EXAM DRILL 6 (Psychiatric Nursing) [76-150 to follow]

4) Methyphenidate [Ritalin] tid is prescribed to a child with attention deficit hyperactivity disorder. The nurse knows that the first daily dose should be given. a) Before breakfast b) Just breakfast c) Immediately before lunch d) As soon as the child awakens

BONUS

50) A female client who has been told by her physician that she has CA, tells the nurse that she believes the physician made an error, she does not have CA, and she is not going to die. The nurse evaluates that the client is experiencing the stage of death and dying known as: a) anger b) sick c) bargaining d) acceptance

BONUS

SITUATION: Mark, age 31 is suffering from schizophrenia. Currently he is experiencing psychotic episode 38) Which statement should the nurse make in order to pursue the matter of Mark's belief about poisoned food? a) "Why do you think the food is poisoned?" b) "You feel someone wants to poison you?" c) "Your feeling is a symptom of your illness." d) "You'll be safe with me. I won't let anyone poison you."

RATIONALE: The statement that the nurse should make in order to pursue the matter of Mark's belief about poisoned food is: "You feel someone wants to poison you?" This statement acknowledges Mark's feelings and delusional belief without directly challenging or confirming the delusion. It allows Mark to express his thoughts and emotions while maintaining a non-confrontational approach.

28) One day Karen suddenly walks up to the nurse and shouts, "You think you're so damned perfect and good. I think you stink!" Which response should the nurse make? a) "You seem angry with me." b) "Stink? I don't understand." c) "Boy, you're in a bad mood." d) "I can't be all that bad, can I?"

a) "You seem angry with me." RATIONALE: The most appropriate response for the nurse to make when Karen suddenly walks up and shouts, "You think you're so damned perfect and good. I think you stink!" is: "You seem angry with me." This response reflects an empathetic and non-judgmental approach to the client's expression of anger. By acknowledging Karen's emotions and reflecting them back to her, the nurse shows that she is listening and trying to understand her feelings without becoming defensive or confrontational.

20) The nurse is developing a nursing care plan for a depressed client. The most therapeutic approach would be: a) Allowing for the client's slowness when planning activities b) Helping the client focus on family strengths and support system c) Encouraging the client to perform menial tasks to meet the need for punishment d) Repeating again and again that the staff views the client as worth-while and important

a) Allowing for the client's slowness when planning activities

SITUATION: Karen, age 16 is withdrawn and non-communicative. She spends most of her time lying on her bed. 25) Which nursing intervention would be the most appropriate way to help Karen accept the realities of daily living? a) Assist her to care for personal hygiene needs b) Encourage her to keep up with school studies c) Encourage her to join other clients in group singing d) Leave her alone when there appears to be a disinterest in the activities in hand

a) Assist her to care for personal hygiene needs RATIONALE: The most appropriate way to help Karen accept the realities of daily living would be to assist her in caring for her personal hygiene needs. Karen's withdrawn and non-communicative behavior, spending most of her time lying on her bed, suggests that she may be experiencing emotional distress or depression. Helping her with personal hygiene can be a gentle and supportive way to engage her in self-care activities and encourage a sense of routine and normalcy in her daily life.

70) The nurse is aware that the defense mechanism commonly used by clients who are alcoholics is: a) Denial b) Projection c) Displacement d) Compensation

a) Denial RATIONALE: The defense mechanism commonly used by clients who are alcoholics is denial. Denial is a psychological defense mechanism in which individuals refuse to acknowledge the reality of a situation or their own behaviors. In the case of alcoholics, they may deny or minimize the extent of their drinking problem, even in the face of clear evidence of its negative impact on their life and relationships.

23) A male client who has delusions of persecution and auditory hallucinations is admitted for psychiatric evaluation after stabbing a friend. Later, the nurse on the unit greets the client by saying, "good evening. How are you? The client, who has been referring to himself as "man," answers, "The man is bad," This is an example of a) Dissociation b) Transference c) Displacement d) Reaction formation

a) Dissociation

SITUATION: Sarah, age 45, has paranoid schizophrenia. 30) Sarah has been awake for several nights. She did not have an interrupted sleep pattern prior to a transfer from a private to a four-bedroom three days ago. Sarah's sleeplessness may be related to which of the ff. stimuli? a) Fear of the other clients c) Watching for an opportunity to escape b) Worry about family at Home d) Trying to work out emotional problem

a) Fear of the other clients RATIONALE: Sarah's sleeplessness may be related to her fear of the other clients in the four-bedroom setting. A change in environment, such as transferring from a private room to a shared room, can be unsettling for individuals with paranoid schizophrenia. The presence of other clients may trigger feelings of anxiety, fear, and discomfort, leading to difficulty falling or staying asleep.

27) Which of the ff. is an important aspect of nursing intervention when caring for Karen? a) Help keep her oriented to reality b) Involve her in activities throughout the day c) Encourage her to discuss why mixing with other people is avoided d) Help her understand that it is harmful to withdraw from situations

a) Help keep her oriented to reality RATIONALE: An important aspect of nursing intervention when caring for Karen is to help keep her oriented to reality. Given her withdrawn and non-communicative state, Karen may be experiencing difficulties in distinguishing between reality and her inner world. Orienting her to reality involves helping her maintain awareness of the present time, place, and situation, which can be grounding and supportive.

1) When thinking about alcohol and drug abuse, the nurse is aware that: a) Most poly drug abusers also abuse alcohol b) Most alcoholics become poly drug abuses c) Addictive individuals tend to use hostile abusive behavior d) An unhappy childhood is a causative factor in many addiction

a) Most poly drug abusers also abuse alcohol

14) The nurse should observe the autistic child for sign of; a) Not wanting to eat b) Crying for attention c) Catatonic like rigidity d) Enjoying being with people

a) Not wanting to eat

SITUATION: Harold, age 23, is a regressed, emotionally disturbed client. 34) Harold uses his hand to eat "arroz caldo" and other soft foods. Which intervention should the nurse make? a) Place a spoon in his hand and suggest it to be used b) Ignore the behavior and observe several additional meals before intervening c) Remove the food and say, "You can't have anything until you use your spoon." d) Say in a joking way, "Well, I guess fingers were made before forks."

a) Place a spoon in his hand and suggest it to be used RATIONALE: The most appropriate nursing intervention in this situation would be to place a spoon in Harold's hand and suggest that he uses it to eat. Offering the spoon in a gentle and supportive manner can encourage him to use proper utensils for eating while respecting his dignity and autonomy.

63) The nurse recognizes that paranoid delusions usually are related to the defense mechanism of a) Projection b) Regression c) Repression d) Identification

a) Projection RATIONALE: Paranoid delusions are often related to the defense mechanism of projection. Projection is a defense mechanism in which an individual attributes their own unacceptable thoughts, feelings, or impulses to others. In the case of paranoid delusions, the person projects their own fears, anxieties, or aggressive impulses onto others, leading to false beliefs that others are plotting against or intending harm to them.

75) The treatment in crisis intervention centers is specifically intended to help clients a) Return to prior levels of functioning b) Understand the dynamics underlying symptoms c) Make long-range plans for the future d) Accept their illness

a) Return to prior levels of functioning RATIONALE: The treatment in crisis intervention centers is specifically intended to help clients return to prior levels of functioning. Crisis intervention focuses on providing immediate and intensive support to individuals experiencing acute psychological or emotional distress. The goal is to stabilize the client's condition, alleviate the crisis, and help the person regain their ability to cope and function effectively.

66) To increase the self-esteem of a client with schizophrenia, the nurse should plan to: a) Reward healthy behaviors c) Encourage good hygiene and grooming b) Identify various means of coping d) Explain the diagnosis and treatment plan

a) Reward healthy behaviors RATIONALE: To increase the self-esteem of a client with schizophrenia, the nurse should plan to reward healthy behaviors. Positive reinforcement can be a powerful tool in encouraging and reinforcing positive behaviors in individuals with schizophrenia. By recognizing and rewarding the client's healthy behaviors, the nurse helps promote a sense of accomplishment and self-worth, which can contribute to increased self-esteem. It is important to focus on the client's strengths and successes, as this can help counteract the negative symptoms and self-perceptions often associated with schizophrenia.

31) While the nurse is talking with another client Sarah comes up and yells, "I hate you! You are talking about me again." And throws a glass of juice at the nurse. Which is the best nursing approach? a) Understand Sarah's behavior and say, "You hate me? Tell me about that." b) Ignore both the behavior and Sarah, clean up the juice, and talk to her when she is better, c) Remove Sarah to an isolation room because she needs to have limits placed on her behavior d) Verbalize feelings of annoyance as an example to Sarah that it is more acceptable to verbalize feelings than to act out.

a) Understand Sarah's behavior and say, "You hate me? Tell me about that."

22) A client on a maintenance dose of lithium therapy develops hand tremors; muscle hyperirritability, and mental confusion. The nurse should a) Withhold the medication, obtain blood lithium and call physician b) Check the nausea, vomiting, thirst, and polyuria before administering the next dose of lithium c) Expect these side effects, administer the medication as ordered, and note these findings in the record d) Withhold the medication, check the BP, and, if within normal limits, administer the correct dosage.

a) Withhold the medication, obtain blood lithium and call physician RATIONALE: The client's symptoms of hand tremors, muscle hyperirritability, and mental confusion are indicative of lithium toxicity. When a client on maintenance lithium therapy develops such symptoms, it is crucial for the nurse to withhold the medication immediately to prevent further toxicity. The nurse should then obtain blood lithium levels to confirm the presence of lithium toxicity. Finally, the physician should be notified promptly so that appropriate interventions can be initiated based on the lithium level and the client's clinical condition.

54) The client is admitted to the hospital because of incapacitating obsessive-compulsive behavior. The statement that best describes how clients with obsessive-compulsive behavior view this disorder would be: a) "It is not my fault that I act this way; the devil makes me do it." b) "I know there is no reason to do these things, but I can't help myself." C) "The things I do take a little time, but they make me a productive person." d) "I don't know why everyone is upset with me. I'm doing nothing wrong."

b) "I know there is no reason to do these things, but I can't help myself." RATIONALE: Clients with obsessive-compulsive disorder (OCD) often have insight into the irrationality of their thoughts and behaviors. They are aware that their obsessive thoughts and compulsive behaviors are excessive and do not make sense logically. However, despite this insight, they feel compelled to engage in these behaviors as a way to reduce anxiety and distress. They may describe feeling trapped and unable to control their urges to perform these rituals.

SITUATION: Mark, age 31 is suffering from schizophrenia. Currently he is experiencing psychotic episode 36) Mark expresses the belief that the "Barangay Tanod" is out to kill him. Which of the ff. terms best illustrate what Mark is experiencing? a) An illusion b) A delusion c) Autistic thinking d) A hallucination

b) A delusion

48) The nurse is aware that in the working phase of the nurse-patient relationship, client a) Often focus the conversation on the nurse. b) Accept limits and initiate topics for discussion c) Commonly exhibit testing behaviors such as flirtation and lateness d) May repress emotionally charged material to avoid shocking the nurse

b) Accept limits and initiate topics for discussion

18) When Methadone Hydrochloride dosage is lowered, the surgical client who is addicted to narcotics must be observed close for evidence of: a) Piloerection, lack of interest in the surroundings b) Agitation, attempts to escape from the hospital c) Skin dryness, scratching under the incisional dressing d) Lethargy, refusal to participate in therapeutic exercise.

b) Agitation, attempts to escape from the hospital

15) Individuals with antisocial personality disorders: a) Suffer from great deal of anxiety b) Are generally unable to postpone gratification c) Rapidly learns by experience and punishment d) Have a great sense of responsibility towards others

b) Are generally unable to postpone gratification RATIONALE: Individuals with antisocial personality disorder tend to have difficulties in delaying or postponing gratification. They often prioritize their immediate desires, needs, and impulses over long-term consequences or the well-being of others. This impulsivity is one of the characteristics associated with this personality disorder.

55) The most critical factor for the nurse to determine during crisis intervention would be the client's: a) Developmental history b) Available situational support c) Underlying unconscious conflict d) Willingness to restructure the personality

b) Available situational support RATIONALE: During crisis intervention, the most critical factor for the nurse to determine is the client's available situational support. Crisis intervention aims to provide immediate support and assistance to individuals who are experiencing acute distress or overwhelming situations. Understanding the client's available support systems, such as family, friends, and community resources, is essential for providing appropriate interventions and ensuring the client's safety and well-being.

16) A client with schizophrenia has just been admitted to the hospital. When working with this client initially the nurse's most therapeutic action would be to: a) Use diversional activity and involve the client in occupational therapy b) Build trust and demonstrate acceptance by spending some time with client c) Delay one to one interaction until medication reduce the psychotic symptoms d) Involve the client in multiple small group discussion to distract attention from the fantasy world

b) Build trust and demonstrate acceptance by spending some time with client RATIONALE: When working with a client with schizophrenia who has just been admitted to the hospital, the most therapeutic action for the nurse would be to build trust and demonstrate acceptance by spending time with the client. Establishing a therapeutic nurse-client relationship is essential in providing effective care for individuals with schizophrenia. By spending time with the client, the nurse can demonstrate care, support, and acceptance, which can help reduce the client's anxiety and increase their comfort level in the hospital setting. It also allows the nurse to gather valuable information about the client's thoughts, feelings, and concerns, which can aid in providing appropriate care and support.

11) A young narcotic addict client had surgery to repair a laceration of the heart caused by a bullet. The client is receiving methadone hydrochloride, which: a) Allows symptoms free termination of narcotic addiction b) Corvert narcotic use from an illicit to a legally controlled drug c) Provide postoperative pain control without causing narcotic dependence d) Counteracts the depressive effects of a long term opiate use on cardiac and thoracic muscles

b) Convert narcotic use from an illicit to a legally controlled drug RATIONALE: Methadone hydrochloride is a synthetic opioid medication used in medication-assisted treatment (MAT) for narcotic addiction, especially for opioid use disorder (OUD). One of its primary purposes is to replace illicit opioid use with a legally prescribed and controlled medication.

10) A person with an antisocial personality disorder has difficulty relating to others. Because the person has never learned to a) Count to others b) Empathize with others c) Be dependent with others d) Communicate with others socially

b) Empathize with others RATIONALE: People with antisocial personality disorder often have difficulty empathizing with others. Empathy involves the ability to understand and share the feelings and emotions of others, which can be challenging for individuals with this personality disorder. Individuals with antisocial personality disorder tend to have a persistent pattern of disregard for, and violation of, the rights of others. They may be manipulative, deceitful, and lack remorse for their actions, which can make it difficult for them to genuinely connect with and understand the emotions of others.

SITUATION: Judy, age 19, has just been admitted to hospital. She has bipolar disorder and is in the manic phase of her illness. 41) Judy is hyperactive and elated. What would the nurse do to redirect her? a) Ask her to guide other clients as they clean their rooms b) Encourage her to tear pictures out of magazines for a scrapbook c) Suggest that she initiate social activities on the unit for the client group d) Provide her with a pencil and paper and encourage her to write a short story.

b) Encourage her to tear pictures out of magazines for a scrapbook

46) According to Erickson, an individual who fails to master the maturational crisis of adolescence will most often: a) Rebel at parental orders b) Experience role confusion c) Be interpersonally isolated d) Use drugs and alcohol to escape

b) Experience role confusion

52) The nurse is aware that a child's emotional problems usually occurs as a result of: a) Rejection by the parents b) Family pathologic factors c) Authoritarian parenting style d) Overbearing over-protectiveness

b) Family pathologic factors RATIONALE: A child's emotional problems can often occur as a result of family pathologic factors. Family pathologic factors refer to dysfunctional or unhealthy patterns within the family that can negatively impact the child's emotional well-being and development.

SITUATION: Karen, age 16 is withdrawn and non-communicative. She spends most of her time lying on her bed. 26) Which is the best plan of nursing intervention to encourage Karen to talk? a) Try to get her to discuss feelings b) Focus on non-threatening subjects c) Ask simple questions that require answers d) Sit and look through magazines with her.

b) Focus on non-threatening subjects

57) Before helping a client who has been sexually assaulted, the nurse should recognize that the rapist is motivated by feeling of: a) Passion b) Hostility c) Inadequacy d) Incompetence

b) Hostility RATIONALE: Before helping a client who has been sexually assaulted, the nurse should recognize that the rapist is motivated by feelings of hostility. Sexual assault is an act of violence and power, and the underlying motivation for the perpetrator is often rooted in feelings of anger, aggression, and a desire to exert control over the victim.

45) According to Erickson, a young adult must accomplish the task associated with the stage known as: a) Initiative versus Guilt b) Intimacy versus Isolation c) Industry versus Intimacy d) Generativity versus Stagnation

b) Intimacy versus Isolation

68) A client with schizophrenia, paranoid type, is delusional, withdrawn, and negativistic. The nurse should plan to: a) Explain to the client the benefits of a group activity b) Matter of factly invite the client to play table tennis c) Encourage the client to become involved in group activities d) Mention to the client that the psychiatrist has ordered increased activity

b) Matter of factly invite the client to play table tennis RATIONALE: When working with a client with schizophrenia, paranoid type, who is delusional, withdrawn, and negativistic, it is important for the nurse to approach the client in a non-threatening and non-confrontational manner. Option b, matter-of-factly inviting the client to play table tennis, is a suitable approach. This option uses a straightforward and casual invitation to engage the client in an activity without placing pressure or expectations on them. Table tennis, being a low-key and non-intrusive activity, can provide an opportunity for the client to participate in a social activity without feeling overwhelmed or exposed.

44) The nurse should first discuss terminating the nurse-client relationship with a client during the: a) Working phase when the client brings it up b) Orientation phase when a contract is established c) Working phase when the client shows some progress d) Termination phase when discharge plans are being made.

b) Orientation phase when a contract is established RATIONALE: The nurse should first discuss terminating the nurse-client relationship with a client during the orientation phase when a contract is established. The orientation phase is the initial stage of the nurse-client relationship, where the nurse and the client establish rapport, discuss the purpose and goals of the therapeutic relationship, and set expectations for the interaction. During this phase, it is essential to address the eventual termination of the relationship to prepare the client for the eventual conclusion of the therapeutic interaction. In the orientation phase, the nurse can discuss the duration of the therapeutic relationship, the expected frequency and duration of sessions, and the process of termination. This discussion provides the client with an understanding of the temporary nature of the relationship and the planned conclusion of the therapeutic work. It also helps the client feel more in control and prepared for the eventual termination, reducing any potential feelings of abandonment or confusion.

9) During the early of hospitalization of a depressed client, an activity that would be most appropriate would be: a) Game of trivial pursuit b) Project involving drawing c) Small dance therapy group d) Card game with three other clients

b) Project involving drawing

42) After caring for a terminally ill client for several weeks, the nurse becomes increasingly aware of a need to get away from this assignment. The best initial action by the nurse would be: a) Request vacation time for a few days b) Seek support from other nurses from the unit c) Withdraw emotional involvement with the client d) Stay with the client and try to work through feelings

b) Seek support from other nurses from the unit RATIONALE: The best initial action by the nurse would be to seek support from other nurses on the unit. Caring for terminally ill clients can be emotionally challenging, and it is not uncommon for healthcare providers to experience feelings of burnout, compassion fatigue, or emotional exhaustion. Seeking support from colleagues who can understand and empathize with the nurse's feelings can be beneficial.

13) The most helpful approach in the meeting the needs of an elderly client hospitalized with the diagnosis of dementia of the Alzheimer's type is: a) Providing a nutritious diet high in carbohydrates and proteins. b) Simplifying the environment as much as possible while eliminating needs for choices c) Developing a consistent nursing plan with fixed time schedules to provide for physical and emotional needs. d) Developing a nursing plan with time schedules convenient to the client and to provide for physical and emotional needs.

b) Simplifying the environment as much as possible while eliminating needs for choices

21) A psychiatric client is to be discharged with prescription to Haloperidol (Haldol) therapy. When developing a teaching plan for discharge, the nurse should include cautioning the client against: a) Driving at night b) Staying in the sun c) Ingesting wines and cheeses d) Taking medications containing ASA

b) Staying in the sun RATIONALE: When developing a teaching plan for discharge with a psychiatric client prescribed Haloperidol (Haldol) therapy, the nurse should caution the client against staying in the sun. Haloperidol is an antipsychotic medication that belongs to a class of drugs known as typical or first-generation antipsychotics. It can cause increased sensitivity to sunlight, leading to a higher risk of sunburn or other skin reactions when exposed to the sun for an extended period.

53) When talking with a female client. who displays many of the emotional and psychological symptoms associated with a panic disorder, the nurse should: a) Describe for her the possible reasons for anxiety b) Use short simple sentences and a firm authoritative voice c) Ask many questions, because she probably is not going to volunteer much information d) Suggest that she refrain from crying, because most of the time crying makes matters worse.

b) Use short simple sentences and a firm authoritative voice RATIONALE: When talking with a female client who displays many of the emotional and psychological symptoms associated with a panic disorder, the nurse should use short, simple sentences and a firm authoritative voice. Panic disorder is characterized by sudden and intense episodes of fear and anxiety, often accompanied by physical symptoms like rapid heartbeat, sweating, trembling, and difficulty breathing. In such situations, the client may have difficulty processing complex information, so using short, clear sentences can be helpful in facilitating communication. A firm and authoritative voice can provide reassurance and a sense of stability, which may help the client feel more secure during a panic episode.

49) A male client is preparing to leave the hospital and return to college. When saying goodbye, he hugs and kisses the nurse or the check. The nurse most appropriate response would be to: a) Hug the client in return b) Wish him well with his studies c) smile at the client and say nothing d) Encourage him to come and say "hello" periodically

b) Wish him well with his studies RATIONALE: In this situation, the most appropriate response for the nurse would be to wish the client well with his studies. The client's gesture of hugging and kissing the nurse on the cheek may be an expression of gratitude or fondness as he prepares to leave the hospital. It is essential for the nurse to maintain a professional boundary and respond in a way that is appropriate in the nurse-client relationship.

64) Dusing a one to one interaction with a client with schizophrenia, paranoid type, the client says to the nurse, "I figured out how foreign agents have infiltrated the news media. They want to shut me up." This statement can best described as: a) nihilistic delusion b) delusion of grandeur c) An auditory hallucination d) An over evaluation of the self

b) delusion of grandeur

67) The nurse planning to establish a trusting relationship with a client who is using paranoid ideation should begin a) Seeking the client out frequently to spend long blocks of time together b) Sitting in the unit and observing the client's behavior throughout the day. c) Being available on the unit frequently but waiting for the client to approach d) Calling the client into the office to establish a contract for a regular therapy session.

c) Being available on the unit frequently but waiting for the client to approach RATIONALE: When establishing a trusting relationship with a client who is experiencing paranoid ideation, it is essential for the nurse to approach the situation with sensitivity and respect for the client's feelings and boundaries. Option c, being available on the unit frequently but waiting for the client to approach, is the most appropriate choice.

SITUATION: Mark, age 31 is suffering from schizophrenia. Currently he is experiencing psychotic episode 37) Mark refuses to eat because he believes that the food is being poisoned. Which of the ff. Is the most appropriate initial nursing intervention? a) Taste the food in Mark's presence b) Suggest that the food be brought in from home c) Convince Mark that the food is not poisoned d) Tell Mark that tube feedings will be started if he does not begin to eat.

c) Convince Mark that the food is not poisoned

62) A male client in a mental health facility is tugging on his ear during a unit meeting. When the nurse comments about it, the client replies, "You know, it's that microchips those foreign agents implanted in my ear. They are trying to control my thoughts and deed." Based on this statement the nurse should recognize that the client is experiencing: a) Illusions b) Hallucinations c) Delusional thoughts d) Neologistic Thinking

c) Delusional thoughts RATIONALE: Based on the client's statement about foreign agents implanting microchips in his ear to control his thoughts and deeds, the nurse should recognize that the client is experiencing delusional thoughts. Delusions are false beliefs that are not based in reality and are often resistant to reasoning or evidence to the contrary. In this case, the client's belief about the microchips controlling his thoughts and actions is an example of a delusional thought.

35) Harold voids on the floor. The nurse should make which of the ff. actions? a) Make Harold mop the floor b) Restrict his fluids throughout the day c) Frequently toilet Harold with supervision d) Withhold privileges each time Harold voids on the floor

c) Frequently toilet Harold with supervision RATIONALE: The most appropriate nursing action in this situation would be to frequently toilet Harold with supervision. As a regressed and emotionally disturbed client, Harold may be experiencing difficulties in controlling his bladder function. Frequent toileting with supervision can help ensure that he has opportunities to use the toilet appropriately and reduce the chances of voiding accidents on the floor.

61) A 25 yr old male client is being treated for schizophrenic disorder. The client accuses the nurse and the physicians of being homosexuals. This behavior indicates that the client is. a) Attempting to keep the focus off his own problems b) Trying to embarrass those perceived as authority figures c) Having difficulty handling unacceptable feelings about himself d) Exploring emotionally charged reactions to threatening situations. RATIONALE: The client's behavior of accusing the nurse and physicians of being homosexuals in the context of a schizophrenic disorder suggests that the client is having difficulty handling unacceptable feelings about himself. In schizophrenia, individuals may experience disorganized thinking, delusions, and hallucinations that can be rooted in their internal conflicts, anxieties, and unresolved emotions. Accusing others of being homosexuals could be a manifestation of the client projecting their own internal conflicts onto others.

c) Having difficulty handling unacceptable feelings about himself RATIONALE: The client's behavior of accusing the nurse and physicians of being homosexuals in the context of a schizophrenic disorder suggests that the client is having difficulty handling unacceptable feelings about himself. In schizophrenia, individuals may experience disorganized thinking, delusions, and hallucinations that can be rooted in their internal conflicts, anxieties, and unresolved emotions. Accusing others of being homosexuals could be a manifestation of the client projecting their own internal conflicts onto others.

3) A male client is diagnosed with a schizoid personality disorder. Nursing intervention should be appropriately directed toward: a) Helping the client enter into group recreational activities b) Convincing the client that the hospital staff is trying to help c) Helping the client learn to trust the staff through selected experiences d) Arranging the hospital environment so that the client's contact with other clients is limited

c) Helping the client learn to trust the staff through selected experiences

43) A client with dementia often assaults the nursing staff, and the staff decides to develop a plan that will make this client's personal care less of a problem. The plan should include a) Limiting staff time with the client b) An outline of the consequences for uncooperative behavior c) Identification of nursing staff members whom the client prefers. d) The client's likes and dislikes for use as a reward of punishment

c) Identification of nursing staff members whom the client prefers.

65) The nurse notices a male client sitting alone in the corner smiling and talking to himself. Realizing that the client is hallucinating, the nurse should: a) Ask the client why he is smiling b) Leave the client alone until he stops talking c) Invite the client to help to decorate the day room d) Tell the client it is not good for him to talk to himself

c) Invite the client to help to decorate the day room

69) A factor that might place a young person in a high risk category for substance abuse would be: a) Curiosity and daring attitude b) Occasional periods of depression c) Loss of a parent through death or separation d) Typical stresses associated with adolescence

c) Loss of a parent through death or separation

7) A nurse is attempting to understand the behavior of an elderly client diagnosed with vascular dementia, the nurse recognize that the client is probably: a) Not capable of using any defense mechanisms b) Using one method of defense for every situation c) Making exaggerated use of old, familiar mechanism d) Attempting to develop new defense mechanism to meet the current situation

c) Making exaggerated use of old, familiar mechanism RATIONALE: In the context of an elderly client diagnosed with vascular dementia, it is common for the individual to rely on old, familiar defense mechanisms to cope with challenging situations. As dementia progresses, cognitive abilities decline, and the individual may have difficulty adapting to new situations. They may revert to previously learned and well-established defense mechanisms to handle stress, anxiety, or other emotional challenges.

SITUATION: Harold, age 23, is a regressed, emotionally disturbed client. 33) Harold is seen openly masturbating. Which nursing action would be most appropriate? a) Restraint his hands b) Put Harold in seclusion c) Not react to the behavior d) State that such behavior is I unacceptable

c) Not react to the behavior

5) A client in the hyperactive phase of a mood disorder [bipolar type] is receiving lithium carbonate. The nurse notes that the client's lithium blood level is 1.8mEq/L. It would be most appropriate for the nurse to: a) Continue the usual dose of lithium and note any adverse reactions b) Discontinue the drug until the lithium serum drops to 0.4 mEq/L c) Notify the physician immediately, since the serum level of lithium may be toxic d) Ask the physician to increase the dose of lithium, since the serum level is too low.

c) Notify the physician immediately, since the serum level of lithium may be toxic RATIONALE: A lithium blood level of 1.8 mEq/L is considered high and potentially toxic. The therapeutic range for lithium in the treatment of bipolar disorder is usually between 0.6 to 1.2 mEq/L. A level of 1.8 mEq/L exceeds the upper limit of the therapeutic range, and the client may be at risk of experiencing lithium toxicity.

72) A client is given antipsychotic drugs. The nurse is aware that all the extrapyramidal effects associated with these drugs the one causing the most concern would be: a) Akathisia c) Parkinsonian syndrome b) Tardive dyskinesia d) An acute dystonic reaction

c) Parkinsonian syndrome

SITUATION: Judy, age 19, has just been admitted to hospital. She has bipolar disorder and is in the manic phase of her illness. 40) Judy becomes vulgar and profane. What should the nurse do? a) State, "We do not like that kind of talk around here." b) Ignore it since the client is using it only to get attention c) Recognize the language as part of the illness but set limits on it. d) State, "When you talk in an acceptable way, we will talk to you."

c) Recognize the language as part of the illness but set limits on it. RATIONALE: However, while recognizing the behavior as part of the illness, it is also essential to set appropriate limits and boundaries. The nurse can calmly and assertively state that the use of vulgar and profane language is not acceptable in the hospital setting. The nurse can redirect the conversation or engage in a therapeutic dialogue with Judy, focusing on topics that are more appropriate and respectful.

17) The major difference between anorexia nervosa and bulimia nervosa is that the individual with bulimia nervosa: a) Is obese and attempting to lose weight b) Has distorted body images and sees the body as fat. c) Recognizes that there is a problem but is helpful to correct it. d) Is struggling with a conflict of dependence versus independence

c) Recognizes that there is a problem but is helpful to correct it. RATIONALE: In bulimia nervosa, individuals engage in episodes of binge eating followed by compensatory behaviors such as purging, fasting, or excessive exercise to prevent weight gain. Unlike individuals with anorexia nervosa, those with bulimia nervosa often recognize that their eating behaviors are problematic and may be motivated to correct their behavior or seek help for their condition. However, despite this awareness, the struggle with bulimia nervosa can be challenging to overcome without appropriate treatment and support.

60) By recognizing common behaviors exhibited by the client who has a diagnosis of schizophrenia, the nurse can anticipate: a) Disorientation, forgetfulness, and anxiety b) Grandiosity, arrogance, and distractibility c) Withdrawal, regressed behavior, and lack of social skills d) Slumped posture, pessimistic outlook, and flight of ideas.

c) Withdrawal, regressed behavior, and lack of social skills RATIONALE: By recognizing common behaviors exhibited by the client with a diagnosis of schizophrenia, the nurse can anticipate withdrawal, regressed behavior, and lack of social skills. Schizophrenia is a mental disorder characterized by a range of symptoms, including social withdrawal, impaired social skills, and regressed behavior, which may include difficulty with self-care and reduced ability to function in social or occupational settings.

59) While taking health history from a client who has a moderate level of cognitive impairment due to dementia, the nurse would expect to note the presence of a) Hypervigilance b) Increased inhibition c) Enhanced intelligence d) Accentuated premorbid traits

d) Accentuated premorbid traits

2) The nurse knows that dementia of the Alzheimer's type is characterized by: a) Aggressive acting out behavior b) Periodic remission and exacerbations c) Hypoxia of selected areas of brain tissue d) Areas of brain called senile plaques

d) Areas of brain called senile plaques RATIONALE: Dementia of the Alzheimer's type is characterized by the presence of abnormal protein deposits in the brain, known as senile plaques. These plaques consist mainly of beta-amyloid protein and are one of the hallmarks of Alzheimer's disease. These plaques are believed to contribute to the cognitive decline and memory impairment seen in individuals with Alzheimer's.

6) Soon after admission of depressed client, the nurse needs to evaluate the potential for suicide. The best approach to gain this information would be; a) Asking the client about plans for future b) Asking the clients about suicide while in the group c) Asking the family if the client has ever attempted suicide d) Asking the if suicide was ever or is now being considered

d) Asking the if suicide was ever or is now being considered RATIONALE: Asking directly about suicidal thoughts and intentions is crucial when assessing the risk of suicide in a depressed client. This approach allows the nurse to obtain essential information about the client's current mental state and whether they are experiencing suicidal ideation.

8) The most therapeutic environment for the clients with bulimia nervosa would be one that is: a) Controlling b) Focused on food c) Empathetic d) Based on realistic limits

d) Based on realistic limits

74) After a client has been receiving a new neuroleptic drug, the nurse observes extrapyramidal symptoms and anticipates that the physician will limit these side effects by prescribing: a) Zolpidem (Ambien) c) Dandrolene (Dantrium) D) Hydroxyzine (Atarax) d) Benztropine mesylate (Cogentin)

d) Benztropine mesylate (Cogentin) RATIONALE: When a client develops extrapyramidal symptoms (EPS) after receiving a new neuroleptic drug (antipsychotic), the physician may prescribe an anticholinergic medication to limit or manage these side effects. Benztropine mesylate (Cogentin) is an anticholinergic medication commonly used to treat EPS associated with antipsychotic drugs.

12) A bedridden client with chronic illness expresses anger through urinary incontinence. The nurse should: a) Limit the client's fluids intake in the evening b) Provide television or radio for client when alone c) Frequent ask if the client needs the bedpan to void d) Create an environment that prevents sensory monotony

d) Create an environment that prevents sensory monotony RATIONALE: The client's expression of anger through urinary incontinence indicates that there may be underlying emotional or psychological issues contributing to the behavior. Creating an environment that prevents sensory monotony can be helpful in addressing this situation. Sensory monotony refers to an unstimulating and monotonous environment, which can exacerbate negative emotions and behaviors. By providing a more engaging and stimulating environment, the client's focus can be redirected away from the expression of anger through urinary incontinence.

56) When counseling the 20 year old parent of a 13 month old, the nurse should expect the defense mechanism most often used by the physically abusive parent is: a) Idealization b) Transference c) Manipulation d) Displacement

d) Displacement RATIONALE: When counseling a physically abusive parent of a 13-month-old child, the nurse should expect that the defense mechanism most often used by the parent is displacement. Displacement is a defense mechanism where an individual directs their unacceptable or aggressive impulses onto a less threatening target. In the context of a physically abusive parent, they may be unable to cope with their own emotions or frustrations and end up displacing these feelings onto the child.

51) A terminally 76 year old client is very quiet and unwilling to have visitors, During the initial contact with the client, the nurse should: a) Attempt to understand what the death and dying process means to the client b) Avoid talking about the client's condition unless the client initiates the discussion c) Ascertain how much pain the client is experiencing and what medications have been ordered. d) Explore the extent to which the client is aware of the prognosis and the client's feeling about the situation.

d) Explore the extent to which the client is aware of the prognosis and the client's feeling about the situation. RATIONALE: During the initial contact with a terminally ill client who is quiet and unwilling to have visitors, the nurse should explore the extent to which the client is aware of the prognosis and the client's feelings about the situation. Open and sensitive communication is essential in providing care to terminally ill clients. Understanding the client's awareness of their condition and their emotional state can help the nurse provide appropriate support and care.

71) Within a few hours of alcohol withdrawal, the nurse should assess a client for the presence of; a) Yawning, anxiety, convulsion c) Disorientation, paranoia, tachycardia b) Tremors, fever, profuse diaphoresis d) Irritability, heightened alertness, jerky movements

d) Irritability, heightened alertness, jerky movements

24) The major reason for treating a severe emotional disorder with tranquilizer is to: a) Reduce neurotic symptoms b) Prevent secondary complications c) Prevent destructiveness of the client d) Make the client more amenable to psychotherapy

d) Make the client more amenable to psychotherapy

73) A client with an organic mental disorder becomes increasingly agitated and abusive. The physician orders Haldol. The nurse should assess the client for untoward effects including: a) Jaundice and vomiting c) Hiccups and postural hypotension b) Tardive dyskinesia and nausea d) Parkinsonism and agranulocytosis

d) Parkinsonism and agranulocytosis

19) An elderly confused client with socially aggressive behavior needs an environment that: a) Can be manipulated b) Allows freedom of expression c) Is mainly group oriented d) Provides control by setting limits

d) Provides control by setting limits RATIONALE: An elderly confused client with socially aggressive behavior requires an environment that provides control by setting limits. Setting clear and appropriate limits is essential to ensure the safety and well-being of the client and others in the environment. Confused clients, especially those with socially aggressive behavior, may have difficulty understanding social norms and appropriate behavior. Providing a structured environment with well-defined boundaries and limits can help manage their behavior and prevent potential harm to themselves and others.

SITUATION: Judy, age 19, has just been admitted to hospital. She has bipolar disorder and is in the manic phase of her illness. 39) Three new nurses are being oriented to the unit. Judy comes up to them and says, "Welcome to the funny farm, I am Jojo the head Yoyo." Which of the ff, describes what is happening to Judy? a) She is trying to fill the "life of the party" role b) She is looking for attention from the new staff c) She is unable to distinguish fantasy from reality d) She is anxious over the arrival of the new nurses

d) She is anxious over the arrival of the new nurses

32) Sarah approaches the nurse and states, "I am hearing voices that are saying bad things about me." Which of the ff. intervention should the nurse make? a) Simply state, "I don't hear the voices." b) Suggest she join other clients playing cards c) Encourage Sarah not to listen to what the voice are saying d) State, "The staff understands that you are frightened and will stay with you while the voices are speaking."

d) State, "The staff understands that you are frightened and will stay with you while the voices are speaking." RATIONALE: The best intervention the nurse should make is to state, "The staff understands that you are frightened and will stay with you while the voices are speaking." This response shows empathy and understanding, and it reassures Sarah that she is not alone in her experience. Staying with her during the episode of auditory hallucinations can provide a sense of security and support.

SITUATION: Sarah, age 45, has paranoid schizophrenia. 29) Sarah refused to eat for 36 hrs. She believes that the voice of her dead father has commanded her to atone for her sins by fasting for 40 days. Which nursing intervention might interrupt Sarah's delusional system? a) Tell her that she has nothing to atone for b) Ask her to repeat exactly what the voice said c) Ask the physician to write an order for tube feedings d) Suggest other means of atonement that may be less damaging.

d) Suggest other means of atonement that may be less damaging. RATIONALE: The most appropriate nursing intervention to interrupt Sarah's delusional system would be to suggest other means of atonement that may be less damaging. When a client with paranoid schizophrenia is experiencing delusions, it is important to approach their beliefs with sensitivity and avoid directly challenging or contradicting the delusions. Instead, the nurse can redirect the client's thoughts and offer alternative perspectives or coping strategies.

58) The nurse discusses the plan of care with a depressed client whose husband has recently died. The nurse recognizes it would be most helpful to: a) Encourage the client to talk about and plan for the future b) Involve the client in group outdoor games each morning c) Motivate the client to interact with male client and the staff d) Talk with the client about her husband and the details of his death

d) Talk with the client about her husband and the details of his death

47) A nurse recognizes that a father's sexual abuse of a 13 year old daughter was probably motivated by his: a) Need to control c) Unfulfilled sexual needs b) Feelings of anger d) Unmet emotional needs

d) Unmet emotional needs