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Hesi Mental Health Practice Questions

Hesi Mental Health Test Bank

1. history of alcoholism admitted for detoxification; 6 mg of ativan what additional prescription administer immediately

- Vitamin B1 (thiamine)


2. hopeless unable to stop crying; evaluate effectiveness of cognitive-behavioral techniques; client outcome?

- Changes thought patterns r/t problem solving


3. Schizoprenia return to clinic 2 weeks after recieving dose of haldol; important info for the nurse to obtain during this visit

- Current vital signs


4. Client who refuses antipsychotic medication disrupt group activities nurse decides client needs constant observation based on

- wanders into client's room


5. PTSD admitted to psychiatric unit, which intervention is most important for plan of care

- provide a quiet room away from the recreational area


6. middle aged female no previous psychiatric history because her family described her having paranoid thoughts "i want to find out why these people are stalking me"

- it sounds like this experience is frightening you


7. "idont know, i just cant think" what activity should the nurse suggest

- set daily goals in the community meeting


8. assessing male client with paranois, which behavior can this client be expected to exhibit

- is openly hostile towards others for no apparent reason


9. 8 month old with profound mental and physcial disabilities

- ask mother is she has ever thought about harming herself or her child


10. recurrent negative symptoms of chronic schizophrenia and medication risperdal. walks laterally contracted position, something has made his body contort

- administer the prescribed anticholinergic benztropine (cogentin) for dystonia


11. bipolar disorder depakote for manic reactions. monitored for seizure

- observe the client for a reduction in hyperexcitable bahaviors because the drug enhances cerebral inhibitory transmitters


12. chronically depressed older male client of a long term care facility becomes more reclusive and today refuses to leave room

- may I sit for you for a while


13. wife having affair, sober of 3 years, i believe in god

- what is troubling you most


14. smearing feces on the bathroom wall

- escort the client out of the bathroom


15. i know marijuana is not addicting

- anytime you alter your ability to think clearly you put yourself and others at risk


16. catatonicschizoprenia, emphysema, DM2, hyperlipidemia

- check blood glucose measurement


17. depression remains in bed most of the day, declines activities and refuses meals

- refusal to address nutritional needs


18. borderline personality disorder self inflicted lacerations on abdomen

- perform the dressing change in a non judgemental manner


19. male client admitted depression and self mutilation

- ask if the client has a plan to harm himself



20. admitted relationship distress wtih spouse and depressed mood, which diagnostic test

- urine drug screen


21. victim of intimate partner violence what 3 things should you do

- 1.establish a code with family and friends to signify violence, 2.plan an escape route to use if the abuser blocks main exit, 3.have a bag ready that has extra clothes for self and children


22. Star this term

- You can study starred terms together


23. 1.5 lithium admitted for suicidal ideations

- instruct client to drink 3 liters of fluid in 24 hours


24. a client throws chairs; what do you do

- obtain staff assistance to help diffuse the escalating situation


25. pre symptomatic genetic testing for mental illness

- the risk for mental ilness is not identified with genetic testing


26. sometimes my thoughts go so fast, is it time to eat

- exhibits tangential thinking


27. male client on atypical antipsychotic drug olanzapine (zyprexa)

- adverse reaction is weight gain


28. patient taking sertraline (zoloft) for postpartum depression, nursing teaching

- contact healthcare provider if having suicidal thoughts (black box warning)


29. female brought to er for rape by date

- my date raped me tonight (exact words from client)


30. nurse documents that a male client with schizophrenia is delusional, what statement made by the client would be a example? Why?

- nurse at night is trying to poison me with pills (false beliefs of unfounded evidence)


31. two days after last drink, shouts at wife and kids, what nursing intervention has the highest priority

- risk for injury (DT)


32. client sitting in corner of day room during admission assessment, what nursing action

- ask client simple questions


33. psychomotor retardation, hypersomnia, and amotivation; what nursing intervention

- teach client to have daily structured acitivites


34. male employee says imgonna shoot a coworker

- find out if he has a weapon


35. female abused by husband, when taking her history which info is most important

- if client has a plan to leave if her life is in danger


36. female depressed patient begins to talk and exhibit energy

- observe her actions continuously


37. mother yells "dont touch him" as the nurse gives child

- projects the feelings onto the nurse


38. Client makes a statement I feel like im going to die, what level of Anxiety is it?

- moderate anxiety


39. female low cut blouse, red lipstick

- assist the client back to her room and help her select appropriate clothing


40. recent suicide attempt, wife filed for divorce, loss job

- encourage activities that will allow him to take control over his environment


41. hears voice and becomes agitated

- move the client to a more quiet area


42. cancer patient who becomes dependent

- expected, as the client to a quiet area of the unit


43. a male client is admitted to the er; overdose of benzodiazepine

- administer narcan


44. 18 year old drug use; important information

- the drug that was ingested


45. How do you take antabuse

- each morning beginning 48 hours after your last drink of alcohol


46. attempted suicide by slashing wrists

- check the client level of consciousness


47. client 164 cm 36 kg after sycopal episode at home

- insert peripheral IV fluid resuscitation


48. 14 year old eating disorder what do you get them involved in

- arts and crafts


49. a client with bulimia what do you do?

- assess and report electrolyte imbalance


50. college student hears kill, kill

- are you planning to obey the voices


51. patient complains of blindness

- Conversion disorder


52. Star this term

- You can study starred terms together


53. patient seeing snakes

- administer activan


54. teen in er for threatening teacher

- discuss methods of clearly communicating






1. A male employee who is assessed weekly in the employee clinic for blood pressure because of a history of hypertension tells the nurse that he is so upset with one of his co-workers that he would like to shoot him. What action should the nurse take first?

a.) Determine if the client has a weapon available for use.

b.) Inform the health care provider of the threat to harm a co-worker.

c.) Notify security of the client’s intention to harm a co-worker.

d.) Have the employee escorted to a mental health facility.

Answ:A


2. A male client who is participating in an anger management assignment asks if he can make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. What defense mechanism is the client using?*

a.) Sublimation.

b.) Suppression.

c.) Regression.

d.) Compensation.

Answ:A


3. A 20-year-old female client with schizophrenia is scheduled to receive risperidone (Risperdal) 2mg at bedtime. When the nurse attempts to administer the medication, the client states. “I am not going to take that medicine, and you can’t make me.” What action should the nurse take?

a.) Administer the medication via a nasogastric tube.

b.) Substitute an injectable form of the medication.

c.) Encourage the client to take the medicine because it will help her sleep.

d.) Document in the client’s record that the medication was refused.

Answ:C


4. An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first?*

a.) Discuss treatment options for abusive partners.

b.) Explore client’s readiness to discuss the situation.

c.) Determine the frequency and type of client’s abuse.

d.) Report the finding to the police department.

Answ:B


5. A male client with bipolar disorder has not slept or eaten in four days. He paces and becomes increasingly agitated and loud while the nurse talks to his spouse. What intervention is the best for the nurse to implement at this time?

a.) Move to a quiet area and provide peanut butter with crackers.

b.) Walk with the client to the cafeteria and star as he eats lunch.

c.) Request a full lunch tray from the dietary department.

d.) Encourage the spouse to eat lunch with the client.

Answ:A


6. The nurse asks a female client with a borderline personality disorder, “How do you feel about your children not coming to visit this weekend?” The client looks out the window and replies, “I really don’t care.” Which response is best for the nurse to provide?

a.) “I noticed you were looking out the window when discussing your feelings.”

b.) “I think you’re lying and it bothers you that your children aren’t coming.”

c.) “I think you should discuss your children not coming in the group meeting.”

d.) “Why do you think your children didn’t want to come visit you this weekend?”

Answ:A


7. What is the most important goal of care for a client diagnosed with generalized anxiety disorder (GAD) who has been taking the benzodiazepine alprazolam (Xanax) long-term? The client will

a.) Describe a decrease in anxiety using a 1 to 10 anxiety scale.

b.) State the importance of not abruptly stopping the medication.

c.) Not experience dizziness, lightheadedness, or sedation.

d.) Attend scheduled individual and group therapy sessions.

Answ:A


8. The nurse is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she has a heart attack four years ago. Use of which substance abuse places the client at highest risk for myocardial infarction.

a.) Benzodiazepine

b.) Marijuana

c.) Methamphetamine

d.) Alcohol

Answ:C


9. During a one-to-one session with the nurse, a female client who has been admitted for chronic depression and attempted suicide discloses her experience of sexual promiscuity and prostitution. When the nurse asks the client if she was ever sexually abused as a child, the client says, “I don’t remember, but my mother ran my father off when I was five.” The nurse should recognize that the client may be using which defense mechanism?

a.) Denial

b.) Projection

c.) Regression

d.) Repression

Answ:D


10. A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words and wanders into client’s room. The nurse decides that the client needs constant observation based on which of these assessment findings?

a.) Disrupts group activities.

b.) Wanders into the client’s rooms.

c.) Talks with nonsensical words.

d.) Refuses antipsychotic medications.

Answ:B

11. A women is brought to the psychiatric clinic by her husband who reports that his wife is reluctant to leave home because of what she describes as fear of open places and crowds. What is the best nursing diagnosis for this client?

a.) High risk for injury related to chronic depression.

b.) Anxiety related to poor self-image.

c.) Ineffective individual coping.

d.) High risk for injury related to isolation.

Answ:C

12. The atypical antipsychotic ziprasidone (Geodon) is prescribed for a client with a medical diagnosis of schizophrenia. After the client has been taking the medication for two weeks, the nurse assesses the drug’s effectiveness. Which client report suggests that the medication is helpful?

a.) Is feeling less depressed.

b.) Sleeps better at night.

c.) The voices are quieter.

d.) Nervousness has decreased.

Answ:C

13. A male college student brings his roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, “kill kill.” What question should the nurse ask the client next?

a.) “When did these voices begin?”

b.) “Have you taken any hallucinogens?”

c.) “Are you planning to obey the voices?”

d.) “Do you believe the voices are real?”

Answ:C

14. A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse’s station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?

a.) Medicate the client with the prescribed PRN antipsychotic trifluoperazine (Stelazine).

b.) Offer the client a prescribed physical therapy treatment of hot pack for muscle spasms.

c.) Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.

d.) Direct the client to occupational therapy to distract him from somatic complaints.

Answ:C

15. The nurse on the evening shift received report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which interventions should the nurse implement the evening before the scheduled ECT?

a.) Implement elopement precautions.

b.) Keep the client NPO after midnight.

c.) Give client an enema at bedtime.

d.) Hold all bedtime medications.

Answ:B

16. During the initial nursing interview, a client tells the nurse, “Sometimes my thoughts go so fast. Wonder if I can sell my fast car. Work is so boring. I wonder if I can get a transfer. Is it time to eat yet?” Which documentation should the nurse use to describe the client’s statements?

a.) Demonstrates thought-blocking.

b.) Uses incoherent speech.

c.) Exhibits tangential thinking.

d.) Displays the use of word salad.

Answ:C

17. A chronically depressed older male resident of a long-term care facility has become more reclusive and today refuses to leave his room. His family moved away from the local area and they are unable to visit as much as they had in the past. Which comment by the nurse is like to be most helpful to this client?

a.) “May I sit with you for a while?”

b.) “I know you are sad about not seeing your family as often, but they are visiting as much as they can.”

c.) “Come into the recreation area. We have your favorite card game and I will play it with you.”

d.) “Why do you want to stay in your room today?”

Answ:A

18. A client with borderline personality disorder tells the nurse, “You are the best nurse on the unit! The other nurses don’t care about me the way you do.” Which response is best for the nurse to provide this client?

a.) “I am not the best nurse. All the nurses are good.”

b.) “The other nurses and I are here to help you get better”

c.) “You don’t think the other nurses care about you?”

d.) “I do care about you as a person but nothing more.”

Answ:A

19. A male client who is admitted with bipolar disorder( manic psychosis), is placed in seclusion after unsuccessful attempts to de-escalate him during a sudden mood swing from laughter to jumping and screaming threats while having a plastic dinner knife. The client is given haloperidol (Haldol) 5 mg IM STAT prior to seclusion. What intervention is most important for the nurse to implement immediately after seclusion?

a.) Observe for extrapyramidal symptoms, such as dystonia.

b.) Release the client as soon as composure is regained.

c.) Provide one-on-one observation at all times.

d.) Secure the room with padded walls and minimal furnishings.

Answ:A

20. The nurse notes that a depressed female client has been more withdrawn and no communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

a.) Engage the client in non-threatening conversations.

b.) Schedule a daily conference with the social worker.

c.) Encourage the client’s family to visit more often.

d.) Encourage the client to participate in group activities.

Answ:D

21. A young adult male client is admitted to the psychiatric unit because of recent suicide attempt. His wife filed for divorce six months ago, he lost his job three months ago, and his best friend moved to another city two weeks ago. Which intervention should the nurse include in the client’s plan of care?

a.) Encourage the client to interact with persons who are recovering from depression.

b.) Allow the client time alone to sort out his feelings.

c.) Avoid discussing subjects that upset the client.

d.) Encourage activities that allow the client to exert control over his environment.

Answ:D

22. A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. What action should the nurse implement?

a.) Attempt to ask the client simple questions.

b.) Postpone the client interview until the next day.

c.) Ask another nurse to talk with the client.

d.) Document the client’s paranoid behavior.

Answ:A

23. The nurse is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the nurse report to the healthcare provider immediately?

a.) Short term memory loss.

b.) Depressed affect.

c.) Five pound weight gain.

d.) Nausea and vomiting.

Answ:D

24. A young female client is admitted to the emergency room because she was raped that evening by her date. How should the nurse record the client’s chief complaint in the medical record?

a.) Client reported that she had sexual relations against her will.

b.) Client claims that she was forced to participate in sexual intercourse.

c.) Client has been sexually assaulted.

d.) Client states, “my date raped me tonight.”

Answ:D

25. An older female adult who lives in a nursing home is loudly demanding that the nurse call her son who has been deceased for five years. Which intervention should the nurse implement?*

a.) Assist the client to call the phone number she has.

b.) Remind the client that her son died five years ago.

c.) Escort the client to a private area.

d.) Direct the client to a new activity.

Answ:D

26. A teenaged male client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when he fell down the stairs at a party. The nurse notices needle marks on the client’s arms and plans to observe for narcotic withdrawal. Early signs of narcotic withdrawal include which assessment findings?

a.) Vomiting, seizures, and loss of consciousness.

b.) Depression, fatigue, and dizziness.

c.) Hypotension, shallow respirations, and dilated pupils.

d.) Agitation, sweating, and abdominal cramps.

Answ:D

27. Two days after his last drink, a male alcoholic client becomes agitated, and yells at his wife and children, “Stay away from me!” His vital signs are elevated. What nursing diagnosis has the highest priority?

a.) High risk for social isolation.

b.) Altered parenting.

c.) Ineffective individual coping.

d.) High risk for injury.

Answ:D

28. The nurse interacts with a male client who is very depressed and slow to respond to questions. The nurse asks the client to explain how he is feeling, but the client looks down at the table. What action would be best for the nurse to implement?

a.) Return at a later time to talk.

b.) Ask if the client heard the question.

c.) Wait for the client to respond.

d.) Ask a different question.

Answ:A

29. A 15-year-old male with mild mental retardation is admitted to the adolescent unit because he repeatedly refuses to complete personal hygiene. The healthcare provider prescribes that the client brush his teeth three times a day. In the psychiatric team conference, a behavior modification program is recommended to engage the client’s participation. When implementing this technique, what reinforcement is best for the nurse to provide?

a.) Privilege restriction or fines for refusals to complete a hygiene task.

b.) Preferred activities or tokens for each compliance.

c.) Unit tasks for each omission of teeth brushing.

d.) Candy for each successful hygiene task, like brushing his teeth.

Answ:A

30. When developing a plan of care for a client to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing diagnosis has the highest priority?

a.) Risk for injury.

b.) Ineffective coping mechanisms.

c.) Alteration in comfort.

d.) Ineffective breathing patterns.

Answ:D

31. A female client with obsessive-compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the nurse at bedtime. What action should the nurse implement?

a.) Ask the client to explain why she is keeping a detailed record of her nursing care.

b.) Teach the client strategies to control her obsessive-compulsive behavior.

c.) Encourage the client to express her feelings regarding the upcoming procedure.

d.) Explain to the client that her behavior invades the rights of the nursing staff.

Answ:C

32. A young adult female client is admitted to a psychiatric facility with a medical diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?*

a.) Schedule the client for group therapy with other bulimic clients.

b.) Assign the client’s care to a nurse of approximately the same age.

c.) Monitor the client carefully for binging activities.

d.) Assess and report the client’s electrolyte status to the healthcare provider.

Answ:D

33. Which client information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?

a.) Reports difficulties with short term memory since a traumatic brain injury.

b.) Client’s medication history includes the frequent use of antidepressants.

c.) Describe self as a social drinker who drinks alcoholic beverages daily.

d.) Medical history includes that the client was recently sexually assaulted.

Answ:C

34. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up?

a.) Describes life as without purpose.

b.) Exhibits an increase in sweating.

c.) States is often fatigued and drowsy.

d.) Complains of nausea and loss of appetite.

Answ:A

35. The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore in depth with the client based on this screening tool?

a.) Cancer screening results, anger, gastritis, daily alcohol intake.

b.) Efforts to cut down, annoyance with questions, guilt, drinking as an “Eye-opener.”

c.) Consumption, liver enzyme, gastrointestinal complaints and bleeding.

d.) Minimizes drinking, frequently misses family events, guilt about drinking, amount if daily intake.

Answ:B

36. A teenaged client, a heroin addict, is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?

a.) Assign the client to a teen support group.

b.) Assess intake and output.

c.) Monitor for wheezing and apnea.

d.) Limit visitors to family members only.

Answ:B

37. A client is admitted to the mental health unit for feelings of depression secondary to a positive HIV report. To provide a safe milieu for this client, what action should the nurse take?

a.) Replace paper trash bags with plastic biohazard bags.

b.) Remove soft drink cans from the nurse’s desk and patient lounge.

c.) Ensure that prescribed medications are kept in a safe place in the room.

d.) Take the client’s cellular telephone and provide a telephone in the room.

Answ:B

38. The nurse documents that a male client with paranoid schizophrenia is delusional. Which statement by the client confirms this assessment?

a.) “The voices are telling me to kill the next person I see.”

b.) “The fire is burning my skin away right now.”

c.) “The snakes on the wall are going to eat me.”

d.) “The nurse at night is trying to poison me with pills.”

Answ:D

39. A male client turns over a table in the dayroom of a psychiatric unit and threatens to throw a chair at another client. Which action is most important for the nurse to implement?*

a.) Calmly approach the client and remove the chair from the client.

b.) Obtain staff assistance to help diffuse the escalating situation.

c.) Offer feedback about what is observed about the client’s behavior.

d.) Summon the hospital security guards as a “show of force.

Answ:B

40. A client is admitted to the mental health unit with a diagnosis of adjustment disorder and depressed mood. Findings of which diagnostic tests provide the most information for developing this client’s plan of care?

a.) Electrocardiogram.

b.) Basic metabolic panel.

c.) Urine drug screen.

d.) Complete blood count.

Answ:C

41. The client is being admitted to the psychiatric unit for depression and self-deprecation. Which intervention should the nurse implement first?

a.) Meet with the client’s significant other to obtain a history.

b.) Establish a therapeutic relationship with the client.

c.) Ask the client if he has a plan to harm himself.

d.) Complete the client’s psychiatric admission assessment.

Answ:C

42. An 8-year-old client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the family?

a.) Past history of depression.

b.) The drug that was ingested.

c.) Reason for the suicide attempt.

d.) The time since the drug ingestion.

Answ:B

43. The nurse is assess a male client with paranoia. Which behavior can this client be expected to?

a) Tries to run the unit, telling everyone what to do and when to do it.

b) Is openly hostile the others for no apparent reason.

c) Talks to voices only he can hear.

d) Repeatedly tries to commit suicide.

Answ:B

44. The nurse completes a health assessment for a client a long alcohol dependency at health finding is the client most likely to report?

a) Pancreatitis.

b) Emphysema.

c) Thombophlebitis.

d) Crohn’s Disease.

Answ:A

45. A client postpartum depression receive prescription Sertraline (Zoloft). What information is most important to include in client teaching?*

A) Avoid processed meats, red wine, and swiss cheese.

B) Contact health care provider immediately if muscle stiffness.

C) Contact health care provider suicidal ideation.

D) Increase activity level to include a daily exercise rotine.

Answ:C

46. When communicating a client Bipolar disorders , the nurse realizes that the client is suddenly becoming tense and verbally abusive. What action should the nurse take?

a) Ask for assistance in placing the client in four point restrains.

b) Move client to an area that is close to occupational therapy.

c) Suggest physical activity to the client such as taking or walk.

d) Encourage the client to participate in board game of chess.

Answ:C




Assignment

1. Which technique is the most important therapeutic tool a nurse should use to provide quality care to a psychiatric client?

A. Context.

B. Self-analysis.

C. Counter transference.

D. Therapeutic self-disclosure.

Answ:B

Self-analysis is a tool for the nurse to examine oneself, view one's responses in various mental and emotional moments, and provide a sense of how sensitive care should be provided relative to one's own needs, so (B) is a primary tool used by the nurse to establish therapeutic empathy and achieve authentic, open, and personal communication with a client. Although (A, C, and D) may occur in a nurse-client relationship, they may not contribute to establishing a therapeutic relationship.

2. The nurse completes an emergency admission of a male client with schizophrenia who has not been taking his antipsychotic medications. The client is pacing, is extremely irritable, and has a blood pressure of 146/96. What is the priority nursing action?**

A. Encourage the client to stop pacing and sit down.

B. Reevaluate the client's blood pressure in an hour.

C. Direct the client to attend recreational therapy.

D. Review the client's baseline blood pressure.

Answ:B

The client is irritable and pacing, which can contribute to the elevated BP, so reevaluation of the client's BP in an hour (B) allows time for the excitement and stress of the admission process to abate. (A) is likely to increase the client's agitated state. Recreational therapy (C) provides another environmental stimulus, which can contribute to the client's anxiety. (D) is helpful, but the most immediate action is to retake the blood pressure in one hour.

3. A young adult female client with panic disorder arrives in the Emergency Center with a 4-day history of chest pain that began when her boyfriend left her. Initial assessment reveals normal cardiopulmonary findings. Which information is most important for the nurse to obtain?

A. Drugs taken in last 7 days.

B. Family history of suicide.

C. Usual coping mechanisms.

D. Frequency of anxiety attacks.

Answ:A

Use of prescribed, over-the-counter, and illicit drugs (A) is the most important information to obtain when planning care because drugs are likely to influence the client's behavior and ability to cope with stressful situations. (B, C, and D) are worthwhile assessment findings, but they do not have the priority of (A).

4. The nurse is planning care for a client with major depression who is admitted to the unit after a recent suicide attempt. Which intervention has the highest priority for inclusion in this client's plan of care?

A. Search the client's personal belongings.

B. Introduce the client to others on the unit.

C. Ask the client about recent stressful events.

D. Move to a room that allows close observation.

Answ:A

To ensure that the client has not acquired some means to inflict self harm, a routine search of personal belongings (A), which is a common safety measure and policy, should be implemented until the client stabilizes and suicidal ideations abate. (B) is a component of the therapeutic milieu, but the client's readiness to interact with others should be assessed first. Although recent stressors (C) may have precipitated the suicide attempt, it is more important to ensure the client's safety from self-harm. Close observation should be initiated (D), but it is most important that any hazardous items are removed from the client's possession.

5. A 6-year-old girl with severe birth defects and mental retardation is brought to the emergency room because of a broken arm. The caregiver reports that the girl sustained the injury when she fell from her wheelchair. Which intervention is most important for the nurse to implement?

A. Prepare the child for cast placement.

B. Evaluate the intellectual functioning of the child.

C. Evaluate the child for other injuries.

D. Ask the child to explain the accident.

Answ:C

The nurse should evaluate the child for other injuries because a 6-year-old child with a low-level fall that results in a fracture should be considered a possible victim of child abuse, until proven otherwise (C). (A) has a lower priority than (C). (B) is not within the scope of nursing practice and should be referred to someone who is an expert. (D) is unrealistic.

6. An older client is admitted to a psychiatric hospital with the diagnosis, "Major depression, single episode." Which laboratory value is most important for the nurse to report to the healthcare provider immediately?

A. Increased serum creatinine level.

B. Positive rapid plasma reagin (RPR).

C. Increased thyroid stimulating hormone (TSH).

D. Elevated serum calcium level.

Answ:C

The healthcare provider should be notified of (C) immediately. An increased TSH suggests a low thyroxine level because the TSH is trying to stimulate thyroxine production, and hypothyroidism symptoms mimic those of depression. (A) often increases with aging. (B) is indicative of syphilis and should be reported, but does not have the priority of (C). (D) has implications for other illnesses, such as non-Hodgkin's lymphoma or hyperparathyroidism.

7. The daughter of a 79-year-old male client tells the nurse that her father is becoming increasingly forgetful. Which finding indicates that the client needs further evaluation of cognitive function?*

A. Repeats the same stories to different family members or friends.

B. Cannot mentally retrace objects that were recently misplaced.

C. Cannot remember instructions to program an electronic device.

D. Forgets a planned event, then remembers the event a short while later.

Answ:B

Inability to retrace misplaced objects (B) is an indicator of possible cognitive impairment that requires further assessment. (A, C, and D) are examples of benign forgetfulness.

8. A 13-year-old female client is admitted to the Emergency Department because she reports being raped. When the male unlicensed assistive personnel (UAP) enters the room to obtain her vital signs, she begins screaming for her mother and curls up in the corner of the room. What action should the nurse implement?

A. Reassure client that the male UAP is a staff member who wants to help her.

B. Tell the client that her fear is understandable under these circumstances.

C. Reassign an all-female healthcare team to the client until her fear subsides.

D. Ask her mother to please stay with her throughout the assessment procedures.

Answ:C

A traumatized client needs to be in a non-threatening environment, and reassigning this client to all-female personnel is likely to reduce her anxiety (C). (A) is negating her fear. While validating the client's feeling (B) is important, this statement does not specifically address the client's issue with the male UAP. (D) might be helpful, but it ignores the anxiety the client feels about the presence of a male UAP.

9. At the end of a group therapy session, a client who is hospitalized for psychosis falls to the floor when attempting to stand. What intervention should the nurse implement first?

A. Ask a group member to seek help.

B. Obtain the client's blood pressure.

C. Position in a recovery position.

D. Assess the client's level of orientation.

Answ:A

First, help should be obtained while the nurse remains with the client (A). Next, assessment of the client (B and D) should be completed. Lastly, the client should be positioned (C) to prevent aspiration while recovering.

10. The nurse is planning care for a female client with depression who cries when asked to make her menu selections. Which therapy group is likely to be most beneficial for this client?

A. Coping skills.

B. Physical exercise.

C. Grief management.

D. Social support.

Answ:A

Ineffective coping skills (A) are characteristic of depression, and based on this client's symptoms, group therapy that focuses on coping skills is likely to be most beneficial. (B, C, and D) are important groups, but they are less likely to be as beneficial as (A).

11. The nurse is planning care for a client with major depression who is admitted to the unit after a recent suicide attempt. Which intervention has the highest priority for inclusion in this client's plan of care?

A. Search the client's personal belongings.

B. Introduce the client to others on the unit.

C. Ask the client about recent stressful events.

D. Move to a room that allows close observation.

Answ:A

To ensure that the client has not acquired some means to inflict self harm, a routine search of personal belongings (A), which is a common safety measure and policy, should be implemented until the client stabilizes and suicidal ideations abate. (B) is a component of the therapeutic milieu, but the client's readiness to interact with others should be assessed first. Although recent stressors (C) may have precipitated the suicide attempt, it is more important to ensure the client's safety from self-harm. Close observation should be initiated (D), but it is most important that any hazardous items are removed from the client's possession.


Questions.....

1. A woman admitted to the Emergency Department is bleeding profusely from a patch where hair was lost from her scalp. She is accompanied by her husband who tells the nurse that his wife caught her hair on the railing and pulled it out when she fell down the stairs. The husband is solicitous of his wife and quickly answers questions on her behalf. He attempts to comfort his wife by saying to her, "I am right here with you, dear. Nothing can keep us apart." What is the priority nursing intervention?

A. Notify the local police of a suspected spousal abuse situation.

B. Ask the hospital security to remove the husband from the treatment room.

C. Reassure the husband that his wife will be treated well while he is in the waiting area.

D. Require the husband to leave the cubicle while the client is being treated.

Answ:D

This client should be questioned about the possibility of spousal abuse and cannot answer truthfully in the presence of the perpetrator, so separating the couple is a priority, and (D) is the best method of providing this separation. (A) is not the priority at this time, and permission to notify the police should be obtained from the client. (B) is premature. Abusive husbands are unlikely to respond to manipulation (C) and are also unlikely to leave based on reassurances alone.

2. While assessing a 70-year-old male client, a nurse working in the outpatient clinic notices bruises on the client's chest. The client admits that his daughter, who is his caregiver, becomes frustrated and sometimes hits him. What is the priority outcome for the elderly client who sustained the abuse?

A. Verbalizes an acceptance of health status.

B. Expresses his feelings of satisfaction with care.

C. States that the frequency of abuse has decreased.

D. Describes the potential danger of his situation.

Answ:B

Abuse cessation should result in the client feeling satisfied with his care (B). (A) is not identified as an issue. Total abuse cessation is the goal, not (C). (D) is of lesser importance than satisfaction with care.

3. The nurse is assessing a client who is believed to have a borderline personality disorder. Which question is most important to include in this assessment?

A. At what age did you begin to exhibit symptoms?

B. Do you have a family history of borderline disorder?

C. How often do you drink alcoholic beverages?

D. Do you frequently have temper tantrums?

Answ:D

Those with a borderline personality disorder demonstrate intense outbursts of anger, so (D) is the most important question to ask. (A, B, and C) provide worthwhile information, but do not have the priority of (D) when assessing a client who is suspected of having a borderline personality disorder.

4. A nurse is teaching a female client who is in a homosexual relationship about women's health. Which topic is the most important for the nurse to address?

A. Sexually transmitted diseases.

B. Annual gynecologic examination.

C. Monthly breast self-examination.

D. Domestic violence interventions.

Answ:D

Since all women, regardless of sexual orientation, are at risk for domestic violence that can be potentially lethal, this is the most important topic for the nurse to address (D). Although (A) can be transferred by skin contact or bodily fluids, they are not immediately life threatening. All women, including those involved in same sex relationships, should receive a screening gynecologic examination (B). Homosexual women have the same risk for breast cancer (C) as heterosexual women.

5. A client who abuses alcohol says to the nurse, I am glad I went in for treatment. Now my problems with alcohol are all behind me. Which response is best for the nurse to provide?

A. Yes, the treatment program you attended has an excellent success profile.

B. Can you tell me more about what you mean when you say that your problems with alcohol are now behind you?

C. You are likely to have a difficult time staying sober if you think that your problems with alcohol are behind you.

D. Do you know what 'one day at a time' means for those who have problems with alcohol?

Answ:B

Those who attend alcohol treatment programs and Alcoholics Anonymous never put drinking problems behind them and describe alcoholics as only one step away from a slip with maintaining sobriety. The nurse should use reflection and encourage the client to further describe the feelings (B). (A) avoids dealing with the client's misperception. (C) is threatening, and (D) could be interpreted as condescending.

6. A male client who is on the liver transplant list is called to the unit for a possible transplant. When learning that the donor organ is no longer available, the client slams doors and shouts vulgarities about his situation. What action should the nurse implement first?

A. Encourage him to share his feelings more appropriately.

B. Express concern over his disappointment.

C. Arrange to have a clergy person visit.

D. Administer a PRN prescription for an antianxiety drug.

Answ:B

Addressing the client's disappointment (B) enables the client to express feelings of frustration in a safe environment. (A) is dismissive, non-supportive, and could incite defensiveness. (C) may be indicated after other interventions are implemented. (D) should be a last resort because clients with liver failure have difficulty metabolizing medications.

7. A client is told that her infant will be stillborn. What is the most important action for the nurse to implement after the birth?

A. Ask the family if they would like to see and hold the infant after birth.

B. Inquire if the parents want a picture taken after the infant is born.

C. Discuss with the parents which funeral home should be notified.

D. Find out if the client has a special outfit for the infant after the birth.

Answ:A

Interventions and support from the nursing staff during a prenatal loss are extremely important in the grief process and healing of the parents. Research had shown it is most helpful for a mother and father to see and hold their deceased infant after delivery, so the parents should be given this opportunity initially after birth (A). (B, C, and D) should be done after determining the parents' wishes and providing the opportunity for bonding and closure with their infant.

8. A client who has a miscarriage at 10-weeks gestation tells the nurse that she already purchased some baby things and picked out a name. After the surgical dilation and curettage (D&C), the client wants to go home as soon as possible. Based on the client's statements, which action should the nurse implement?

A. Ready the client for discharge.

B. Notify pastoral care to offer the client a blessing.

C. Ask the client what name she had picked out for the infant.

D. Inquire if the client would like to see what was obtained from her D&C.

Answ:C

The client's cues about her preparation for the baby indicate her need to express her feelings of loss, so encouraging further discussion about the infant's name (C) provides an opportunity to offer support. (A) should be implemented upon direction of the healthcare provider. Although it may be therapeutic to offer religious support (B), the client should first be allowed to ventilate her feelings. (D) may be traumatic for the client.

9. Which nursing intervention should the nurse implement with parents who experience a fetal demise and express the wish not to see the baby?

A. Tell them there is nothing to fear.

B. Insist that they hold infant so they can grieve.

C. Respect their wishes and release the body to the morgue.

D. Keep the body available for a few hours in case they change their minds.

Answ:D

Grieving parents should be encouraged to hold their infant after death to facilitate closure. If parents are hesitant about seeing or holding their dead infant, the fetus should be available for a few hours (D) in the event they change their mind after the initial shock. (A) is non-supportive. (B) imposes the nurse's opinion and does not allow for individual expressions of grief. (C) does not provide a ready opportunity for the parents to hold the infant if they change their minds later.

10. A client actively involved in substance addiction therapy frequently relapses into benzodiazepines and alcohol use. The client tells the nurse, I don't think I will ever be able to kick this habit. How should the nurse respond?

A. The goal of the individual is one of growth, health, autonomy, and self-actualization.

B. All people have the right to an equal opportunity for adequate health care.

C. Dependence on an extensive support system is needed to overcome any addiction.

D. The client must participate in making decisions about his/her own physical and mental health.

Answ:D

The client has the right to self-determination and the responsibility to make a decision to pursue health or illness, so the client must actively participate (D). (A, B, and C) are components in addiction recovery, but do not indicate the client's responsibility and primary commitment for decision-making about his/her health.

11. A client who is admitted with the chief complaint of feeling depressed tells the nurse, I want to feel normal again. How should the nurse respond?

A. How long have you felt this way?

B. We are all here to help you get better.

C. What do you think the hospital can do for you?

D. Tell me more about how things are with you.

Answ:D

When a client offers psycho-emotional complaints as the reason for admission, open-ended statements that seek clarification and elaboration provide the nurse with information about the client's life experiences that helps the nurse empathize, establish rapport, and support the client while reexamining and expressing feelings. (A and C) are short answer responses that do not allow the client to vent. (B) dismisses the client's statement and is not therapeutic.

12. The nurse is planning the care for a client based on the psychoanalytical model. Which intervention should the nurse include?

A. Emphasize the client's strengths and assets.

B. Teach the importance of medication compliance.

C. Offer the client psychoeducational materials to read.

D. Focus on the client's positive or negative feelings toward the nurse.

Answ:D

Interactions and interventions that focus on the client's positive or negative feelings toward the nurse (D) are based on the psychoanalytical model of mental health care. (A, B, and C) are not interventions associated with the psychoanalytical model.

13. A female client responds to the nurse with negative comments and antagonistic behavior. The nurse tells the client that she is unconsciously casting the nurse in the role of the client's mother. The nurse's feedback is based on which model of therapy?

A. Medical.

B. Existential.

C. Interpersonal.

D. Psychoanalytical.

Answ:D

The psychoanalytical model (D) uses concepts that interpret and focus on working through previously unresolved conflicts. The medical model (A) focuses on the diagnosis of a mental illness and its subsequent treatments, such as somatic treatments, pharmacotherapy, and electroconvulsive therapy. The existential model (B) focuses on the person's experience in the here and now, with much less attention focused on the person's past. The interpersonal model (C) focuses on the belief that behavior evolves around interpersonal relationships.

14. Which client should the nurse identify as the highest risk for the onset of stress-related problems?

A. A man whose new business is growing slowly, who plans to adopt a child with his wife, and says, I think I'm in control of my destiny.

B. A woman who is graduating from college, getting married in one month, and states, I'm anticipating the changes these events will make in my life.

C. A client who is passed over for promotion, quits a job to start a new business, and states, This is just one of a series of challenges I've faced in my life.

D. A person whose father died three months ago, who is losing a job due to company downsizing, and states, Living with loss and the threat of loss makes me feel helpless.

Answ:D

A client who is dealing with two stressful life events and expresses a cognitive appraisal of loss and helplessness (D) is at the highest risk for a stress-related health problem. (A, B, and C) describe persons who are coping with change using healthy strategies, such as perceiving change as challenging, expressing commitment to change, and believing they have control over their life paths.

15. The client with depression asks the nurse, What are neurotransmitters? My doctor thinks my problem may lie with the neurotransmitters in my brain. What information should the nurse use to support an explanation of neurotransmitters?

A. Chemical messengers that cause brain cells to turn on or off.

B. Areas of the brain that are responsible for controlling emotions.

C. Clumps of cells that alert the other brain cells to receive messages.

D. Web-like structures that provide connections among parts of the brain.

Answ:A

Neurotransmitters are chemicals manufactured in the brain that are responsible for exciting or inhibiting brain cells to produce an action (A). Neurons are clumps of cells (C) that alert the other brain cells to receive messages. The limbic system is the area of the brain responsible of controlling emotions (B). Astrocytes are glial cells that are web-like structures that connect blood vessels to neurons in the brain (D).

16. A client is scheduled to complete a positron emission tomography (PET) scan. The client asks the nurse to explain the reason the test was prescribed. How should the nurse respond?

A. Images indicate the presence of tumors and scars.

B. The scan clearly outlined structures of the brain.

C. Results show activity in various portions of the brain.

D. PET shows biochemical levels of neurotransmitters.

Answ:C

The results of a PET scan (used to detect cerebral activity in depression, schizophrenia, and Alzheimer's disease) shows brightly colored cerebral areas where an accumulation of a radioactively tagged glucose is used as a tracer to visualize brain activity (C), blood flow, and glucose metabolism. (A, B, or D) are not revealed by a PET scan.

17. A client with panic disorder tells the nurse, This illness is awful. I'm frightened that I will always be this way and that there's no hope for me. What is the best information for the nurse to provide?

A. Panic disorder is treatable in a number of different ways, including medication.

B. Understanding the fact that a cure is not attainable helps the client learn to adjust.

C. This disorder is a biologically determined hereditary disease that has no cure.

D. Evidence based practice indicates that neuroleptic drugs can be used prophylactically.

Answ:A

To foster the client's ability to cope, effective treatment options for panic disorder, such as desensitization, cognitive restructuring, relaxation, and psychotropic medications (A), should be discussed. (B, C, and D) do not provide accurate information.

18. A female client who is admitted for treatment of uncontrolled diabetes mellitus is withdrawn and tearful. She complains she has gained excessive weight because she hates her diet, hates taking insulin, and just wants to be normal again. What therapeutic action should the nurse take?

A. Assist the client in verbalizing distress about the disease.

B. Inquire about emotional factors affecting the client's present condition.

C. Assess priorities to be set for the client's overall nursing care plan.

D. Encourage the client to emotionally accept the chronicity of the disease.

Answ:B

Holistic care considers biological, psychological, and sociocultural factors that influence one's health status. The client is giving clues to psychological distress, so assessment for emotional factors that have impacted the client's present condition (B) should be made. The client is expressing distress, so (A) is redundant. Although priorities (C) should be determined, the client's current emotional distress should be addressed at this time. (D) is not indicated at this time.

19. Which action is most important for the nurse to implement during the initial interview for a client who is admitted to the mental health unit?

A. Establish rapport in each phase of the nurse-client relationship.

B. Determine the client's ability to communicate effectively.

C. Reflect on previous psychiatric interviews the nurse has performed.

D. Ensure data is collected and recorded in a systematic sequence.

Answ:A

A client with whom the nurse establishes rapport (A) during the initial interview and in each phase of the nurse-client relationship feels understood by the nurse and is more likely to cooperate and provide feedback during the admission process. Although the ability to communicate (B) is a component of the client's recovery, it is not always needed to establish rapport or maintain a therapeutic relationship. Experience (C) strengthens the therapeutic self, but it not the most important skill used during the initial interview. Systematic collection and documentation of data (D) ensures a comprehensive and complete assessment, which is dependent upon the use of rapport and the therapeutic self.

20. When assessing a client's emotional intelligence, which client capabilities should the nurse focus the interview on with a client diagnosed with a chronic mental illness?

A. Linguistic and musical abilities.

B. Interpersonal and intrapersonal skills.

C. Bodily kinesthetic and spatial abilities.

D. Logical mathematics and linguistic abilities.

Answ:B

Interpersonal and intrapersonal intelligence form one's personal intelligence or emotional quotient, so the nurse should focus inquiries on social skills (B). (A and D) assesses cognitive and mental status. (C) determines neurophysical interpretation of one's body within the environment, but does not assess emotional intelligence.

21. A female client with severe depression is given information about the risks, benefits, alternatives, and expected outcomes of electroconvulsive therapy (ECT) and signs the informed consent for treatment. After the client's family leaves, the client tells the nurse, I signed the papers because my husband told me I will be deported if my depression is not cured. What information should the nurse report to the healthcare provider?

A. The client's consent may have been coerced.

B. All the elements of informed consent were met.

C. The woman may not fully understand the risks and benefits.

D. The client is not competent to sign permission for treatment.

Answ:A

Informed consent requires that the choice is freely given. Although the staff acted ethically and observed the client's right to give informed consent, the decision may have been coerced (A) based on family pressure. (B, C, and D) are not accurate.

22. A male client tells the nurse that he plans to kill his spouse and her lover as soon as he is released from the hospital. What action should the nurse implement?

A. Keep this information confidential until the client's release.

B. Immediately contact the client's spouse and the lover.

C. File oral and written reports with the local police department.

D. Inform the healthcare provider and document the plan in the record.

Answ:D

The Tarasoff decision gives mental health professionals a duty to warn prospective victims, but the extent and discharge of the duty may vary from state to state. The healthcare provider should be notified, and the information documented in the client's record (D). (A) may cause harm to unwitting individuals. Although the scope of practice requires ensuring the safety of the client and others, (B and C) violates client confidentiality and are not indicated.

23. A male client is brought to the emergency department by a police officer, who reports the client was disturbing the peace by running naked in the street, striking out at others, and smashing car windows. Which behaviors should the client demonstrate to determine if he should be evaluated for involuntary commitment? (Choose all that apply.)

A. Threats to kill his friend.

B. Disruptive behaviors in a community setting.

C. Hears voices telling him to kill himself.

D. Reports he has not needed a bath in 4 months.

E. Created extensive private property damage.

F. Says he has not eaten in 3 days.

Answ:A,C,D,F

Correct responses are (A, C, D, and F). Most states provide for emergency involuntary hospitalization or civil commitment for a specified period to prevent dangerous behavior that is likely to cause harm to self or others. Police officers and healthcare providers may be designated by statute to authorize the detention of persons who are a danger to themselves or others (A and C) or who are unable to provide for their own basic needs (D and F) due to mental illness. (B and E) are civil issues, not factors related to involuntary commitment.

24. What action should the nurse take when a client who is psychotic proposes goals that are both unrealistic and undesirable?

A. Do nothing and remember the client's rights.

B. Express doubt that the goal can be achieved.

C. Tell the client that the goal is unrealistic.

D. Reflect the client's behavior and its consequences.

Answ:D

A client who is psychotic is unable to visualizing the consequences of proposed goals, so the use of reflection about the client's behavior and its consequences (D) is the most therapeutic approach. (A) is not therapeutic. Although negative confrontation (B and C) challenge the client's perception of reality, a client who is psychotic is not capable of responsible judgment, and these responses halt therapeutic communication.

25. A client is pacing in the hall near the nurses' station and swearing loudly. What response is best for the nurse to provide?

A. Hey, what's going on?

B. Others are being distracted. Please, quiet down.

C. You seem pretty upset. Tell me about it.

D. Please go to your room to get control of yourself.

Answ:C

A client who is distressed and acting out angrily should be assessed for additional information about what may be causing a change in the client's behavior. Therapeutic responses to disruptive behavior or language should begin with the nurse's reflective interpretation of the client's distress, and followed with an open-ended statement (C). (A and B) are not client-centered. (D) may prompt additional agitation because it does not recognize or attempt to understand the client's need.

26. A client is responding to auditory hallucinations and shakes a fist at a nurse and says, Back off, witch! The nurse follows the client into the day room. What action should the nurse implement?

A. Sit down in a chair near the client.

B. Position self within an arm's length of the client.

C. Ensure that there is physical space between the nurse and client.

D. Move to a position that allows the client to be closest to the room's door.

Answ:C

Personal space needs increase when a client feels anxious and threatened, so adequate social space (4 to 12 feet) between the nurse and the client should be maintained to minimize the client's escalation. An arm's length distance from the client (B) may be within the client's intimate space (0 to 1.5 feet) or personal space (1.5 to 3 feet) and increases the risk for physical contact. A posture at the same level of eye contact minimizes a threatening physical presence, so sitting (A) is inadvisable, unless the client is sitting. Allowing the client to block the nurse s exit from the room (D) places the nurse at risk for injury.

27. A male client with severe orthopedic injuries following a motor vehicle collision is irritable, angry, and belittles the nurses. While a nurse is changing the dressing over a laceration, the client screams, Don't touch me! You're so stupid that you'll make it worse! Which intervention is best for the nurse to implement?

A. Leave the room without saying a word.

B. Provide information about infection prevention.

C. Allow the client to change the dressing himself.

D. Explain the healthcare provider's prescription.

Answ:B

Several factors impact a client with anger, which is a cognitively driven problem. The correct nursing intervention helps the client test cognition and may lead to lowering anger, which impacts the client's readiness for acceptance of the nurse's interventions in providing care. Since the dressing change is initiated, making the client aware of why the dressing change is necessary (B) is therapeutic to forming a relationship. The feelings of powerlessness that are currently being expressed through anger only escalate if the nurse offers no alternatives to addressing the presenting issues (A or D). (C) is not therapeutic.

28. A 35-year-old married woman works full-time in a factory and has been absent from work for three days at a time on several occasions. Each time she returns to work, she wears dark glasses to cover facial bruising. Her supervisor refers her to the occupational health nurse. What assessment question is most important for the nurse to initially use?

A. Do you drink excessively?

B. Did your husband beat you?

C. How did this happen to you?

D. What did you do to deserve this?

Answ:C

Domestic violence can present in several forms, including sexual, physical, mental, and neglect. The victim of spousal abuse is often frightened or may feel at fault about the abuse, so a therapeutic relationship should be established with the client using non-judgmental, open-ended questions, such as (C), so the client is comfortable to disclose details about the injury, if abuse is suspected. (A and B) are close-ended questions that can be answered with yes or no answers. (D) implies fault and is not therapeutic.

29. A female client presents to the emergency center with confusion, emotional numbness, and expresses to the nurse a feeling of disbelief that she was raped. The nurse determines the client is in the acute phase of rape-trauma syndrome. What action should the nurse implement first?

A. Secure samples of vaginal hair combings.

B. Offer prophylactic antibiotic medication.

C. Explain the rape protocol to the client.

D. Implement crisis intervention counseling.

Answ:C

Impact reactions of the acute phase of the rape-trauma syndrome include shock, emotional numbness, confusion, disbelief, restless, and agitated motor activity, so explanation of the forensic rape protocol (C) and permission to proceed with examination should be provided first to minimize additional trauma during assessment and the collection of evidence (A). After the collection of evidence, prophylactic antibiotic medication (B) is provided and then crisis intervention counseling initiated (D).

30. Which client outcome indicates improvement for a client who is admitted with auditory hallucinations?

A. Argues with the voices.

B. Tells when voices decrease.

C. Follows what the voices say.

D. Tells the nurse what the voices say.

Answ:B

Hallucinations are defined as false sensory perceptions, and the goal of nursing interventions with clients who are hallucinating is to help them to increase awareness of their symptoms (B) and distinguish between the world of psychosis and reality. Arguing with the voices (A) and following the directions of the voices (C) indicates that the client is consumed by altered reality, which may place the client at risk for self-harm or danger to others. (D) provides the nurse with information about the client's risk for self-injury.

31. The nurse is caring for an adult male client with catatonic schizophrenia who is mute and motionless. What is the priority nursing diagnosis?

A. Impaired mobility.

B. Ineffective individual coping.

C. Impaired verbal communication.

D. High risk for fluid and electrolyte imbalance.

Answ:D

Maintaining physiological stability by first addressing basic physiological needs is the priority. A client who is in a catatonic or stuporous state is at risk for malnutrition and/or dehydration, so risk for fluid and electrolyte imbalance (D) is the priority nursing diagnosis for this client at this time. Lack of mobility (A) is related to psychomotor retardation rather than to physical limitations, and is not life-threatening. The client's mute state (C) and ineffective individual coping (B) can be addressed later in treatment.

32. A client with a history of alcoholism is admitted with a compound fracture of the femur after falling down the previous night. What additional assessment should be the priority focus for the nurse?

A. Collect a specimen for a blood alcohol level (BAL).

B. Do nothing because the time for BAL determination is passed.

C. Review the results of a Breathalyzer obtained in the emergency department upon admission.

D. Ask the client about the quantity, frequency, and time the last alcohol drink was ingested.

Answ:D

The priority assessment is to determine the client's risk for alcohol withdrawal, which can appear within 48 hours since the ingestion of the last alcoholic drink, so (D) is priority. (A) is not indicated at this time. The client with a history of alcoholism is at risk for delirium tremens (DT), which can develop within 48 to 96 hours of the last drink, and should be monitored for symptoms of confusion, hallucinations, and severe autonomic nervous system hyperactivity, not (B). Although (C) may provide data that confirms recent alcohol ingestion, it does not provide historical client information that may indicate the client's risk for DT, a life-threatening syndrome.

33. A client who is intoxicated is admitted for alcohol and multiple substance detoxification. The nurse determines that the client is becoming increasingly anxious, agitated, and diaphoretic. The client is also experiencing sensory perceptual disturbances and a clouded sensorium. What is the priority nursing intervention for this client at this time?

A. Check on the client every 15 minutes.

B. Begin one-on-one supervision immediately.

C. Keep the room dimly lit and turn on the radio.

D. Push fluids and provide calorie-rich nutritional supplements.

Answ:B

One-on-one supervision (B) ensures the client's physical safety until the client is sedated adequately to reduce feelings of terror and tactile and visual hallucinations. Checking every 15 minutes (A) does not provide sufficient assessment of the client's safety. Additional auditory stimulation and a dimly lit room (C) can create illusions that contribute to the client's altered sensory distress and should be avoided. Fluid replacement and nutritional supplements (D) should be initiated when the client is more stable because the risk for overhydration can occur as blood alcohol levels fall and fluids are retained.

34. A female client comes to an outpatient therapy appointment intoxicated. The spouse tells the nurse, There wasn't anything I could do to stop her drinking this morning. What intervention should the nurse take at this time?

A. Arrange for emergency admission to a detoxification unit.

B. Talk to the spouse about strategies to limit the client's drinking.

C. Have the client admitted to the inpatient psychiatric unit.

D. Tell the client that therapy cannot take place while she is intoxicated.

Answ:D

Therapy sessions are designed to confront the issues that the client with alcohol dependence may be experiencing. If the client presents inebriated, a therapeutic and confrontational meeting cannot occur (D) because the client's judgment is altered. (A and C) are not necessary at this time. (B) is ineffective.

35. Which client statement should the nurse identify as most typical of a client with mania?

A. I can't do anything anymore.

B. I can't understand where all our money goes.

C. I manage our finances great because I buy in big quantities.

D. I wonder why my wife is so upset that I spend money easily.

Answ:C

A client with bipolar disorder, mania, characteristically demonstrates thoughts of inflated self-esteem, grandiosity, and a tendency for excessiveness, such as excessive spending (C). (A) is a statement of dispair that is more likely made by a client with depression. Although a client with mania may lack insight (B) regarding the impact that excessive, bizarre behaviors have on the lives around them (D), the diagnostic criteria that hallmarks mania is excessive involvement in pleasurable activities with painful consequences.

36. What nursing assessment is the priority focus for a client with major depression?

A. Mood and affect.

B. Suicidal ideation.

C. Nutritional status.

D. Fluid and electrolyte balance.

Answ:B

Suicidal ideation (B) is a major risk factor in a client with major depression. Although mood and affect (A) are assessed while determining if the client has suicidal ideations, the client's risk for self-injury is the priority. Nutritional status (C) should be assessed at a later point in the initial assessment. Fluid and electrolyte balance (D) should be confirmed by evaluation of admission laboratory results.

37. The nurse is caring for a client who received the first-time electroconvulsive therapy (ECT) a half hour ago. Which action should the nurse implement first?

A. Offer oral fluids.

B. Monitor vital signs.

C. Evaluate ECT effectiveness.

D. Encourage group participation.

Answ:B

Sedatives, muscle relaxants, and an anticholinergic agent are often prescribed for the client during ECT. Vital signs (B) should be monitored during recovery after the ECT procedure. Oral fluids (A) should be withheld until the client is alert and oriented to avoid the risk of aspiration. Improvement in mood or affect (C) may not be apparent for several weeks. Confusion and memory loss may be an initial reaction experienced by some clients, so group interaction (D) is not indicated in the immediate hours after recovery.

38. A client with substance abuse is admitted to the mental health unit. Which action should be implemented by the nurse, and not delegated to a unlicensed assistive personnel (UAP)?

A. Provide menus for dietary selections.

B. Clarify visiting hours and telephone usage.

C. Collect a complete substance abuse history.

D. Obtain vital signs and orient the client to the unit.

Answ:C

As part of a comprehensive assessment, the nurse should assess the client for past and present alcohol, tobacco, prescription drug, over-the-counter drug, and illicit drug use (C). The UAP is qualified to provide the client with menus for dietary selection (A), clarify unit policies including visiting hours and telephone use (B), obtain vital signs and orient the client to the unit (D).

39. Which action should the nurse implement first for a client experiencing alcohol withdrawal?

A. Apply vest or extremity restraints.

B. Give an alpha-adrenergic blocker.

C. Provide a diet high in protein and calories.

D. Prepare the environment to prevent self-injury.

Answ:D

Self-destructive or violent behavior provides a potentially immediate and life-threatening risk to the client and others, so a safe environment should be provided (D) by removing any potential objects that could inflict self-injury. Secondary prevention strategies (frequent orientation to surroundings, restraints to prevent self-injury (A), and the administration of antianxiety agents or alpha-adrenergic blockers (B) for hallucinations, delusions, confusion, and agitation) should then be implemented. Once the client is stabilized, nutritional issues (C) should be addressed.

40. The nurse is caring for a client who was admitted for alcohol detoxification 2 days ago. Which finding is most critical for the nurse to report to the healthcare provider?

A. Restlessness, anxiety, and difficulty sleeping.

B. Global confusion and inability to recognize family members.

C. Agitation, vomiting, and visual and auditory hallucinations.

D. Low-grade fever, diaphoresis, hypertension, and tachycardia.

Answ:B

Delirium tremens (DT) or alcohol withdrawal delirium usually peaks 2 to 3 days (48 to 72 hours) after cessation or reduction of intake (although it can occur later) and lasts 2 to 3 days. The risk of DT carries a 2% to 5% mortality rate, so this critical syndrome of alcohol withdrawal, manifested as global confusion and an inability to recognize family members (B), is life-threatening and requires emergency medical intervention. The early signs of withdrawal (A) develop within a few hours after cessation or reduction of alcohol (ethanol) intake; the signs peak after 24 to 48 hours (C and D) and then rapidly and dramatically disappear, unless the withdrawal progresses to alcohol withdrawal delirium.

41. During a one-to-one interaction, a male client describes the sadness he experienced when his mother died. Suddenly, the nurse begins to think about her grandmother's death. As a result, the nurse asked the client to describe his thoughts when he learned of his own mother's illness. What is the nurse doing?

A. Reflection.

B. Clarification.

C. Self-Awareness.

D. Focusing.

ANSW:C

Self-awareness (C) defines the nurse's awareness of his or her own feelings while empathizing with the client. (A) involves restating what the client is saying. (B) involves asking the client to explain feelings more specifically. (D) directs the client to focus on emotional or behavioral responses to feelings.

42. The community health nurse facilitates a substance abuse prevention group for a homeless population. Which statement demonstrates that a client has a realistic understanding of the recovery process?

A. I do OK as long as I can get methadone from the clinic regularly.

B. By learning what led to my latest relapse, I know what to do in the future.

C. A 12-step program is the only treatment approach that is proven effective.

D. I know now that I wasn't ready to make a change until I hit rock bottom.

Answ:B

Recovery is a lifelong process in which clients must constantly learn and apply new behaviors to replace ineffective ones. Every attempt toward recovery improves long-term chances of success, so those who learn from their relapses demonstrate an understanding of the process (B). Methadone treatment is not indicated for all substance abusers, only those addicted to opiates, and enrollment in this type of program does not necessarily mean that the client is committed to recovery (A). While 12-step programs are known to work, there are many other effective treatment approaches (C). Client readiness is highly individualized, and can stem from a variety of experiences and situations, so hitting rock bottom is not necessary before clients can attempt recovery (D).

43. A female client with bipolar disorder, manic phase, is planning weekend activities with the other clients on the unit. The client interrupts the group, insists that they change their plans to a disco party, and begins to curse loudly when the group refuses to change the plans. Which intervention should the nurse implement?

A. Tell the client to quiet down.

B. Escort the client to a quieter place.

C. Ask the group to reconsider the suggestion.

D. Ignore the client's manic outbursts.

Answ:B

A client in the manic phase has an inflated ego, feelings of grandiosity, and is unlikely to respond to limit-setting. To curtail further escalation and disruption, the client should be escorted to a less stimulating environment (B). (A) is ineffective because a client in the manic phase is often unable to control their behavior. The group decision should be supported, not (C). Ignoring the client's outbursts (D) frequently leads to escalation of the behaviors and increases the client's risk of self-injury or injury of others.

44. Which action should the nurse implement during the termination phase of the nurse-client relationship?

A. Identify new problem areas.

B. Confront changes not completed.

C. Explore the client's past in depth.

D. Help summarize accomplishments.

Answ:D

By noting the client's accomplishments (D), the client's progress and self-confidence can be summarized. The working phase focuses on identifying new problem areas (A) and confronting necessary changes (B). The orientation phase includes an in-depth assessment of the client, including past history (C).

45. Which statement made by an adolescent in group therapy should the nurse identify as a priority in planning care?

A. If I fail another class, I'm going to kill myself.

B. I have a necktie in my room that I can use to hang myself.

C. When I leave home to live on my own, I'm buying myself a gun.

D. I took two bottles of Mom's pills and had to have my stomach pumped.

ANSW:B

Assessment of suicidal ideations should include the degree of lethality of the method, the individual's access to whatever is needed to carry out the attempt, and the specifics of the plan. The more detailed the plan, the greater the risk for a successful attempt. A necktie in the adolescent's room (B) implies a lethal plan with an accessible, available means to act and implement a suicidal ideation. (A and C) are expressions of future suicidal plans with stipulations, which allows time for intervention. (D) is an historical account of a suicidal attempt.

46. The nurse is caring for a female client who is admitted for depression with the nursing diagnosis, Self-esteem, chronic low. Which client response indicates to the nurse that the client has improved self-esteem?

A. Identifies own strengths.

B. Stops crying during every session.

C. Talks with other clients about marital advice.

D. Asks the nurse if her behavior has improved.

ANSW:A

Identifying one's personal strengths (A) is an important part of increasing self-esteem. Crying during sessions with the nurse or other members of the healthcare team is a sign of depression or sadness, and (B) does not indicate an improved self-esteem. Talking with peers about marital advice (C) implies a lack of confidence in decision-making. Asking the nurse if one's behavior is improving (D) indicates a need for reassurance.

47. During an inpatient therapy group session, a client tells the members that he hears voices that say his doctor is going to poison him. He continues, "I look around to see who's talking to me, and I can't see anybody." Another client replies, "I used to hear voices, too. I found out they were my imagination. The voices you hear aren't real either." Which phenomenon, common to groups, is exemplified in this interchange?

A. Catharsis.

B. Ventilation.

C. Universality.

D. Reality testing.

Answ:D

Reality testing is a process in which an individual validates one's perception of reality. Group members can provide reality testing (D) by monitoring each member's reactions and behaviors and providing feedback in an open and nonthreatening manner. In group therapy, catharsis (A) is the release of intense, overwhelming emotions that members learn to express and experience immediate relief. Group members experience universality (C) through awareness that they are not unique and others have reactions and thoughts similar to their own. Ventilation (B) is the verbalization of impulsive or negative feelings that reduces the risk of acting-out behaviors.

48. An adolescent who attempted suicide with a drug overdose arrives in the emergency department with an empty 30-tablet bottle of acetaminophen (Tylenol). Which action should the nurse implement?

A. Administer acetylcysteine (Mucocyst).

B. Monitor cardiac rhythm for flat T waves.

C. Check both serum AST and ALT levels.

D. Prepare to administer Syrup of Ipecac.

ANSW:A

Tylenol overdose is treated with immediate administration of Mucomyst (A) to prevent hepatic insult. Tylenol is not cardiotoxic, so (B) is not indicated. Although (C) provides a baseline evaluation of hepatic function, the priority is antidotal drug treatment. (D) may interfere with the therapeutic use of Mucomyst and is not indicated.

49. A client on the mental health unit reports concerns about weight gain as a result of taking divalproex (Depakote) and requests assistance to fill out a menu. The nurse should initiate a referral to which healthcare team member?

A. Occupational therapist.

B. Recreational therapist.

C. Dietician.

D. Physician.

Answ:C

The nurse should ask for a referral to the dietician (C) who can assist the client with meal planning for weight reduction. (A and B) do not give guidance about meal planning. (D) can prescribe a special diet or talk to the client about the medication, but concerns about meal planning and weight gain should be addressed by the dietician.

50. During the admission of a male client to the mental health unit, the client tells the nurse that he had a panic attack today and ran out of the physician's office. Which question is most important for the nurse to ask this client?

A. On a scale of 1 to 10 how do you rate your anxiety level?

B. How would you describe your mood right now?

C. Have you had any thoughts of hurting yourself?

D. What medications have you taken in the last 24 hours?

Answ:C

Assessing for suicidal ideation (C) is most essential. Asking the client to rate anxiety (A) and mood (B), and obtaining a medication history (D) are important, but assessing for thoughts of self-harm is most important because it involves client safety.

51. The daughter of a female client with stage-1 Alzheimer's disease (AD) asks the nurse what changes should she expect her mother to demonstrate in this stage. What finding should the nurse tell the daughter is common?

A. Inability to recognize one's location.

B. Personality changes and agitation.

C. Depression and emotional lability.

D. Alterations in communication.

Answ:A

Evidence indicates that frequent incidences of confusion, such as being unable to recognize one's location (A) in a familiar environment is associated with the early stages of Alzheimer's Disease. (B, C, and D) occur with later stages of AD.

15. A male client on a psychiatric unit becomes extremely agitated and begins to smash his head against doors. He seems frightened, and his verbalizations suggest he is experiencing distorted sensory perceptions. What action should the nurse take first?

A. Place the client in mechanical restraints until calm.

B. Administer a PRN dose of haloperidol (Haldol) IM.

C. Use a calm, soothing voice to diffuse the situation.

D. Encourage the client to focus on his feelings of anger.

Answ:A

This client is demonstrating behaviors that may be a danger to himself or others, and in such an emergency situation, restraints may be applied by an authorized staff member (A). (B) may pose a danger to the staff. This client is experiencing distorted sensory perceptions, so he is unlikely to respond to (C) or have the ability to verbalize his feelings (D). Category: Psychiatric Mental Health

16. During an admission assessment interview, a client states, "I do not use many drugs." How should the nurse respond?

A. "Tell me about the drugs you use now."

B. "Explain what you mean by many drugs."

C. "Do you mean legal drugs or illegal ones?"

D. "What kind of drugs are you talking about?"

Answ:A

Open-ended questioning (A) allows the client provide specific information without probing. (B) is critical of the client's descriptors and does not encourage further dialog. (C and D) are close-ended questions that require one word responses, and stop further exploration with the client.




1. A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. His temperature is 100.0 F, pulse is 100, and blood pressure is 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis?

a. Risk for injury related to suicidal ideation.

b. Risk for injury related to alcohol detoxification.

c. Knowledge deficit related to ineffective coping.

d. Health seeking behaviors related to personal crisis.

Answ:B

The most important nursing diagnosis is related to alcohol detoxification (B) because the client has elevated vital signs, a sign of alcohol detoxification. Maintaining client safety related to suicidal ideation (A) should be addressed after giving the client Ativan for elevated vital signs secondary to alcohol withdrawal. The client's knowledge deficit and health seeking behaviors (C and D) can be addressed when immediate needs for safety are met.

2. A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse?

a. Obtain objective data such as x-rays before reporting suspicions.

b. Confirm suspicions of abuse with the physician.

c. Report any case of suspected child abuse.

d. Document injuries to confirm suspected abuse.

Answ:C

It is the nurse's legal responsibility to report all suspected cases of child abuse (C), and notifying the nurse manager or charge nurse starts the legal reporting process. (A, B, and D) delay the first step in reporting the abuse.

3. A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the mother's statements?

a. She is regressing to an earlier behavior pattern.

b. She is sublimating her anger.

c. She is projecting her feelings onto the nurse.

d. She is suppressing her fear.

Answ:C

Projection is attributing one's own thoughts, impulses, or behaviors onto another--it is the mother who is probably harming the child and she is attributing her actions to the nurse (C). The mother may be immature, but regression (A) is not the best description of her behavior. Sublimation (B) is substituting a socially acceptable feeling for an unacceptable one. These are not socially acceptable feelings. The mother may be suppressing her fear (D) by displaying anger, but such an interpretation cannot be concluded from the data presented.

4. A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach should the nurse take?

a. Ask the staff to escort the client to his room.

b. Have the client ask his physician to change his privileges.

c. Remind the client of the importance of following the rules.

d. Disregard the client's inappropriate verbal outburst.

Answ:D

The client is trying to engage the nurse in a dispute. Ignoring the behavior (D) provides no reinforcement for the inappropriate behavior. (A) is not necessary unless the client becomes a physical threat to the nurse. It is inappropriate to delegate the situation to the physician (B) and is not in keeping with good health team management. Consistent limits must be established and enforced. (C) would subject the nurse to more verbal abuse. The client could use any response as an excuse to attack the nurse once again.

5. A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms?

a. Perphenazine (Trilafon).

b. Diphenylhydramine (Benadryl).

c. Chlordiazepoxide (Librium).

d. Isocarboxazid (Marplan).

Answ:C

Librium (C), an antianxiety drug, as well as other benzodiazepines, are used for benzodiazepine withdrawal. (A) is an antipsychotic agent. (B) is an antihistamine and antianxiety drug. (D) is an MAO inhibitor.

6. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care?

a. Client will not demonstrate cross addiction.

b. Co-dependent behaviors will be decreased.

c. Excessive CNS stimulation will be reduced.

d. Client's level of consciousness will increase.

Answ:C

Substitution therapy with another CNS depressant is intended to decrease the excessive CNS stimulation that can occur during benzodiazepine withdrawal (C). (A, B, and D) are all appropriate outcome statements for the client described, but do not have the priority of (C).

7. A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of which disorder?

a. Claustrophobia.

b. Acrophobia.

c. Agoraphobia.

d. Necrophobia.

Answ:C

Agoraphobia (C) is the fear of crowds or being in an open place. Claustrophobia (A) is the fear of being in closed places. Acrophobia (B) is the fear of high places. Necrophobia is an abnormal fear of death or bodies after death (D). A phobia is an unrealistic fear associated with severe anxiety.

8. A 19-year-old female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the nurse take?

a. Encourage the client's self motivation by asking her to pass trays for the rest of the week.

b. Provide an additional challenge by asking the client to help feed the older clients.

c. Suggest another way for this client to participate in the unit's activities.

d. Tell the client that hospital guidelines allow only staff to pass the trays.

Answ:C

Clients with anorexia gain pleasure from providing others with food and watching them eat. Such behaviors reinforce their perception of self-control. These clients should not be allowed to plan or prepare food for unit activities and their desires to do so should be redirected (C). (A and B) are contraindicated for a client with anorexia nervosa. (D) avoids addressing the problem, so it is best to suggest another activity for the client.

9. A female client with depression attends a group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response?

a. "Can your case manager take you to your appointments?"

b. "Take your medication for anxiety before you ride the bus."

c. "Let's talk about what happens when you feel very anxious."

d. "What are some ways that you can cope with your anxiety?"

Answ:D

The best response is to explore ways for the client to cope with anxiety (D). The nurse should encourage problem-solving rather than dependence on the case manager (A) for transportation. Strategies for coping with anxiety should be encouraged before suggesting medication (B). Talking about anxious feelings (C) is therapeutic, but the best response is an open-ended question to explore ways to cope with the anxiety.

10. A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with which condition?

a. Dissociative disorder.

b. Obsessive-compulsive disorder.

c. Panic disorder.

d. Post-traumatic stress syndrome.

Answ:A

Sleepwalking, amnesia, and multiple personalities are examples of detaching emotional conflict from one's consciousness (A). (B) is characterized by persistent, recurrent intrusive thoughts or urges (obsessions) that are unwilled and cannot be ignored, and provoke impulsive acts (compulsions) such as handwashing. Panic (C) is an acute attack of anxiety characterized by personality disorganization. (D) is re-experiencing a psychologically terrifying or distressing event that is outside the usual range of human experience, such as war, rape, etc.

11. At the first meeting of a group of older adults at a day care center for the elderly, the nurse asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, "You tell me, you're the leader." What would be the best response for the nurse to make?

a. "Yes, I am the leader today. Would you like to be the leader tomorrow?"

b. "Yes, I will be leading this group. What would you like to accomplish?"

c. "Yes, I have been assigned to lead this group. I will be here for the next six weeks."

d. "Yes, I am the leader. You seem angry about not being the leader yourself."

Answ:B

Anxiety over participation in a group and testing of the leader characteristically occur in the initial phase of group dynamics. (B) provides information and refocuses the group to defining its function. (A) is manipulative bargaining. (C) does not focus the group on its purpose or task. (D) is interpreting the client's feelings and is almost challenging.

12. Over a period of several weeks, one male client participant of a socialization group at a community day care center for the elderly monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation?

a. Talk to the client outside the group about his behavior.

b. Ask the client to give others a chance to talk.

c. Allow the group to handle the problem.

d. Ask the client to join another group.

Answ:C

After several weeks, the group is in the working phase and the group members should be allowed to determine the direction of the group. The nurse should ignore the client's comments and allow the group to handle the situation (C). A good leader should not have separate meetings with group members (A), as such behavior is manipulative on the part of the leader. (B) is dictatorial and is not in keeping with good leadership skills. (D) is avoiding the problem. Remember, identify what phase the group is in--initial, working, or termination--as an aid to determining expected communication style.

13. A client in the critical care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant changes, and the nurse formulates the diagnosis: "Confusion related to ICU psychosis." Which intervention is best to implement based on this client's behavior?

a. Move all machines away from the client's bedside at once.

b. Allay fears by teaching the client about disease etiology.

c. Cluster care to allow for brief rest periods during the day.

d. Encourage visitation by the client's family members.

Answ:C

The critical care unit contains many life-saving treatment modalities that offer clients an array of auditory, visual, and even painful stimuli. These stressers can result in isolation and confusion. The best intervention is to provide the client with rest periods (C). Removing machinery (A) is not practical because the client may not survive without it. The client is too ill to receive an in-depth overview of his disease process (B). Although family members' presence (D) may be supportive, young children are routinely prohibited from critical care units due to increased risk of infectious disease transmission.

14. A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client?

a. Sublimation.

b. Identification.

c. Introjection.

d. Repression.

Answ:B

Identification (B) is an attempt to be like someone or emulate the personality traits of another. Sublimation (A) is substituting an unacceptable feeling for one that is more socially acceptable. Introjection (C) is incorporating the values or qualities of an admired person or group into one's own ego structure. Repression (D) is the involuntary exclusion of painful thoughts or memories from one's awareness.

15. A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 to 4 days." The nurse should initiate a referral based on which assessment?

a. Altered thought processes.

b. Moderate levels of anxiety.

c. Inadequate social support.

d. Altered health maintenance.

Answ:B

The nurse should initiate a referral based on anxiety levels (B) and feelings of nervousness that interfere with sleep, appetite, and the inability to solve problems. The client does not report symptoms of altered thoughts (A) or evidence of inadequate social support (C). There is not enough information to initiate a referral based on altered health maintenance (D).

16. An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client?

a. Plan an outing within the first week of admission.

b. Distract her whenever she expresses her discomfort about being with others.

c. Confront her fears and discuss the possible causes of these fears.

d. Accompany her outside for an increasing amount of time each day.

Answ:D

The process of gradual desensitization by controlled exposure to the situation which is feared (D), is the treatment of choice in phobic reactions. (A and C) are far too aggressive for the initial treatment period and could even be considered hostile. (B) promotes denial of the problem, and gives the client the message that discussion of the phobia is not permitted.

17. Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior?

a. Administer a prescribed PRN anti-anxiety medication.

b. Assist the client to identify stimuli that precipitates the ritualistic activity.

c. Allow time for the ritualistic behavior, then redirect the client to other activities.

d. Teach the client relaxation and thought stopping techniques.

Answ:C

Initially, the nurse should allow time for the ritual (C) to prevent anxiety. Administering a prescribed antianxiety medication (A) may help reduce the client's anxiety, but will not prevent ritualistic behavior resulting from the client's ineffective coping ability. (B) is a long-term goal of individual therapy, but is not directly related to controlling the behavior at this time. Thought stopping and relaxation (D) are techniques that can be used to assist the client in learning new ways of interrupting obsessive thoughts and resulting ritualistic behavior.

18. The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group?

a. Each resident's length of stay at this nursing home.

b. A brief description of each resident's family life.

c. The age and medication regimen of each group member.

d. The usual activity patterns of each group member.

Answ:D

An older person's level of activity (D) is a determining factor in adjustment to aging as described by the Activity Theory of Aging. All information described in (A, B, and C) might be useful to the nurse, but is not as helpful during the initiation of the socialization group. The most useful initial information would be an assessment of each individual's adjustment to the aging process.

19. Which ego-defense mechanisms are exhibited by a client with a phobia related to refusal to leave home?

a. Denial.

b. Symbolization.

c. Fantasy.

d. Intellectualization.

Answ:B

Symbolization (B) allows external objects to carry the internal emotional feeling through some act such as refusing to leave a "safe" harbor. Denial (A) is the unconscious failure to acknowledge an event, thought, or feeling. Fantasy (C) is pretending, usually of a more desirable situation. Intellectualization (D) is using reason to avoid emotional conflicts.

20. A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad. No one can help me." Which response would be best for the nurse to make?

a. "How can I help you? Tell me more about your problems."

b. "Things probably aren't as bad as they seem right now."

c. "Let's talk about what is right with your life."

d. "I hear your misery, but things will get better soon."

Answ:A

Offering self shows empathy and caring (A), and offers the client the opportunity to talk while the nurse listens. (B) dismisses the client's perception that things are really bad, and potentially shuts down further communication with the client. (C) avoids the client's problems and promotes denial. "I hear your misery" (D) is an example of reflective dialogue and would be the best choice if it were not for the rest of the sentence--"but things will get better soon," which offers false reassurance.

21. A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?

a. He ingested the drug 3 hours prior to admission to the emergency center.

b. The family reports that he took an entire bottle of acetaminophen (Tylenol).

c. He is unresponsive to instructions and is unable to cooperate with emetic therapy.

d. Those with repeated suicide attempts desire punishment to relieve their guilt.

Answ:C

Because the client is unable to follow instructions, emetic therapy would be very difficult to implement and gastric lavage would be necessary (C). (A and B) should be considered in determining the course of treatment, but they are not the basis for determining if gastric lavage will be implemented. Medical treatments should never be used as "punitive" measures (D).

22. A 68-year-old retired secretary is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of guilt." What is true about the goal statement referring to the client's depression?

a. Implementation of this goal should be deferred until further data can be gathered.

b. The depression is most likely age-related and will dissipate once she becomes accustomed to retirement.

c. Depressed clients are often unaware of guilt feelings, and should be encouraged to increase self-awareness.

d. Nursing goals should be approved by the treatment team before they are initiated.

Answ:C

Depression is associated with feelings of guilt, and clients are often not aware of these feelings (C). Awareness is the first step in dealing with guilt (or any other feeling), so the nurse's efforts should be directed toward increasing the client's awareness of feelings. Although a goal may be changed based on an evaluation of interventions to meet the goal, a goal should never be "ignored" (A). (B) dismisses the client's symptoms as "age-related." Setting goals for the nursing care plan is a function of the nurse (D), although the nurse can collaborate with the treatment team.

23. The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently, the client's viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. What should the nurse do first while taking the client's history upon admission to the hospital?

a. Determine if the client attends a support group weekly.

b. Hold all anti-depressant medications until further notice.

c. Ask the client if he takes St. John's Wort routinely.

d. Have the client describe any recent changes in mood.

Answ:C

St. John's Wort, an herbal preparation, is an alternative (non-conventional) therapy for depression, but it may adversely interact with medications used to treat HIV infection (C). Thus, the nurse's top priority upon admission is to determine if the client has been taking this herb concurrently with HIV anti-viral drugs, which may explain the rise in the viral load. Asking about attendance at a support group (A) or mood changes (D) may be helpful in gathering more data about the client's depressive state, but these issues do not have the priority of (C). Holding antidepressants may be harmful to the client (B).

24. The nurse admits a client with depression to the mental health unit. The client reports difficulty concentrating, losing 10 pounds in two weeks, and sleeping 12 hours a day. Which outcome is most important for the client to meet by discharge?

a. Tries to interact with a few peers and staff.

b. Reports feeling better and less depressed.

c. Sits attentively with peers in group therapy.

d. Easily awakens for morning medications.

Answ:B

The client is experiencing symptoms of depression, and the outcome by discharge for this client would be that the client reports feeling better and less depressed (B). The client may interact with peers and staff (A) and sit attentively in groups (C) without any improvement in depression. Difficulty awakening is usually due to the medication regimen for depression, so awakening (D) is not an indication of improvement.

25. Which diet selection by a depressed client taking tranylcypromine sulfate (Parnate), an MAO inhibitor, indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen?

a. Hamburger, french fries, and chocolate milkshake.

b. Liver and onions, broccoli, and decaffeinated coffee.

c. Pepperoni and cheese pizza, tossed salad, and soda.

d. Roast beef, baked potato with butter, and iced tea.

Answ:D

Parnate is classified as an MAOI antidepressant. Tyramine in foods interacts with MAOI in the body causing a hypertensive crisis which is life-threatening. (D) contains no tyramine. Chocolate in milk (A), liver (B), and pepperoni and cheese (C) contain tyramine and would not be permitted for a client taking Parnate.

26. A 72-year-old female is admitted to the psychiatric unit with a medical diagnosis of major depression. Which statement by the client would be of greatest concern to the nurse and would require further assessment?

a. "I think my cat is going to die."

b. "I don't feel like eating this morning."

c. "I just went to my friend's funeral."

d. "Don't you have more important things to do?"

Answ:A

Sometimes a client will use an analogy to describe themselves, and (A) would be an indication for conducting a suicide assessment. (B) could have a variety of etiologies, and while further assessment is indicated, this statement does not indicate potential suicide. Normal grief process differs from depression, and at this client's age peer/cohort deaths are more frequent, so (C) would be within normal limits. (D) is an expression of low self-esteem typical of depression. (B, C, and D) are examples of decreased energy and mood levels which would negate suicide ideation at this time.

27. A 33-year-old is admitted to a Psychiatric facility with a medical diagnosis of major depression. When the nurse is assigning the client to a room, which roommate is best for this client?

a. A 35-year-old who recently attempted suicide.

b. A manic client who has started lithium carbonate treatment.

c. A client who is bipolar and is pacing the floor telling jokes to everyone.

d. A paranoid client who believes that the staff is trying to poison the food.

Answ:B

(B) appears to be the most stable client described since he has begun treatment with lithium carbonate (treatment of choice for manic depression). Being around another depressed individual might enhance this client's own depression and possibly support suicidal ideation (A). Clients in the manic stage of bipolar disease (C), enhance the level of anxiety of those around them which would not be therapeutic for this client at this time. Paranoid ideation (D), which is characterized by suspiciousness, would also increase anxiety in this client.

28. A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression?

a. Grandiose ideation.

b. Self-destructive thoughts.

c. Suspiciousness of others.

d. Negative views of self.

Answ:D

A negative self-image (D) is a specific indicator for depression. Grandiose ideation (A) occurs with paranoia or paranoid ideation (C). Self-destructive thoughts (B) may be seen in depressed clients, but are not always present.

29. A 22-year-old female is admitted to the psychiatric unit from the medical unit following a suicide attempt with an overdose of diazepam (Valium). When developing the nursing care plan for this client, what intervention would be most important to include?

a. Assist the client to focus on her strengths.

b. Set limits on the client's self-defacing comments.

c. Remind the client of daily activities in the milieu.

d. Assist the client to identify why she was self-destructive.

Answ:A

Encouraging the client to focus on her strengths (A) helps her become aware of her positive qualities, assists in improving her self-image, and aids her in coping with past and present situations. Although nursing actions should assist the client in decreasing self-defacing behaviors (B) and inform the client of milieu activities (C), these interventions are not a priority at this time. "Why" the client attempted suicide (D), is not as important as assisting her to overcome the depression, which resulted in the overdose, and asking "why" is non-therapeutic.

30. A female client in an acute care facility has been on antipsychotic medications for the past three days. Her psychotic behaviors have decreased and she has had no adverse reactions. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. What action should the nurse initiate?

a. Place the client on seizure precautions and monitor frequently.

b. Take the client's vital signs and notify the physician immediately.

c. Describe the symptoms to the charge nurse and document them in the client's record.

d. No action is required at this time as these are known side effects of her medications.

ANSW:B

symptoms are descriptive of neuroleptic malignant syndrome (NMS), which is an extremely serious/life threatening reaction to neuroleptic drugs. The major symptoms of this syndrome are fever, rigidity, autonomic instability, and encephalopathy. Respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure can result in death. This is an emergency situation, and the client requires immediate management in a critical care setting (B). Seizure precautions (A) are not indicated in this situation. (C) does not consider the seriousness of the situation. (D) is a false statement.

31. A 27-year-old female is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. What intervention should the nurse include in this client's plan of care?

a. Schedule the client to attend various group activities.

b. Reinforce the client's ability to make her own decisions.

c. Encourage the client to identify feelings of anger.

d. Provide a structured environment with little stimuli.

Answ:D

Clients in the manic phase of a bipolar disorder require decreased stimuli and a structured environment (D). Plan noncompetitive activities that can be carried out alone. Group activities (A) are contraindicated; stimuli should be reduced as much as possible. Impulsive decision-making is characteristic of clients with bipolar disorder. To prevent future complications, the nurse should monitor these clients' decisions and assist them in the decision-making process (B). Suppressed anger (C) is more often associated with depression than with bipolar disorder.

32. A manic depressive male client on the psychiatric unit becomes loud, and shouts at one of the nurses, "You fat tub of lard, get something done around here." What is the best initial action for the nurse to take?

a. Have the staff escort the client to his room.

b. Tell the client that his behavior will be recorded in his record.

c. Redirect the client by asking him to play card games with peers.

d. Review the medication record for an antipsychotic drug.

Answ:C

Distracting the client, or redirecting him toward a constructive activity (C), prevents further escalation of the inappropriate behavior. (A) could result in escalating the abuse and unnecessarily involve another staff member in the abusive situation. (B) may be more threatening to the client. (D) may be indicated if the behavior escalates, but at this time, the best initial action is (C).

33. A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make?

a. "Did you really believe you were Jesus Christ?"

b. "I think you're getting well."

c. "Others have had similar thoughts when under stress."

d. "Why did you think you were Jesus Christ?"

Answ:C

(C) offers support by assuring the client that others have experienced similar situations. (A) is belittling. (B) is making an inappropriate judgement. You may have narrowed your choices to (C and D). However, you should eliminate (D) because it is a "why" question, and the client does not know why!

34. A 38-year-old woman is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her room, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." What response by the nurse is the most therapeutic?

a. "I'll leave your tray here; I am available if you need anything else."

b. "You're not being poisoned. Why do you think someone is trying to poison you?"

c. "No one on this unit has ever died from poisoning. You're safe here."

d. "I will talk to your physician about the possibility of changing your diet."

Answ:A

(A) is the best choice because the nurse does not argue with the client nor demand that she eat, but offers support by agreeing to "be there if needed," which provides an open, rather than closed, response to the client's statement. (B and C) are challenging the client's delusions, and (B) asks "why." Probing questions, which usually start with "why," are usually not therapeutic communication for a psychotic client. (D) has nothing to do with the actual problem, i.e., the problem is not with any particular diet, but with client delusions.

35. A 35-year-old male client admitted to the psychiatric unit of an acute care hospital tells the nurse that he believes someone is trying to poison him. The client's delusions are most likely related to which factor?

a. Authority issues in childhood.

b. Anger about being hospitalized.

c. Low self-esteem.

d. Phobia of food.

Answ:C

Delusional clients have difficulty with trust and have low self-esteem (C). Nursing care should be directed at building trust and promoting positive self-esteem. Activities with limited concentration and no competition should be encouraged to build self-esteem. (A, B, and D) are not specifically related to the development of delusions.

36. A 35-year-old male client who has been hospitalized for two weeks for paranoia complains continuously to the staff that someone is trying to steal his clothing. What is the correct action for the nurse to take based on this client's complaints?

a. Enroll the client in an exercise class to promote self-esteem.

b. Place a lock on the client's closet to deter any theft.

c. Promote extinction of the ideation by ignoring the client.

d. Explain to the client that these suspicions are false.

Answ:A

Diverting the client's attention from paranoid ideation (A) and encouraging him to engage in positive activities can be helpful in assisting him to develop a positive self-image. Placing a lock on the closet (B) actually supports his paranoid ideation. Ignoring the client's symptoms (C) may lower his self-esteem. The nurse should not argue with the client about his delusions (D).

37. An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response is best for the nurse to provide?

a. "Anywhere you want to stand as long as you do not get hurt by those in the parade."

b. "You are confused because of all the activity in the hall. There is no parade."

c. "Let's go back to the activity room and see what is going on in there."

d. "Remember I told you that this is a nursing home and I am your nurse."

Answ:C

It is common for those with Alzheimer's disease to use the wrong words. Redirecting the client (using an accepting non-judgmental dialogue) to a safer place and familiar activities (C) is most helpful because clients experience short-term memory loss. (A) dismisses the client's attempt to find order and does not help her relate to her surroundings. (B) dismisses the client and may increase her anxiety level because it merely labels the client's behavior and offers no solution. It is very frustrating for those with Alzheimer's disease to "remember," and scolding them (D) may hurt their feelings.

38. The nurse is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the physician informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning?

a. Ineffective denial related to situational anxiety.

b. Ineffective coping related to inadequate support.

c. Social isolation related to difficult interactions.

d. Self-care deficit related to cognitive impairment.

Answ:A

The best nursing diagnosis is (A) because the client is unable to acknowledge the move to a boarding home. Ineffective coping (B), social isolation (C), and self-care deficit (D) are potential nursing diagnoses, but denial is most important because it is a defense mechanism that keeps the client from dealing with his feelings about living arrangements.

39. A client who is diagnosed as schizophrenic is admitted to the hospital. The nurse assesses the client's mental status. Which assessment finding is most characteristic of a client with schizophrenia?

a. Mood swings.

b. Extreme sadness.

c. Manipulative behavior.

d. Flat affect.

Answ:D

Disinterest, and diminished or lack of facial expression is characteristic of schizophrenia and is referred to as a flat affect (D). (A) is associated with bipolar disorder. (B) is associated with depression. (C) is usually associated with personality disorders and is often seen in clients who abuse substances.

40. On admission, a highly anxious client is described as delusional. The nurse understands that delusions are most likely to occur with which disorder?

a. Dissociative disorders.

b. Personality disorders.

c. Anxiety disorders.

d. Psychotic disorders.

Answ:D

Delusions are false beliefs characteristic of psychosis (D). Delusions are generally not characteristic of (A, B, and C).

41. A 25-year-old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, "Please let me go. I must leave because the secret police are after me." What response is best for the nurse to make?

a. "No one is after you, you're safe here."

b. "You'll feel better after you have rested."

c. "I know you must feel lonely and frightened."

d. "Come with me to your room and I will sit with you."

Answ:D

(D) is the best response because it offers support without judgment or demands. (A) is challenging the client's delusion. (B) is offering false reassurance. (C) is a violation of therapeutic communication in that the nurse is telling the client how she feels (frightened and lonely), rather than allowing the client to describe her own feelings. Hallucinating and/or delusional clients are not capable of discussing their feelings, particularly when they perceive a crisis.

42. A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. What action should the nurse take?

a. Notify the physician immediately and force fluids.

b. Prior to giving the next dose, notify the physician of the symptoms.

c. Record the symptoms and continue medication as prescribed.

Answ:B

d. Hold the medication and refuse to administer additional amounts of the drug.

Early side effects of lithium carbonate (occurring with serum lithium levels below 2.0 mEq per liter) generally follow a progressive pattern beginning with diarrhea, vomiting, drowsiness, and muscular weakness (B). At higher levels, ataxia, tinnitus, blurred vision, and large dilute urine output may occur. Forcing fluids (A) will lower the lithium level. Although these are expected symptoms, the physician should be notified prior to the next administration of the drug (C). Refusing to administer the medication (D) is not warranted.

43. A male schizophrenic client, taking fluphenazine deconate (Prolixin deconate), is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation and will return in 18 days. Which statement by the client indicates a need for health teaching?

a. "I am going to have lots of time in the sun."

b. "While I am on vacation, I will not eat or drink anything that contains alcohol."

c. "I will notify the doctor if I have a sore throat or flu-like symptoms."

d. "I will continue to take my benzotropine mesylate (Congentin) every day."

Answ:A

Photosensitivity is a side effect of Prolixin, therefore the client should be instructed to avoid the sun (A). (B, C, and D) indicate accurate knowledge. Alcohol acts synergistically with Prolixin (B). A sore throat and flu-like symptoms (C) are signs of agranulocytosis which is also a side effect of Prolixin. To avoid extrapyramidal symptoms (EPS), anticholinergic drugs, such as Cogentin (D), are often prescribed prophylactically with Prolixin.

44. An adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate) because of medication noncompliance. What is important to teach the client and family about this change in medication regimen?

a. Long-acting medication is more effective than daily medication.

b. A client with substance abuse must not take any oral medications.

c. There will continue to be a risk of alcohol and drug interaction.

d. Support groups are only helpful for substance abuse treatment.

Answ:C

Alcohol enhances the side effects of Prolixin. The half-life of Prolixin po is 8 hours, whereas the half-life of the Prolixin Decanoate IM is 2 to 4 weeks. Therefore, the side effects of drinking alcohol are far more severe when the client drinks alcohol after taking the long acting Prolixin Decanoate IM. (A, B, and D) provide incorrect information.

45. The nurse develops a plan of care for a client with symptoms of paranoia and psychosis. The priority nursing diagnosis is "Impaired social interactions related to inability to trust." Which intervention is most important for the nurse to implement?

a. Greet the client by first name during each social interaction.

b. Determine if the client is experiencing auditory hallucinations.

c. Introduce the client to peers on the unit as soon as possible.

d. Assign the client to a group about developing social skills.

Answ:A

The most important nursing intervention is to greet the client by name (A) and provide short, frequent contact to establish trust. The presence of auditory hallucinations can impact social interactions (B), but it is not a priority intervention. Introducing the client to peers (C) and assigning the client to a group about social skills (D) are effective interventions after individual rapport has been established with the client.

46. The nurse is conducting discharge teaching for a client who has schizophrenia and plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge?

a. "Crickets are a good source of protein."

b. "I have not heard any voices for a week."

c. "Only my belief in God can help me."

d. "Sometimes I have a hard time sitting still."

Answ:C

The most frequent cause of increased symptoms in psychotic clients is non-compliance with the medication regime. If clients believe that "God alone" is going to heal them (C), then they may discontinue their medication. Therefore (C) would pose the greatest threat to this client's prognosis. ( A) would require further teaching, but is not as significant a statement as (C). (B) indicates an improvement in the client's condition. (D) may be a sign of anxiety that could improve with treatment, but does not have the priority of (C).

47. An 8-year-old child is seen in the clinic with a green vaginal discharge. What action is most important for the nurse to implement?

a. Assess the child's blood pressure.

b. Counsel the child to wear cotton underwear.

c. Report as suspected child abuse.

d. Determine if the child takes bubble baths.

Answ:C

A green vaginal discharge is indicative of gonorrhea, a sexually transmitted disease. Since the child is 8 years old, the nurse should suspect child abuse and should report the incident to the proper authorities (C). Blood pressure (A) is usually not related to infection. Wearing cotton underwear (B) and avoiding bubble baths (D) are helpful in preventing bladder infections, but a green vaginal discharge is not a symptom of a bladder infection.

48. Clients are preparing to leave the mental health unit for an outdoor smoke break. A client on constant observation cannot leave and becomes agitated and demands to smoke a cigarette. What action should the nurse take first?

a. Remind the client to wear the nicoderm (nicotine) patch.

b. Determine if the client still needs constant observation.

c. Encourage the client to attend the smoking cessation group.

d. Explain that clients on constant observation cannot smoke.

Answ:B

The nurse should continually reassess the need for constant observation (B) so that the client can have unit privileges such as outdoor breaks. (A and C) do not meet the client's need and desire to smoke. (D) will cause more agitation.

49. The nurse collaborates with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours of hospital admission?

a. Assign the client a case manager.

b. Document activities.

c. Maintain safety in the client's milieu.

d. Identify current psychosocial stresses.

Answ:C

It is most important to maintain safety (C) in the milieu, or environment, since suicide can be a risk with depression. Though (A, B, and D) are also important to include in this client's plan of care, these interventions do not have the priority of (C).

50. The charge nurse collaborates with the nursing staff members about the plan of care for a client who is depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit?

a. Monitor appetite and observe intake at meals.

b. Maintain safety in the client's milieu.

c. Provide ongoing, supportive contact.

d. Encourage participation in activities.

Answ:B

The most important reason for closely observing a depressed client immediately after admission is to maintain safety (B), since suicide is a risk with depression. Monitoring appetite (A), providing frequent contact when a client is withdrawn (C), and encouraging participation in activities (D) are all important interventions, but safety is the priority.





Psychiatric Hesi book

1. A nurse working in the emergency department of a children's hospital admits a child whose injuries could have been the result of abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse?

A.


Obtain objective data such as radiographs before reporting suspicions.


B.


Confirm suspicions of abuse with the healthcare provider.


C.


Report any case of suspected child abuse.


D.


Document injuries to confirm suspected abuse.

Answ:C

Rationale: It is the nurse's legal responsibility to report all suspected cases of child abuse (C), and notifying the nurse manager or charge nurse starts the legal reporting process. (A, B, and D) delay the first step in reporting the abuse.


2. An 8-year-old child is seen in the clinic with a green vaginal discharge. What action is most important for the nurse to implement?

A.


Assess the child's blood pressure.


B.


Counsel the child to wear cotton underwear.


C.


Report as suspected child abuse.


D.


Determine if the child takes bubble baths.

Answ:C

Rationale: A green vaginal discharge is indicative of gonorrhea, a sexually transmitted disease. Since the child is 8 years old, the nurse should suspect child abuse and report the incident to the proper authorities (C). (A) is usually not related to infection. (B and D) are helpful in preventing bladder infections, but a green vaginal discharge is not a symptom of a bladder infection.

3. On admission, a highly anxious client is described as delusional. The nurse understands that delusions are most likely to occur with which disorder?

A.


Dissociative disorders


B.


Personality disorders


C.


Anxiety disorders


D.


Psychotic disorders

Answ:D

Rationale: Delusions are false beliefs characteristic of psychosis (D). Delusions are generally not characteristic of (A, B, and C).

4. Over a period of several weeks, one male participant of a socialization group at a community daycare center for older adults monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation?


A.


Talk to him outside the group about his behavior.


B.


Ask him to give others a chance to talk.


C.


Allow the group to handle the problem.


D.


Ask him to join another group.

Answ:C

Rationale: After several weeks, the group is in the working phase and the group members should be allowed to determine the direction of the group. The nurse should ignore the comments and allow the group to handle the situation (C). A good leader should not have separate meetings with group members (A), as such behavior is manipulative on the part of the leader. (B) is dictatorial and is not in keeping with good leadership skills. (D) is avoiding the problem. Remember, identify what phase the group is in (initial, working, or termination) as an aid to determining expected communication style.

5. A 22-year-old female client is admitted to the psychiatric unit from the medical unit following a suicide attempt with an overdose of diazepam (Valium). When developing the nursing care plan for this client, what intervention would be most important to include?

A.


Assist her to focus on her strengths.


B.


Set limits on her self-defacing comments.


C.


Remind her of daily activities in the milieu.


D.


Assist her to identify why she was self-destructive.

ANSW:A

Rationale: Encouraging the client to focus on her strengths (A) helps her become aware of her positive qualities, assists in improving her self-image, and aids her in coping with past and present situations. Although nursing actions should assist the client in decreasing (B) and inform the client of (C), these interventions are not a priority at this time. (D) is not as important as assisting her to overcome the depression, which resulted in the overdose, and asking "why" is nontherapeutic.

6. The nurse reviews the laboratory findings for a client's urine drug screen that is positive for cocaine. Which client behavior should be expected during cocaine withdrawal?


A.


Psychomotor impairment


B.


Agitation and hyperactivity


C.


Detachment from reality and drowsiness


D.


Distorted perceptions and hallucinations

Answ:A

Rationale: During cocaine withdrawal, the nurse should expect (A) and a pattern of withdrawal symptoms similar to those of one who uses amphetamines. (B, C, and D) are signs and symptoms of a person who is high on cocaine rather than experiencing withdrawal from cocaine.

7. A 25-year-old client has suffered extensive burns and is crying during dressing change treatment. The client tells the nurse, "Please let me die. Why are you all torturing me like this? I just want to die." Which response by the nurse is best?

A.


"We aren't torturing you. These treatments are necessary to prevent a terrible infection."


B.


"I know these treatments must seem like torture to you, but we want to help you recover."


C.


"You have so much to live for, and all of your family members want you to live."


D.


"Would you like me to call the chaplain so that you can privately discuss your feelings?"

Answ:B

Rationale: (B) offers an empathetic response without sounding patronizing. (A) is not empathetic and is actually somewhat argumentative. The client is not asking for information as much as pleading for understanding. (C) is almost scolding and places blame on the client for wanting to die and possibly hurting his family members as a result. (D) might be appropriate if the nurse simply asks the client if a chaplain's visit is desired, but the nurse is dismissing the client's needs by not addressing them at the moment.

8. A 33-year-old client is admitted to a psychiatric facility with a medical diagnosis of major depression. When the nurse is assigning the client to a room, which roommate is best for this client?


A.


A 35-year-old who recently attempted suicide


B.


A manic client who has started lithium carbonate treatment


C.


A client who is bipolar and is pacing the floor while telling jokes to everyone


D.


A paranoid client who believes that the staff is trying to poison the food

ANSW:B

Rationale: (B) appears to be the most stable client described since treatment has begun with lithium carbonate (treatment of choice for manic depression). Being around another depressed individual might enhance this client's own depression and possibly support suicidal ideation (A). Clients in the manic stage of bipolar disease (C) enhance the level of anxiety of those around them which would not be therapeutic for this client at this time. Paranoid ideation (D), which is characterized by suspiciousness, would also increase anxiety in this client.

9. A male client who was admitted 2 days earlier to a drug rehabilitation unit tells the nurse, "I'm going to do what you people tell me to do so I can get out of here and get a job." What is the most accurate interpretation of this client's statement?

A.


The treatment program is effective and the client is highly motivated.


B.


Defense mechanisms are being used to decrease anxiety.


C.


Manipulation is being used to achieve the client's personal goals.


D.


The client has insight into his behaviors, so privileges should be given.

Answ:C

Rationale: Drug abusers tend to be manipulative, so (C) is the best interpretation of the client's statement at this time in the client's treatment. He has been in treatment only 2 days, which is not enough time to benefit from the program, so (A and D) are highly unlikely. Although defense mechanisms (B) are frequently used to decrease anxiety, this statement is more likely due to (C).

10. A middle-aged client tells the clinic nurse, "I'm again starting to feel overwhelmed and anxious with all my responsibilities. I don't know what to do." Which is the best response for the nurse to make?

A.


"Describe in more detail your feelings about being overwhelmed."


B.


"Why don't you give up some of your commitments?"


C.


"What has worked for you in the past?"


D.


"I know, but it is important to take time for yourself."

Answ:C

Rationale: A nurse can help the client problem-solve by identifying past coping mechanisms that could be transferred into current situations that the client finds to be overwhelming (C). The client has already expressed some degree of hopelessness (overwhelmed and anxious), so (A) is redundant. (B) is advice-giving and may not be possible for the person, and this response does not encourage the client to employ known methods of coping. (D) is also considered advice-giving, with an implied value judgment.

11. The nurse admits a client with depression to the mental health unit. The client reports difficulty concentrating, has lost 10 pounds in 2 weeks and is sleeping 12 hours a day. Which outcome is most important for the client to meet by discharge?

A.


Tries to interact with a few peers and staff


B.


Reports feeling better and less depressed


C.


Sits attentively with peers in group therapy


D.


Easily awakens for morning medications

Answ:B

Rationale: The client is experiencing symptoms of depression, and the outcome by discharge for this client would be that the client reports feeling better and less depressed (B). The client may interact with peers and staff (A) and sit attentively in groups (C) without any improvement in depression. Difficulty awakening is usually due to the medication regimen for depression, so awakening (D) is not an indication of improvement.

12. A 25-year-old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, "Please let me go! I must leave because the secret police are after me." What response is best for the nurse to make?

A.


"No one is after you. You're safe here."


B.


"You'll feel better after you have rested."


C.


"I know you must feel lonely and frightened."


D.


"Come with me to your room and I will sit with you."

ANSW:D

Rationale: (D) is the best response because it offers support without judgment or demands. (A) is challenging the client's delusion. (B) is offering false reassurance. (C) is a violation of therapeutic communication because the nurse is telling the client how she feels (frightened and lonely), rather than allowing the client to describe her own feelings. Hallucinating and/or delusional clients are not capable of discussing their feelings, particularly when they perceive a crisis.

13. On admission, a depressed female client tells the nurse, "I can't eat because my tongue is rubber." Which is the best action for the nurse to implement?

A.


Provide packaged foods for the client to eat.


B.


Begin the client on total parenteral nutritional (TPN) therapy.


C.


Provide a liquid diet for the client.


D.


No action is necessary. The client will eat when she is hungry.

Answ:C

Rationale: The nurse should strive to provide a safe environment (adequate nutrition is part of such a safe environment), and should not argue with the client's delusions. (C) is the least invasive while providing nutrition that does not argue with the client's delusion. (A) is given to those with paranoid delusions. (B) is invasive and would be used as a last resort. (C) should be tried first. This client's delusion could be life threatening, and should not be ignored (D).

14. A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make?

A.


"Did you really believe you were Jesus Christ?"


B.


"I think you're getting well."


C.


"Others have had similar thoughts when under stress."


D.


"Why did you think you were Jesus Christ?"

Answ:C

Rationale: (C) offers support by assuring the client that others have experienced similar situations. (A) is belittling. (B) is making an inappropriate judgment. You may have narrowed your choices to (C and D). However, you should eliminate (D) because it is a "why" question, and the client does not know why.

15. The nurse notes multiple burns on the arms and chest of a 2-year-old Vietnamese child who is being treated for dehydration. When questioned, the child's father states that he treated the child's vomiting with the cultural practice called "coining," which resulted in burned areas. Which expected outcome statement has the highest priority?

A.


The child will be protected from further harm.


B.


The family's cultural values will be respected.


C.


The parents will express regret at harming their child.


D.


The parents will demonstrate ability to care for the burn wounds.

Answ:A

Rationale: The nurse's highest priority is to ensure that no further harm befalls the child (A). (B, C, and D) are also important objectives but are secondary to (A).

16. A client in the critical care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveals no significant changes, and the nurse formulates the diagnosis Confusion related to ICU psychosis. Which intervention is best to implement based on this client's behavior?

A.


Move all machines away from the client's bedside at once.


B.


Allay fears by teaching the client about disease etiology.


C.


Cluster care to allow for brief rest periods during the day.


D.


Encourage visitation by the client's family members.

Answ:C

Rationale: The best intervention is to provide the client with rest periods (C). The critical care unit contains many life-saving treatment modalities that offer clients an array of auditory, visual, and even painful stimuli. These stressors can result in isolation and confusion. (A) is not practical because the client may not survive without it. The client is too ill to receive (B). Although (D) may be supportive, young children are routinely prohibited from critical care units due to increased risk of infectious disease transmission.

17. Which ego-defense mechanisms are exhibited by a client with a phobia related to refusal to leave home?

A.


Denial


B.


Symbolization


C.


Fantasy


D.


Intellectualization

Answ:B

Rationale: Symbolization (B) allows external objects to carry the internal emotional feeling through some act such as refusing to leave a "safe" harbor. (A) is the unconscious failure to acknowledge an event, thought, or feeling. (C) is pretending, usually of a more desirable situation. (D) is using reason to avoid emotional conflicts.

18. The nurse is caring for a client who is taking the mood stabilizer divalproex sodium (Depakote). Which laboratory finding is most important to include in this client's record?

A.


Liver function tests


B.


Creatinine clearance


C.


Complete blood count


D.


Chemistry panel

Answ:A

Rationale: Depakote is metabolized by the liver and can cause hepatotoxicity, so laboratory findings of liver function tests (A) should be included in the client's record. (B) should be in the client record of those who are receiving Lithium because it is excreted by the kidneys. (C and D) are routine laboratory tests and are not specifically related to administration of Depakote.

19. Which topics should the nurse include in an education program for clients with schizophrenia and their families? (Select all that apply.)


A.


Importance of adherence to medication regimen


B.


Current treatment measures for substance abuse


C.


Signs and symptoms of an exacerbation


D.


Prevention of criminal activity


E.


Behavior modification for aggression


F.


Chronic grief associated with long-term illness

Answ:A,C,F

Rationale: Correct choices are (A, C, and F). Medication adherence is an important component of successful rehabilitation (A). Clients and their families also need to know the signs and symptoms of an exacerbation or relapse of their disease (C), which is frequently associated with poor medication compliance. Acknowledging the chronic sorrow associated with severe and persistent mental illness (F) helps individuals negotiate the grieving process. (B, D, and E) are not universal problems associated with schizophrenia.

20. A female client in an acute care facility has been on antipsychotic medications for the past 3 days. Her psychotic behaviors have decreased and she has had no adverse reactions. On the fourth day, the client's blood pressure increases, and she becomes pale and febrile and demonstrates muscular rigidity. What action should the nurse initiate?

A.


Place the client on seizure precautions and monitor frequently.


B.


Take the client's vital signs and notify the healthcare provider immediately.


C.


Describe the symptoms to the charge nurse and document them in the client's record.


D.


No action is required at this time as these are known side effects of her medications.

Answ:B

Rationale: This is an emergency situation, and the client requires immediate management in a critical care setting (B). These symptoms are descriptive of neuroleptic malignant syndrome (NMS), an extremely serious/life-threatening reaction to neuroleptic drugs. The major symptoms of this syndrome are fever, rigidity, autonomic instability, and encephalopathy. Respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure can result in death. (A) is not indicated in this situation. (C) does not consider the seriousness of the situation. (D) is a false statement.

21. A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad. No one can help me." Which response would be best for the nurse to make?


A.


"How can I help you? Tell me more about your problems."


B.


"Things probably aren't as bad as they seem right now."


C.


"Let's talk about what is right with your life."


D.


"I hear your misery, but things will get better soon."

Answ:A

Rationale: Offering self shows empathy and caring (A), and offers the client the opportunity to talk while the nurse listens. (B) dismisses the client's perception that things are really bad, and potentially shuts down further communication with the client. (C) avoids the client's problems and promotes denial. "I hear your misery" (D) is an example of reflective dialogue and would be the best choice if it were not for the rest of the sentence—"but things will get better soon," which offers false reassurance.

22. What behavior indicates to the nurse that a male client with paranoid ideas is improving? The client


A.


arrives on time for all activities.


B.


talks more openly about his plans to protect his possessions.


C.


aggressively uses the punching bag in the gym.


D.


discusses his feelings of anxiety with the nurse.

Answ:D

Rationale: Anxious feelings increase paranoid ideation. If the client is able to discuss these feelings (D), he is improving in that he will have less paranoid ideas. (A) would indicate a client with depression, or that one who is passive-aggressive is improving. (B) indicates feelings of paranoia. (C) indicates the release of anger, and "anger turned inward" is sometimes used as a definition for depression.

23. A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last 6 months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of which disorder?

A.


Claustrophobia


B.


Acrophobia


C.


Agoraphobia


D.


Necrophobia

Answ:C

Rationale: Agoraphobia (C) is the fear of crowds or of being in an open place. (A) is the fear of being in closed places. (B) is the fear of high places. (D) is an abnormal fear of death or bodies after death. A phobia is an unrealistic fear associated with severe anxiety.

24. A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. What action should the nurse take?

A.


Notify the healthcare provider immediately and force fluids.


B.


Prior to giving the next dose, notify the healthcare provider of the symptoms.


C.


Record the symptoms and continue medication as prescribed.


D.


Hold the medication and refuse to administer additional amounts of the drug.

Answ:B

Rationale: Although these are expected symptoms, the healthcare provider should be notified prior to the next administration of the drug (B). Early side effects of lithium carbonate (occurring with serum lithium levels below 2 mEq/L) generally follow a progressive pattern beginning with diarrhea, vomiting, drowsiness, and muscular weakness (C). At higher levels, ataxia, tinnitus, blurred vision, and large dilute urine output may occur. (A) will lower the lithium level. (D) is not warranted.

25. A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client?

A.


Sublimation


B.


Identification


C.


Introjection


D.


Repression

Answ:B

Rationale: Identification (B) is an attempt to be like someone or emulate the personality traits of another. (A) is substituting an unacceptable feeling for one that is more socially acceptable. (C) is incorporating the values or qualities of an admired person or group into one's own ego structure. (D) is the involuntary exclusion of painful thoughts or memories from one's awareness.

26. A male client begins taking an atypical antipsychotic medication. The nurse must provide informed consent and education about common medication side effects. Which client education will be most important?


A.


Maintain a balanced diet and adequate exercise.


B.


Be sure the diet is adequate in salt intake.


C.


Monitor for any changes in sleep pattern.


D.


Report any unusual facial movements.

Answ:A

Rationale: Several atypical antipsychotic medications can cause significant weight gain, so the client should be advised to maintain a balanced diet and adequate exercise (A). (B) is important with lithium, a mood stabilizer. (C and D) are less common than weight gain.

27. The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group?


A.


Each resident's length of stay at this nursing home


B.


A brief description of each resident's family life


C.


The age and medication regimen of each group member


D.


The usual activity patterns of each group member

Answ:D

Rationale: An older person's level of activity (D) is a determining factor in adjustment to aging as described by the Activity Theory of Aging. All information described in (A, B, and C) might be useful to the nurse, but is not as helpful during the initiation of the socialization group. The most useful initial information would be an assessment of each individual's adjustment to the aging process.

28. A 35-year-old male client admitted to the psychiatric unit of an acute care hospital tells the nurse that he believes someone is trying to poison him. The client's delusions are most likely related to which factor?

A.


Authority issues in childhood


B.


Anger about being hospitalized


C.


Low self-esteem


D.


Phobia of food

Answ:C

Rationale: Delusional clients have difficulty with trust and have low self-esteem (C). Nursing care should be directed at building trust and promoting positive self-esteem. Activities with limited concentration and no competition should be encouraged to build self-esteem. (A, B, and D) are not specifically related to the development of delusions.

29. A female client believes that her healthcare provider is an FBI agent and that her apartment is a site for slave trading. She believes that the FBI has cameras in her apartment, so she cannot return there. Based on these symptoms, which class of medication is the nurse most likely to find to be prescribed for this client?


A.


Antianxiety medication


B.


Mood stabilizer


C.


Antipsychotic


D.


Sedative-hypnotic

Answ:C

Rationale: The nurse will most likely find an antipsychotic (C) prescribed, because the client's thoughts are delusional. (A) may lessen anxiety associated with the delusions, but it is not the treatment of choice for altered thoughts. (B) will manage mood swings and (D) will be prescribed for sleep. The client needs an antipsychotic medication to promote rational thoughts.

30. A 27-year-old female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. What intervention should the nurse include in this client's plan of care?


A.


Schedule the client to attend various group activities.


B.


Reinforce the client's ability to make her own decisions.


C.


Encourage the client to identify feelings of anger.


D.


Provide a structured environment with little stimuli.

Answ:D

Rationale: Clients in the manic phase of a bipolar disorder require decreased stimuli and a structured environment (D). Plan noncompetitive activities that can be carried out alone. (A) is contraindicated because stimuli should be reduced as much as possible. Impulsive decision-making is characteristic of clients with bipolar disorder. To prevent future complications, the nurse should monitor these clients' decisions and assist them in the decision-making process (B). (C) is more often associated with depression than with bipolar disorder.

31. A male schizophrenic client who is taking fluphenazine decanoate (Prolixin decanoate) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation and will return in 18 days. Which statement by the client indicates to the nurse a need for health teaching?


A.


"I am going to have lots of time in the sun."


B.


"While I am on vacation, I will not eat or drink anything that contains alcohol."


C.


"I will notify the healthcare provider if I have a sore throat or flu-like symptoms."


D.


"I will continue to take my benztropine mesylate (Cogentin) every day."

Answ:A

Rationale: Photosensitivity is a side effect of Prolixin, so the client should be instructed to avoid the sun (A). (B, C, and D) indicate accurate knowledge. Alcohol acts synergistically with Prolixin (B). A sore throat and flu-like symptoms (C) are signs of agranulocytosis, which is also a side effect of Prolixin. To avoid extrapyramidal symptoms (EPS), anticholinergic drugs, such as Cogentin (D), are often prescribed prophylactically with Prolixin.

32. During a home visit, a male client with schizophrenia reports hearing voices that tell him to walk in the middle of the street. The nurse records several statements made by the client. Based on which statement should the nurse determine that the client needs hospitalization?

A.


"Sometimes I take an extra one of my pills when I hear the voices."


B.


"The voices are louder when I forget to take my medication."


C.


"No matter what I do, I can't make the voices go away."


D.


"I just try to tell the voices to stop when they bother me."

Answ:C

Rationale: Hospitalization is needed if the client continues to hear voices telling him to do things that can cause self-harm (C). (A or B) do not require hospitalization unless symptoms become severe. The client should continue symptom-management strategies (D) to prevent hospitalization.

33. An adult male client who lives in a residential facility is mentally retarded and has a history of bipolar disorder. During the past week, he has refused to wear clothes and frequently exposes himself to other residents. Which intervention should the nurse implement?

A.


Establish a one-to-one relationship to discuss his behavior.


B.


Redirect the client to physically demanding activities.


C.


Encourage the client to verbalize his thoughts when acting-out.


D.


Restrict social interactions with other residents in the facility.

Answ:B

Rationale: The client is exhibiting manic behavior related to bipolar disorder, and the nurse should redirect him to activities that are physically demanding (B), so he can expend his energy in a socially acceptable manner. Psychotic clients are not capable of (A). When exhibiting acting-out behavior, the client is distracted and (C) is difficult. Restrictions (D) are likely to increase manic behaviors, such as mood swings and acting-out behaviors.

34. The nurse is assessing a young female client admitted to the psychiatric unit for acute depression related to a recent divorce. Which statement is most indicative of a client suffering from depression?


A.


"I'm not very pretty or likeable."


B.


"I've lost 20 pounds in the past month."


C.


"I like to keep things to myself."


D.


"I think everyone is out to get me."

Answ:A

Rationale: Feelings of hopelessness (A) are characteristic of one who is depressed. Although (B) might be indicative of depression, further assessment would be required to rule out an organic cause before attributing the statement to depression. (C and D) are indicative of a paranoid personality.

35. A 68-year-old female client, a retired secretary, is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of guilt." What is true about the goal statement referring to the client's depression?

A.


Implementation of this goal should be deferred until further data can be gathered.


B.


The depression is most likely age-related and will dissipate once she becomes accustomed to retirement.


C.


Depressed clients are often unaware of guilt feelings and should be encouraged to increase self-awareness.


D.


Nursing goals should be approved by the treatment team before they are initiated.

Answ:C

Rationale: Depression is associated with feelings of guilt, and clients are often not aware of these feelings (C). Awareness is the first step in dealing with guilt (or any other feeling), so the nurse's efforts should be directed toward increasing the client's awareness of feelings. Although a goal may be changed based on an evaluation of interventions to meet the goal, a goal should never be "ignored" (A). (B) dismisses the client's symptoms as "age-related." Setting goals for the nursing care plan is a function of the nurse (D), although the nurse can collaborate with the treatment team.

36. A male client on the psychiatric unit, diagnosed as bipolar disorder, becomes loud and shouts at one of the nurses, "You fat tub of lard, get something done around here!" What is the best initial action for the nurse to take?


A.


Have the staff escort the client to his room.


B.


Tell the client that his behavior will be recorded in his record.


C.


Redirect the client by asking him to play card games with peers.


D.


Review the medication record for an antipsychotic drug.

Answ:C

Rationale: Distracting the client, or redirecting him toward a constructive activity (C), prevents further escalation of the inappropriate behavior. (A) could result in escalating the abuse and unnecessarily involve another staff member in the abusive situation. (B) may be more threatening to the client. (D) may be indicated if the behavior escalates, but at this time, the best initial action is (C).

37. An individual with a known history of alcohol abuse is admitted for emergency surgery following a motor vehicle collision. The nurse includes in the client's plan of care, "Observe for signs of delirium tremens." What early signs indicate that the client is beginning to have delirium tremens?

A.


Abdominal cramping and watery eyes


B.


Depression and fatigue


C.


Restlessness and confusion


D.


Hostility and anger

Answ:C

Rationale: A client experiencing alcohol withdrawal often has delirium tremens (DTs) which is characterized by progressive disorientation. Initially, the client will appear restless and confused (C) and develop tachycardia, tachypnea, and diaphoresis. Hallucinations, paranoia, and seizures can also occur later in the development of DTs. (A) is indicative of withdrawal from opiates such as heroin or morphine. (B) is often seen in cocaine withdrawal. (D) is most characteristic of the paranoid client.

38. A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with which condition?


A.


Dissociative disorder


B.


Obsessive-compulsive disorder


C.


Panic disorder


D.


Posttraumatic stress syndrome

Answ:A

Rationale: Sleepwalking, amnesia, and multiple personalities are examples of detaching emotional conflict from one's consciousness (A). (B) is characterized by persistent, recurrent intrusive thoughts or urges (obsessions) that are unwilled and cannot be ignored, and provoke impulsive acts (compulsions) such as handwashing. (C) is an acute attack of anxiety characterized by personality disorganization. (D) is re-experiencing a psychologically terrifying or distressing event that is outside the usual range of human experience, such as war, rape, etc.

39. An adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate) because of medication noncompliance. What should the nurse teach the client and family about this change in medication regimen?

A.


Long-acting medication is more effective than daily medication.


B.


A client with substance abuse must not take any oral medications.


C.


There will continue to be a risk of alcohol and drug interaction.


D.


Support groups are only helpful for substance abuse treatment.

Answ:C

Rationale: Alcohol enhances the side effects of Prolixin. The half-life of Prolixin PO is 8 hours, whereas the half-life of the Prolixin Decanoate IM is 2 to 4 weeks. Therefore, the side effects of drinking alcohol are far more severe when the client drinks alcohol after taking the long acting Prolixin Decanoate IM. (A, B, and D) provide incorrect information.

40. A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression?

A.


Grandiose ideation


B.


Self-destructive thoughts


C.


Suspiciousness of others


D.


Negative views of self

Answ:D

Rationale: A negative self-image (D) is a specific indicator for depression. (A) occurs with paranoia or paranoid ideation (C). (B) may be seen in depressed clients, but not always.

41. A female client mumbles out loud whether anyone is talking to her or not and she also mumbles in group when others are talking. The nurse determines that the client is experiencing hallucinations. Which intervention should the nurse implement?

A.


Respond to the client's feelings rather than the illogical thoughts.


B.


Identify beliefs and thoughts about what the client is experiencing.


C.


Provide the client with hope that the voices will eventually go away.


D.


Ask the client how she has previously managed the voices.

Answ:D

Rationale: The nurse should promote symptom management and determine how the client previously managed the voices (D). (A and B) are interventions that are useful with clients who are experiencing delusions. (C) is important, but the most important intervention is to promote symptom management.

42. A child is brought to the emergency department with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the mother's statements? She is

A.


regressing to an earlier behavior pattern.


B.


sublimating her anger.


C.


projecting her feelings onto the nurse.


D.


suppressing her fear.

Answ:C

Rationale: Projection is attributing one's own thoughts, impulses, or behaviors onto another: it is the mother who is probably harming the child and she is attributing her actions to the nurse (C). The mother may be immature, but (A) is not the best description of her behavior. (B) is substituting a socially acceptable feeling for an unacceptable one. These are not socially acceptable feelings. The mother may be suppressing her fear (D) by displaying anger, but such an interpretation cannot be concluded from the data presented.

43. A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her room, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." What response by the nurse is the most therapeutic?

A.


"I'll leave your tray here. I am available if you need anything else."


B.


"You're not being poisoned. Why do you think someone is trying to poison you?"


C.


"No one on this unit has ever died from poisoning. You're safe here."


D.


"I will talk to your healthcare provider about the possibility of changing your diet."

Answ:A

Rationale: (A) is the best choice because the nurse does not argue with the client or demand that she eat but offers support by agreeing to "be there if needed," which provides an open, rather than closed, response to the client's statement. (B and C) are challenging the client's delusions, and (B) asks "why." Probing questions, which usually start with "why," are usually not therapeutic communication for a psychotic client. (D) has nothing to do with the actual problem (i.e., the problem is not with any particular diet, but with client delusions).

44. Clients are preparing to leave the mental health unit for an outdoor smoke break. A client on constant observation cannot leave and becomes agitated and demands to smoke a cigarette. What action should the nurse take first?

A.


Remind the client to wear the nicotine (NicoDerm) patch.


B.


Determine if the client still needs constant observation.


C.


Encourage the client to attend the smoking cessation group.


D.


Explain that clients on constant observation cannot smoke.

Answ:B

Rationale: The nurse should continually reassess the need for constant observation (B) so that the client can have unit privileges such as outdoor breaks. (A and C) do not meet the client's need and desire to smoke. (D) will cause more agitation.

45. The nurse develops a plan of care for a client with symptoms of paranoia and psychosis. The priority nursing diagnosis is Impaired social interactions related to inability to trust. Which intervention is most important for the nurse to implement?


A.


Greet the client by first name during each social interaction.


B.


Determine if the client is experiencing auditory hallucinations.


C.


Introduce the client to peers on the unit as soon as possible.


D.


Assign the client to a group about developing social skills.

Answ:A

Rationale: The most important nursing intervention is to greet the client by name (A) and provide short, frequent contact to establish trust. The presence of auditory hallucinations can impact social interactions (B), but it is not a priority intervention. (C and D) are effective interventions after individual rapport has been established with the client.

46. At the first meeting of a group of older adults at a daycare center for older adults, the nurse asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, "You tell me. You're the leader." What would be the best response for the nurse to make?

A.


"Yes, I am the leader today. Would you like to be the leader tomorrow?"


B.


"Yes, I will be leading this group. What would you like to accomplish?"


C.


"Yes, I have been assigned to lead this group. I will be here for the next 6 weeks."


D.


"Yes, I am the leader. You seem angry about not being the leader yourself."

Answ:B

Rationale: Anxiety over participation in a group and testing of the leader characteristically occur in the initial phase of group dynamics. (B) provides information and refocuses the group to defining its function. (A) is manipulative bargaining. (C) does not focus the group on its purpose or task. (D) is interpreting the client's feelings and is almost challenging.

47. While in group therapy, a male client who is diagnosed with posttraumatic stress disorder (PTSD) is processing an experience from the war in Iraq when another client tips over a chair. What action should the nurse take when the client with PTSD falls to the floor in a fetal position?

A.


Confront the client who tipped over the chair about the inconsiderate behavior.


B.


Dismiss the other clients from the group therapy session for a 10-minute break.


C.


Reinforce reality to the client on the floor and remove him to a quiet space.


D.


Call a security code and medicate both clients with an antianxiety drug.

Answ:C

Rationale: The client who is diagnosed with PTSD is re-experiencing the traumatic experience and needs reality reassurance (confirmation that he is not in danger at this time) and reduced stimuli (C). (A, B, and D) do not consider the needs of these two clients at this time.

48. Physical examination of a 6-year-old boy reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse would be most appropriate?

A.


"I need to tell the healthcare provider about your child's tendency to be accident prone."


B.


"Tell me more about these accidents that your child has been having."


C.


"I need to report these injuries to the authorities because they do not seem accidental."


D.


"Boys this age always seem to require more supervision and can be quite accident prone."

Answ:B

Rationale: (B) seeks more information using an open ended, nonthreatening statement. (A) might be appropriate, but it is not the best answer because the nurse is being somewhat sarcastic and is also avoiding the situation by referring it to the healthcare provider for resolution. Although it is true that suspected cases of child abuse must be reported, (C) is virtually an attack and is jumping ahead before conclusive data are obtained. (D) is a cliché and dismisses the seriousness of the situation.

49. A middle-aged adult was discharged from a treatment center 6 weeks ago following treatment for suicide ideation and alcohol abuse. In a follow-up visit to the mental health clinic, the client complains of lethargy, apathy, irritability, and anxiety. Which question is most important for the nurse to ask?

A.


"Are you taking prescribed antidepressants?"


B.


"How much alcohol do you consume daily?"


C.


"What seems to precipitate the anxious feelings?"


D.


"How many hours do you sleep per day?"

Answ:B

Rationale: First, and most important, the client's use of alcohol should be determined (B) because further treatment is dependent on the client's sobriety, and asking how much alcohol is being consumed is a better question than asking if the client is drinking, which is a "yes/no" answer that does not promote dialogue. (A, C, and D) provide worthwhile assessment data, but first the nurse should determine if the client is still drinking because all efforts to treat symptoms associated with depression are diminished if the client is still consuming alcohol.

50. A 35-year-old male client who has been hospitalized for 2 weeks for paranoia complains continuously to the staff that someone is trying to steal his clothing. What is the correct action for the nurse to take based on this client's complaints?


A.


Enroll the client in an exercise class to promote self-esteem.


B.


Place a lock on the client's closet to deter any theft.


C.


Promote extinction of the ideation by ignoring the client.


D.


Explain to the client that these suspicions are false.

Answ:A

Rationale: Diverting the client's attention from paranoid ideation (A) and encouraging him to engage in positive activities can be helpful in assisting him to develop a positive self-image. (B) actually supports his paranoid ideation. (C) may lower his self-esteem. The nurse should not argue with the client about his delusions (D).

Practice exam

1. A 30-year-old sales manager tells the nurse, "I am thinking about a job change. I don't feel like I am living up to my potential." Which of Maslow's developmental stages is the sales manager attempting to achieve?

A. Self-Actualization.

B. Loving and Belonging.

C. Basic Needs.

D. Safety and Security.

Answ:A

Self-actualization is the highest level of Maslow's development stages, which is an attempt to fulfill one's full potential (C). (B) is identifying support systems. (C) is the first level of Maslow's developmental stages and is the foundation upon which higher needs rest. Individuals who feel safe and secure (D) in their environment perceive themselves as having physical safety and lack fear of harm.

2. The nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using words that rhyme but that have no context or relationship with one topic to the next in the conversation. This client's behavior and thought processes are consistent with which syndrome?

A. Dementia.

B. Depression.

C. Schizophrenia.

D. Chronic brain syndrome.

Answ:C

The client is demonstrating symptoms of schizophrenia (C), such as disorganized speech that may include word salad (communication that includes both real and imaginary words in no logical order), incoherent speech, and clanging (rhyming). Dementia (A) is a global impairment of intellectual (cognitive) functions that may be progressive, such as Alzheimer's or organic brain syndrome (D). Depression (C) is typified by psychomotor retardation, and the client appears to be slowed down in movement, in speech, and would appear listless and disheveled.

3. A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider?

A. Decreased thyroid stimulating hormone level.

B. Elevated liver function profile.

C. Increased white blood cell count.

D. Decreased hematocrit and hemoglobin levels.

Answ:A

Hyperthyroidism causes an increased level of serum thyroid hormones (T3 and T4), which inhibit the release of TSH (A), so the client's manic behavior may be related to an endocrine disorder. (B, C, and D) are abnormal findings that are commonly found in the homeless population because of poor sanitation, poor nutrition, and the prevalence of substance abuse.

4. An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide?

A. You are in the hospital, and I am the nurse caring for you.

B. It must be difficult for you to control your anxious feelings.

C. Go to occupational therapy and start a project.

D. You are not in a war area now; this is the United States.

Answ:C

Delusions often generate fear and isolation, so the nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others (C). Delusions are often well-fixed, and though (A) reinforces reality, it is argumentative and dismisses the client's fears. It is often difficult for the client to recognize the relationship between delusions and anxiety (B), and the nurse should reassure the client that he is in a safe place. Dismissing delusional thinking (D) is unrealistic because neurochemical imbalances that cause positive symptoms of schizophrenia require antipsychotic drug therapy.

5. The nurse is assessing a client's intelligence. Which factor should the nurse remember during this part of the mental status exam?

A. Acute psychiatric illnesses impair intelligence.

B. Intelligence is influenced by social and cultural beliefs.

C. Poor concentration skills suggests limited intelligence.

D. The inability to think abstractly indicates limited intelligence.

Answ:B

Social and cultural beliefs (B) have significant impact on intelligence. Chronic psychiatric illness may impair intelligence (A), especially if it remains untreated. Limited concentration does not suggest limited intelligence (C). Difficulties with abstractions are suggestive of psychotic thinking (D), not limited intelligence.

6. At a support meeting of parents of a teenager with polysubstance dependency, a parent states, "Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide." The nurse's response should be based on which information?

A. Addiction is a chronic, incurable disease.

B. Tolerance to the effects of drugs causes feelings of depression.

C. Feelings of depression frequently lead to drug abuse and addiction.

D. Careful monitoring should be provided during withdrawal from the drugs.

Answ:D

The priority is to teach the parents that their son will need monitoring and support during withdrawal (D) to ensure that he does not attempt suicide. Although (A and C) are true, they are not as relevant to the parent's expressed concern. There is no information to support (B).

7. The wife of a male client recently diagnosed with schizophrenia asks the nurse, "What exactly is schizophrenia? Is my husband all right?" Which response is best for the nurse to provide to this family member?

A. It sounds like you're worried about your husband. Let's sit down and talk.

B. It is a chemical imbalance in the brain that causes disorganized thinking.

C. Your husband will be just fine if he takes his medications regularly.

D. I think you should talk to your husband's psychologist about this question.

Answ:B

The nurse should answer the client's question with factual information and explain that schizophrenia is a chemical imbalance in the brain (B). (A) is a therapeutic response but does not answer the question, and may be an appropriate response after the nurse answers the question asked. Although (C) is likely true to some degree, it is also true that some clients continue to have disorganized thinking even with antipsychotic medications. Referring the spouse to the psychologist (D) is avoiding the issue; the nurse can and should answer the question.

8. A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying poison him. What intervention should the nurse include in this client's plan of care?

A. Remind the client that his suspicions are not true.

B. Ask one nurse to spend time with the client daily.

C. Encourage the client to participate in group activities.

D. Assign the client to a room closest to the activity room.

Answ:B

A client with paranoid schizophrenia has difficulty with trust and developing a trusting relationship with one nurse (B) is likely to be therapeutic for this client. (A) is argumentative. Stress increases anxiety, and anxiety increases paranoid ideation; (C) would be too stressful and anxiety-promoting for a client who is experiencing pathological suspicions. (D) also might increase anxiety and stress.

9. The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority?

A. Excessive work activity.

B. Decreased need for sleep.

C. Medication management.

D. Inflated self-esteem.

Answ:C

The most important nursing problem is medication management (C) because compliance with the medication regimen will help prevent hospitalization. The client is also exhibiting signs of (A, B, and C); however, these problems do not have the priority of medication management.

10. A female client with obsessive-compulsive disorder (OCD) is describing her obsessions and compulsions and asks the nurse why these make her feel safer. What information should the nurse include in this client's teaching plan? (Select all that apply.)

A. Compulsions relieve anxiety.

B. Anxiety is the key reason for OCD.

C. Obsessions cause compulsions.

D. Obsessive thoughts are linked to levels of neurochemicals.

E. Antidepressant medications increase serotonin levels.

Answ:A,B,D,E

Correct choices are (A, B, D, and E). To promote client understanding and compliance, the teaching plan should include explanations about the origin and treatment options of OCD symptomology. Compulsions are behaviors that help relieve anxiety (A), which is a vague feeling related to unknown fears, that motivate behavior (B) to help the client cope and feel secure. All obsessions (C) do not result in compulsive behavior. OCD is supported by the neurophysiology theory, which attributes a diminished level of neurochemicals (D), particularly serotonin, and responds to selective serotonin reuptake inhibitors (SSRI).

11. The nurse observes a female client with schizophrenia watching the news on TV. She begins to laugh softly and says, "Yes, my love, I'll do it." When the nurse questions the client about her comment she states, "The news commentator is my lover and he speaks to me each evening. Only I can understand what he says." What is the best response for the nurse to make?

A. What do you believe the news commentator said to you?

B. Let's watch news on a different television channel.

C. Does the news commentator have plans to harm you or others?

D. The news commentator is not talking to you.

Answ:A

It is imperative that the nurse determine what the client believes she heard (A). The idea of reference may be to hurt herself or someone else, and the main function of a psychiatric nurse is to maintain safety. (B) is acceptable, but it is best to determine the client's beliefs. (C) is validating the idea of reference, while (D) is challenging the client.

12. A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is the client in at this time?

A. Isolation.

B. Stagnation.

C. Despair.

D. Role confusion.

Answ:B

The client is in Erikson's "Generativity vs. Stagnation" stage (age 24 to 45), and meeting the task includes maintaining intimate relationships and moving toward developing a family (B). (A) occurs in young adulthood (age 18 to 25), (C) occurs in maturity (age 45 to death), and (D) occurs in adolescence (age 12 to 20). These are all stages that occur if individuals are not successfully coping with their psychosocial developmental stage.

13. The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The mother states, "I think he took some of my pain pills." During initial assessment of the teenager, what information is most important for the nurse to obtain from the parents?

A. If he has seemed depressed recently.

B. If a drug overdose has ever occurred before.

C. If he might have taken any other drugs.

D. If he has a desire to quit taking drugs.