. A) Captopril B) Fluoxetine C) Hydrochlorothiazide D) Mannitol E) Isosorbide
Ans: A, B, C
5. A client is to receive lithium therapy as part of the treatment plan for bipolar disorder. When reviewing the client's medication history, which agents would alert the nurse to the possibility that a decrease in the lithium dosage may be needed? Select all that apply. A) Lisinopril B) Hydrochlorothiazide C) Indomethacin D) Caffeine E) Aspirin
Ans: A, B, C
5. When presenting posttraumatic stress disorder (PTSD) to a group of nursing students, the faculty gives examples of traumatic events that may precede PTSD, which include which of the following? Select all that apply. A) Personal assault by a family member B) Military combat mission where there were casualties C) Surviving an EF 4 tornado D) Falling off a playground swing E) Urinary incontinence due to a prolapsed bladder
Ans: A, B, C
9. A nurse is obtaining a history from a client who drinks about six cups of coffee and several diet cola drinks per day. The client states, "I just cut down my coffee and soda intake to one per day." Which of the following would the nurse most likely expect to assess? Select all that apply. A) Headache B) Fatigue C) Yawning D) Flushing E) Diuresis
Ans: A, B, C
18. A client is brought to the emergency department after having overdosed on cocaine. When assessing the client, which of the following would a nurse expect to find? Select all that apply. A) Euphoria B) Seizures C) Cardiac arrhythmia D) Paranoia E) Insomnia
Ans: B, C
22. A nurse is reading a journal article about the various theories associated with the development of antisocial personality disorder. The article mentions difficult temperament as a possible theory. The nurse demonstrates understanding of this concept when identifying which of the following as a key behavior associated with a difficult temperament? Select all that apply. A) Aggression B) Inattention C) Hyperactivity D) Impulsivity E) Depression F) Paranoia
Ans: A, B, C, D
28. A client is brought into the emergency department because of complaints from neighbors that the client was acting strangely. The nurse assesses the client and suspects schizotypal personality disorder based on assessment of which of the following? Select all that apply. A) Magical beliefs B) Hallucinations C) Paranoia D) Avoidance of eye contact E) Meticulous dress
Ans: A, B, C, D
16. A group of students is preparing a class presentation about negligence. Which of the following would the group include as an element required for proving negligence? Select all that apply. A) Duty to provide care B) Proximate cause C) Resultant damages D) Breach of duty E) Cause in fact F) Evidence of mistake
Ans: A, B, C, D, E
20. When assessing a client's anger, which of the following would be important for a nurse to obtain? Select all that apply. A) How the person expresses the anger B) Problems at work resulting from the anger C) Frequency of the anger episodes D) Evidence of coping techniques E) The intensity of the anger, outwardly or inwardly
Ans: A, B, C, D, E
37. A nurse is assessing a client who is reported to have a difficult temperament. Which of the following behaviors would the nurse expect to assess? Select all that apply. A) Aggression B) Inattention C) Hypoactivity D) Impulsivity E) Talkativeness
Ans: A, B, D
7. Of the following actions, which indicate that the relationship between nurse and client may be moving outside professional boundaries? Select all that apply. A) The client brings the nurse a baked item for their lunch. B) The nurse is spending more time with the client than the others in the group. C) The nurse objectively listens and contributes to the team meeting about behaviors the client is displaying. D) The nurse tells a friend that she is the only one who truly understands this client. E) The nurse informs her supervisor that the client asked her to "keep a secret from the rest of the staff."
Ans: A, B, D
4. A nurse is completing the admission of a client who is seeking treatment for alcoholism. He tells the nurse that the last time he had any alcohol to drink was at 10 a.m., before he left for the hospital. The nurse closely monitors the client. Which of the following would lead the nurse to suspect that the client is experiencing stage 1 of alcohol withdrawal syndrome? Select all that apply. A) Slight diaphoresis B) Hand tremors C) Intermittent confusion D) Heart rate of 135 beats/min E) Normal blood pressure
Ans: A, B, D, E
14. A unit in an inpatient psychiatric facility is experiencing an increase in violence episodes by clients. A group of nurses working on this unit is developing a plan to address this issue. When developing this plan, which of the following would the nurses most likely address as the problem areas? Select all that apply. A) Inconsistent unit activities B) Medication power struggles C) Empathetic staff response D) Clearly set boundaries E) Little client participation in treatment plan
Ans: A, B, E
2. A client with obsessive-compulsive disorder (OCD) is using cue cards to help restructure thought patterns. Which statements would be appropriate to include on a cue card? Select all that apply. A) "These are the OCD thoughts." B) "Trust myself." C) "Keep on checking." D) "Safety is the key." E) "I did it right the first time."
Ans: A, B, E
19. To promote sleep hygiene, a nurse should encourage a client with posttraumatic stress disorder (PTSD) to incorporate which of the following strategies into his routine? Select all that apply. A) Go to bed at a regular time nightly. B) Sleep in during the mornings when he had a restless night of sleep. C) Avoid drinking alcohol before bedtime. D) Enjoy a cup of caffeinated tea in the midafternoon if he gets sleepy. E) Exercise within 2 hours of bedtime to make him tired and enable him to fall to sleep faster.
Ans: A, C
23. A nurse is developing a plan of care for a client diagnosed with an antisocial personality disorder who has been admitted to the inpatient psychiatric unit. Which of the following would the nurse most likely include? Select all that apply. A) Developing a therapeutic relationship B) Bargaining about the unit rules C) Holding the client responsible for behavior D) Discouraging client from discussing thoughts E) Using a firm, lecture-like approach for teaching
Ans: A, C
3. Which of the following statements is accurate with regard to resilience in clients who have experienced posttraumatic stress disorder (PTSD)? Select all that apply. A) The stronger the resilience, the less likely the person will develop maladaptive behaviors. B) When one is feeling out of control in one's life, resilience is no longer possible. C) As positive self-concept increases, resilience also increases over time. D) Everyone who experiences a traumatic event can develop resilience. E) Only those with a supportive family can develop resilience.
Ans: A, C
7. In posttraumatic stress disorder (PTSD), which of the following signs/symptoms could be classified as intrusive? Select all that apply. A) When the client reexperiences a traumatic image B) No longer dream during REM sleep C) Have feelings that the event is reoccurring D) Complain of excessive sleeping, usually 12 hours or more per day E) Feel like they are suspended in outer space and cannot find their way home
Ans: A, C
10. A nursing instructor is preparing a class discussion on the topic of self-determinism. Which of the following would the instructor expect to include? Select all that apply. A) Personal autonomy as a key value B) Choices based on pleasing others C) Activities reflect personal goals D) Right to refuse treatment E) Lack of empowerment
Ans: A, C, D
11. A nurse is performing a biopsychosocial assessment of a client with depression. Which of the following would the nurse assess as part of the psychological domain? Select all that apply. A) Abstract reasoning B) Medication use C) Mood D) Orientation E) Self-care
Ans: A, C, D
9. Common manifestations following a traumatic experience that leaves a nurse thinking a client is experiencing physiologic hyperarousal include which of the following? Select all that apply. A) Urinates frequently B) Startles easily C) Overreacts to others D) Avoids places associated with the event E) Has vivid dreams
Ans: B, C
12. A client comes to the clinic for an evaluation of headache, fatigue, and an overall feeling of being "down." When assessing the client, which statement by the client would alert the nurse to suspect possible suicide? Select all that apply. A) "I've been drinking about three or four more beers every night." B) "I've been going out with my friends about once or twice a week." C) "I'm so tired that all I ever want to do is sleep all the time." D) "Most times, I feel like I'm trapped with no way out." E) "I'm looking for a new job because my job is so stressful."
Ans: A, C, D
17. A nurse is providing care for a client who has somatic symptom disorder and is exhibiting anxiety about having a severe illness. Which of the following would be appropriate for the nurse to do? Select all that apply. A) Listen closely to the client's report of symptoms. B) Ignore the client's report of symptoms and make a professional nursing assessment. C) Acknowledge that what the client is saying may be real. D) Encourage the client to write down symptoms in a journal. E) Review the symptom pattern with the client.
Ans: A, C, D, E
3. A client is diagnosed with obsessive-compulsive disorder (OCD) and is to receive medication therapy. Which of the following agents might the nurse expect to be prescribed? Select all that apply. A) Clomipramine B) Lithium C) Sertraline D) Fluvoxamine E) Paroxetine F) Alprazolam
Ans: A, C, D, E
35. A nurse is conducting an in-service program on personality disorders. When describing obsessive-compulsive personality disorder, which characteristics would the nurse most likely include? Select all that apply. A) Preoccupation with control B) Inability to delay rewards C) Strict attention to rules D) Difficulty with decision making E) Relationships primarily formal and polite
Ans: A, C, D, E
8. A nursing instructor is preparing a class discussion on personality disorders and characteristics. Which term would the instructor include to differentiate personality disorders from normal personality? Select all that apply. A) Inflexible B) Short term C) Pervasive D) Unstable over time E) Distressing
Ans: A, C, D, E
9. As part of a follow-up home visit to an client age 80 years who has had surgery, a nurse discusses the client's risk for delirium with his family members. Which of the following would the nurse include as placing the client at increased risk? Select all that apply. A) Urinary tract infection B) Hypertension C) Acute stress D) Bone fractures E) Dehydration F) Electrolyte balance
Ans: A, C, D, E
14. When describing the characteristics associated with borderline personality disorder (BPD), which of the following would a nurse most likely include? Select all that apply. A) Difficulty regulating moods B) Overinflated self-identity C) Problems with interpersonal relationships D) Thinking that is based on delusions E) Impulsive behavior
Ans: A, C, E
18. A client is brought to the emergency department by his wife. The wife states that over the past few hours, the client has become disoriented and confused. "He didn't know where he was and didn't seem to recognize me or be able to carry on a coherent conversation." The nurse suspects delirium. When reviewing the client's medication history with the wife, which of the following medications would alert the nurse to a potential cause? Select all that apply. A) Propranolol B) Acetaminophen C) Diphenhydramine D) Verapamil E) Quinidine
Ans: A, C, E
12. A client with bipolar disorder has a lithium drug concentration of 1.2 mEq/L. Which of the following would the nurse expect to assess? Select all that apply. A) Metallic taste B) Ataxia C) Diarrhea D) Slurred speech E) Fasciculations F) Muscle weakness
Ans: A, C, F
13. A nurse is preparing a presentation for a local middle school health class about eating disorders as a means for prevention and early detection. Which of the following would the nurse incorporate into the presentation as being common to both anorexia nervosa and bulimia nervosa? Select all that apply. A) Body dissatisfaction B) Feelings of control C) Obsessiveness D) Boundary problems E) Sexuality fears F) Cognitive distortions
Ans: A, C, F
13. A nursing instructor is describing the prevalence of sleep-wake disorders as being greater among individuals with mental health disorders. Which disorders would the instructor include as being associated with sleep-wake disorders? Select all that apply. A) Depression B) Borderline personality disorder C) Schizophrenia D) Posttraumatic stress disorder E) Anxiety
Ans: A, D
13. The middle phase of a deteriorating relationship usually consists of which of the following? Select all that apply. A) The client trying to avoid the nurse. B) The nurse trying to smother the client with attention. C) The client beginning to break as many rules as possible. D) The nurse ignoring and avoiding the client's requests for help. E) The client feeling defeated and hopeless.
Ans: A, D
14. After teaching a class about circadian rhythm disorders, a nursing instructor determines that the education was successful when the class identifies which of the following as a subtype identified in the DSM-5? Select all that apply. A) Delayed sleep phase B) Nightmare C) Sleep terror D) Shift work type E) Jet lag type
Ans: A, D
21. A nursing instructor is preparing an education plan about antisocial personality disorder for a class of nursing students. Which of the following would the nurse include as a term often used to describe the behaviors associated with this condition? Select all that apply. A) Psychopath B) Manipulator C) Criminality D) Sociopath E) Psychotic
Ans: A, D
13. A nurse is preparing an education session for parents of children with autism spectrum disorder. When describing problems associated with communication, which of the following would the nurse most likely include as common? Select all that apply. A) Repetition of words or phrases B) Abstract interpretation of language C) Early language development D) Reversal of pronouns E) Abnormal intonation
Ans: A, D, E
18. A group of students is reviewing information about social anxiety disorder in preparation for an oral class presentation. Which of the following would the students expect to include when describing a person with this condition? Select all that apply. A) Fear that others will judge them negatively B) Openly speak up in crowds to reduce fear C) Are insensitive to other's criticism D) Demonstrate a distorted view of their own strengths E) Exaggerate personal flaws
Ans: A, D, E
12. A nursing instructor is reviewing the various theories related to anorexia nervosa. Which of the following would the instructor include when describing theories related to the biologic domain? Select all that apply. A) Genetic vulnerability B) Separation-individuation C) Role pressures D) Dieting leading to starvation E) Pursuit of thinness F) Decreased serotonin activity
Ans: A, F
12. When assessing a client experiencing aggression, a nurse applies the general aggression model. Which of the following would the nurse assess as the person factors? Select all that apply. A) Client's personality traits B) Insult initiating the behavior C) Previous behavior patterns D) Client's shouting E) Client's mood F) Client's gender
Ans: A, F
1. A nurse is assessing the sleep patterns of a female client age 70 years with a mental disorder. Based on the knowledge of circadian rhythms and the influence of age, which of the following would the nurse anticipate that the client would report about her sleep pattern? A) "When I was younger, I didn't notice any differences in how I felt in the morning or evening." B) "Now it seems like I have difficulty falling asleep or staying asleep even when circumstances are adequate for sleep." C) "When I worked days, I'd always have trouble feeling sleepy in the morning." D) "When I was younger, the amount of sleep I got didn't seem to matter."
Ans: B
1. When engaged in therapeutic communication with a client who has a mental disorder, which of the following is the most important for a nurse to keep in mind? A) The nurse should self-disclose when indicated. B) The client is the primary focus of the interaction. C) The nurse should have an empathetic relationship with the client. D) The client's conversations should be recorded.
Ans: B
1. Which of the following questions would be most helpful in beginning an initial assessment interview for a client who has just been admitted to a psychiatric inpatient unit? A) "Have you had any previous psychiatric admissions?" B) "What brings you into the hospital today?" C) "Have you had any thoughts about trying to harm yourself? D) "How would you describe your relationship with your spouse?"
Ans: B
10. A client with somatic symptom disorder (SSD) also has anxiety. Which of the following would the nurse expect to be prescribed? A) Monoamine oxidase inhibitor (MAOI) B) Selective serotonin reuptake inhibitor (SSRI) C) Tricyclic antidepressant (TCAs) D) Atypical antipsychotic
Ans: B
10. A group of nursing students is reviewing information about intimate partner violence (IPV). The group demonstrates understanding of this topic when they identify which of the following? A) Men are more likely to be seriously injured even though more women are typically victims. B) Men may not consider behaviors such as slapping or shoving as abuse. C) IPV in same-sex couples occurs less frequently than in heterosexual relationships. D) The reactions to IPV are similar in male and female victims.
Ans: B
10. A group of students is reviewing information about anxiety disorders in preparation for a class examination. The students demonstrate understanding of the material when they state which of the following? A) Anxiety disorders rank second to depression in psychiatric illnesses being treated. B) Women experience anxiety disorders more often than do men. C) Most anxiety disorders tend to be short term, with individuals achieving full recovery. D) Anxiety disorders are more common among children than among adolescents.
Ans: B
10. A nurse is assessing a client with borderline personality disorder. Which question would be most appropriate to assess the client's level of impulsivity? A) "What things bother you and what things make you feel happy?" B) "Have you ever felt sorry after acting as you did on the spur of the moment?" C) "How do you view other people around you?" D) "Have you ever felt like you were separated from your body?"
Ans: B
10. A nurse is preparing to assess a middle-aged male client who was brought to the emergency department by his wife. She reports that her husband has been "extremely depressed lately." When assessing this client, which of the following would be a priority assessment? A) Changes in sleeping patterns B) Thoughts of self-harm C) Appetite changes D) Level of fatigue
Ans: B
10. While interviewing a client, a nurse asks, "What do you do when you get angry?" Which client response would indicate to the nurse that the client engages in anger suppression? A) "I've been known to fly off the handle when I'm angry." B) "People say I withdraw and pout about the problem." C) "I usually approach the person directly to talk about it." D) "I try to discuss how I'm feeling about it with a close friend."
Ans: B
11. A client is receiving methadone maintenance therapy. After teaching the client about this treatment, the nurse determines that the education was successful when the client states which of the following? A) "I can have a glass of wine with dinner if I choose." B) "I should eat small frequent meals if I get nauseated." C) "I should take the drug on an empty stomach." D) "I might experience diarrhea with this drug."
Ans: B
11. A client with posttraumatic stress disorder (PTSD) asks the nurse about this eye movement, desensitization, and reprocessing (EMDR) treatment. The nurse explains that this treatment: A) Takes a long time because you have to have counseling sessions a minimum of twice a week. B) Guides the client through images of the trauma, allowing for progressive desensitization. C) Blocks the trauma from appearing in the client's psychological frame using carefully placed electrical stimuli. D) Helps the client understand why recovering from the trauma is difficult and gives them new ways of coping.
Ans: B
11. After educating a class on factors that enhance the risk of suicide, the instructor determines the need for additional education when the class identifies which of the following? A) Family member committing suicide B) Cautiousness C) Delusions D) Loss
Ans: B
11. The plan of care for a client with anger includes behavioral interventions. Which of the following would the nurse be likely to find? A) Self-monitoring of cues B) Anger management C) Relaxation training D) Response disruption
Ans: B
12. A client comes to the emergency department complaining of a severe pounding headache in the temples and a stiff neck. The client is flushed and diaphoretic, and his pulse is racing. The client states that he is being treated for depression with selegiline. Which question by the nurse would be most important to ask at this time? A) "When did you last have blood drawn to check your drug level?" B) "What have you had to eat or drink today?" C) "Are you having any chest pain?" D) "Do you use any herbal remedies?"
Ans: B
12. A client with a history of alcohol abuse is participating in a 12-step Alcoholics Anonymous (AA) program. The nurse determines that the client is at step 2 when he states which of the following? A) "I've admitted to myself and others the wrongdoings I've done." B) "I realize that there is a higher power that can help me." C) "I know now that I am powerless over alcohol." D) "I am making amends to all those that I've harmed."
Ans: B
12. A group of nursing students is reviewing information about the types of abuse. The students demonstrate understanding of the information when they identify stalking as a crime of which of the following? A) Violence B) Intimidation C) Jealousy D) Fear
Ans: B
12. A nursing instructor is describing somatic symptom disorder to a group of nursing students. The instructor determines that the education was successful when the students state which of the following? A) The disorder typically is diagnosed in men. B) The first symptom usually appears during adolescence. C) The disorder commonly occurs with substance abuse. D) Highly educated individuals often develop this disorder.
Ans: B
12. During an interview, a client tells the nurse that he was recently let go from his job. As the interaction continues, the client states, "I was really overqualified for that position anyway. It was definitely below my area of expertise." The nurse interprets this information as reflecting which of the following? A) Denial B) Intellectualization C) Projection D) Passive aggression
Ans: B
13. A client is involuntarily committed without a court order. The nurse understands that the emergency, short-term hospitalization can occur for how long? A) A maximum of 24 hours B) 48 to 92 hours C) 3 to 5 days D) 1 week
Ans: B
13. A nurse is preparing an in-service presentation about panic disorders and associated theories related to the cause. When describing the cognitive-behavioral concepts associated with panic disorders, which of the following would the nurse expect to address? A) Personal losses B) Conditioned response C) Early separation D) Dysfunctional family communication
Ans: B
13. A nurse is preparing an in-service program about substance abuse and its etiology. Which of the following would the nurse most likely include in the presentation when discussing possible etiologies? A) Mixed self-esteem B) Genetic predisposition C) Dysfunctional family D) Peer influence
Ans: B
13. When utilizing cognitive restructuring for a client with obsessive-compulsive disorder (OCD), the nurse teaches the client to monitor automatic thoughts and recognize the connection between thoughts, emotional response, and behavior. The goal would be for the client to: A) Decrease their compulsive actions by 50%. B) Analyze their thoughts as incongruent with reality. C) Improve their sleeping patterns. D) Build time in their daily schedule to perform the compulsion without interruption.
Ans: B
14. A client with bipolar disorder has a history of multiple episodes and states, "I'm so frustrated with what's happened because of these episodes." Which of the following would the nurse encourage to help support this client's recovery? A) Codependence B) Hope C) Self-control D) Independent decision making
Ans: B
14. A nurse is developing a plan of care for a client with panic disorder that will include pharmacologic therapy. Which of the following would the nurse most likely expect to administer? A) Benzodiazepine B) Selective serotonin reuptake inhibitor (SSRI) C) Monoamine oxidase inhibitor (MAOI) D) Tricyclic antidepressant (TCA)
Ans: B
14. A nursing instructor is describing uncomplicated grief to a class. Which of the following would the instructor most likely include in the discussion? A) Uncomplicated grief differs from normal grief because it lasts longer. B) Most bereaved persons experience uncomplicated grief. C) Uncomplicated grief is primarily loss associated with death. D) This type of grief is less painful and disruptive than normal grief.
Ans: B
14. An instructor is educating a group of nursing students on defense mechanisms. The instructor determines that the education was successful when the group states which of the following? A) Most defense mechanisms are considered to be maladaptive, regardless of the situation. B) Defense mechanisms help mediate a person's response to emotional conflicts and external stressors. C) Use of defense mechanisms indicates that a person's mental state is dysfunctional. D) Persistent use of defense mechanisms commonly enhances a person's quality of life.
Ans: B
15. A nurse is working on developing a safety plan with a client who is a survivor of violence. Which of the following would the nurse address first? A) Devising an escape route B) Recognizing the signs of danger C) Identifying a safe place to hide D) Identifying a signal to indicate it is safe to leave
Ans: B
15. During assessing of a client with depression, the client states, "I just feel so sad and hopeless. I just don't care anymore. I don't even enjoy doing the crossword puzzles like I used to." The nurse documents this finding as indicative of which of the following? A) Dysthymic disorder B) Anhedonia C) Delusion D) Psychosis
Ans: B
16. A child diagnosed with autism spectrum disorder is hospitalized in an inpatient mental health unit. When developing the plan of care for this child, which of the following would be most important for the nurse to include? A) Ensuring that a variety of caregivers are available for the child B) Providing a consistent, structured environment with predictable routines C) Allowing the child frequent visits off the unit to provide stimulation D) Sending the child to the "time out" area if the child continually repeats phrases
Ans: B
16. A nurse is developing a plan of care for a client newly diagnosed with bulimia nervosa. Which of the following would the nurse expect to implement in conjunction with pharmacologic therapy? A) Behavioral therapy B) Cognitive behavioral therapy C) Interpersonal therapy D) Family therapy
Ans: B
16. A nurse is implementing a brief intervention with a client who is abusing alcohol. The nurse most likely would be involved with which of the following? A) Asking the client questions about alcohol use B) Negotiating a conversation with the client to reduce use C) Pointing out the inconsistencies in thoughts, feelings, and actions D) Helping the client change the way he thinks about a situation
Ans: B
16. Which of the following statements regarding posttraumatic stress disorder (PTSD) and children is accurate? A) The risk of developing PTSD following leukemia treatment is about the same as all children of the same age. B) Best practices demonstrate that adolescents who have PTSD are at increased risk of drug abuse. C) In a family unit where one child is diagnosed with cancer, all the children in the household are at increased risk for developing PTSD. D) Children who were abused during childhood are more likely to be diagnosed with obsessive-compulsive disorder rather than PTSD.
Ans: B
17. A nurse is preparing a presentation for family members of clients who have been diagnosed with depression. When describing the family response to depression, which of the following would the nurse include? A) Family members typically can understand how disabling depression can be. B) Depression in one family member affects the entire family. C) Abuse of the depressed person is a rare occurrence in families. D) Families of women older than 55 years of age with depression experience the majority of problems.
Ans: B
17. A psychiatric-mental health nurse is documenting information in a client's medical record. Which of the following would be least likely to increase the nurse's legal liability? A) "Client reported that he was feeling better today than yesterday." B) "Administered haloperidol 10 mg IM stat as ordered for agitation." C) "Client was talking with another staff member and started screaming." D) "Applied restraints to all four client extremities."
Ans: B
17. After teaching a group of nursing students about crisis, the instructor determines that the education was successful when the students state which of the following? A) "Crisis triggers maladaptive responses." B) "Crisis is a time-limited event." C) "Chronic crisis is a real situation." D) "Events causing a crisis are similar for everyone."
Ans: B
18. A client is engaged in bibliotherapy and begins to express his feelings because he closely associates his experience with that provided by the reading material. The nurse interprets this as which of the following? A) Insight B) Catharsis C) Anxiety reduction D) Problem solving
Ans: B
18. A client with posttraumatic stress disorder (PTSD) who is having recurring nightmares may be prescribed which of the following medications (as an off-label use) to treat the nightmares and improve sleep? A) Lorazepam, a benzodiazepine B) Prazosin, an alpha1 inhibitor C) Metoprolol, a β-adrenergic blocking agent D) Zolpidem, a sedative
Ans: B
18. A nurse is evaluating the outcomes for a client diagnosed with somatic symptom disorder. Which of the following would the nurse most likely identify as interfering with achievement? A) Outcomes were stated in realistic terms B) Outcomes addressed overall issues C) Outcomes indicated small successes D) Outcomes identified specific behaviors
Ans: B
19. A 34-year-old client with depression is admitted to an inpatient psychiatric unit. The nurse enters her room and initiates interaction with the client. When talking with the client, which approach would be least appropriate? A) Quiet and empathetic manner B) Animated and cheerful manner C) Matter-of-fact manner D) Respectful, direct manner
Ans: B
19. A client is prescribed disulfiram as part of his alcohol treatment program to prevent relapse. The client asks a nurse, "How will this drug help me?" Which response by the nurse would be most appropriate? A) "It will help to cure your alcoholism." B) "It can help to prevent you from drinking." C) "It makes the withdrawal symptoms less troublesome." D) "It helps to clear the alcohol out of your body."
Ans: B
19. A nurse is with an adolescent who tells the nurse that she has nothing to live for and she just wishes she was dead. Which nursing action would be the priority? A) Going to the client's psychiatrist to tell him of the girl's suicidal ideation B) Staying with the client to explore more of her thoughts about suicide C) Putting the client in seclusion with a staff assigned to watch her at all times D) Ascertaining the client's beliefs about what happens when you die
Ans: B
2. A client comes to the emergency department because he thinks he is having a heart attack. Further assessment determines that the client is not having a heart attack, but is having a panic attack. When beginning to interview the client, which question would be most appropriate for the nurse to use? A) "Are you feeling much better now that you are lying down?" B) "What did you experience just before and during the attack?" C) "Do you think you will be able to drive home?" D) "What do you think caused you to feel this way?"
Ans: B
2. A client's 5-year-old poodle ran in front of a car and was killed. The client continues to be upset by her pet's death, and she explains to a community counseling center nurse that she can't stop crying because, "My Precious meant the world to me, and now my world will never be the same!" If the nurse were to determine that the client was experiencing a crisis, which of the following types of crisis would it most likely be? A) Maturational B) Situational C) Traumatic D) Developmental
Ans: B
2. A nurse is counseling a parent whose child has a communication disorder. Which of the following would the nurse emphasize when educating the parent on this disorder? A) Providing the child with nonverbal activities B) Initiating conversations with the child frequently C) Stopping the child's conversation if stuttering begins D) Asking the physician for medication to improve the child's speech
Ans: B
2. A nurse is performing an admission assessment for an adolescent girl with an eating disorder who is being admitted to the psychiatric unit. Which statement would the nurse interpret as most likely supporting the client's diagnosis? A) "My father was always very thin." B) "I've never really liked myself." C) "I have a lot of confidence in myself." D) "I feel really close to my parents and my brother."
Ans: B
2. A psychiatric-mental health nurse determines that a client is competent when he is able to do which of the following? A) Speak coherent English B) Communicate his or her choices C) Write a "living will" D) Comply with the medical regimen
Ans: B
20. A group of nursing students is reviewing information about grief and bereavement. The students demonstrate understanding of the information when they identify which of the following? A) Grief and bereavement are used interchangeably as responses to loss. B) Bereavement is the process of mourning and grief is the emotional reaction. C) Grief involves confronting the stressor, but bereavement helps to avoid the stressor. D) Bereavement is influenced by culture, but grief is not.
Ans: B
20. New research by Singh and Jones (2013) found that clients diagnosed with hoarding may benefit from which of the following? A) Increased regular dose of an antianxiety medication B) Using a "buddy" system where members support each other outside the group C) Daily visits from a social worker trained to perform hypnosis D) Waste treatment companies stopping by to offer their services at a reduced rate
Ans: B
21. When assessing a client with dementia, a nurse identifies that the client is experiencing hallucinations. Based on the nurse's understanding of this disorder, which type of hallucination would the nurse expect as most common? A) Auditory B) Visual C) Gustatory D) Olfactory
Ans: B
24. A nurse is working with the family of a client who has been diagnosed with antisocial personality disorder. Which of the following would be most important for the nurse to focus on when teaching the family about this disorder? A) Anger management B) Boundary setting C) Medication therapy D) Self-responsibility
Ans: B
25. A group of nursing students is reviewing information about antisocial personality disorder. The students demonstrate understanding of this disorder when they state which of the following? A) The disorder occurs more frequently in women. B) The individual must be at least 18 years of age. C) The disorder is found primarily in Asian individuals. D) Alcohol abuse disorder rarely accompanies this disorder.
Ans: B
3. A client with a panic disorder has been prescribed a benzodiazepine medication. Which of the following would the nurse emphasize as a risk associated with using this medication? A) Dietary restrictions B) Withdrawal symptoms C) Agitation D) Fecal impaction
Ans: B
31. A nurse is developing an education plan for a client with an impulse-control disorder. The nurse is planning to explain the emotional aspects associated with the behavior as part of the plan. Which of the following would the nurse describe as occurring first, before the individual commits the act? A) Remorse B) Tension C) Regret D) Pleasure
Ans: B
36. A nurse is reviewing the medical record of a client diagnosed with antisocial personality disorder (ASPD). Which of the following would the nurse identify as having increased the client's risk for this condition? A) Conduct disorder at age 12 B) History of childhood attention deficit hyperactivity disorder (ADHD) C) Hispanic American cultural background D) Female gender with alcohol use disorder
Ans: B
38. A nurse is working with a client diagnosed with antisocial personality disorder. The nurse needs to keep in mind which of the following about the therapeutic relationship? A) The goal is to alleviate dysfunctional thinking. B) The relationship initially is superficial because of a lack of client commitment. C) The client uses the relationship to change the problem behavior. D) The client continuously focuses on new topics during the relationship.
Ans: B
4. A client is admitted to a mental health unit because she was found trying to inject diluted feces into her hospitalized child's intravenous line. The client has a history of similar attempts of harming the child. The nurse would most likely suspect which of the following? A) Schizoid personality traits B) Factitious disorder imposed on another C) Functional neurologic symptoms D) Borderline personality disorder
Ans: B
4. A nurse is caring for a client with major depression. The client tells the nurse that she "just isn't sure that life is worth living." The nurse documents which nursing diagnosis as the priority? A) Self-esteem, Low, related to depressive episode B) Hopelessness related to symptoms of depression C) Anxiety related to lack of energy for self-care activities D) Thought Processes, Disturbed, related to memory loss and depression
Ans: B
4. A nurse is providing an in-service educational program for beginning nurses regarding mental health assessment needs of older adults. One of the topics addressed is the importance of interviewing family members in addition to the older adult client. The nurse tells the audience that family members are sometimes able to give a more accurate history than the client himself if the client has memory impairment. The nurse also emphasizes that interviewing family members provides which of the following? A) A more accurate picture of the social support resources available B) Evaluation of the family's ability to effectively care for the older client C) Determination of the extent of the client's memory impairment D) A much-needed period of respite and support for the family members
Ans: B
4. A woman diagnosed with obsessive-compulsive disorder comes to the clinic with her husband. During the visit, the husband states, "She's always checking and rechecking to make sure that all of the appliances are turned off before we go out. It's nerve-wracking. We can never get out of the house on time. Isn't checking once enough?" An understanding of which of the following would the nurse need to incorporate into the response? A) The client is attempting to exert control over the situation. B) The client performs the ritual to relieve anxiety temporarily. C) The woman's behavior reflects a need for safety. D) The woman is attempting to use thought stopping to decrease her behavior.
Ans: B
4. The history of a child newly diagnosed with attention deficit hyperactivity disorder reveals that the child is experiencing sleeping difficulties. Which agent would the nurse most likely use? A) Methylphenidate B) Atomoxetine C) Bupropion D) Clonidine
Ans: B
5. A client is prescribed phenelzine to treat her depression. She is at a local café for lunch with a friend. Which of the following items on the menu would be least appropriate for the client to order? A) Roast beef, mashed potatoes, and gravy B) A Cobb salad with blue cheese and Roquefort salad dressing C) Scrambled eggs, toast, and grape jelly D) Medium-well steak, french fries, and broccoli
Ans: B
5. A nurse has instructed a client with panic disorder about how to use the technique of positive self-talk. The nurse determines that the client has understood the instructions when the client verbalizes which statement to use during an impending panic attack? A) "I am feeling very nervous right now." B) "I can handle this anxiety; it will be over shortly." C) "I am taking medication to eliminate these symptoms." D) "Relax your muscles, relax your muscles."
Ans: B
5. A nurse is preparing to initiate a behavioral treatment program for a child with encopresis. Which of the following would the nurse most likely implement first? A) Administration of mineral oil B) Bowel cleansing C) Low-fiber diet D) Sitting on the toilet after each meal
Ans: B
5. A nurse is working with a psychiatric client who was admitted to the inpatient facility and is being discharged. The client asks the nurse what he should do when he goes home to promote getting adequate sleep. Which response by the nurse would be most appropriate? A) "Go to bed at the same time every night and watch a television show that relaxes you." B) "Save your bedroom for sleeping; that means no work and no TV in the bedroom." C) "Why don't you ask your psychiatrist for a prescription for a sleeping pill?" D) "Make sure to keep the bedroom warm and toasty."
Ans: B
5. After educating a group of nurses about somatic symptom disorder (SSD), an instructor determines that the education was successful when the group identifies which of the following as a characteristic? A) Symptoms that remain relatively static B) Manifestations highly variable C) Symptoms that are easily manageable D) Reports of overall health as good
Ans: B
5. Which client would a nurse determine to be the most likely candidate for involuntary commitment? The client who: A) Refuses to take the prescribed medication B) Is screaming in the street disturbing neighbors C) Refuses to participate in the planned therapy D) Is homeless and has been diagnosed with a mental disorder
Ans: B
6. A client with somatic symptom disorder is complaining of significant pain in the joints. When providing care to this client, which of the following would be most important for a nurse to keep in mind? A) Opioid analgesics are the primary mode of therapy. B) The client's experience of pain is real. C) Complementary therapies are usually of little benefit. D) Outcomes need to reflect the biologic aspects of the pain.
Ans: B
6. A nurse is assessing a girl age 8 years with a mood disorder. Which of the following would the nurse most likely expect to assess? A) Statement from the child that she feels sad B) Behavioral problems C) Recurrent obsessions D) Ritualistic behavior
Ans: B
6. A nurse is providing care to a male client who is hospitalized with a diagnosis of schizophrenia. Which of the following would be appropriate for the nurse to include in the client's medical record? A) "Client states that he had a good night with no complaints." B) "Complained of being unable to sleep because he heard voices throughout the night." C) "Had a typical night without incidence of insomnia or nightmares." D) "Acted crazily throughout the night; kept hearing voices and noises."
Ans: B
6. A nurse is working with a female client who is anticipating the possibility of leaving an abusive relationship. In helping the client make the decision to leave or to stay in the abusive situation, which of the following would be most important for the nurse to do? A) Ensure that the client can effectively describe the behaviors inherent in each phase of the cycle of domestic violence. B) Inform the client that if she leaves the abusive situation, there is a possibility her partner will attempt to murder her. C) Assist the client in finding a new apartment and a new job so she will be safe after she leaves her current situation. D) Suggest that the client legally change her name and move out of state so she will be safe from future harm.
Ans: B
6. A nurse is working with a potentially violent client in a community clinic. Which of the following would the nurse implement to minimize personal risk? A) Using protective devices B) Staying close to a door C) Keeping the door closed to ensure privacy D) Wearing inexpensive jewelry to distract the client
Ans: B
6. A woman explains to her health care provider that she just has this cleaning ritual that she goes through every day. If something disrupts this cleaning schedule, she becomes: A) Depressed. B) Extremely anxious. C) Aggressive to the point of lashing out. D) Isolated from others.
Ans: B
7. A client with borderline personality disorder tells a nurse, "I'm afraid to get on a train because we'll probably get into a wreck." Which response by the nurse would be most appropriate? A) "Have you had a bad experience riding a train?" B) "What are the chances of that actually happening?" C) "Now, you know that won't happen." D) "Have you thought about going by automobile?"
Ans: B
7. A group of nurses is reviewing medications used to treat attention deficit hyperactivity disorder. The students demonstrate understanding of the information when they identify methylphenidate as which of the following? A) Selective serotonin reuptake inhibitor B) Psychostimulant C) Noradrenergic reuptake inhibitor D) Alpha agonist
Ans: B
7. A group of nursing students is reviewing information about age-related changes occurring in cognition and intellectual performance. The students demonstrate understanding of the concepts when they identify which of the following as a cognitive change for a patient diagnosed with delirium? A) Orientation to time B) Inability to recognize familiar objects C) Diminished executive functioning D) Restricted judgment
Ans: B
7. A nurse is part of team working with hurricane victims. One of the hurricane victims is staying in a temporary shelter provided by the Red Cross. To determine the extent to which this victim can cognitively cope with his situation and how much support he needs, which question would be most appropriate for the nurse to ask? A) "What kind of help do you need from us?" B) "What are your thoughts about what you will do during the next few days?" C) "How are you feeling about all that you have gone through?" D) "Are you feeling guilty because you survived and some of your neighbors did not?"
Ans: B
7. A nurse who has worked with a client diagnosed with generalized anxiety disorder (GAD) when he was an inpatient on the psychiatric unit sees the client in the waiting room of the outpatient psychiatric clinic. The client tells the nurse how things have been going since he was discharged. The nurse determines that the client's therapy has been effective when the client states which of the following? A) "I am still experiencing quite a bit of stress at home and at work; things are different at home than they were in the hospital." B) "When my mother-in-law comes over now, I go out to my workshop and work on one of my projects." C) "I'm still drinking coffee; I can't quit after drinking it all these years." D) "I've learned having a beer after I get home from work helps me relax."
Ans: B
13. A nurse is engaged in active listening. Which of the following would the nurse use? Select all that apply. A) Changing the subject to gather more information B) Responding indirectly to statements C) Using open-ended statements D) Concentrating on what the client says E) Allowing the client to talk as he wishes
Ans: B, C, D
7. Based on assessment data, a nurse formulates the nursing diagnosis for a client as sleep pattern disturbance. After educating the client on how to relax before bedtime, the nurse determines that the education was effective based on which outcome? A) The client discusses feelings about not being able to fall asleep B) Within 3 days, the client reports feeling rested upon awakening in the morning C) The client requests sleeping medication each night before bedtime D) The client is able to sleep for short intervals throughout the night
Ans: B
8. A client was admitted to the psychiatric unit 3 days ago because of suicidal ideation. His suicidal risk has lessened considerably, and he currently denies having any desire to kill himself. In addition, he is able to identify reasons why he wants to be alive. Which nursing intervention would be most appropriate at this time? A) Assigning nursing staff to stay with him during his suicidal crisis B) Developing a personal plan for managing suicidal thoughts when they occur C) Advising the client that he should consider electroconvulsive therapy treatments D) Administering psychotropic drugs that decrease the client's serotonin levels
Ans: B
8. A nurse is preparing to administer medications to a female client with bipolar disorder who is experiencing acute mania. Which of the following would be most appropriate for the nurse to do? A) Tell the client firmly that she must take her medication. B) Allow the client to participate in the treatment decision. C) Restrain the client before administering the medication. D) Notify the physician about the client's refusal of the medication.
Ans: B
8. A nurse is working with a client diagnosed with insomnia. When developing an education plan for the client, which sleep promotion intervention would the nurse implement first? A) Encouraging the client to stop smoking B) Instructing the client to keep regular bedtimes and rising times C) Encouraging the client to take frequent naps D) Administering prescribed sleep medications
Ans: B
8. A school nurse is aware that a student has requested aspirin three times during the past week because his "back hurts." The nurse has noticed that he often wears long-sleeved sweaters and sweatshirts even in warm weather. The nurse suspects that the student may be the victim of physical abuse. The nurse is preparing to ask the child about his ongoing backache. Which of the following would the nurse anticipate being reported by the child if he was being abused? A) His father is beating him on a regular basis B) Be reluctant to report abuse because of shame or fear of retaliation C) Give the same reason his sister would give were she asked to explain his injuries D) Carefully explain that his mother disciplines him because she loves him
Ans: B
8. Which of the following statements made by a client diagnosed with posttraumatic stress disorder (PTSD) leads the nurse to believe the client is experiencing dissociative symptoms? A) "It's like I'm having flashbacks every time I fall asleep." B) "I describe my feelings like I'm having an out-of-body experience." C) "Loud noises always make me a little jittery now." D) "I feel guilty that I survived the attack and my friend didn't."
Ans: B
9. A nurse is initiating a group for adolescent girls diagnosed with anorexia nervosa. Many of the clients in the group are irritable and resent having to attend. One of them comments, "This is a stupid waste of time!" Which response by the nurse would be most appropriate? A) "If you feel that way, then you can just leave." B) "You sound irritated; tell me about what is bothering you." C) "You were assigned to this group by your therapist, so you must participate." D) "Sit down and be quiet; your peers would appreciate some peace and quiet."
Ans: B
9. A nurse is preparing to administer an as-needed (PRN) medication. Which of the following would the nurse need to keep in mind when documenting administration? A) It requires a separate entry that includes reason for administration, dosage, route, and response to the medication the first time it is administered to a client. B) It requires a separate entry that includes reason for administration, dosage, route, and response to the medication every time it is administered to a client. C) It requires a separate entry that includes reason for administration, dosage, and route the first time it is administered to a client. D) It requires a separate entry that includes reason for administration, dosage, and route every time it is administered to a client.
Ans: B
9. A nurse is presenting to a church group a program about domestic violence. During the presentation, a member of the audience asks the nurse to explain what "intergenerational transmission of violence" means because he has seen that phrase used in the media. Which of the following responses by the nurse would be most appropriate? A) "People who are violent are that way because of the various neurochemical imbalances in their brains." B) "People who grow up in violent home situations tend to be involved in domestic violence situations as an adult." C) "Recent research has identified a gene that is responsible for transmission of a risk for violent behavior that is passed on from generation to generation." D) "Domestic violence seems to skip every other generation when it is traced in families."
Ans: B
9. A nurse responds to a client's statement with silence based on the rationale that this technique is used primarily to do which of the following? A) Allow the nurse to determine an appropriate response B) Permit the client to gather his or her thoughts C) Encourage self-reflection by the nurse D) Demonstrate passive listening
Ans: B
9. A nursing instructor is lecturing to students about how to respond to individuals who are in the midst of a disaster. Which statement would be most appropriate to include about initial nursing interventions for such individuals? A) "You should ask them to give you a brief medical history so their physical needs can be met." B) "Focus on safety needs and provide simple, clear instructions to help them function effectively." C) "Help them determine what their long-term goals will be so they can maintain a sense of hope." D) "Try to redirect their attention away from the problems at hand so you can decrease their anxiety."
Ans: B
14. A nurse is preparing a client for treatment with repetitive transcranial magnetic stimulation. When educating the client about this procedure, which of the following would the nurse include? Select all that apply. A) "You will receive a short-acting anesthetic to relax you." B) "You will be awake and alert during the procedure." C) "You can resume your normal activities right after the treatment." D) "We will need to shave your scalp at the area where the magnet is placed." E) "You might feel a moderate amount of stinging at the site."
Ans: B, C
17. A client with a history of substance abuse is a member of a skills training group. Which of the following would the client be involved in to enhance intrapersonal coping skills? Select all that apply. A) Substance refusal skills B) Problem solving C) Anger awareness D) Emergency planning E) Social support networking
Ans: B, C, D
17. A group of students is reviewing the signs and symptoms associated with anxiety. The students demonstrate an understanding of the information when they identify which of the following as cognitive symptoms? Select all that apply. A) Edginess B) Feelings of unreality C) Difficulty concentrating D) Tunnel vision E) Apprehensiveness F) Speech dysfluency
Ans: B, C, D
12. A client with borderline personality disorder has difficulty maintaining boundaries of the therapeutic relationship. Which of the following would be most effective for the nurse to do? Select all that apply. A) Punish the client with seclusion for violating established boundaries. B) Respond to the client's arrogance in a neutral, non-confrontational manner. C) Discuss the purpose of the limits in the therapeutic relationship. D) State the parameters of the limits and boundaries clearly. E) Ensure that any established limits are maintained consistently.
Ans: B, C, D, E
15. Assessment of a client indicates complicated grief. Which statements would the nurse identify as supporting this reaction? Select all that apply. A) "It's been 2 months, and I still want my son back." B) "I still wait for him to come right through the door every day." C) "I'm really struggling with trusting anybody anymore." D) "I wish I could go back to the days before he died." E) "Life seems so empty now that he's gone. What will I do?"
Ans: B, C, D, E
13. A nurse is engaged in role-playing with a client with borderline personality disorder to assist the client in learning how to communicate effectively. Which of the following would the nurse encourage the client to use? Select all that apply. A) "Me" statements B) Validating perceptions with others C) Paraphrasing before responding D) Listening passively E) Compromising
Ans: B, C, E
13. A nurse is presenting an in-service program about aggression and violence to a group of newly hired nurses who will be working in an inpatient psychiatric facility. When describing characteristics that may predict the risk for violence and aggression in clients, which of the following would the nurse include? Select all that apply. A) Age B) Impulsivity C) Alcohol withdrawal D) Gender E) Suspiciousness
Ans: B, C, E
15. When assessing a client with borderline personality disorder (BPD), which of the following would a nurse expect to assess? Select all that apply. A) Freely shares feelings with others B) Control necessary for a relationship C) Fear of rejection D) Exaggerated sense of self E) Self-injurious behavior
Ans: B, C, E
7. A group of nursing students is reviewing information about the epidemiology of depressive disorders. The students demonstrate understanding of the information when they identify which of the following as possible risk factors? Select all that apply. A) History of substance abuse as a teenager B) Little social support C) Inadequate coping skills D) Prior episode of anxiety disorder E) Concomitant medical illnesses
Ans: B, C, E
8. A nursing instructor is preparing a class discussion about major depression. Which of the following would the instructor expect to include? Select all that apply. A) Depression in children manifests in the same manner as in adults. B) The risk for suicide is especially high during the mid-adolescent years. C) Response to treatment in older adults is slower than that for younger adults. D) People older than age 65 years have the lowest suicide rates of any age group. E) Episodes of depression tend to occur more frequently over time. F) Depressive disorders are most often treated in the primary care setting.
Ans: B, C, E, F
10. A group of nursing students is reviewing information about substances that are abused. The students demonstrate understanding of the information when they identify which of the following as stimulants? Select all that apply. A) Alcohol B) Cocaine C) Heroin D) Nicotine E) Phencyclidine
Ans: B, D
13. A nurse is reviewing a drawing that a client completed as a self-portrait. The nurse observes that the drawing lacks arms and feet. The nurse interprets this as indicating which of the following? Select all that apply. A) Low self-esteem B) Powerlessness C) Insecurity D) Inadequacy
Ans: B, D
20. A nurse is conducting a class about eating disorders for a group of adolescents. One of the adolescents asks, "What can I do if I think my friend has an eating disorder?" Which response by the nurse would be most appropriate? Select all that apply. A) "Confront your friend and say, 'You have an eating disorder.'" B) "Try reaching out to an adult if your friend refuses help." C) "Frequently ask your friend about how many calories she or he is eating." D) "Try to talk about other things besides food and weight." E) "If your friend won't eat, be strong and force her to eat."
Ans: B, D
20. When giving a community lecture about posttraumatic stress disorder (PTSD) for clients and their families, a nurse would include which of the following topics for discussion? Select all that apply. A) Daily use of a sedative will assist with rest and sleep. B) Try to identify triggers that lead to reexperiencing the trauma. C) Find people who can assist with watching the client during stressful periods. D) Try various treatment options if one does not help. E) Do not discuss smoking cessation techniques if the client is stressed.
Ans: B, D
16. A client is experiencing traumatic grief resulting from the suicide of a family member. In addition to the usual emotions experienced with bereavement and grief, which of the following would the person most likely exhibit? Select all that apply. A) Acceptance of the loss B) Sense of rejection C) Disgust D) Stigmatization E) Self-blame
Ans: B, D, E
19. A client diagnosed with an eating disorder is to be hospitalized. When reviewing the client's medical record, which of the following would the nurse expect to find? Select all that apply. A) Blood pressure of 100/60 mm Hg B) Hypokalemia C) Hyperphosphatemia D) Heart rate of 44 beats/minute E) Suicidal ideation
Ans: B, D, E
5. A nurse is engaged in a therapeutic nurse-client relationship. The relationship is in the working phase. With which of the following would the client be involved? Select all that apply. A) Beginning to identify a need B) Testing new ways for problem solving C) Testing the relationship D) Discussing problems related to needs E) Examining personal issues
Ans: B, D, E
1. A client has been prescribed naltrexone for treatment of alcohol dependence. The nurse has explained the drug's purpose to the client. The nurse determines that the client has understood the instructions when the client identifies which of the following about the drug? A) Causes itching if alcohol is consumed B) Produces the euphoria of alcohol C) Reduces the appeal of alcohol D) Improves appetite and nutritional status
Ans: C
1. A nurse is assessing a woman age 35 years who is seeking assistance at a local community counseling center. Which of the following statements made by the woman would indicate that she is experiencing a crisis? A) "I'm so upset; my husband has never left me like this before." B) "I'm confused and hurt; I have lost my best friend and my lover." C) "I don't understand; I can't seem to function like I usually do." D) "No matter what I do, I am still overcome by these sad feelings."
Ans: C
1. A nurse is caring for a group of hospitalized clients with various psychiatric diagnoses. The nurse identifies which client as having the greatest risk for a suicide attempt? A) Man with bipolar I disorder B) Woman with acute stress disorder C) Man with major depressive disorder D) Woman with somatoform disorder
Ans: C
10. Research related to "Best Practice: PTSD and Sexual Revictimization" has found that revictimization was associated with: A) Increased viewing of pornographic material B) Acting out more sexual bondage with strangers C) Increased substance use across all age groups D) Obsessive-compulsions associated with cleaning the genitals
Ans: C
10. When planning for a client with obsessive-compulsive disorder (OCD)who has been admitted for severe exacerbation of symptoms, the nurse should set which of the following interventions as a priority? A) Giving medications in a timely fashion to maintain steady blood levels. B) Starting all group sessions on time and incorporating all group members into the discussion. C) Assessing the patient for suicide risk since they may also have a major depression. D) Discussing with the patient whether their obsessions involve self-mutilation acts like pulling their hair.
Ans: C
11. A client with depression is prescribed fluoxetine. On a return visit to the clinic, the client tells the nurse that he also just started taking St. John's wort to feel better. The nurse assesses the client for which of the following? A) Water intoxication B) Increased depressive symptoms C) Serotonin syndrome D) Hypertensive crisis
Ans: C
11. A group of nursing students is reviewing information about internal rights protection systems. The students demonstrate understanding of this information when they identify which of the following as an example? A) American Hospital Association B) American Public Health Association C) State mental health provider D) The Joint Commission
Ans: C
11. A nurse is assessing a survivor of intimate partner violence. During the interview, the nurse determines that the survivor's partner is using power and control over the client through coercion and threats. Which client statement would lead the nurse to suspect this? A) "He always tells me that the abuse never happened." B) "He tells me who I can and cannot see." C) "He tells me that he'll tell Child Services I'm a bad mother." D) "He acts like he's the master of his castle and I'm his servant."
Ans: C
11. A nurse makes a home visit to a family caring for a client with Alzheimer's disease. The client's wife tells the nurse that she hasn't been out of the house for more than 2 weeks because her sister has been unable to help care for the client. Which nursing diagnosis would the nurse identify as the priority? A) Ineffective Family Coping related to care of a client with Alzheimer's disease B) Risk for Activity Intolerance related to Alzheimer's disease C) Caregiver Role Strain related to social isolation D) Powerlessness related to seclusion and long-term care of client
Ans: C
11. During an interview, a client reports an intense fear of spiders, stating, "I can't be near them. I get so upset. I start to sweat and hyperventilate if I see one." The nurse documents this finding as which of the following? A) Algophobia B) Entomophobia C) Arachnophobia D) Cynophobia
Ans: C
11. When communicating with a client, which of the following would a nurse use to convey positive body language? A) Sitting erect with back against the chair B) Crossing the arms over the chest C) Sitting at the client's eye level D) Keeping the feet flat on the floor with the legs crossed
Ans: C
12. A nurse is counseling a family whose child, age 4 years, has mild intellectual disability. The nurse is working with the family on realistic long-term goals. Which of the following would be most appropriate? A) Locating suitable residential placement for the child B) Finding a foster home for the child C) Having the child function independently as an adult D) Preventing the onset of psychiatric disorders in the child
Ans: C
12. In a nontherapeutic relationship, a client may respond by: A) Going to the supervisor and ask to be placed in another group. B) Getting angry and start attacking the nurse. C) Leaving the unit and not be available for the scheduled meeting. D) Asking the nurse to talk about her relationships outside of work.
Ans: C
13. A nurse determines that a client is at imminent risk for suicide. Which of the following would be least appropriate to include in the client's plan of care? A) Listening intently and nonjudgmentally B) Validating the client's feelings and experience C) Instituting strict restriction on the client's activity D) Using cognitive interventions to foster hope
Ans: C
13. The husband of a client diagnosed with somatic symptom disorder asks the nurse, "What causes this condition?" Which response by the nurse would be most accurate? A) "There is definitely an underlying genetic link for this disorder." B) "Your wife is experiencing chronic stress that causes hypoarousal." C) "The symptoms reflect an emotion that your wife cannot verbalize." D) "The symptoms reflect an internal preoccupation with events."
Ans: C
14. A nurse is reviewing the plan of care for a client with anorexia nervosa and notes a behavioral plan for increasing weight. The nurse correlates this intervention with which nursing diagnosis? A) Disturbed Body Image B) Anxiety C) Imbalanced Nutrition: Less Than Body Requirements D) Ineffective Coping
Ans: C
1. A nurse is assessing a client with posttraumatic stress disorder (PTSD). Which of the following would the nurse categorize as reflecting intrusion? Select all that apply. A) Irritability B) Difficulty sleeping C) Flashbacks D) Acting as if the event is reoccurring E) Dissociation
Ans: C, D
15. A client diagnosed with body dysmorphic disorder (BDD) will primarily focus on which of the following? A) Raising money to surgically repair their body part so that everything will return to "normal" B) Researching their family tree to pinpoint when their body part became defective C) Real or imagined defects in appearance, such as having a "long" nose D) Analyzing why others think they look fine and that they [the client] should just get on with life
Ans: C
15. A client with a history of opioid abuse is exhibiting manifestations of moderate withdrawal. Which of the following would the nurse expect to assess? A) Rhinorrhea B) Lacrimation C) Dilated pupils D) Dysphoria
Ans: C
15. A female client with pain who has been diagnosed with somatic symptom disorder and depression is prescribed medication therapy to treat both the pain and the symptoms of depression. When educating the client about the medication, which of the following would the nurse emphasize? A) Use of sunscreen when exposed to bright sunlight B) Limiting of the amount of water ingested C) Avoiding foods such as aged cheeses D) Stopping the medication if there is no change after 1 week
Ans: C
15. A psychiatric-mental health client has an advance care directive on his medical record. A clinician provides treatment that disregards the client's directive. The clinician would be liable for which of the following? A) Assault B) Battery C) Medical battery D) False imprisonment
Ans: C
15. When lecturing about dissociative disorders to a group of nursing students, a nurse states that an essential feature of their disorder involves which of the following? A) Total amnesia of the events that caused the disorder B) Overuse of sedatives like alcohol C) Failure to integrate identity, memory, and consciousness D) Disinhibited social engagement, being overly friendly with strangers
Ans: C
16. A nurse is assisting a client in using simple relaxation techniques. Which of the following would the nurse do first? A) Have the client assume a relaxed position. B) Advise the client to let the sensations happen. C) Ensure a quiet, undisruptive environment. D) Instruct the client to take an initial slow, deep breath.
Ans: C
16. A nurse is performing an assessment of a client with suicidal ideation. Which question would the nurse most likely ask to determine the degree of planning? A) "How seriously do you want to die?" B) "Have you attempted suicide before?" C) "Could you stop yourself from killing yourself?" D) "How much do the thoughts distress you?"
Ans: C
16. After working with a client who has a history of violent behavior to identify possible clues that suggest the behavior is escalating, the nurse and client develop a plan for prevention. Which strategy would they be least likely to include? A) Counting to 10 B) Taking slow deep breaths C) Turning up the music loudly D) Taking a voluntary time out
Ans: C
16. The plan of care for a client diagnosed with depression includes cognitive interventions. A nurse would expect to assist with which of the following? A) Social skills training B) Activity scheduling C) Thought stopping D) Interpersonal therapy
Ans: C
16. While reviewing the medical record of a client with moderate dementia of the Alzheimer type, a nurse notes that the client has been receiving memantine. The nurse identifies this drug as which type? A) Atypical antipsychotic B) Cholinesterase inhibitor C) NMDA receptor antagonist D) Benzodiazepine
Ans: C
17. A group of nursing students is reviewing information about counseling interventions. The students demonstrate a need for additional review when they identify counseling interventions as involving which of the following? A) Specific, time-limited intervention B) Focus on coping improvement C) Goal of regaining functional abilities D) Prevention of disability
Ans: C
17. A nurse determines that a client has poor social skills that have interfered with his ability to engage others, which has contributed to his feelings of purposelessness, hopelessness, and withdrawal. Which of the following would be most important for the nurse to recommend in order to help the client begin to develop social skills? A) Self-help group B) Recovery group C) Nurse-client relationship D) Limit setting
Ans: C
17. To rule a behavior as obsessive-compulsive disorder (OCD), the obsession or compulsion must: A) Be the client's primary thought process throughout the entire day. B) Cause considerable anguish if not performed first thing in the morning. C) Take up more than 1 hour/day and cause stress to the client. D) Convince the client that their obsessive thoughts are true.
Ans: C
18. The nurse is providing follow-up care to victims of a disaster that occurred several months ago. Assessment of which of the following would lead the nurse to suspect that the victims are experiencing possible aftereffects of the disaster? A) Tachycardia B) Profuse perspiration C) Unexplained gastrointestinal disturbance D) Tremors
Ans: C
19. A fellow nurse was confronted by the pharmacist about a medication error that was detected in the automated dispensing device. The medication administered to a client receiving palliative care may have caused an earlier death since the medication significantly decreases the client's respiratory rate when given at the administered dose. Which of the following statements by the nurse displays the use of rationalization? A) "Thank you for pointing this error out. I will fill out an incident report immediately." B) "Please don't tell my supervisor. She will put me on probation if she knows this information." C) "I didn't think I needed to disclose this error since the patient is going to die anyway." D) "Are you sure I made this error? I can't recall this incident."
Ans: C
19. A nurse is assessing a client diagnosed with Alzheimer's disease. As part of the assessment, the nurse asks the client to identify common objects. The nurse is assessing for which of the following? A) Aphasia B) Apraxia C) Agnosia D) Executive functioning
Ans: C
19. A nurse is working with a client diagnosed with somatic symptom disorder. Which of the following would the nurse identify as the most difficult aspect of providing care to this client? A) Managing the client's pain B) Relieving the client's anxiety C) Developing the therapeutic relationship D) Monitoring the client's treatment program
Ans: C
12. During assessment, a nurse asks a client to explain what the following means: "A penny saved is a penny earned." The nurse is assessing which of the following? A) Affect B) Attention C) Concentration D) Abstract reasoning
Ans: D
19. A nurse is working with a client who is in crisis. Which of the following would be least appropriate for the nurse to do? A) Support the client's cultural beliefs about expressing feelings. B) Encourage the client to focus on one aspect at a time. C) Provide the client with an understanding that everything will be okay. D) Explain information clearly to clarify any misconceptions or myths.
Ans: C
19. After educating a class on the etiology of bipolar disorders, a nursing instructor determines that the education was successful when the class describes the kindling theory as involving which of the following? A) A dysregulation in the circadian rhythm, leading to sleep disturbance B) A single gene or sequence of genes causing pathologic changes C) Exposure to repetitive subthreshold stressors at vulnerable times D) "Wear and tear" on the body from mood episodes leading to increased problems
Ans: C
2. A client is being admitted to a psychiatric unit. While explaining his reason for seeking admission, he describes how his 32-year-old son recently died of a heart attack. Which response by the nurse would enhance the effectiveness of this interview? A) "How is your wife handling your son's death?" B) "Do you have any other living children that can help you cope with this loss?" C) "This must be a very difficult time for you." D) "I know exactly how you're feeling; my 23-year-old son died unexpectedly last year."
Ans: C
2. A nurse is assessing a client with bipolar disorder who is experiencing mania. The client states, "I'm just so beautiful. Everyone just stops and stares at how gorgeous I am. Men constantly want to have sex with me." The nurse interprets these statements as indicative of which type of mood? A) Irritable B) Elevated C) Expansive D) Euphoric
Ans: C
2. A nurse is in the orientation phase of the nurse-client relationship with a client diagnosed with a mental disorder. When interviewing the client during this first encounter, which information about the client would be most important for the nurse to obtain? A) Known allergies B) Recent hospitalizations C) Perception of the problem D) Family history
Ans: C
2. While assessing a client thought to have a factitious disorder, a nurse asks the client to describe when she felt nurtured as a child. Which response would the nurse interpret as supporting the client's diagnosis? A) "I never felt nurtured or loved when I was growing up." B) "The only time I felt loved and appreciated was when I made the honor roll at school." C) "The only time I ever felt loved was when I was sick enough to miss school." D) "I felt loved and accepted when my father apologized for spanking me so hard."
Ans: C
20. A nurse is assessing a client's immediate and short-term memory. Which of the following would be most appropriate? A) Questioning the client about an event that has occurred within the past several months B) Giving the client a simple scenario and having him identify what would be the best response C) Giving the client three words and asking him to recite them now and then again in 5 minutes D) Asking the client to tell the nurse the date, time, and current location
Ans: C
20. Following a change in job position, a minister asks a client how he likes his new job. The client states, "Oh everything is great. I can really see myself going far in this new position." However, the client's voice is monotone and his face is nearly absent of affective expression. The minister is worried about this client and describes his facial expression as which of the following? A) Inappropriate B) Blunted C) Flat D) Constricted
Ans: C
22. A nurse is talking with the husband of a female client diagnosed with Alzheimer's disease. During the conversation, the husband tells the nurse that "she often begins to scream and curse for no apparent reason." The nurse interprets this as which of the following? A) Hypersexuality B) Disinhibition C) Hypervocalization D) Apathy
Ans: C
26. A nurse is providing care to a client with antisocial personality disorder. As part of the plan of care, the client is to participate in a problem-solving group. The nurse understands that this intervention is effective based on which rationale? A) It requires the client to develop attachments. B) It sets up specific boundaries for the client. C) It helps to reinforce self-responsibility. D) It avoids confrontation about dysfunctional patterns.
Ans: C
3. A family member of an adolescent who has expressed a desire to commit suicide asks the nurse, "What might predict the possibility of future suicide attempts?" Which of the following would the nurse include in the response? A) Unemployment B) Death of a spouse C) Previous suicide attempt D) Polydrug use
Ans: C
3. A man 62 years of age experienced the loss of his 87-year-old father a week ago. A hospice nurse is making a follow-up visit to determine how he is handling his father's death. Which of the following statements made indicates to the hospice nurse that client is in the acute mourning stage of bereavement? A) "I keep thinking about my father; I have trouble believing he's dead. I feel guilty because I didn't go to the nursing home to visit him last week!" B) "I've been grieving my father; losing him is a tremendous loss, but I have to get on with my life." C) "My father was a saint. I am so angry at God for taking him away! I'm crying all the time; I haven't been able to work for days." D) "I'm going to spend the weekend with my children; they understand what I've been going through, and I can relax around them."
Ans: C
3. A nurse has explained some of the biologic theories of causation to a client diagnosed with borderline personality disorder and his family. The nurse determines that the client and family have understood the instructions when they state which of the following? A) "The disorder may be caused by increased serotonin activity." B) "The disorder is caused by decreased dopamine activity in my brain." C) "A frontal lobe dysfunction may be causing this condition." D) "A decrease in hormonal substances increases the risk for this illness."
Ans: C
3. A son brings his father to the clinic and tells the nurse that his father has begun to act strangely in the past few days, with unprovoked outbursts of anger. After the incidents, the father expresses remorse for his outburst. The son says, "I've never seen him act this way." Which question would be most appropriate for the nurse to ask next? A) "Does your father have a history of an anxiety disorder, such as panic disorder?" B) "Has your father exhibited previous problems expressing anger appropriately?" C) "Has your father suffered any traumatic injury to his brain recently?" D) "Has your father injured the back of his head or neck in the past week?"
Ans: C
3. An emergency department nurse is assessing a female client with traumatic injuries. To assess whether the client's injuries have resulted from abuse, which question would be most appropriate for the nurse to ask the client? A) "Is your partner being mean to you?" B) "Why do you think your husband has beaten you?" C) "It looks like someone has hurt you. Tell me about it." D) "Can you describe the person who did this to you?"
Ans: C
33. A nurse is working with the parents of a child with a conduct disorder and teaching them how to use "time out." Which statement by the parents indicates that they have understood the information? A) "We should put him in a chair in the corner of the room, away from all to see." B) "The time starts as soon as he begins the behavior." C) "We should keep him in time out for about 5 minutes." D) "He needs to say why he is going to time out before we put him there."
Ans: C
4. A female psychiatric client is talking to a nurse about her reasons for being hospitalized. The client begins to discuss her relationship with her female significant other. She is describing the things in her relationship that are making her uncomfortable, and she asks the nurse, "Should I break up with my partner?" Which response by the nurse would be most effective in building rapport between the client and nurse? A) "Of course you should; being a lesbian is just not natural." B) "Yes, I think you should pursue building a relationship with a man." C) "It sounds like you're beginning to be uncomfortable in this relationship." D) "You need to focus on yourself rather than the relationship right now."
Ans: C
4. A nurse is caring for several hospitalized clients with anorexia nervosa. The nurse would be especially alert for which of the following if noted in the clients' histories? A) Paranoia B) Primary insomnia C) Depression D) Aggression
Ans: C
4. A nurse is developing a presentation for families who have members who have been diagnosed with bipolar disorders. When describing this condition to the group, which of the following would the nurse most likely include? A) As the person ages, the episodes tend to decrease. B) Environmental stressors are a key cause of these disorders. C) The risk for suicide is high with either depression or mania. D) Risk-taking behaviors are more common during a depressive episode.
Ans: C
4. After assessing a client, a nurse noted the following: "He was tearful, he tried to kill himself before coming into the hospital, he had no immediate plan for another suicide attempt, he was unable to concentrate, and he reported having trouble sleeping and having little or no appetite." The nurse also noted that the client's appearance was unkempt, that he spoke in a low monotone, and that he was unable to establish and maintain eye contact. Based on this information, which nursing diagnosis would be the most appropriate? A) Ineffective Role Performance B) Risk for Infection C) Risk for Suicide D) Risk for Self-Mutilation
Ans: C
5. A client diagnosed with borderline personality disorder tells the nurse that she "frequently spaces out." Which response by the nurse would be most appropriate? A) "Do you feel stressed most of the time?" B) "Does this frighten you when it happens?" C) "What's happening around you when this occurs?" D) "Do you feel as if you are out of your body?"
Ans: C
5. A client has been admitted to the detoxification unit after binge drinking. Even though the client is not currently intoxicated, he is combative and exhibits altered thought processes. Which nursing diagnosis would be the priority? A) Risk for Injury related to effects of alcohol abuse B) Risk for Self-Mutilation related to alcohol withdrawal and altered thought processes C) Risk for Other-Directed Violence related to alcohol withdrawal D) Risk for Delayed Development related to chronic effects of alcohol intoxication
Ans: C
5. A nurse is caring for a family in which the elderly mother has been a victim of abuse and neglect by her son, 48 years of age. Which of the following would be most important for the nurse to keep in mind before interviewing the family? A) A top nursing priority would be to legally remove the son from the home. B) The main focus of the nurse's actions should be on improving the elderly mother's self-esteem. C) The nurse must allow the older adult mother to decide whether she wants to leave the situation. D) Placement for the older adult woman in a nursing home within the community is crucial.
Ans: C
5. A nurse is talking with a client 57 years of age who has been a heavy drinker for many years. The client is being treated for alcoholism, and this is her second week as an inpatient on the psychiatric unit. It is 5 a.m. and the client has been having difficulty sleeping. The client is an orthopedic nurse, and although she is clothed in a hospital-issued gown and robe, she is wearing a stethoscope around her neck that the nurse recognizes as belonging to one of the staff nurses. When the nurse asks her why she is wearing the stethoscope and where she got it, the client gives her a long and involved reply that describes how her nursing supervisor came to visit and gave it to her to wear "so she'd remember to get well." The nurse suspects that the client may be experiencing which of the following? A) Wernicke's syndrome B) Delirium tremens C) Korsakoff's amnesic syndrome D) Malignant hyperthermia
Ans: C
5. A teenager and her parents visits the clinic to discuss the teen's skin picking. There are many bleeding wounds and various stages of scabs located up and down both arms. The parents are very upset about this behavior and want it to stop. Which of the following would the health care provider documents? A) Body dysmorphic disorder B) Disrupted family dynamics C) Excoriation disorder D) Control dysfunction.
Ans: C
6. A client is hospitalized on a psychiatric unit secondary to a suicide attempt. He has been diagnosed with depression and is consistently depressed. When assessing the client, which of the following would alert the nurse that the client's suicidal risk has worsened? A) He tells the nurse that he feels more depressed than ever. B) He is lethargic, remaining isolated from other clients. C) He says he feels better as he interacts more with other clients. D) His energy level and degree of depression remain the same.
Ans: C
11. During the termination phase, a client begins to raise old problems that have already been resolved. Which of the following would be the most appropriate nursing response? Select all that apply. A) Immediately stop the client and inform them that the nurse is running the session. B) Get angry at the client and ask them to leave the session. C) Reassure the client that they already covered these issues. D) Review with the client the learned methods to control the problems. E) Do not acknowledge this issue and continue on with the session as planned.
Ans: C, D
6. A client with a mental disorder is being discharged from an inpatient unit. During the hospital stay, the client eventually was able to get an adequate night's sleep even though he had experienced chronic insomnia over the years. The client's spouse asks the nurse what the family can do in the home environment to promote healthy sleep. Which response by the nurse would be most appropriate? A) "It is basically up to your husband to focus on promoting his own sleep." B) "You might consider a glass of wine about 30 minutes before he is ready to go to bed." C) "Remember to keep stimulating activities at a minimum before he goes to bed." D) "Give him a spicy snack with a warm cup of tea at night before bedtime."
Ans: C
6. A nurse is preparing a presentation for a group of colleagues about suicide and the older adult population. Which of the following would the nurse include in this presentation? A) Suicide is less of a risk in this population compared with middle-aged adults. B) Married African American men are at the greatest risk for suicide in this group. C) Depression is greatest risk factor for suicide in this population group. D) White women account for the highest number of suicide deaths in this age group.
Ans: C
6. While providing care to a client with a mental disorder, the client asks the nurse, "Does mental illness run in your family?" Which response by the nurse would be most inappropriate? A) "Mental illnesses do run in families, and I've had a lot of experience caring for people with mental illness." B) "It sounds like you are concerned that there may be a family connection to your current problem?" C) "Yes, it does. I have a sister who was diagnosed several years ago with severe major depression." D) "Mental illness can be family related. Let's focus the discussion on you and how you're doing today."
Ans: C
7. A client has made multiple visits to the clinic. A nurse suspects that the client may be experiencing somatic symptom disorder (SSD) based on which of the following? A) Expressions of concern about psychological problems B) Indications that their parents were always in good health C) Reports of symptoms changing to different body systems D) Evidence of a need for social support from friends
Ans: C
7. A nurse is planning to explain the purpose of the behavioral therapy technique of self-monitoring to a client with bulimia nervosa. The nurse would emphasize keeping a diary to record which of the following? A) Feelings of hunger B) Efforts at distraction C) Environmental stimuli D) Rigid rules about eating
Ans: C
7. A nurse working on a psychiatric unit receives a telephone call from the employer of one of the clients on the unit. The employer asks to be sent a copy of Mr. Murray's latest laboratory work and psychological testing results so Mr. Murray's medical records in employee health can be kept up-to-date. Based on the nurse's knowledge about issues surrounding breach of confidentiality, which response would be the most appropriate? A) "I'm sorry; we're not allowed to give out that information about our client." B) "I'll have to get the client's signed consent before we can send that information to you." C) "I am unable to acknowledge whether or not a Mr. Murray is a client on this unit." D) "Sure, give me your address, and I will see that the information is sent to you."
Ans: C
7. A nursing instructor is describing the nurse-client relationship to a group of nursing students. Which of the following would the instructor emphasize as crucial for establishing and maintaining the relationship? A) Rapport B) Empathy C) Self-awareness D) Values
Ans: C
8. A migrant worker client is brought to the emergency department for an injury, and it soon becomes evident that the client cannot speak English. A nurse on duty offers to find an interpreter so the client can communicate with the medical staff. The nurse's offer is an example of which type of nursing intervention? A) Milieu therapy B) Conflict resolution C) Cultural brokering D) Structured interaction
Ans: C
8. A nurse is assessing a client who has received a tentative diagnosis of delirium. The nurse is explaining to the family about the major cause of the client's condition. Which statement by the nurse would be most appropriate? A) "Basically, this diagnosis is based on the client's inability to talk normally." B) "Your report of gradually developing confusion over time was the basis for the diagnosis." C) "His diagnosis is primarily based on the rapid onset of his change in consciousness." D) "The client's exposure to an infectious agent led us to determine the diagnosis."
Ans: C
9. A client who is receiving lithium comes to the clinic for an evaluation. During the visit, the client reports a fine hand tremor. Which action by the nurse would be most appropriate? A) Immediately obtain a specimen to determine the client's blood drug concentration. B) Suggest that the client take the medication with meals or snacks. C) Assist the client in minimizing exposure to stressors. D) Encourage the client to elevate the affected hand on a pillow.
Ans: C
9. A nurse determines that a client who is experiencing anxiety is using relief behaviors. The nurse determines that the client is experiencing which degree of anxiety? A) Mild B) Moderate C) Severe D) Panic
Ans: C
9. A nurse is assessing a client for somatic symptom disorder. Which client statement would the nurse interpret as most likely supporting this diagnosis? A) "It's like my foot is asleep all the time; I can't feel anything that touches my foot." B) "I'm losing weight no matter what or how much I eat." C) "I am always in pain; there is nothing I can do to relieve it." D) "It seems like I am always having diarrhea at the most inconvenient times."
Ans: C
9. A nurse is presenting a discussion about suicide to a local community group. Which comment from an audience member indicates the need to clarify the information? A) "Warning signs about the person's intention often occur." B) "People who are suicidal are undecided about living or dying." C) "Suicides more often occur during the holiday seasons." D) "People who talk about suicide need to be taken seriously."
Ans: C
9. The sleep history of a client experiencing sleep problems reveals that the client ingests a significant amount of caffeine each day. When reviewing with the client the effect of caffeine on sleep, which of the following would the nurse incorporate into the discussion as a caffeine effect? A) Decreased sleep latency B) Increased total sleep time C) Decreased REM sleep D) Increased slow-wave sleep
Ans: C
9. Which of the following would be considered a "usual or expected" response during the first few sessions? A) Showing up late for the first session B) Being confrontational with nurse and other group members C) Rambling due to nervousness D) Bragging about sexual conquests
Ans: C
6. A nurse knows rapport has been established when the client: Select all that apply. A) Tries to isolate him- or herself from others in the group. B) Acknowledges that they wish to keep many topics off limit and private. C) Develops a sense of sharing. D) Displays decreased anxiety and feels comfortable in the presence of the nurse. E) Begins speaking with a more rapid, repetitive speech.
Ans: C, D
10. An adolescent is brought to the emergency department by her parents because they were concerned about their daughter's appearance. The client appears emaciated and pale. The parents tell the nurse that the client has been diagnosed with anorexia nervosa. A history, physical examination, and laboratory testing are completed. Which of the following would lead the nurse to suspect that the client will be admitted to the hospital? Select all that apply. A) Blood pressure of 110/60 mm Hg B) Elevated serum potassium concentration C) Decreased serum magnesium concentration D) Heart rate of 40 beats/min E) Statements of being "hopeless"
Ans: C, D, E
11. A client is brought to the emergency department by his brother. The client has a history of bipolar disorder, for which he is taking valproate. The brother reports that he watched the client take the medication about 2 hours ago. He stated, "A little while ago, he got very disoriented and agitated." The nurse suspects toxicity based on assessment of which of the following? Select all that apply. A) Tachypnea B) Bradycardia C) Hypotension D) Dizziness E) Respiratory depression
Ans: C, D, E
13. A nurse is preparing an education plan for the family of a client who has been diagnosed with bipolar disorder. After teaching them about potential indicators for relapse, the nurse determines that the education was effective when the family identifies which of the following as suggesting mania? Select all that apply. A) Avoiding people B) Sleeping more than usual C) Talking faster than usual D) Being hungry all the time E) Reading several books at once
Ans: C, D, E
1. A client with obsessive-compulsive disorder has been taking fluoxetine for 1 month. The client tells the nurse, "These pills are making me sick. I think I'm getting a brain tumor because of the headaches." Which response by the nurse would be most appropriate? A) "Let's talk about how often you have been performing the rituals lately." B) "Tell me how many times you have washed your hands today." C) "Have you been practicing your deep breathing and relaxation exercises?" D) "These medications have side effects that can cause increased headaches."
Ans: D
1. A nurse is caring for an older client in a residential care facility. The client has been extremely irritable the entire day. When modifying the client's plan of care, which of the following would be an appropriate snack to offer the client to decrease the irritability? A) Chocolate candy bar B) Handful of raisins C) Granola bar D) Glass of milk
Ans: D
1. A school nurse is caring for a child age 7 years who has demonstrated a significantly lower-than-average score for mental age on standardized tests in reading. However, the child's IQ scores were within the average range. The nurse interprets this information as suggesting which of the following? A) Communication disorder B) Attention deficit hyperactivity disorder C) Asperger syndrome D) Dyslexia
Ans: D
10. A client with insomnia is taught to avoid watching television, eating, and doing work in the bedroom. Which technique is being used? A) Sleep restriction B) Relaxation training C) Cognitive-behavioral therapy D) Stimulus control
Ans: D
10. A client's blood concentration of carbamazepine is increased. When reviewing the client's medication history, which of the following would alert the nurse to a possible interaction? A) Phenobarbital B) Primidone C) Phenytoin D) Diltiazem
Ans: D
10. A group of nursing students is reviewing information about suicide and associated concepts. The group demonstrates understanding of the information when they identify which of the following as the probability that a person will successfully complete suicide? A) Parasuicide B) Suicidal ideation C) Suicidality D) Lethality
Ans: D
10. Which of the following behaviors would be considered a "testing behavior" that usually happens during the "honeymoon phase" of the relationship? A) Talking nonstop and monopolizing the conversation B) Sitting away from the group and not participating in the discussion C) Accusing the nurse of being too controlling during the session D) Expressing anger and accusing the nurse of breaking confidentiality
Ans: D
11. A nurse is caring for a family with a child who has autism spectrum disorder. When developing an education plan for the parents, which of the following would the nurse most likely emphasize? A) The child is at higher risk for seizure disorder. B) The child's IQ will typically be higher than that of other children. C) Dyslexia also may be a comorbid condition. D) A structured physical environment is important for the child.
Ans: D
11. As part of a client's treatment plan for borderline personality disorder, the client is engaged in dialectical behavior therapy. As part of the therapy, the client is learning how to control and change behavior in response to events. The nurse identifies the client as learning which type of skills? A) Emotion regulation skills B) Mindfulness skills C) Distress tolerance skills D) Self-management skills
Ans: D
11. While administering an admission assessment for a client with obsessive-compulsive disorder (OCD), which of the following is the best technique for the nurse to use? A) Simple questions with yes/no responses B) Short questions that require one or two sentences to answer C) Stopping the patient and getting them to focus on the topic when they start to ramble D) Calm, nonauthoritarian approach with patience and active listening
Ans: D
12. A group of nursing students is reviewing the various agents used to treat insomnia. The students demonstrate an understanding of the information when they identify which agent as a melatonin receptor agonist? A) Trazodone B) Estazolam C) Mirtazapine D) Ramelteon
Ans: D
12. After educating a class on competency and how it is assessed, a nursing instructor determines the need for additional instruction when the class identifies which ability as being evaluated? A) Communication of choices B) Understanding of relevant information C) Appreciation for a situation and its consequences D) Discussion of what is right and wrong
Ans: D
14. A nurse is interviewing a client who is a survivor of abuse. The client is telling the nurse about how the violence occurred. Which statement would the nurse interpret as reflecting phase 3 of the cycle of violence? A) "He threw me against the wall and started punching my face." B) "He yells at me for not having dinner waiting for him when he comes home." C) "He calls me stupid and incompetent, asking himself why he ever married me." D) "He tells me that he is sorry and that he will never hit me again."
Ans: D
14. A nurse is preparing to interview a client diagnosed with somatic symptom disorder. The nurse anticipates that the client will most likely exhibit which of the following? A) No facial expression during the interview B) Intermittent nodding and glancing at the clock on the wall C) Altered mental status D) Rapidly changing moods during the interview
Ans: D
15. A nurse is assessing a client's spirituality. Which question would be most appropriate to ask? A) "Have you ever tried to harm yourself?" B) "How important is your family to you?" C) "How do you define good and evil?" D) "What gives your life meaning?"
Ans: D
15. A nurse is interviewing a client diagnosed with bulimia nervosa about her family and her relationship with her mother. Which statement by the client would the nurse least likely associate with bulimia nervosa? A) "My mother is my confidante for everything." B) "My mother's happiness depends on me." C) "My family basically has very few rules." D) "My mother and I are close but not joined at the hip."
Ans: D
15. An advantage to utilizing phone/video conferencing includes: A) Ability to rely heavily on nonverbal communication. B) All patients have access to reliable technology. C) No documentation required since it is recorded on video. D) Ability to access clients in remote areas.
Ans: D
16. A child has to verbalize his thoughts using three syllables at a time, pause, and then state another three syllables. If he is not allowed to do this, he gets frustrated and angry. Which of the following describes this action? A) Obsession with the number 3 B) Tradition that started when he was learning to formulate words C) Magical thinking performance D) Ritual behavior common in childhood.
Ans: D
16. A group of students is reviewing information about the etiology of generalized anxiety disorder (GAD). The students demonstrate understanding of this information when they identify which of the following as representing the bases for this disorder? A) Inaccurate environmental danger assessment B) Exposure to multiple stressful life events C) Kindling caused by overstimulation D) Intense worry and stress about work or simple family life
Ans: D
17. While talking with a client with an eating disorder, the client states, "I've gained 2 pounds, so I'll be up by 100 pounds soon." The nurse interprets this as which of the following? A) Magnification B) Selective abstraction C) Overgeneralization D) Dichotomous thinking
Ans: D
18. A nurse is reviewing the medical record of a client diagnosed with depression and notes that the client has been prescribed mirtazapine. The nurse identifies this agent as which drug category? A) Selective serotonin reuptake inhibitor B) Cyclic antidepressant C) Norepinephrine dopamine reuptake inhibitor D) Alpha-2 antagonist
Ans: D
18. After educating a class of nursing students about the rights of persons receiving mental health services, the instructor determines a need for additional instruction when the students identify which of the following as a right? A) Freedom from restraints or seclusion B) Access to one's own mental health records upon request C) An individualized written treatment plan D) Refuse treatment during an emergency situation
Ans: D
18. After educating a group of students on the various concepts involving suicide, the instructor determines that the education was successful when the students describe parasuicide as which of the following? A) Voluntary act of killing oneself B) All suicide-related behaviors and suicidal thoughts C) Nonfatal act with the intent to die D) Voluntary attempt without death as the aim
Ans: D
18. After teaching a class about the general aggression model, a nurse determines that additional education is needed when the class identifies which of the following as an interactive component of the model? A) Cognition B) Affect C) Arousal D) Rewards
Ans: D
19. After teaching a group of nursing students about milieu therapy, the instructor determines that additional education is needed when the students identify which of the following as a key concept of milieu therapy? A) Structure interaction B) Open communication C) Validation D) De-escalation
Ans: D
19. When prescribing an antidepressant for the treatment of an adolescent with obsessive-compulsive disorder (OCD), a higher dose is usually ordered by the health care provider. As part of the education of the client/family, the health care provider should warn about safety due to an increased risk for which of the following? A) Nightmares B) Sleepwalking C) Amnesia D) Suicidality.
Ans: D
2. A client has been diagnosed with major depression. The client reports that he often wakes up during the night and has trouble returning to sleep. The nurse interprets this finding as suggesting which of the following? A) Initial insomnia B) Terminal insomnia C) Hypersomnia D) Middle insomnia
Ans: D
2. A nurse is assessing a client on an inpatient psychiatric unit. The client's history for which of the following would the nurse identify as the strongest indicator of risk for violence? A) Panic disorder B) Problematic anxiety C) Somatoform disorder D) Previous episodes of rage
Ans: D
2. A nurse is reviewing the medical records of several clients diagnosed with major depression. The nurse identifies which client as least likely to commit suicide? A) Divorced man B) Widowed woman C) Single woman D) Married man
Ans: D
2. An adolescent client tells a nurse that he or she occasionally "sniffs airplane glue." When discussing the effects of long-term use of inhalants, which of the following would the nurse most likely include? A) Tremors and central nervous system arousal B) Enhanced normal heart rhythms C) Enhanced attention on focus and memory D) Brain damage and cognitive abnormalities
Ans: D
2. While caring for a client age 88 years suspected of having dementia, the nurse assesses the client for a common delusional thought. Which of the following would the nurse interpret as a common delusion? A) "I am the king of the universe." B) "Creatures are living in my closet." C) "The government has people following me." D) "My roommate keeps stealing my clothes."
Ans: D
20. A nurse is assisting in planning a series of group therapy sessions with several female clients diagnosed with somatic symptom disorder. The nurse plans to focus the sessions on which of the following as a priority? A) Causes of medical illnesses B) Positive self-talk C) Side effects of medications D) Assertiveness skills
Ans: D
24. A nurse is providing care to a client with Alzheimer's disease who is exhibiting suspiciousness and delusional thinking. Which of the following would be most important for the nurse to do with this client? A) Tell the client that he is experiencing delusions. B) Confront the client about his distorted thinking. C) Correct the client's interpretation of the situation. D) Determine the trigger for the distorted thinking.
Ans: D
3. A client was admitted to the hospital after a suicide attempt following his daughter's death in an automobile accident; the client had been driving and survived with only minor injuries. Even though the accident was unavoidable, he feels responsible. During the assessment interview, the client begins to describe the last conversation he had with his daughter before he lost control of the automobile. As he speaks about his daughter, his voice trembles, and a tear rolls down his face. He makes a visible attempt to "straighten up" and smiles superficially at the nurse, stating, "I'll get over this. I just need to keep a stiff upper lip. I think all I need to do is stay overnight. I'll be as good as new by tomorrow." Which response by the nurse would be most appropriate? A) "Tell me about your daughter. How would you describe the relationship you had with her?" B) "I'm sure you are right; a good night's rest should make a big difference." C) "As good as new?" D) "You made a serious attempt on your life; you will not be ready go home by tomorrow."
Ans: D
3. A client with bulimia nervosa is being treated at an outpatient clinic and is prescribed a selective serotonin reuptake inhibitor (SSRI). Which of the following would the nurse include when teaching the client about the prescribed medication? A) Closely monitor your fluid intake while taking this medication. B) Stop taking this medication if it causes weight gain. C) Expect menstrual irregularities, particularly if they've occurred previously. D) Report any weight changes that occur during the first few weeks this medication is taken.
Ans: D
3. A female client who is receiving counseling at a community health center has complained during the last three weekly sessions about being unable to sleep. A nurse interviews the family members to determine the effect of the client's problem on them. Which response would the nurse most likely expect to hear? A) "It really hasn't seemed to be a problem for us." B) "There's been little change in how she gets along with other family members." C) "The not sleeping has really had a positive effect on her and us." D) "It's been exhausting living with her these past few weeks."
Ans: D
3. A nurse is assessing a child who is suspected of having attention deficit hyperactivity disorder. Which of the following would the nurse identify as reflecting impulsiveness in the child? A) Inability to wait his turn B) Restlessness C) Difficulty completing a task D) Risk-taking behavior
Ans: D
3. A nurse is assessing a client age 78 years who lives alone in his own home. To assess the client's instrumental activities of daily living, which question would be most appropriate to ask? A) "How often do you bathe or shower?" B) "How many times do you change clothes during the day?" C) "How often do you cook meals for yourself?" D) "How often do you go to the store to buy groceries?"
Ans: D
3. Termination takes place during the resolution phase of a nurse-client relationship. During the termination process, a client brings up resolved problems and presents them as new issues to work toward. The nurse interprets the client's action as indicating which of the following? The client: A) Is angry that the nurse is abandoning him. B) Requires additional therapy. C) Is unhappy that the therapy was ineffective D) Is attempting to prolong the nurse-client relationship.
Ans: D
4. A female client has been admitted to an inpatient psychiatric facility with a diagnosis of posttraumatic stress disorder after a history of violence by her boyfriend. During the initial assessment interview, which assessment would be the priority? A) Nutritional status B) Hydration status C) Sleep patterns D) Suicide risk
Ans: D
4. A female client is diagnosed with panic disorder. The client tells the nurse that she hasn't left her house in more than a month because she was afraid of another attack. She visited the mental health clinic today only because her son brought her. Which nursing diagnosis would be a priority for this client? A) Powerlessness related to symptoms of anxiety B) Decisional Conflict related to fear of leaving the house C) Ineffective Family Coping related to symptoms of anxiety D) Social Isolation related to fear of recurrence of anxiety symptoms
Ans: D
4. A legal secretary 25 years of age is seeking counseling because she recently lost her job unexpectedly. Which question would be most appropriate for a nurse to use in assessing the client's response to losing her job? A) "What happened to cause you to lose your job?" B) "How did you feel immediately after being told you no longer had a job?" C) "How do you expect yourself to be able to handle this situation?" D) "How have you responded to previous stressful situations?"
Ans: D
4. A nurse is caring for a client who is hospitalized for a mental disorder. The nurse is legally obligated to breach the client's confidentiality if the client states which of the following? A) "I think that the federal government is spying on me." B) "I get really 'turned on' by your appearance." C) "That doctor I had today really made me angry." D) "When I get out of here, I'm going to kill my neighbor."
Ans: D
4. A nurse is caring for an older adult client who has no history of violence but is agitated and appears ready to strike out at a staff member. The nurse would assess the client for which of the following? A) Panic disorder B) Epilepsy C) Bipolar disorder D) Sensory losses
Ans: D
4. A nurse is completing an admission assessment of a young adult woman who has a history of depression, and who was brought to the hospital by her boyfriend. In response to the nurse's question regarding suicidal ideation, the client discloses that she is thinking about killing herself. Which question would be most appropriate for the nurse to ask next? A) "What does your boyfriend think about your desire to kill yourself?" B) "What are your spiritual beliefs about suicide?" C) "What will killing yourself accomplish?" D) "What thoughts have you had about how you would kill yourself?"
Ans: D
4. A nurse is discussing strategies to enhance sleep with a client who is experiencing insomnia. Which of the following would be most appropriate for the nurse to suggest? A) "Eat right before you go to bed, as long as it is something rich that will make you sleepy." B) "Try exercising a bit right before your bedtime so you will feel tired and sleepy." C) "Drinking a warm cup of tea right before bedtime will help to relax you." D) "Establish a regular time for going to bed and getting up in the morning."
Ans: D
4. An abused child has been placed in a loving foster home. The foster parents express concern when the child has not developed a positive attachment after living in their home for the past 9 months. The case manager concludes that the child has developed which of the following? A) Acute stress disorder B) Adjustment disorder C) Disinhibited social engagement disorder D) Reactive attachment disorder
Ans: D
5. A nurse is caring for a white man age 30 years whose wife has recently died. The client has been diagnosed with clinical depression and is demonstrating insufficient coping skills. Which action by the nurse would be most important? A) Refer the client for long-term psychotherapy. B) Determine the client's risk of psychosis. C) Determine whether anyone in the client's family has had depression. D) Ask the client whether he is thinking about killing himself.
Ans: D
5. A nurse is preparing to discharge a client who has been hospitalized with anorexia nervosa. Which of the following would the nurse include in the education plan? A) Knowing the calorie content of numerous foods B) Learning strategies to control impulses C) Describing physiologic consequences of anorexia nervosa D) Setting realistic goals
Ans: D
6. A nurse is determining the success of a client's plan of care by evaluating outcome indicators. A positive outcome for the client with schizophrenia who has been experiencing numerous hallucinations would be: A) On the day of discharge, the client reports they are hearing only two voices today. B) During the initial assessment, the nurse observes the client talking to themselves throughout the interview phase. C) At the initial interview, the client is unable or unwilling to answer all questions, at times just staring off in space. D) After some intense therapy sessions and medication readjustment, the client reports they are no longer hearing voices.
Ans: D
6. A nurse is using motivational therapy with a female client suffering from alcoholism. The client, who is unwilling to consider changing her drinking behavior, emphatically states, "I am not an alcoholic; you can't make me stop drinking." Which response by the nurse would be most appropriate? A) "You have to stop drinking and driving. You could kill someone." B) "You're right. You are not an alcoholic." C) "You should consider what you are doing to your marital relationship." D) "You're the only one who can make yourself stop drinking."
Ans: D
6. Which of the following symptoms leads the nurse to suspect a young child is experiencing posttraumatic stress disorder (PTSD)? A) Becomes disrespectful of authority figures B) Feel guilty that they could not save their friends during the attack on their school C) Having thoughts of revenge toward the boys who were bullying him at their school D) Acts out the scary event during playtime
Ans: D
7. A nurse is caring for a family whose older father with dementia is living in their home. The nurse has instructed the family about how to decrease the father's agitation. The nurse determines that the son has understood the instructions when he states which of the following? A) "Restraints can help reduce my father's agitation." B) "I should place my father in the bedroom with me so I can watch him more closely." C) "It's important that he gets out shopping with me or my wife." D) "If I simplify our home environment, my father may be less agitated."
Ans: D
7. A nurse is conducting a public information seminar on the topic of rape and sexual assault at a local community center. Which of the following would the nurse include when describing power rapists? A) Committed by sadistic perpetrators who plan the rape before committing it to experience erotic enjoyment in response to the victim's suffering B) Target very young or elderly victims, may involve extreme force, and often results in victim injury C) Are not planned ahead of time and result from the perpetrator being obsessed with uncontrollable sexual urges D) Target victims near the age of the perpetrators and involve minimal physical force and intimidation in controlling their victims
Ans: D
8. A family has just lost their home in a fire. An on-call nurse from a community counseling center has been called in to the emergency department to help them with this traumatic event. Which of the following would the nurse identify as the priority for this family? A) Arranging for follow-up therapy to deal with the crisis B) Completing a family genogram to determine family patterns C) Assessing the impact of the loss on their lifestyle D) Arranging for emergency shelter and food supplies
Ans: D
8. A nurse is caring for a client who is being treated in the emergency department for a panic attack. Which of the following nursing interventions would be most appropriate? A) Demonstrate empathy for the client by trying to mimic the client's state of anxiety. B) Tell the client that you must leave to go report his symptoms to the psychiatrist on duty. C) Tell the client this is an acute exacerbation with a positive prognosis and low morbidity. D) Stay with the client, emphasizing that he is safe and that you will remain with him.
Ans: D
8. A nursing instructor is educating a class of nursing students on anger, aggression, and violence. Which statement by the instructor would be most appropriate to include? A) "Anger, aggression, and violence are points along a continuum." B) "The terms used to describe anger are very precise." C) "Anger is a knee-jerk reaction to external events." D) "Women experience anger as frequently as men do."
Ans: D
9. The mother of a child with autism spectrum disorder tells the nurse that her child has few playmates. She states, "He has real trouble interacting with other children and when there is a change in his routine, he throws a tantrum." Based on this information, the nurse identifies which nursing diagnosis as the priority? A) Self-Care Deficits related to repeated tantrums B) Risk for Injury related to autism spectrum disorder C) Compromised Family Coping related to having a child with autism spectrum disorder D) Social Isolation related to poor social skills
Ans: D
14. A client with posttraumatic stress disorder (PTSD) has been prescribed sertraline. While educating this client about possible side effects, the nurse should stress that the client needs to call their health care provider if they experience which of the following signs/symptoms? Select all that apply. A) Fatigue B) Constipation C) Dry eyes D) Muscle twitching E) Tachycardia (racing heart)
Ans: D, E