SET A PSYCH PRACTICE TEST
The client will establish adequate daily nutritional intake
1. Flumazenil (Romazicon) has been ordered for a male client who has
overdosed on oxazepam (Serax). Before administering
the medication, nurse Gina should be prepared for which common
adverse effect?
A. Seizures
B. Shivering
C. Anxiety
D. Chest pain
2. Nurse Tamara is caring for a client diagnosed with bulimia. The most
appropriate initial goal for a client diagnosed with bulimia is to:
A. Avoid shopping for large amounts of food
B. Control eating impulses
C. Identify anxiety-causing situations
D. Eat only three meals per day
3. A female client who’s at high risk for suicide needs close
supervision. To best ensure the client’s safety, Nurse Mary should:
A. Check the client frequently at irregular intervals throughout the
night
B. Assure the client that the nurse will hold in confidence anything
the client says
C. Repeatedly discuss previous suicide attempts with the client
D. Disregard decreased communication by the client because this is
common with suicidal clients
4. Which of the following drugs should Nurse Mary prepare to
administer to a client with a toxic acetaminophen (Tylenol) level?
A. Deferoxamine mesylate (Desferal)
B. Succimer (Chemet)
C. Flumazenil (Romazicon)
D. Acetylcysteine (Mucomyst)
5. A male client is admitted to the substance abuse unit for alcohol
detoxification. Which of the following medications is Nurse Alice most
likely to administer to reduce the symptoms of alcohol withdrawal?
A. Naloxone (Narcan)
B. Haloperidol (Haldol)
C. Magnesium sulfate
D. Chlordiazepoxide (Librium)
6. During postprandial monitoring, a female client with bulimia nervosa
tells the nurse, “You can sit with me, but you’re just wasting your time.
After you had sat with me yesterday, I was still able to purge. Today,
my goal is to do it twice.” What is the nurse’s best response?
A. “I trust you not to purge.”
B. “How are you purging and when do you do it?”
C. “Don’t worry. I won’t allow you to purge today.”
D. “I know it’s important for you to feel in control, but I’ll monitor
you for 90 minutes after you eat.”
7. A male client admitted to the psychiatric unit for treatment of
substance abuse says to the nurse, “It felt so wonderful to get high.”
Which of the following is the most appropriate response?
A. “If you continue to talk like that, I’m going to stop speaking to you.”
B. “You told me you got fired from your last job for missing too many
days after taking drugs all night.”
C. “Tell me more about how it felt to get high.”
D. “Don’t you know it’s illegal to use drugs?”
8. For a female client with anorexia nervosa, Nurse Jimmy is aware
that which goal takes the highest priority?
A.
B. The client will make a contract with the nurse that sets a target
weight
C. The client will identify self-perceptions about body size as unrealistic
D. The client will verbalize the possible physiological consequences of
self-starvation
9. When interviewing the parents of an injured child, which of the
following is the strongest indicator that child abuse may be a problem?
A. The injury isn’t consistent with the history or the child’s age
B. The mother and father tell different stories regarding what happened
C. The family is poor
D. The parents are argumentative and demanding with emergency
department personnel
10. For a female client with anorexia nervosa, nurse Rose plans to
include the parents in therapy sessions along with the client. What fact
should the nurse remember to be typical of parents of clients with
anorexia nervosa?
A. They tend to overprotect their children
B. They usually have a history of substance abuse
C. They maintain emotional distance from their children
D. They alternate between loving and rejecting their children
11. In the emergency department, a client with facial lacerations states
that her husband beat her with a shoe. After the health care team
repairs her lacerations, she waits to be seen by the crisis intake nurse,
who will evaluate the continued threat of violence. Suddenly the client’s
husband arrives, shouting that he wants to “finish the job.” What is the
first priority of the health care worker who witnesses this scene?
A. Remaining with the client and staying calm
B. Calling a security guard and another staff member for assistance
C. Telling the client’s husband that he must leave at once
D. Determining why the husband feels so angry
12. Nurse Mary is caring for a client with bulimia. Strict management of
dietary intake is necessary. Which intervention is also important?
A. Fill out the client’s menu and make sure she eats at least half of
what is on her tray.
B. Let the client eat her meals in private. Then engage her in social
activities for at least 2 hours after each meal
C. Let the client choose her own food. If she eats everything she
orders, then stay with her for 1 hour after each meal
D. Let the client eat food brought in by the family if she chooses, but
she should keep a strict calorie count.
13. Nurse Mary is assigned to care for a suicidal client. Initially, which
is the nurse’s highest care priority?
A. Assessing the client’s home environment and relationships outside
the hospital
B. Exploring the nurse’s own feelings about suicide
C. Discussing the future with the client
D. Referring the client to a clergyperson to discuss the moral
implications of suicide
14. A 24-year old client with anorexia nervosa tells the nurse, “When I
look in the mirror, I hate what I see. I look so fat and ugly.” Which
strategy should the nurse use to deal with the client’s distorted
perceptions and feelings?
A. Avoid discussing the client’s perceptions and feelings
B. Focus discussions on food and weight
C. Avoid discussing unrealistic cultural standards regarding weight
D. Provide objective data and feedback regarding the client’s weight
and attractiveness
15. Nurse Alice is caring for a client being treated for alcoholism.
Before initiating therapy with disulfiram (Antabuse), the nurse teaches
the client that he must read labels carefully on which of the following
products?
A. Carbonated beverages
B. Aftershave lotion
C. Toothpaste
D. Cheese
16. Nurse Harry is developing a plan of care for a client with anorexia
nervosa. Which action should the nurse include in the plan?
A. Restrict visits with the family until the client begins to eat
B. Provide privacy during meals
C. Set up a strict eating plan for the client
D. Encourage the client to exercise, which will reduce her anxiety
17. Nurse Taylor is aware that the victims of domestic violence should
be assessed for what important information?
A. Reasons they stay in the abusive relationship (for example, lack of
financial autonomy and isolation)
B. Readiness to leave the perpetrator and knowledge of resources
C. Use of drugs or alcohol
D. History of previous victimization
18. A male client is hospitalized with fractures of the right femur and
right humerus sustained in a motorcycle accident. Police suspect the
client was intoxicated at the time of the accident. Laboratory tests
reveal a blood alcohol level of 0.2% (200 mg/dl). The client later admits
to drinking heavily for years. During hospitalization, the client
periodically complains of tingling and numbness in the hands and feet.
Nurse Gian realizes that these symptoms probably result from:
A. Acetate accumulation
B. Thiamine deficiency
C. Triglyceride buildup.
D. A below-normal serum potassium level
19. A parent brings a preschooler to the emergency department for
treatment of a dislocated shoulder, which allegedly happened when the
child fell down the stairs. Which action should make the nurse suspect
that the child was abused?
A. The child cries uncontrollably throughout the examination
B. The child pulls away from contact with the physician.
C. The child doesn’t cry when the shoulder is examined
D. The child doesn’t make eye contact with the nurse.
20. When planning care for a client who has ingested phencyclidine
(PCP), nurse Wayne is aware that the following is the highest priority?
A. Client’s physical needs
B. Client’s safety needs
C. Client’s psychosocial needs
D. Client’s medical needs
21. The nurse is aware that the outcome criteria would be appropriate
for a child diagnosed with oppositional defiant disorder?
A. Accept responsibility for own behaviors
B. Be able to verbalize own needs and assert rights.
C. Set firm and consistent limits with the client
D. Allow the child to establish his own limits and boundaries
22. A male client is found sitting on the floor of the bathroom in the day
treatment clinic with moderate lacerations on both wrists. Surrounded
by broken glass, he sits staring blankly at his bleeding wrists while staff
members call for an ambulance. How should Nurse Anuktakanuk
approach her initially?
A. Enter the room quietly and move beside him to assess his injuries
B. Call for staff back-up before entering the room and restraining him
C. Move as much glass away from him as possible and sit next to him
quietly
D. Approach him slowly while speaking in a calm voice, calling him
name, and telling him that the nurse is here to help him
23. A female client with anorexia nervosa describes herself as “a
whale.” However, the nurse’s assessment reveals that the client is 5′ 8″
(1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client’s
unrealistic body image, which intervention should nurse Angel be
included in the plan of care?
A. Asking the client to compare her figure with magazine photographs
of women her age
B. Assigning the client to group therapy in which participants provide
realistic feedback about her weight
C. Confronting the client about her actual appearance during one-on-
one sessions, scheduled during each shift
D. Telling the client of the nurse’s concern for her health and desire to
help her make decisions to keep her healthy
24. Eighteen hours after undergoing an emergency appendectomy, a
client with a reported history of social drinking displays these vital
signs: temperature, 101.6° F (38.7° C); heart rate, 126 beats/minute;
respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm
Hg. The client exhibits gross hand tremors and is screaming for
someone to kill the bugs in the bed. Nurse Melinda should suspect:
A. A postoperative infection
B. Alcohol withdrawal
C. Acute sepsis.
D. Pneumonia.
25. Clonidine (Catapres) can be used to treat conditions other
than hypertension. Nurse Sally is aware that the following conditions
might the drug be administered?
A. Phencyclidine (PCP) intoxication
B. Alcohol withdrawal
C. Opiate withdrawal
D. Cocaine withdrawal
26. A male client with a history of cocaine addiction is admitted to the
coronary care unit for evaluation of substernal chest pain. The
electrocardiogram (ECG) shows a 1-mm ST-segment elevation the
anteroseptal leads and T-wave inversion in leads V3 to V5.
Considering the client’s history of drug abuse, nurse Greg expects the
physician to prescribe:
A. Lidocaine (Xylocaine).
B. Procainamide (Pronestyl).
C. Nitroglycerin (Nitro-Bid IV).
D. Epinephrine.
27. A 14-year-old client was brought to the clinic by her mother. Her
mother expresses concern about her daughter’s weight loss and
constant dieting. Nurse Kris conducts a health history interview. Which
of the following comments indicates that the client may be suffering
from anorexia nervosa?
A. “I like the way I look. I just need to keep my weight down because
I’m a cheerleader.”
B. “I don’t like the food my mother cooks. I eat plenty of fast food when
I’m out with my friends.”
C. “I just can’t seem to get down to the weight I want to be. I’m so fat
compared to other girls.”
D. “I do diet around my periods; otherwise, I just get so bloated.”
28. Nurse Fey is aware that the drug of choice for treating Tourette
syndrome?
A. Fluoxetine (Prozac)
B. Fluvoxamine (Luvox)
C. Haloperidol (Haldol)
D. Paroxetine (Paxil)
29. A male client tells the nurse he was involved in a car accident while
he was intoxicated. What would be the most therapeutic response from
nurse Julia?
A. “Why didn’t you get someone else to drive you?”
B. “Tell me how you feel about the accident.”
C. “You should know better than to drink and drive.”
D. “I recommend that you attend an Alcoholics Anonymous meeting.”
30. A male adult client voluntarily admits himself to the substance
abuse unit. He confesses that he drinks one (1) qt or more of vodka
each day and uses cocaine occasionally. Later that afternoon, he
begins to show signs of alcohol withdrawal. What are some early signs
of this condition?
A. Vomiting, diarrhea, and bradycardia
B. Dehydration, temperature above 101° F (38.3° C), and pruritus
C. Hypertension, diaphoresis, and seizures
D. Diaphoresis, tremors, and nervousness
31. When monitoring a female client recently admitted for treatment of
cocaine addiction, nurse Aaron notes sudden increases in the arterial
blood pressure and heart rate. To correct these problems, the nurse
expects the physician to prescribe:
A. Norepinephrine (Levophed) and Lidocaine (Xylocaine)
B. Nifedipine (Procardia) and Lidocaine.
C. Nitroglycerin (Nitro-Bid IV) and Esmolol (Brevibloc)
D. Nifedipine and Esmolol
32. A 25 –year old client experiencing alcohol withdrawal is upset
about going through detoxification. Which of the following goals is a
priority?
A. The client will commit to a drug-free lifestyle
B. The client will work with the nurse to remain safe
C. The client will drink plenty of fluids daily
D. The client will make a personal inventory of strength
33. A male client is admitted to a psychiatric facility by court order for
evaluation for antisocial personality disorder. This client has a long
history of initiating fights and abusing animals and recently was
arrested for setting a neighbor’s dog on fire. When evaluating this client
for the potential for violence, nurse Perry should assess for which
behavioral clues?
A. A rigid posture, restlessness, and glaring
B. Depression and physical withdrawal
C. Silence and noncompliance
D. Hypervigilance and talk of past violent acts
34. A male client is brought to the psychiatric clinic by family members,
who tell the admitting nurse that the client repeatedly drives while
intoxicated despite their pleas to stop. During an interview with the
nurse Linda, which statement by the client most strongly supports a
diagnosis of psychoactive substance abuse?
A. “I’m not addicted to alcohol. In fact, I can drink more than I used to
without being affected.”
B. “I only spend half of my paycheck at the bar.”
C. “I just drink to relax after work.”
D. “I know I’ve been arrested three times for drinking and driving, but
the police are just trying to hassle me.”
35. A female client with borderline personality disorder is admitted to
the psychiatric unit. Initial nursing assessment reveals that the client’s
wrists are scratched from a recent suicide attempt. Based on this
finding, the nurse Lenny should formulate a nursing diagnosis of:
A. Ineffective individual coping related to feelings of guilt.
B. Situational low self-esteem related to feelings of loss of control
C. Risk for violence: Self-directed related to impulsive mutilating acts
D. Risk for violence: Directed toward others related to verbal threats
36. A male client recently admitted to the hospital with sharp,
substernal chest pain suddenly complains of palpitations. Nurse Ryan
notes a rise in the client’s arterial blood pressure and a heart rate of
144 beats/minute. On further questioning, the client admits to having
used cocaine recently after previously denying use of the drug. The
nurse concludes that the client is at high risk for which complication of
cocaine use?
A. Coronary artery spasm
B. Bradyarrhythmias
C. Neurobehavioral deficits
D. Panic disorder
37. A male client is being admitted to the substance abuse unit for
alcohol detoxification. As part of the intake interview, the nurse asks
him when he had his last alcoholic drink. He says that he had his last
drink six (6) hours before admission. Based on this response, nurse
Lorena should expect early withdrawal symptoms to:
A. Begin after seven (7) days
B. Not occur at all because the time period for their occurrence has
passed
C. Begin anytime within the next one (1) to two (2) days
D. Begin within two (2) to seven (7) days
38. Nurse Helen is assigned to care for a client with anorexia nervosa.
Initially, which nursing intervention is most appropriate for this client?
A. Providing one-on-one supervision during meals and for one (1) hour
afterward
B. Letting the client eat with other clients to create a normal mealtime
atmosphere
C. Trying to persuade the client to eat and thus restore nutritional
balance
D. Giving the client as much time to eat as desired
39. A female client begins to experience alcoholic hallucinosis. Nurse
Joy is aware that the best nursing intervention at this time?
A. Keeping the client restrained in bed
B. Checking the client’s blood pressure every 15 minutes and offering
juices
C. Providing a quiet environment and administering medication as
needed and prescribed
D. Restraining the client and measuring blood pressure every 30
minutes
40. Nurse Bella is aware that assessment finding is most consistent
with early alcohol withdrawal?
A. Heart rate of 120 to 140 beats/minute
B. Heart rate of 50 to 60 beats/minute
C. Blood pressure of 100/70 mmHg
D. Blood pressure of 140/80 mmHg
41. Nurse Amy is aware that the client is at highest risk for suicide?
A. One who appears depressed frequently thinks of dying and gives
away all personal possessions
B. One who plans a violent death and has the means readily available
C. One who tells others that he or she might do something if life
doesn’t get better soon
D. One who talks about wanting to die
42. Nurse Penny is aware that the following medical conditions is
commonly found in clients with bulimia nervosa?
A. Allergies
B. Cancer
C. Diabetes mellitus
D. Hepatitis A
43. Kellan, a high school student is referred to the school nurse for
suspected substance abuse. Following the nurse’s assessment and
interventions, what would be the most desirable outcome?
A. The student discusses conflicts over drug use
B. The student accepts a referral to a substance abuse counselor
C. The student agrees to inform his parents of the problem
D. The student reports increased comfort with making choice
44. A male client who reportedly consumes one (1) qt of vodka daily is
admitted for alcohol detoxification. To try to prevent alcohol withdrawal
symptoms, Dr. Smith is most likely to prescribe which drug?
A. Clozapine (Clozaril)
B. Thiothixene (Navane)
C. Lorazepam (Ativan)
D. Lithium carbonate (Eskalith)

45. A male client is being treated for alcoholism. After a family meeting,
the client’s spouse asks the nurse about ways to help the family deal
with the effects of alcoholism. Nurse Lily should suggest that the family
join which organization?

A. Al-Anon
B. Make Today Count
C. Emotions Anonymous
D. Alcoholics Anonymous

46. A female client is admitted to the psychiatric clinic for treatment of

anorexia nervosa. To promote the client’s physical health, nurse Tair
should plan to:

A. Severely restrict the client’s physical activities

B. Weigh the client daily, after the evening meal
C. Monitor vital signs, serum electrolyte levels, and acid-base balance
D. Instruct the client to keep an accurate record of food and fluid intake

47. Kevin is remanded by the courts for psychiatric treatment. His

police record, which dates to his early teenage years, includes
delinquency, running away, auto theft, and vandalism. He dropped out
of school at age 16 and has been living on his own since then. His
history suggests maladaptive coping, which is associated with:

A. Antisocial personality disorder

B. Borderline personality disorder
C. Obsessive-compulsive personality disorder
D. Narcissistic personality disorder

48. Macoy and Helen seek emergency crisis intervention because he

slapped her repeatedly the night before. The husband indicates that his
childhood was marred by an abusive relationship with his father. When
intervening with this couple, nurse Gerry knows they are at risk for
repeated violence because the husband:

A. Has only moderate impulse control

B. Denies feelings of jealousy or possessiveness
C. Has learned violence as an acceptable behavior
D. Feels secure in his relationship with his wife

49. A client whose husband just left her has a recurrence of anorexia
nervosa. Nurse Vic caring for her realizes that this exacerbation of
anorexia nervosa results from the client’s effort to:

A. Manipulate her husband

B. Gain control of one part of her life
C. Commit suicide
D. Live up to her mother’s expectations

50. A male client has approached the nurse asking for advice on how
to deal with his alcohol addiction. Nurse Sally should tell the client that
the only effective treatment for alcoholism is:

SET A PSYCH ANSER KEY

A. Psychotherapy
B. Total abstinence
C. Alcoholics Anonymous (AA) 1. Answer A. Seizures
D. Aversion therapy

Seizures are the most common serious adverse effect of using

flumazenil to reverse benzodiazepine overdose. The effect is magnified
if the client has a combined tricyclic antidepressant and benzodiazepine
overdose.

Options B, C, and D: Less common adverse effects include shivering,

anxiety, and chest pain.

2. Answer C. Identify anxiety-causing situations

Bulimic behavior is generally a maladaptive coping response to stress

and underlying issues. The client must identify anxiety-causing
situations that stimulate the bulimic behavior and then learn new ways
of coping with the anxiety.
Option A: Controlling shopping for large amounts of food isn’t a goal
early in treatment.
Option B: Managing eating impulses and replacing them with adaptive
coping mechanisms can be integrated into the plan of care after initially
addressing stress and underlying issues.
Option D: Eating three meals per day isn’t a realistic goal early in
treatment.
3. Answer A. Check the client frequently at irregular intervals
throughout the night
Checking the client frequently but at irregular intervals prevents the
client from predicting when observation will take place and altering
behavior in a misleading way at these times.
Option B may encourage the client to try to manipulate the nurse or seek
attention for having a secret suicide plan.
Option C may reinforce suicidal ideas.
Option D: Decreased communication is a sign of withdrawal that may
indicate the client has decided to commit suicide; the nurse shouldn’t
disregard it.
4. Answer D. Acetylcysteine (Mucomyst)
The antidote for acetaminophen toxicity is acetylcysteine. It enhances
conversion of toxic metabolites to nontoxic metabolites.
Option A: Deferoxamine mesylate is the antidote for iron intoxication.
Option B: Succimer is an antidote for lead poisoning.
Option C: Flumazenil reverses the sedative effects of benzodiazepines.
5. Answer D. Chlordiazepoxide (Librium)
Chlordiazepoxide (Librium) and other tranquilizers help reduce the
symptoms of alcohol withdrawal.
Option A: Naloxone (Narcan) is administered for narcotic overdose.
Option B: Haloperidol (Haldol) may be given to treat clients with
psychosis, severe agitation, or delirium.
Option C: Magnesium sulfate and other anticonvulsant medications are
only administered to treat seizures if they occur during withdrawal.
6. Answer D. “I know it’s important for you to feel in control, but I’ll
monitor you for 90 minutes after you eat.”
This response acknowledges that the client is testing limits and that the
nurse is setting them by performing postprandial monitoring to prevent
self-induced emesis. Clients with bulimia nervosa need to feel in control
of the diet because they feel they lack control over all other aspects of
their lives.
Option A: Because their therapeutic relationships with caregivers are
less important than their need to purge, they don’t fear betraying the
nurse’s trust by engaging in the activity. They commonly plot to purge
and rarely share their secrets about it.
Options B and C: An authoritarian or challenging response may trigger
a power struggle between the nurse and client.
7. Answer B. “You told me you got fired from your last job for
missing too many days after taking drugs all night.”
Confronting the client with the consequences of substance abuse helps
to break through denial.
Option A: Making threats isn’t an effective way to promote self-
disclosure or establish a rapport with the client.
Option C: Although the nurse should encourage the client to discuss
feelings, the discussion should focus on how the client felt before, not
during, an episode of substance abuse. Encouraging elaboration about
his experience while getting high may reinforce the abusive behavior.
Option D: The client undoubtedly is aware that drug use is illegal; a
reminder to this effect is unlikely to alter behavior.
8. Answer A. The client will establish adequate daily nutritional
intake
According to Maslow’s hierarchy of needs, all humans need to meet
basic physiological needs first. Because a client with anorexia nervosa
eats little or nothing, the nurse must first plan to help the client meet this
basic, immediate physiological need.
Options B, C, and D: The nurse may give lesser priority to goals that
address long-term plans, self-perception, and potential complications.
9. Answer A. The injury isn’t consistent with the history or the
child’s age
When the child’s injuries are inconsistent with the history given or
impossible because of the child’s age and developmental stage, the
emergency department nurse should be suspicious that child abuse is
occurring.
Option B: The parents may tell different stories because their perception
may be different regarding what happened. If they change their story
when different health care workers ask the same question, this is a clue
that child abuse may be a problem.
Option C: Child abuse occurs in all socioeconomic groups.
Option D: Parents may argue and be demanding because of the stress
of having an injured child.
10. Answer A. They tend to overprotect their children
Clients with anorexia nervosa typically come from a family with parents
who are controlling and overprotective. These clients use eating to gain
control of an aspect of their lives.
The characteristics described in options B, C, and D isn’t typical of
parents of children with anorexia.
11. Answer B. Calling a security guard and another staff member
for assistance
The health care worker who witnesses this scene must take precautions
to ensure personal as well as client safety but shouldn’t attempt to
manage a physically aggressive person alone. Therefore, the first
priority is to call a security guard and another staff member.
Option A: After doing this, the health care worker should inform the
husband what is expected, speaking in concise statements and
maintaining a firm but calm demeanor. This approach makes it clear that
the health care worker is in control and may diffuse the situation until the
security guard arrives.
Option C: Telling the husband to leave would probably be ineffective
because of his agitated and irrational state.
Option D: Exploring his anger doesn’t take precedence over
safeguarding the client and staff.
12. Answer C. Let the client choose her own food. If she eats
everything she orders, then stay with her for 1 hour after each meal
Allowing the client to select her own food from the menu will help her
feel some sense of control.
Option A: She must then eat 100% of what she selected.
Option B: Remaining with the client for at least 1 hour after eating will
prevent purging.
Option D: Bulimic clients should only be allowed to eat food provided by
the dietary department.
13. Answer B. Exploring the nurse’s own feelings about suicide
The nurse’s values, beliefs, and attitudes toward self-destructive
behavior influence responses to a suicidal client; such responses set the
overall mood for the nurse-client relationship. Therefore, the nurse
initially must explore personal feelings about suicide to avoid conveying
negative feelings to the client.
Option A: Assessment of the client’s home environment and
relationships may reveal the need for family therapy; however,
conducting such an assessment isn’t a nursing priority.
Option C: Discussing the future and providing anticipatory guidance can
help the client prepare for future stress, but this isn’t a priority.
Option D: Referring the client to a clergyperson may increase the client’s
trust or alleviate guilt; however, it isn’t the highest priority.
14. Answer D. Provide objective data and feedback regarding the
client’s weight and attractiveness
By focusing on reality, this strategy may help the client develop a more
realistic body image and gain self-esteem.
Option A is inappropriate because discussing the client’s perceptions
and feeling wouldn’t help her to identify, accept, and work through them.
Option B: Focusing discussions on food and weight would give the client
attention for not eating.
Option C is inappropriate because recognizing unrealistic cultural
standards wouldn’t help the client establish more realistic weight goals.
15. Answer B. Aftershave lotion
Disulfiram may be given to clients with chronic alcohol abuse who wish
to curb impulse drinking. Disulfiram works by blocking the oxidation of
alcohol, inhibiting the conversion of acetaldehyde to acetate. As
acetaldehyde builds up in the blood, the client experiences noxious and
uncomfortable symptoms. Even alcohol rubbed onto the skin can
produce a reaction. The client receiving disulfiram must be taught to read
ingredient labels carefully to avoid products containing alcohol such as
aftershave lotions.
Options A, C, and D: Carbonated beverages, toothpaste, and cheese
don’t contain alcohol and don’t need to be avoided by the client.
16. Answer C. Set up a strict eating plan for the client
Establishing a consistent eating plan and monitoring the client’s weight
are important for this disorder.
Option A: The family should be included in the client’s care.
Option B: The client should be monitored during meals — not given
privacy.
Option D: Exercise must be limited and supervised.
17. Answer B. Readiness to leave the perpetrator and knowledge of
resources
Victims of domestic violence must be assessed for their readiness to
leave the perpetrator and their knowledge of the resources available to
them. Nurses can then provide the victims with information and options
to enable them to leave when they are ready.
Option A: The reasons they stay in the relationship are complex and can
be explored at a later time.
Option C: The use of drugs or alcohol is irrelevant.
Option D: There is no evidence to suggest that previous victimization
results in a person’s seeking or causing abusive relationships.
18. Answer B. Thiamine deficiency
Numbness and tingling in the hands and feet are symptoms of peripheral
polyneuritis, which results from inadequate intake of vitamin B1
(thiamine) secondary to prolonged and excessive alcohol intake.
Treatment includes reducing alcohol intake, correcting nutritional
deficiencies through diet and vitamin supplements, and preventing such
residual disabilities as foot and wrist drop.
Options A, C, and D: Acetate accumulation, triglyceride buildup, and a
below-normal serum potassium level are unrelated to the client’s
symptoms.
19. Answer C. The child doesn’t cry when the shoulder is examined
A characteristic behavior of abused children is the lack of crying when
they undergo a painful procedure or are examined by a health care
professional. Therefore, the nurse should suspect child abuse.
Options A, B, and D: Crying throughout the examination, pulling away
from the physician, and not making eye contact with the nurse are
normal behaviors for preschoolers.
20. Answer B. Client’s safety needs
The highest priority for a client who has ingested PCP is meeting safety
needs of the client as well as the staff. Drug effects are unpredictable
and prolonged, and the client may lose control easily.
Options A, C, and D: After safety needs have been met, the client’s
physical, psychosocial, and medical needs can be met.
21. Answer A. Accept responsibility for own behaviors
Children with oppositional defiant disorder frequently violate the rights of
others. They are defiant, disobedient, and blame others for their actions.
Accountability for their actions would demonstrate progress for the
oppositional child.
Option B is incorrect as the oppositional child usually, focuses on his
own needs.
Options C and D aren’t outcome criteria but interventions.
22. Answer D. Approach her slowly while speaking in a calm voice,
calling her name, and telling her that the nurse is here to help her
Ensuring the safety of the client and the nurse is the priority at this time.
Therefore, the nurse should approach the client cautiously while calling
her name and talking to her in a calm, confident manner.
Option A: The nurse should keep in mind that the client shouldn’t be
startled or overwhelmed. After explaining that the nurse is there to help,
the nurse should observe the client’s response carefully.
Option B: If the client shows signs of agitation or confusion or poses a
threat, the nurse should retreat and request assistance.
Option C: The nurse shouldn’t attempt to sit next to the client or examine
injuries without first announcing the nurse’s presence and assessing the
dangers of the situation.
23. Answer D. Telling the client of the nurse’s concern for her
health and desire to help her make decisions to keep her healthy
A client with anorexia nervosa has an unrealistic body image that causes
consumption of little or no food. Therefore, the client needs assistance
with making decisions about health.
Instead of protecting the client’s health, options A, B, and C may serve
to make the client defensive and more entrenched in her unrealistic body
image.
24. Answer B. Alcohol withdrawal
The client’s vital signs and hallucinations suggest delirium tremens or
alcohol withdrawal syndrome.
Options A, C, and D: Although infection, acute sepsis, and pneumonia
may arise as postoperative complications; they wouldn’t cause this
client’s signs and symptoms and typically would occur later in the
postoperative course
25. Answer C. Opiate withdrawal
Clonidine is used as adjunctive therapy in opiate withdrawal.
Option A: Benzodiazepines and neuroleptic agents are typically used to
treat PCP intoxication.
Option B: Benzodiazepines, such as chlordiazepoxide (Librium), and
neuroleptic agents, such as haloperidol, are used to treat alcohol
withdrawal.
Option D: Antidepressants and medications with dopaminergic activity
in the brain, such as fluoxetine (Prozac), are used to treat cocaine
withdrawal.
26. Answer C. Nitroglycerin (Nitro-Bid IV).
The elevated ST segments in this client’s ECG indicate myocardial
ischemia. To reverse this problem, the physician is most likely to
prescribe an infusion of nitroglycerin to dilate the coronary arteries.
Options A and B: Lidocaine and procainamide are cardiac drugs that
may be indicated for this client at some point but aren’t used for coronary
artery dilation.
Option D: If a cocaine user experiences ventricular fibrillation or
asystole, the physician may prescribe epinephrine. However, this drug
must be used with caution because cocaine may potentiate its
adrenergic effects.
27. Answer C. “I just can’t seem to get down to the weight I want to
be. I’m so fat compared to other girls.”
Low self-esteem is the highest risk factor for anorexia nervosa. Constant
dieting to get down to a “desirable weight” is characteristic of the
disorder. Feeling inadequate when compared to peers indicates poor
self-esteem.
Option A: Most clients with anorexia nervosa don’t like the way they look,
and their self-perception may be distorted. A girl with cachexia may
perceive herself to be overweight when she looks in the mirror.
Option B: Preferring fast food over healthy food is common in this age-
group.
Option D: Because of the absence of body fat necessary for proper
hormone production, amenorrhea is common for a client with anorexia
nervosa.
28. Answer C. Haloperidol (Haldol)
Haloperidol is the drug of choice for treating Tourette syndrome.
Options A, B, and D: Prozac, Luvox, and Paxil are antidepressants and
aren’t used to treat Tourette syndrome
29. Answer B. “Tell me how you feel about the accident.”
An open-ended statement or question is the most therapeutic response.
It encourages the widest range of client responses, makes the client an
active participant in the conversation, and shows the client that the nurse
is interested in his feelings.
Option A: Asking the client why he drove while intoxicated can make him
feel defensive and intimidated.
Option C: A judgmental approach isn’t therapeutic.
Option D: By giving advice, the nurse suggests that the client isn’t
capable of making decisions, thus fostering dependency.
30. Answer D. Diaphoresis, tremors, and nervousness
Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic
hallucinosis, and alcohol withdrawal delirium (formerly delirium
tremens). Signs of alcohol withdrawal include diaphoresis, tremors,
nervousness, nausea, vomiting, malaise, increased blood pressure and
pulse rate, sleep disturbance, and irritability.
Option A: Although diarrhea may be an early sign of alcohol withdrawal,
tachycardia — not bradycardia — is associated with alcohol withdrawal.
Option B: Dehydration and an elevated temperature may be expected,
but a temperature above 101° F indicates an infection rather than
alcohol withdrawal. Pruritus rarely occurs in alcohol withdrawal.
Option C: If withdrawal symptoms remain untreated, seizures may arise
later.
31. Answer D. Nifedipine and Esmolol
This client requires a vasodilator, such as nifedipine, to treat
hypertension, and a beta-adrenergic blocker, such as esmolol, to reduce
the heart rate.
Options A and B: Lidocaine, an antiarrhythmic, isn’t indicated because
the client doesn’t have an arrhythmia.
Option C: Although nitroglycerin may be used to treat coronary
vasospasm, it isn’t the drug of choice in hypertension.
32. Answer B. The client will work with the nurse to remain safe
The priority goal in alcohol withdrawal is maintaining the client’s safety.
Options A, C, and D: Committing to a drug-free lifestyle, drinking plenty
of fluids, and identifying personal strengths are important goals, but
ensuring the client’s safety is the nurse’s top priority.
33. Answer A. A rigid posture, restlessness, and glaring
Behavioral clues that suggest the potential for violence includes: a rigid
posture, restlessness, glaring, a change in usual behavior, clenched
hands, overtly aggressive actions, physical withdrawal, noncompliance,
overreaction, hostile threats, recent alcohol ingestion or drug use, talk of
past violent acts, inability to express feelings, repetitive demands and
complaints, argumentativeness, profanity, disorientation, inability to
focus attention, hallucinations or delusions, paranoid ideas or
suspicions, and somatic complaints.
Options B, C, and D: Violent clients rarely exhibit depression, silence, or
hypervigilance.
34. Answer D. “I know I’ve been arrested three times for drinking
and driving, but the police are just trying to hassle me.”
According to the Diagnostic and Statistical Manual of Mental Disorders,
4th edition, diagnostic criteria for psychoactive substance abuse include
a maladaptive pattern of such use, indicated either by continued use
despite knowledge of having a persistent or recurrent social,
occupational, psychological, or physical problem caused or exacerbated
by substance abuse or recurrent use in dangerous situations (for
example, while driving).
For this client, psychoactive substance dependence must be ruled out;
criteria for this disorder include a need for increasing amounts of the
substance to achieve intoxication (option A), increased time and money
spent on the substance (option B), inability to fulfill role obligations
(option C), and typical withdrawal symptoms.
35. Answer C. Risk for violence: Self-directed related to impulsive
mutilating acts
The predominant behavioral characteristic of the client with borderline
personality disorder is impulsiveness, especially of a physically self-
destructive sort. The observation that the client has scratched wrists
doesn’t substantiate the other options.
36. Answer A. Coronary artery spasm
Cocaine use may cause such cardiac complications as coronary artery
spasm, myocardial infarction, dilated cardiomyopathy, acute heart
failure, endocarditis, and sudden death. Cocaine blocks reuptake of
norepinephrine, epinephrine, and dopamine, causing an excess of these
neurotransmitters at postsynaptic receptor sites.
Option B: Consequently, the drug is more likely to cause
tachyarrhythmias than bradyarrhythmias.
Option C: Although neurobehavioral deficits are common in neonates
born to cocaine users, they are rare in adults.
Option D: As craving for the drug increases, a person who’s addicted to
cocaine typically experiences euphoria followed by depression, not
panic disorder
37. Answer C. Begin anytime within the next one (1) to two (2) days
Acute withdrawal symptoms from alcohol may begin 6 hours after the
client has stopped drinking and peak 1 to 2 days later. Delirium tremens
may occur 2 to 4 days — even up to 7 days — after the last drink.
38. Answer A. Providing one-on-one supervision during meals and
for one (1) hour afterward
Because the client with anorexia nervosa may discard food or induce
vomiting in the bathroom, the nurse should provide one-on-one
supervision during meals and for 1 hour afterward.
Option B wouldn’t be therapeutic because other clients may urge the
client to eat and give attention for not eating.
Option C would reinforce control issues, which are central to this client’s
underlying psychological problem.
Instead of giving the client unlimited time to eat, the nurse should set
limits and let the client know what is expected.
39. Answer C. Providing a quiet environment and administering
medication as needed and prescribed
Manifestations of alcoholic hallucinosis are best treated by providing a
quiet environment for reducing stimulation and administering prescribed
central nervous system depressants in dosages that control symptoms
without causing oversedation.
Option A: Although bed rest is indicated, restraints are unnecessary
unless the client poses a danger to himself or others. Also, restraints
may increase agitation and make the client feel trapped and helpless
when hallucinating.
Option B: Offering juice is appropriate, but measuring blood pressure
every 15 minutes would interrupt the client’s rest.
Option D: To avoid overstimulating the client, the nurse should check
blood pressure every 2 hours.
40. Answer A. Heart rate of 120 to 140 beats/minute
Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign
of alcohol withdrawal. Blood pressure may be labile throughout
withdrawal, fluctuating at different stages. Hypertension typically occurs
in early withdrawal. Hypotension, although rare during the early
withdrawal stages, may occur in later stages. Hypotension is associated
with cardiovascular collapse and most commonly occurs in clients who
don’t receive treatment. The nurse should monitor the client’s vital signs
carefully throughout the entire alcohol withdrawal process.
41. Answer B. One who plans a violent death and has the means
readily available
The client at highest risk for suicide is one who plans a violent death (for
example, by gunshot, jumping off a bridge, or hanging), has a specific
plan (for example, after the spouse leaves for work), and has the means
readily available (for example, a rifle hidden in the garage).
Options A, C, and D: A client who gives away possessions thinks about
death, or talks about wanting to die or attempting suicide is considered
at a lower risk for suicide because this behavior typically serves to alert
others that the client is contemplating suicide and wishes to be helped.
42. Answer C. Diabetes mellitus
Bulimia nervosa can lead to many complications, including diabetes,
heart disease, and hypertension.
Options A, B, and D: The eating disorder isn’t typically associated with
allergies, cancer, or hepatitis A.
43. Answer B. The student accepts a referral to a substance abuse
counselor
All of the outcomes stated are desirable; however, the best outcome is
that the student would agree to seek the assistance of a professional
substance abuse counselor
44. Answer C. Lorazepam (Ativan)
The best choice for preventing or treating alcohol withdrawal symptoms
is lorazepam, a benzodiazepine.
Options A, B and D: Clozapine, and Thiothixene are antipsychotic
agents, and lithium carbonate is an antimanic agent; these drugs aren’t
used to manage alcohol withdrawal syndrome.
45. Answer A. Al-Anon
Al-Anon is an organization that assists family members to share
common experiences and increase their understanding of alcoholism.
Option B: Make Today Count is a support group for people with life-
threatening or chronic illnesses.
Option C: Emotions Anonymous is a support group for people
experiencing depression, anxiety, or similar conditions.
Option D: Alcoholics Anonymous is an organization that helps alcoholics
recover by using a twelve-step program.
46. Answer C. monitor vital signs, serum electrolyte levels, and
acid-base balance
An anorexic client who requires hospitalization is in poor physical
condition from starvation and may die as a result of arrhythmias,
hypothermia, malnutrition, infection, or cardiac abnormalities secondary
to electrolyte imbalances. Therefore, monitoring the client’s vital signs,
serum electrolyte level, and acid-base balance is crucial.
Option A may worsen anxiety.
Option B is incorrect because a weight obtained after breakfast is more
accurate than one obtained after the evening meal.
Option D would reward the client with attention for not eating and
reinforce the control issues that are central to the underlying
psychological problem; also, the client may record food and fluid intake
inaccurately.
47. Answer A. Antisocial personality disorder
The client’s history of delinquency, running away from home, vandalism,
and dropping out of school are characteristic of antisocial personality
disorder. This maladaptive coping pattern is manifested by a disregard
for societal norms of behavior and an inainability to relate meaningfully
to others.
Option B: In borderline personality disorder, the client exhibits mood
instability, poor self-image, identity disturbance, and labile affect.
Option C: Obsessive-compulsive personality disorder is characterized
by a preoccupation with impulses and thoughts that the client realizes
are senseless but can’t control.
Option D: Narcissistic personality disorder is marked by a pattern of self-
involvement, grandiosity, and demand for constant attention.
48. Answer C. Has learned violence as an acceptable behavior
Family violence usually is a learned behavior, and violence typically
leads to further violence, putting this couple at risk.
Option A: Repeated slapping may indicate poor, not moderate, impulse
control.
Options B and D: Violent people commonly are jealous and possessive
and feel insecure in their relationships
49. Answer B. Gain control of one part of her life
By refusing to eat, a client with anorexia nervosa is unconsciously
attempting to gain control over the only part of her life she feels she can
control.
Option A: This eating disorder doesn’t represent an attempt to
manipulate others or live up to their expectations (although anorexia
nervosa has a high incidence in families that emphasize achievement).
Option C: The client isn’t attempting to commit suicide through
starvation; rather, by refusing to eat, she is expressing feelings of
despair, worthlessness, and hopelessness.
50. Answer B. Total abstinence
Total abstinence is the only effective treatment for alcoholism.
Psychotherapy, attendance at AA meetings, and aversion therapy are
all adjunctive therapies that can support the client in his efforts to
abstain.
Options A, C, and D: Psychotherapy, attendance at AA meetings, and
aversion therapy are all adjunctive therapies that can support the client
in his efforts to abstain.

SET B PSYCH PRACTICE TEST
1. Mental health is defined as:
A. The ability to distinguish what is real from what is not.
B. A state of well-being where a person can realize his own abilities
can cope with normal stresses of life and work productively.
C. Is the promotion of mental health, prevention of mental disorders,
nursing care of patients during illness and rehabilitation
D. Absence of mental illness
2. Which of the following describes the role of a technician?
A. Administers medications to a schizophrenic patient.
B. The nurse feeds and bathes a catatonic client
C. Coordinates diverse aspects of care rendered to the patient
D. Disseminates information about alcohol and its effects.
3. Letty says, “Give me ten (10) minutes to recall the name of our
college professor who failed many students in our anatomy class.” She
is operating on her:
A. Subconscious
B. Conscious
C. Unconscious
D. Ego
4. The superego is that part of the psyche that:
A. Uses defensive function for protection.
B. Is impulsive and without morals.
C. Determines the circumstances before making decisions.
D. The censoring portion of the mind.
5. Primary level of prevention is exemplified by:
A. Helping the client resume self-care.
B. Ensuring the safety of a suicidal client in the institution.
C. Teaching the client stress management techniques
D. Case finding and surveillance in the community
6. Situation: In a home visit done by the nurse, she suspects that the
wife and her child are victims of abuse. Which of the following is the
most appropriate for the nurse to ask?
A. “Are you being threatened or hurt by your partner?
B. “Are you frightened of you partner.”
C. “Is something bothering you?”
D. “What happens when you and your partner argue?”
7. The wife admits that she is a victim of abuse and opens up about
her persistent distaste for sex. This sexual disorder is:
A. Sexual desire disorder
B. Sexual arousal disorder
C. Orgasm disorder
D. Sexual Pain Disorder
8. What would be the best approach for a wife who is still living with her
abusive husband?
A. “Here’s the number of a crisis center that you can call for help .”
B. “It’s best to leave your husband.”
C. “Did you discuss this with your family?”
D. “ Why do you allow yourself to be treated this way.”
9. Which comment about a 3-year-old child if made by the parent may
indicate child abuse?
A. “Once my child is toilet trained, I can still expect her to have some.”
B. “When I tell my child to do something once, I don’t expect to have to
tell.”
C. “My child is expected to try to do things such as dress and feed.”
D. “My three (3)-year-old loves to say NO.”
10. The primary nursing intervention for a victim of child abuse is:
A. Assess the scope of the problem
B. Analyze the family dynamics
C. Ensure the safety of the victim
D. Teach the victim coping skills
11. Situation: A 30-year-old male employee frequently complains of low
back pain that leads to frequent absences from work. Consultation and
tests reveal negative results. The client has which somatoform
disorder?
A. Somatization Disorder
B. Hypochondriasis
C. Conversion Disorder
D. Somatoform Pain Disorder
12. Freud explains anxiety as:
A. Strives to gratify the needs for satisfaction and security
B. Conflict between id and superego
C. A hypothalamic-pituitary-adrenal reaction to stress
D. A conditioned response to stressors
13. The following are the appropriate nursing diagnosis for the client
EXCEPT:
A. Ineffective individual coping
B. Alteration in comfort, pain
C. Altered role performance
D. Impaired social interaction
14. The following statements describe somatoform disorders:
A. Physical symptoms are explained by organic causes
B. It is a voluntary expression of psychological conflicts
C. Expression of conflicts through bodily symptoms
D. Management entails a specific medical treatment
15. What would be the best response to the client’s repeated
complaints of pain:
A. “I know the feeling is real tests revealed negative results.”
B. “I think you’re exaggerating things a little bit.”
C. “Try to forget this feeling and have activities to take it off your mind.” D. Psychological dependence
D. “So tell me more about the pain.”
27. The client admitted for alcohol detoxification develops increased
16. Situation: A nurse may encounter children with mental disorders. tremors, irritability, hypertension, and fever. The nurse should be alert
Her knowledge of these various disorders is vital. When planning for impending:
school interventions for a child with a diagnosis of attention deficit
hyperactivity disorder, a guide to remember is to: A. Delirium tremens
B. Korsakoff’s syndrome
A. Provide as much structure as possible for the child C. Esophageal varices
B. Ignore the child’s overactivity. D. Wernicke’s syndrome
C. Encourage the child to engage in any play activity to dissipate
energy 28. The care for the client places priority on which of the following:
D. Remove the child from the classroom when disruptive behavior
occurs A. Monitoring his vital signs every hour
B. Providing a quiet, dim room
17. The child with conduct disorder will likely demonstrate: C. Encouraging adequate fluids and nutritious foods
D. Administering Librium as ordered
A. Easy distractibility to external stimuli.
B. Ritualistic behaviors 29. Another client is brought to the emergency room by friends who
C. Preference for inanimate objects. state that he took something an hour ago. He is actively hallucinating,
D. Serious violations of age related norms. agitated, with an irritated nasal septum.

18. Ritalin is the drug of choice for children with ADHD. The side A. Heroin
effects of the following may be noted: B. Cocaine
C. LSD
A. Increased attention span and concentration D. Marijuana
B. Increase in appetite
C. Sleepiness and lethargy 30. A client is admitted with needle tracks on his arm, stuporous and
D. Bradycardia and diarrhea with pin point pupil will likely be managed with:

19. School phobia is usually treated by: A. Naltrexone (Revia)

B. Narcan (Naloxone)
A. Returning the child to the school immediately with family support. C. Disulfiram (Antabuse)
B. Calmly explaining why attendance in school is necessary D. Methadone (Dolophine)
C. Allowing the child to enter the school before the other children
D. Allowing the parent to accompany the child in the classroom 31. Situation: An old woman was brought for evaluation due to the
hospital for evaluation due to increasing forgetfulness and limitations in
20. A 10 year old child has very limited vocabulary and interaction daily function. The daughter revealed that the client used her
skills. She has an I.Q. of 45. She is diagnosed to have Mental toothbrush to comb her hair. She is manifesting:
retardation of this classification:
A. Apraxia
A. Profound B. Aphasia
B. Mild C. Agnosia
C. Moderate D. Amnesia
D. Severe
32. She tearfully tells the nurse “I can’t take it when she accuses me of
21. The nurse teaches the parents of a mentally retarded child stealing her things.” Which response by the nurse will be most
regarding her care. The following guidelines may be taught except: therapeutic?

A. Overprotection of the child A. ”Don’t take it personally. Your mother does not mean it.”
B. Patience, routine, and repetition B. “Have you tried discussing this with your mother?”
C. Assisting the parents set realistic goals C. “This must be difficult for you and your mother.”
D. Giving reasonable compliments
D. “Next time ask your mother where her things were last seen.”
22. The parents express apprehensions on their ability to care for their
maladaptive child. The nurse identifies what nursing diagnosis: 33. The primary nursing intervention in working with a client with
moderate stage dementia is ensuring that the client:
A. Hopelessness
B. Altered parenting role A. Receives adequate nutrition and hydration
C. Altered family process B. Will reminisce to decrease isolation
D. Ineffective coping C. Remains in a safe and secure environment
D. Independently performs self-care
23. A 5-year-old boy is diagnosed to have autistic disorder. Which of
the following manifestations may be noted in a client with autistic 34. She says to the nurse who offers her breakfast, “Oh no, I will wait
disorder? for my husband. We will eat together” The therapeutic response by the
nurse is:
A. Aargumentativeness, disobedience, angry outburst
B. Intolerance to change, disturbed relatedness, stereotypes A. “Your husband is dead. Let me serve you your breakfast.”
C. Distractibility, impulsiveness, and overactivity B. “I’ve told you several times that he is dead. It’s time to eat.”
D. Aggression, truancy, stealing, lying C. “You’re going to have to wait a long time.”
D. “What made you say that your husband is alive?
24. The therapeutic approach in the care of an autistic child includes
the following EXCEPT: 35. Dementia, unlike delirium, is characterized by:

A. Engage in diversionary activities when acting -out A. Slurred speech

B. Provide an atmosphere of acceptance B. Insidious onset
C. Provide safety measures C. Clouding of consciousness
D. Rearrange the environment to activate the child D. Sensory perceptual change
25. According to Piaget, a 5-year-old is at what stage of development:
36. Situation: A 17-year-old gymnast is admitted to the hospital due to
A. Sensorimotor stage weight loss and dehydration secondary to starvation. Which of the
B. Concrete operations following nursing diagnoses will be given priority for the client?
C. Pre-operational
D. Formal operation A. Altered self-image
B. Fluid volume deficit
26. Situation: The nurse assigned to the detoxification unit attends to C. Altered nutrition less than body requirements
various patients with substance-related disorders. A 45 years old male D. Altered family process
revealed that he experienced a marked increase in his intake of alcohol
to achieve the desired effect This indicates: 37. What is the best intervention to teach the client when she feels the
need to starve?
A. Withdrawal
B. Tolerance A. Allow her to starve to relieve her anxiety
C. Intoxication B. Do a short term exercise until the urge passes
C. Approach the nurse and talk out her feelings 49. Malingering is different from somatoform disorder because the
D. Call her mother on the phone and tell her how she feels former:

38. The client with anorexia nervosa is improving if: A. Has evidence of an organic basis.
B. It is a deliberate effort to handle upsetting events
A. She eats meals in the dining room. C. Gratification from the environment are obtained.
B. Weight gain D. Stress is expressed through physical symptoms.
C. She attends ward activities.
D. She has a more realistic self-concept. 50. Unlike psychophysiologic disorder Linda may be best managed
with:
39. The characteristic manifestation that will differentiate bulimia
nervosa from anorexia nervosa is that bulimic individual A. Medical regimen
B. Milieu therapy
A. Have episodic binge eating and purging C. Stress management techniques
B. Have repeated attempts to stabilize their weight D. Psychotherapy
C. Have peculiar food handling patterns
D. Have threatened self-esteem

40. A nursing diagnosis for bulimia nervosa is powerlessness related to

feeling not in control of eating habits. The goal for this problem is:

A. Patient will learn problem-solving skills

B. Patient will have decreased symptoms of anxiety.
C. Patient will perform self-care activities daily.
D. Patient will verbalize how to set limits on others.

41. In the management of bulimic patients, the following nursing

interventions will promote a therapeutic relationship EXCEPT:

A. Establish an atmosphere of trust

B. Discuss their eating behavior.
C. Help patients identify feelings associated with binge-purge behavior
D. Teach patient about bulimia nervosa

42. Situation: A 35-year-old male has an intense fear of riding an

elevator. He claims “ As if I will die inside.” This has affected his
studies The client is suffering from:

A. Agoraphobia
B. Social phobia
C. Claustrophobia
D. Xenophobia

43. Initial intervention for the client should be to:

A. Encourage to verbalize his fears as much as he wants.

B. Assist him to find meaning to his feelings in relation to his past.
C. Establish trust through a consistent approach.
D. Accept her fears without criticizing.
44. The nurse develops a countertransference reaction. This is
evidenced by:
A. Revealing personal information to the client
B. Focusing on the feelings of the client.
C. Confronting the client about discrepancies in verbal or non-verbal
behavior
D. The client feels angry towards the nurse who resembles his mother.
45. Which is the desired outcome in conducting desensitization:
A. The client verbalize his fears about the situation
B. The client will voluntarily attend group therapy in the social hall.
C. The client will socialize with others willingly
D. The client will be able to overcome his disabling fear.
46. Which of the following should be included in the health teachings
among clients receiving Valium:
A. Avoid taking CNS depressant like alcohol.
B. There are no restrictions in activities.
C. Limit fluid intake.
D. Any beverage like coffee may be taken
SET B PSYCH ANSWER KEY
1. Answer: B. A state of well-being where a person can realize his
own abilities can cope with normal stresses of life and work
productively.
Mental health is a state of emotional and psychosocial well being. A
mentally healthy individual is self-aware and self-directive has the
ability to solve problems, can cope with the crisis without assistance
beyond the support of family and friends fulfill the capacity to love and
work and sets goals and realistic limits.
Option A: This describes the ego function reality testing.
Option C: This is the definition of Mental Health and Psychiatric
Nursing.
Option D: Mental health is not just the absence of mental illness.
2. Answer: A. Administers medications to a schizophrenic patient.
Administration of medications and treatments, assessment,
documentation are the activities of the nurse as a technician.
Option B: Activities as a parent surrogate.
Option C: Refers to the ward manager role.
Option D: Role as a teacher.
3. Answer: A. Subconscious

47. Situation: A 20-year-old college student is admitted to the medical
ward because of sudden onset of paralysis of both legs. Extensive
examination revealed no physical basis for the complaint. The nurse
plans intervention based on which correct statement about conversion
disorder?
A. The symptoms are conscious effort to control anxiety
B. The client will experience a high level of anxiety in response to the
paralysis.
C. The conversion symptom has symbolic meaning to the client
D. A confrontational approach will be beneficial for the client.
Subconscious refers to the materials that are partly remembered partly
forgotten but these can be recalled spontaneously and voluntarily.
Option B: This functions when one is awake. One is aware of his
thoughts, feelings actions and what is going on in the environment.
Option C: The largest portion of the mind that contains the memories of
one’s past particularly the unpleasant. It is difficult to recall the
unconscious content.
Option D: The conscious self that deals and tests reality.
4. Answer: D. The censoring portion of the mind.

48. Nikki reveals that the boyfriend has been pressuring her to engage
in premarital sex. The most therapeutic response by the nurse is:
A. “I can refer you to a spiritual counselor if you like.”
B. “You shouldn’t allow anyone to pressure you into sex.”
C. “It sounds like this problem is related to your paralysis.”
D. “How do you feel about being pressured into sex by your boyfriend?”
The critical censoring portion of one’s personality; the conscience.
Option A: This refers to the ego function that protects itself from
anything that threatens it.
Option B: The Id is composed of the untamed, primitive drives and
impulses.
Option C: This refers to the ego that acts as the moderator of the
struggle between the id and the superego.
5. Answer: C. Teaching the client stress management techniques
Primary level of prevention refers to the promotion of mental health and
prevention of mental illness. This can be achieved by rendering health
teachings such as modifying one’s responses to stress.
Option A: This is tertiary level of prevention that deals with
rehabilitation.
Options B and D. Secondary level of prevention which involves
reduction of actual illness through early detection and treatment of
illness.
6. Answer: A. “Are you being threatened or hurt by your partner?
The nurse validates her observation by asking simple, direct question.
This also shows empathy.
Options B, C, and D are indirect questions which may not lead to the
discussion of abuse.
7. Answer: A. Sexual desire disorder
Has little or no sexual desire or has a distaste for sex.
Option B: Failure to maintain the physiologic requirements for sexual
intercourse.
Option C: Persistent and recurrent inability to achieve an orgasm.
Option D: Also called dyspareunia. Individuals with this disorder suffer
genital pain before, during and after sexual intercourse.
8. Answer: A. “Here’s the number of a crisis center that you can
call for help .”
Protection is a priority concern in abuse. Help the victim to develop a
plan to ensure safety.
Option B: Do not give advice to leave the abuser. Making decisions for
the victim further erodes her esteem. However, discuss options
available.
Option C: The victim tends to isolate from friends and family.
Option D: This is judgmental. Avoid in any way implying that she is at
fault.
9. Answer: B. “When I tell my child to do something once, I don’t
expect to have to tell.”
Abusive parents tend to have unrealistic expectations on the child.
Options A, B, and C are realistic expectations on a 3-year-old.
10. Answer: C. Ensure the safety of the victim
The priority consideration is the safety of the victim. Attend to the
physical injuries to ensure the physiologic safety and integrity of the
child. Reporting suspected case of abuse may deter recurrence of
abuse.
Options A, B, and D may be addressed later.
11. Answer: D. Somatoform Pain Disorder
This is characterized by severe and prolonged pain that causes
significant distress.
Option A: This is a chronic syndrome of somatic symptoms that cannot
be explained medically and is associated with psychosocial distress.
Option B: This is an unrealistic preoccupation with a fear of having a
serious illness.
Option C: Characterized by alteration or loss in sensory or motor
function resulting from a psychological conflict.
12. Answer: B. Conflict between id and superego
Freud explains anxiety as due to opposing action drives between the id
and the superego.
Option A: Sullivan identified 2 types of needs, satisfaction and security.
Failure to gratify these needs may result in anxiety.
Option C: Biomedical perspective of anxiety.
Option D: Explanation of anxiety using the behavioral model.
13. Answer: D. Impaired social interaction
The client may not have difficulty in social exchange. The cues do not
support this diagnosis.
Option A: The client maladaptively uses body symptoms to manage
anxiety.
Option B: The client will have discomfort due to pain.
Option C: The client may fail to meet environmental expectations due
to pain.
14. Answer: C. Expression of conflicts through bodily symptoms
Bodily symptoms are used to handle conflicts.
Option A: Manifestations do not have an organic basis.
Option B: This occurs unconsciously.
Option D: Medical treatment is not used because the disorder does not
have a structural or organic basis.
15. Answer: A. “I know the feeling is real tests revealed negative
results.”
Shows empathy and offers information.
Option B: This is a demeaning statement.
Option C: This belittles the client’s feelings.
Option D: Giving undue attention to the physical symptom reinforces
the complaint.
16. Answer: A. provide as much structure as possible for the child
Decrease stimuli for behavior control thru an environment that is free of
distractions, a calm non–confrontational approach and setting limit to
time allotted for activities.
Option B: The child will not benefit from a lenient approach.
Option C: Dissipate energy through safe activities.
Option D: This indicates that the classroom environment lacks
structure.
17. Answer: D. Serious violations of age-related norms.
This is a disruptive disorder among children characterized by more
serious violations of social standards such as aggression, vandalism,
stealing, lying and truancy.
Option A: This is characteristic of attention deficit disorder.
Options B and C: These are noted among children with autistic
disorder.
18. Answer: A. increased attention span and concentration
The medication has a paradoxical effect that decreases hyperactivity
and impulsivity among children with ADHD.
Options B, C, D. Side effects of Ritalin include anorexia, insomnia,
diarrhea, and irritability.
19. Answer: A. Returning the child to the school immediately with
family support.
Exposure to the feared situation can help in overcoming anxiety.
Option B: This will not help in relieving the anxiety due separation from
a significant other.
Options C: Anxiety in school phobia is not due to being in school but
due to separation from parents/caregivers so these interventions are
not applicable.
Option D: This will not help the child overcome the fear
20. Answer: C. Moderate
The child with moderate mental retardation has an I.Q. of 35-50
Option A: Profound Mental retardation has an I.Q. of below 20.
Option B: Mild mental retardation 50-70.
Option D: Severe mental retardation has an I.Q. of 20-35.
21. Answer: A. Overprotection of the child
The child with mental retardation should not be overprotected but need
protection from injury and the teasing of other children.
Options B, C, and D Children with mental retardation have a learning
difficulty. They should be taught with patience and repetition, start from
simple to complex, use visuals and compliment them for motivation.
Realistic expectations should be set and optimize their capability.
22. Answer: B. altered parenting role
Altered parenting role refers to the inability to create an environment
that promotes optimum growth and development of the child. This is
reflected in the parent’s inability to care for the child.
Option A: This refers to the lack of choices or inability to mobilize one’s
resources.
Option C: Refers to change in family relationship and function.
Option D: Ineffective coping is the inability to form valid appraisal of the
stressor or inability to use available resources
23. Answer: B. intolerance to change, disturbed relatedness,
stereotypes
These are manifestations of autistic disorder.
Option A: These manifestations are noted in Oppositional Defiant
Disorder, a disruptive disorder among children.
Option C: These are manifestations of Attention Deficit Disorder.
Option D: These are the manifestations of Conduct Disorder
24. Answer: D. Rearrange the environment to activate the child
The child with autistic disorder does not want change. Maintaining a
consistent environment is therapeutic.
Option A: Angry outburst can be re-channelled through safe activities.
Option B: Acceptance enhances a trusting relationship.
Option C: Ensure safety from self-destructive behaviors like head
banging and hair pulling.
25. Answer: C. Pre-operational
Preoperational stage (2-7 years) is the stage when the use of
language, the use of symbols and the concept of time occur.
Option A: Sensorimotor stage (0-2 years) is the stage when the child
uses the senses in learning about the self and the environment through
exploration.
Option B: Concrete operations (7-12 years) when inductive reasoning
develops.
Option D: Formal operations (2 till adulthood) is when abstract thinking
and deductive reasoning develop.
26. Answer: B. Tolerance
Tolerance refers to the increase in the amount of the substance to
achieve the same effects.
Option A: Withdrawal refers to the physical signs and symptoms that
occur when the addictive substance is reduced or withheld.
Option B: Intoxication refers to the behavioral changes that occur upon
recent ingestion of substance.
Option D: Psychological dependence refers to the intake of the
substance to prevent the onset of withdrawal symptoms.
27. Answer: A. Delirium tremens
Delirium Tremens is the most extreme central nervous system
irritability due to withdrawal from alcohol.
Option B: This refers to an amnestic syndrome associated with chronic
alcoholism due to a deficiency in Vit. B.
Option C: This is a complication of liver cirrhosis which may be
secondary to alcoholism.
Option D: This is a complication of alcoholism characterized by
irregularities of eye movements and lack of coordination.
28. Answer: A. Monitoring his vital signs every hour
Pulse and blood pressure are usually elevated during withdrawal;
Elevation may indicate impending delirium tremens.
Option B: Client needs quiet, well lighted, consistent and secure
environment. Excessive stimulation can aggravate anxiety and cause
illusions and hallucinations.
Option C: Adequate nutrition with supplements of Vit. B should be
ensured.
Option D: Sedatives are used to relieve anxiety.
29. Answer: B. Cocaine
The manifestations indicate intoxication with cocaine, a CNS stimulant.
Option A: Intoxication with heroine is manifested by euphoria then
impairment in judgment, attention and the presence of papillary
constriction. Option C: Intoxication with hallucinogen like LSD is
manifested by grandiosity, hallucinations, synesthesia and increase in
vital signs. Option D: Intoxication with Marijuana, a cannabinoid is
manifested by
Option A: Intoxication with heroine is manifested by euphoria then
impairment in judgment, attention and the presence of papillary
constriction.
Option C: Intoxication with hallucinogen like LSD is manifested by
grandiosity, hallucinations, synesthesia and increase in vital signs.
Option D: Intoxication with Marijuana, a cannabinoid is manifested by
the sensation of slowed time, conjunctival redness, social withdrawal,
impaired judgment, and hallucinations.
30. Answer: B. Narcan (Naloxone)
Narcan is a narcotic antagonist used to manage the CNS depression
due to overdose with heroin.
Option A: This is an opiate receptor blocker used to relieve the craving
for heroin.
Option C: Disulfiram is used as a deterrent in the use of alcohol.
Option D: Methadone is used as a substitute in the withdrawal from
heroin
31. Answer: C. Agnosia
This is the inability to recognize objects.
Option A: Apraxia is the inability to execute motor activities despite
intact comprehension.
Option B: Aphasia is the loss of ability to use or understand words.
Option D: Amnesia is loss of memory.
32. Answer: C. “This must be difficult for you and your mother.”
This reflecting the feeling of the daughter that shows empathy.
Options A and D. Giving advice does not encourage verbalization.
Option B: This response does not encourage verbalization of feelings.
33. Answer: C. Remains in a safe and secure environment
Safety is a priority consideration as the client’s cognitive ability
deteriorates.
Option A is appropriate interventions because the client’s cognitive
impairment can affect the client’s ability to attend to his nutritional
needs, but it is not the priority
Option B: Patient is allowed to reminisce but it is not the priority.
Option D: The client in the moderate stage of Alzheimer’s disease will
have difficulty in performing activities independently
34. Answer: A. “Your husband is dead. Let me serve you your
breakfast.”
The client should be reoriented to reality and be focused on the here
and now.
Option B: This is not a helpful approach because of the short term
memory of the client.
Option C: This indicates a pompous response.
Option D: The cognitive limitation of the client makes the client
incapable of giving an explanation.
35. Answer: B. Insidious onset
Dementia has a gradual onset and progressive deterioration. It causes
pronounced memory and cognitive disturbances.
Options A, C, and D are all characteristics of delirium.
36. Answer: B. Fluid volume deficit
Fluid volume deficit is the priority over altered nutrition since the
situation indicates that the client is dehydrated.
Options A and D are psychosocial needs of a client with anorexia
nervosa but they are not the priority.
37. Answer: C. Approach the nurse and talk out her feelings
The client with anorexia nervosa uses starvation as a way of managing
anxiety. Talking out feelings with the nurse is an adaptive coping.
Option A: Starvation should not be encouraged. Physical safety is a
priority. Without adequate nutrition, a life threatening situation exists.
Option B: The client with anorexia nervosa is preoccupied with losing
weight due to disturbed body image. Limits should be set on attempts
to lose more weight.
Option D: The client may have a domineering mother which causes the
client to feel ambivalent. The client will not discuss her feelings with her
mother.
38. Answer: B. Weight gain
Weight gain is the best indication of the client’s improvement. The goal
is for the client to gain 1-2 pounds per week.
Option A: The client may purge after eating.
Option C: Attending an activity does not indicate improvement in the
nutritional state.
Option D: Body image is a factor in anorexia nervosa, but it is not an
indicator of improvement.
39. Answer: A. Have episodic binge eating and purging
Bulimia is characterized by binge eating which is characterized by
taking in a large amount of food over a short period of time.
Options B and C are characteristics of a client with anorexia nervosa.
Option D: Low esteem is noted in both eating disorders
40. Answer: A. Patient will learn problem-solving skills
If the client learns problem-solving skills she will gain a sense of control
over her life.
Option B: Anxiety is caused by powerlessness.
Option C: Performing self-care activities will not decrease one’s
powerlessness.
Option D: Setting limits to control imposed by others is a necessary
skill but problem-solving skill is the priority.
41. Answer: B. Discuss their eating behavior.
The client is often ashamed of her eating behavior. Discussion should
focus on feelings.
Options A, C, and D promote a therapeutic relationship
42. Answer: C. Claustrophobia
Claustrophobia is fear of closed space.
Option A: Agoraphobia is fear of open space or being a situation where
escape is difficult.
Option B: Social phobia is fear of performing in the presence of others
in a way that will be humiliating or embarrassing.
Option D: Xenophobia is fear of strangers.
43. Answer: D. Accept her fears without criticizing.
The client cannot control her fears although the client knows it’s silly
and can joke about it.
Option A: Allow expression of the client’s fears but he should focus on
other productive activities as well.
Options B and C: These are not the initial interventions.
44. Answer: A. Revealing personal information to the client
Countertransference is an emotional reaction of the nurse on the client
based on her unconscious needs and conflicts.
Options B and C: These are therapeutic approaches.
Option D: This is transference reaction where a client has an emotional
reaction towards the nurse based on her past.
45. Answer: D. The client will be able to overcome his disabling
fear.
The client will overcome his disabling fear by gradual exposure to the
feared object.
Options A, B, and C are not the desired outcome of desensitization.
46. Answer: A. Avoid taking CNS depressant like
alcohol.
Valium is a CNS depressant. Taking it with other CNS depressants like
alcohol; potentiates its effect.
Option B: The client should be taught to avoid activities that require
alertness.
Option C: Valium causes dry mouth so the client must increase her
fluid intake.
Option D: Stimulants must not be taken by the client because it can
decrease the effect of Valium.
47. Answer: C. The conversion symptom has symbolic meaning to
the client
the client uses body symptoms to relieve anxiety.
Option A: The condition occurs unconsciously.
Option B: The client is not distressed by the lost or altered body
function.
Option D: The client should not be confronted by the underlying cause
of his condition because this can aggravate the client’s anxiety.
48. Answer: D. “How do you feel about being pressured into sex
by your boyfriend?”
Focusing on the expression of feelings is therapeutic. The central force
of the client’s condition is anxiety.
Option A: This is not therapeutic because the nurse passes the
responsibility to the counselor.
Option B: Giving advice is not therapeutic.
Option C: This is not therapeutic because it confronts the underlying
cause.
49. Answer: B. It is a deliberate effort to handle upsetting events
Malingering is a conscious simulation of an illness while somatoform
disorder occurs unconsciously.
Option A: Both disorders do not have an organic or structural basis.
Option C: Both have primary gains.
Option D: This is a characteristic of the somatoform disorder.
50. Answer: C. stress management techniques
Stress management techniques is the best management of
somatoform disorder because the disorder is related to stress and it
does not have a medical basis. Option A: This disorder is not
supported by organic pathology so no medical regimen is required.
Options B and D: Milieu therapy and psychotherapy may be used
Option A: This disorder is not supported by organic pathology so no
medical regimen is required.
Options B and D: Milieu therapy and psychotherapy may be used
therapeutic modalities but these are not the best.
SET C PSYCH PRACTICE TEST
1. Which nursing intervention is best for facilitating communication with
a psychiatric client who speaks a foreign language?
A. Rely on nonverbal communication.
B. Select symbolic pictures as aids.
C. Speak in universal phrases.
D. Use the services of an interpreter.
2. The nurse explains to a mental health care technician that a client’s
obsessive-compulsive behaviors are related to an unconscious conflict
between id impulses and the superego (or conscience). On which of
the following theories does the nurse base this statement?
A. Behavioral theory
B. Cognitive theory
C. Interpersonal theory
D. Psychoanalytic theory
3. The nurse observes a client pacing in the hall. Which statement by
the nurse may help the client recognize his anxiety?
A. “I guess you’re worried about something, aren’t you?
b. “Can I get you some medication to help calm you?”
c. “Have you been pacing for a long time?”
d. “I notice that you’re pacing. How are you feeling?”
4. A client with obsessive-compulsive disorder is hospitalized on an
inpatient unit. Which nursing response is most therapeutic?
A. Accepting the client’s obsessive-compulsive behaviors
B. Challenging the client’s obsessive-compulsive behaviors
C. Preventing the client’s obsessive-compulsive behaviors
D. Rejecting the client’s obsessive-compulsive behaviors
5. A 45-year-old woman with a history of depression tells a nurse in her
doctor’s office that she has difficulty with sexual arousal and is fearful
that her husband will have an affair. Which of the following factors
would the nurse identify as least significant in contributing to the
client’s sexual difficulty?
A. Education and work history
B. Medication used
C. Physical health status
D. Quality of spousal relationship
6. Which nursing intervention is most appropriate for a client with
anorexia nervosa during initial hospitalization on a behavioral therapy
unit?
A. Emphasize the importance of good nutrition to establish normal
weight.
B. Ignore the client’s mealtime behavior and focus instead on issues of
dependence and independence.
C. Help establish a plan using privileges and restrictions based on
compliance with refeeding.
D. Teach the client information about the long-term physical
consequence of anorexia.
7. A nurse is evaluating therapy with the family of a client with anorexia
nervosa. Which of the following would indicate that the therapy was
successful?
A. The parents reinforce increased decision making by the client.
B. The parents clearly verbalize their expectations for the client.
C. The client verbalizes that family meals are now enjoyable.
D. The client tells her parents about feelings of low self-esteem.
8. The nurse is working with a client with a somatoform disorder. Which
client outcome goal would the nurse most likely establish in this
situation?
A. The client will recognize signs and symptoms of physical illness.
B. The client will cope with physical illness.
C. The client will take prescribed medications.
D. The client will express anxiety verbally rather than through physical
symptoms.
9. Which method would a nurse use to determine a client’s potential
risk for suicide?
A. Wait for the client to bring up the subject of suicide.
B. Observe the client’s behavior for cues of suicide ideation.
C. Question the client directly about suicidal thoughts.
D. Question the client about future plans.
10. A client with a bipolar disorder exhibits manic behavior. The
nursing diagnosis is Disturbed thought processes related to difficulty
concentrating, secondary to flight of ideas. Which of the following
outcome criteria would indicate improvement in the client?
A. The client verbalizes feelings directly during treatment.
B. The client verbalizes positive “self” statement.
C. The client speaks in coherent sentences.
D. The client reports feelings calmer.
11. A client tells a nurse. “Everyone would be better off if I wasn’t
alive.” Which nursing diagnosis would be made based on this
statement?
A. Disturbed thought processes
B. Ineffective coping
C. Risk for self-directed violence
D. Impaired social interaction
12. Which information is the most essential in the initial teaching
session for the family of a young adult recently diagnosed with
schizophrenia?
A. Symptoms of this disease imbalance in the brain.
B. Genetic history is an important factor related to the development of
schizophrenia.
C. Schizophrenia is a serious disease affecting every aspect of a
person’s functioning.
D. The distressing symptoms of this disorder can respond to treatment
with medications.
13. A nurse is working with a client who has schizophrenia, paranoid
type. Which of the following outcomes related to the client’s delusional
perceptions would the nurse establish?
A. The client will demonstrate realistic interpretation of daily events in
the unit.
B. The client will perform daily hygiene and grooming without
assistance.
C. The client will take prescribed medications without difficulty.
D. The client will participate in unit activities.
14. A client with bipolar disorder, manic type, exhibits extreme
excitement, delusional thinking, and command hallucinations. Which of
the following is the priority nursing diagnosis?
A. Anxiety
B. Impaired social interaction
C. Disturbed sensory-perceptual alteration (auditory)
D. Risk for other-directed violence
15. A client who abuses alcohol and cocaine tells a nurse that he only
uses substances because of his stressful marriage and difficult job.
Which defense mechanisms is this client using?
A. Displacement
B. Projection
C. Rationalization
D. Sublimation
16. An 11-year-old child diagnosed with conduct disorder is admitted to
the psychiatric unit for treatment. Which of the following behaviors
would the nurse assess?
A. Restlessness, short attention span, hyperactivity
B. Physical aggressiveness, low-stress tolerance disregard for the
rights of others
C. Deterioration in social functioning, excessive anxiety, and worry,
bizarre behavior
D. Sadness, poor appetite and sleeplessness, loss of interest in
activities
17. The nurse understands that if a client continues to be dependent
on heroin throughout her pregnancy, her baby will be at high risk for:
A. Mental retardation.
B. Heroin dependence.
C. Addiction in adulthood.
D. Psychological disturbances.
18. The emergency department nurse is assigned to provide care for a
victim of a sexual assault. When following legal and agency guidelines,
which intervention is most important?
A. Determine the assailant’s identity.
B. Preserve the client’s privacy.
C. Identify the extent of an injury.
D. Ensure an unbroken chain of evidence.
19. Which factor is least important in the decision regarding whether a
victim of family violence can safely remain in the home?
A. The availability of appropriate community shelters
B. The non-abusing caretaker’s ability to intervene on the client’s
behalf
C. The client’s possible response to relocation
D. The family’s socioeconomic status
20. The nurse would expect a client with early Alzheimer’s disease to
have problems with:
A. Balancing a checkbook.
B. Self-care measures.
C. Relating to family members.
D. Remembering his own name
21. Which nursing intervention is most appropriate for a client with
Alzheimer’s disease who has frequent episodes emotional lability?
A. Attempt humor to alter the client mood.
B. Explore reasons for the client’s altered mood.
C. Reduce environmental stimuli to redirect the client’s attention.
D. Use logic to point out reality aspects.
22. Which neurotransmitter has been implicated in the development of
Alzheimer’s disease?
A. Acetylcholine
B. Dopamine
C. Epinephrine
D. Serotonin
23. Which factors are the most essential for the nurse to assess when
providing crisis intervention foer a client?
A. The client’s communication and coping skills
B. The client’s anxiety level and ability to express feelings
C. The client’s perception of the triggering event and availability of
situational supports
D. The client’s use of reality testing and level of depression
24. The nurse considers a client’s response to crisis intervention
successful if the client:
A. Changes coping skills and behavioral patterns.
B. Develops insight into reasons why the crisis occurred.
C. Learns to relate better to others.
D. Returns to his previous level of functioning.
25. Two nurses are co-leading group therapy for seven clients in the
psychiatric unit. The leaders observe that the group members are
anxious and look to the leaders for answers. Which phase of
development is this group in?
A. Conflict resolution phase
B. Initiation phase
C. Working phase
D. Termination phase
26. Group members have worked very hard, and the nurse reminds 36. Which client outcome is most appropriately achieved in a
them that termination is approaching. Termination is considered community approach setting in psychiatric nursing?
successful if group members:
A. The client performs activities of daily living and learns about crafts.
A. Decide to continue. B. The client is able to prevent aggressive behavior and monitors his
B. Elevate group progress use of medications.
C. Focus on positive experience C. The client demonstrates self-reliance and social adaptation.
D. Stop attending prior to termination. D. The client experience experiences anxiety relief and learns about
his symptoms.
27. The nurse is teaching a group of clients about the mood-stabilizing
medications lithium carbonate. Which medications should she instruct 37. A client with panic disorder experiences an acute attack while the
the clients to avoid because of the increased risk of lithium toxicity? nurse is completing an admission assessment. List the following
interventions according to their level of priority.
A. Antacids
B. Antibiotics A. Remain with the client.
C. Diuretics B. Encourage physical activity.
D. Hypoglycemic agents C. Encourage low, deep breathing.
D. Reduce external stimuli.
28. When providing family therapy, the nurse analyzes the functioning E. Teach coping measures.
of healthy family systems. Which situations would not increase stress
on a healthy family system? 38. The doctor has prescribed haloperidol (Haldol) 2.5 mg. I.M. for an
agitated client. The medication is labeled haloperidol 10 mg/2 ml. The
A. An adolescent’s going away to college nurse prepares the correct dose by drawing up how many milliliters in
B. The birth of a child the syringe?
C. The death of a grandparent
D. Parental disagreement A. 0.3
B. 0.4
C. 0.5
D. 0.6

39. The nurse enters the room of a client with a cognitive impairment
disorder and asks what day of the week it is: what the date, month, and
29. A client taking the monoamine oxidase inhibitor (MAOI) year are; and where the client is. The nurse is attempting to assess:
antidepressant isocarboxazid (Marplan) is instructed by the nurse to
avoid which foods and beverages? A. Confabulation
B. Delirium
A. Aged cheese and red wine C. Orientation
B. Milk and green, leafy vegetables D. Perseveration
C. Carbonated beverages and tomato products
D. Lean red meats and fruit juices 40. Which of the following will the nurse use when communicating with
a client who has a cognitive impairment?
30. Prior to administering chlorpromazine (Thorazine) to an agitated
client, the nurse should: A. Complete explanations with multiple details
B. Picture or gestures instead of words
A. Assess skin color and sclera C. Stimulating words and phrases to capture the client’s attention
B. Assess the radial pulse D. Short words and simple sentences
C. Take the client’s blood pressure
D. Ask the client to void 41. A 75-year-old client has dementia of the Alzheimer’s type and
confabulates. The nurse understands that this client:
31. The nurse understands that electroconvulsive therapy is primarily
used in psychiatric care for the treatment of: A. Denies confusion by being jovial.
B. Pretends to be someone else.
A. Anxiety disorders. C. Rationalizes various behaviors.
B. Depression. D. Fills in memory gaps with fantasy.
C. Mania.
D. Schizophrenia. 42. An elderly client with Alzheimer’s disease becomes agitated and
combative when a nurse approaches to help with morning care. The
32. A client taking the MAOI phenelzine (Nardil) tells the nurse that he most appropriate nursing intervention in this situation would be to:
routinely takes all of the medications listed below. Which medication
would cause the nurse to express concern and therefore initiate further A. Tell the client family that it is time to get dressed.
teaching? B. Obtain assistance to restrain the client for safety.
C. Remain calm and talk quietly to the client.
A. Acetaminophen (Tylenol) D. Call the doctor and request an order for sedation.
B. Diphenhydramine (Benadryl)
C. Furosemide (Lasix) 43. In clients with a cognitive impairment disorder, the phenomenon of
D. Isosorbide dinitrate (Isordil) increased confusion in the early evening hours is called:

33. The nurse is administering a psychotropic drug to an elderly client A. Aphasia

who has a history of benign prostatic hypertrophy. It is most important B. Agnosia
for the nurse to teach this client to: C. Sundowning
D. Confabulation
A. Add fiber to his diet.
B. Exercise on a regular basis.
C. Report incomplete bladder emptying 44. Which of the following outcome criteria is appropriate for the client
D. Take the prescribed dose at bedtime. with dementia?

34. The nurse correctly teaches a client taking the Benzodiazepine A. The client will return to an adequate level of self-functioning.
Oxazepam (Serax) to avoid excessive intake of: B. The client will learn new coping mechanisms to handle anxiety.
C. The client will seek out resources in the community for support.
A. Cheese D. The client will follow an establishing schedule for activities of daily
B. Coffee living.
C. Sugar
D. Shellfish 45. The school guidance counselor refers a family with an 8-year-old
child to the mental health clinic because of the child’s frequent fighting
35. The nurse provides a referral to Alcoholics Anonymous to a client in school and truancy. Which of the following data would be a priority to
who describes a 20-year history of alcohol abuse. The primary function the nurse doing the initial family assessment?
of this group is to:
A. The child’s performance in school
A. Encourage the use of a 12-step program. B. Family education and work history
B. Help members maintain sobriety. C. The family’s perception of the current problem
C. Provide fellowship among members. D. The teacher’s attempt to solve the problem
D. Teach positive coping mechanisms.
46. The parents of a young man with schizophrenia express feelings of
responsibility and guilt for their son’s problems. How can the nurse
best educate the family?
A. Acknowledge the parent’s responsibility.
B. Explain the biological nature of schizophrenia.
C. Refer the family to a support group
D. Teach the parents various ways they must change.
47. The nurse collecting family assessment data asks. “Who is in your
family and where do they live?” which of the following is the nurse
attempting o identify?
A. Boundaries
B. Ethnicity
C. Relationships
D. Triangles
48. According to the family systems theory, which of the following best
describes the process of differentiation?
A. Cooperative action among members of the family
B. Development of autonomy within the family
C. Incongruent messages wherein the recipient is a victim
D. Maintenance of system continuity or equilibrium
49. The nurse is interacting with a family consisting of a mother, a
father, and a hospitalized adolescent who has a diagnosis of alcohol
abuse. The nurse analyzes the situation and agrees with the
adolescent’s view about family rules. Which intervention is most
appropriate?
A. The nurse should align with the adolescent, who is the family
scapegoat.
B. The nurse should encourage the parents to adopt more realistic
rules.
C. The nurse should encourage the adolescent to comply with parental
rules.
D. The nurse should remain objective and encourage mutual
negotiation of issues.
50. A 16-year-old girl has returned home following hospitalization for
treatment of anorexia nervosa. The parents tell the family nurse
performing a home visit that their child has always done everything to
please them and they cannot understand her current stubbornness
about eating. The nurse analyzes the family situation and determines it
is characteristic of which relationship style?
A. Differentiation
B. Disengagement
C. Enmeshment
D. Scapegoating
SET C PSYCH ANSWER KEY
1. Answer: D. Use the services of an interpreter.
An interpreter will enable the nurse to better assess the client’s
problems and concerns.
Option A: Nonverbal communication is important; however for the
nurse to fully determine the client’s problems and concerns, the
assistance of an interpreter is essential.
Options B and C: The use of symbolic pictures and universal phrases
may assist the nurse in understanding the basic needs of the client;
however these are insufficient to assess the client with a psychiatric
problem.
2. Answer: D. Psychoanalytic theory
Psychoanalytic is based on Freud’s beliefs regarding the importance of
unconscious motivation for behavior and the role of the id and
superego in opposition to each other.
Options A and B: Behavioral cognitive and interpersonal theories do
not emphasize unconscious conflicts as the basis for symptomatic
behavior.
3. Answer: D. “I notice that you’re pacing. How are you feeling?”
By acknowledging the observed behavior and asking the client to
express his feelings the nurse can best assist the client to become
aware of his anxiety.
In option A, the nurse is offering an interpretation that may or may not
be accurate; the nurse is also asking a question that may be answered
by a “yes” or “no” response, which is not therapeutic.
In option B, the nurse is intervening before accurately assessing the
problem.
Option C, which also encourages a “yes” or “no” response, avoids
focusing on the client’s anxiety, which is the reason for his pacing.
4. Answer: A. Accepting the client’s obsessive-compulsive
behaviors
A client with obsessive-compulsive behavior uses this behavior to
decrease anxiety. Accepting this behavior as the client’s attempt to feel
secure is therapeutic. When a specific treatment plan is developed,
other nursing responses may also be acceptable.
Options B, C, and D: The remaining answer choices will increase the
client’s anxiety and therefore are inappropriate.
5. Answer: A. Education and work history
Education and work history would have the least significance in relation
to the client’s sexual problem.
Options B, C, and D: Age, health status, physical attributes and
relationship issues have great influence on sexual expression.
6. Answer: C. Help establish a plan using privileges and
restrictions based on compliance with refeeding.
Inpatient treatment of a client with anorexia usually focuses initially on
establishing a plan for refeeding to combat the effects of self-induced
starvation. Refeeding is accomplished through behavioral therapy,
which uses a system of rewards and reinforcements to assist in
establishing weight restoration.
Options A and D: Emphasizing nutrition and teaching the client about
the long-term physical consequences of anorexia maybe appropriate at
a later time in the treatment program.
Option B: The nurse needs to assess the client’s mealtime behavior
continually to evaluate treatment effectiveness.
7. Answer: A. The parents reinforce increased decision making by
the client.
One of the core issues concerning the family of a client with anorexia is
control. The family’s acceptance of the client’s ability to make
independent decisions is key to successful family intervention.
Options B, C, and D: Although the remaining options may occur during
the process of therapy they would not necessarily indicate a successful
outcome; the central family issues of dependence and independence
are not addressed in these responses.
8. Answer: D. The client will express anxiety verbally rather than
through physical symptoms.
The client with a somatoform disorder displaces anxiety into physical
symptoms. The ability to express anxiety verbally indicates a positive
change toward improved health.
Options A, B, and C: The remaining responses do not indicate any
positive change toward increased coping with anxiety.
9. Answer: C. Question the client directly about suicidal thoughts.
Directly questioning a client about suicide is important to determine
suicide risk.
Option A: The client may not bring up this subject for several reasons,
including guilt regarding suicide, wishing not to be discovered, and his
lack of trust in staff.
Option B: Behavioral cues are important, but direct questioning is
essential to determine suicide risk.
Option D: Indirect questions convey to the client that the nurse is not
comfortable with the subject of suicide and, therefore, the client may be
reluctant to discuss the topic.
10. Answer: C. The client speaks in coherent sentences
A client exhibiting flight of ideas typically has a continuous speech flow
and jumps from one topic to another. Speaking in coherent sentences
is an indicator that the client’s concentration has improved and his
thoughts are no longer racing.
Options A, B, and D: The remaining options do not relate directly to the
stated nursing diagnosis.
11. Answer: C. Risk for self-directed violence
The nurse should take any nurse statements indicating suicidal
thoughts seriously and further assess for other risk factors.
Options A, B, and D: The remaining diagnoses fail to address the
seriousness of the client’s statement.
12. Answer: D. The distressing symptoms of this disorder can
respond to treatment with medications.
This statement provides accurate information and an element of hope
for the family of a schizophrenic client.
Options A, B, and C: Although the remaining statements are true, they
do not provide the empathic response the family needs after just
learning about the diagnosis. These facts can become part of the
ongoing teaching.
13. Answer: A. The client will demonstrate realistic interpretation
of daily events in the unit.
A client with schizophrenia, paranoid type, has distorted perceptions
and views people, institutions, and aspects of the environment as
plotting against him. The desired outcome for someone with delusional
perceptions would be to have a realistic interpretation of daily events.
Option B: The client with a distorted perception of the environment
would not necessarily have impairments affecting hygiene and
grooming skills.
Options C and D: Although taking medications and participating in unit
activities may be appropriate outcomes for nursing intervention; these
responses are not related to client perceptions.
14. Answer: D. Risk for other-directed violence
A client with these symptoms would have poor impulse control and
would therefore be prone to acting-out behavior that may be harmful to
either himself or others. All of the remaining nursing diagnoses may
apply to the client with mania; however, the priority diagnosis would be
risk for violence.
Options A, B, and C: All of the remaining nursing diagnoses may apply
to the client with mania; however, the priority diagnosis would be risk
for violence.
15. Answer: C. Rationalization
Rationalization is the defense mechanism that involves offering
excuses for maladaptive behavior. The client is defending his
substance abuse by providing reasons related to life stressors. This is
a common defense mechanism used by clients with substance abuse
problems.
Options A, B, and D: None of the remaining defense mechanisms
involves making excuses for behaviors.
16. Answer: B. Physical aggressiveness, low-stress tolerance
disregard for the rights of others
Physical aggressiveness, low-stress tolerance, and a disregard for the
rights of others are common behaviors in clients with conduct
disorders.
Option A: Restlessness, short attention span, and hyperactivity are
typical behaviors in a client with attention deficit hyperactivity disorder.
Option C: Deterioration in social functioning, excessive anxiety and
worry and bizarre behaviors are typical in schizophrenic disorders.
Option D: Sadness, poor appetite, sleeplessness, and loss of interest
in activities are behaviors commonly seen in depressive disorders.
17. Answer: B. Heroin dependence.
Babies born to heroin-dependent women are also heroin-dependent
and need to go through withdrawal. There is no evidence to support
any of the remaining answer choices.
18. Answer: D. Ensure an unbroken chain of evidence.
Establishing an unbroken chain of evidence is essential in order to
ensure that the prosecution of the perpetrator can occur.
Options A and D: The nurse will also need to preserve the client’s
privacy and identify the extent of an injury. However, it is essential that
the nurse follows legal and agency guidelines for preserving evidence.
Option C: Identifying the assailant is the job of law enforcement, not
the nurse.
19. Answer: D. The family’s socioeconomic status
Socioeconomic status is not a reliable predictor of abuse in the home
so that it would be the least important consideration in deciding issues
of safety for the victim of family violence.
Options A and B: The availability of appropriate community shelters
and the ability of the non-abusing caretaker to intervene on the client’s
behalf are important factors when making safety decisions.
Option C: The client’s response to possible relocation (if the client is a
competent adult) would be the most important factor to consider;
feelings of empowerment and being treated as a competent person
can help a client feel less like a victim.
20. Answer: A. Balancing a checkbook.
In the early stage of Alzheimer’s disease, complex tasks (such as
balancing a checkbook) would be the first cognitive deficit to occur.
Options B, C, and D: The loss of self-care ability, problems with
relating to family members, and difficulty remembering one’s own
name are all areas of cognitive decline that occur later in the disease
process.
21. Answer: C. Reduce environmental stimuli to redirect the
client’s attention.
The client with Alzheimer’s disease can have frequent episode of labile
mood, which can best be handled by decreasing a stimulating
environment and redirecting the client’s attention.
Option A: The client with Alzheimer’s disease loses the cognitive ability
to respond to either humor or logic.
Option B: An over stimulating environment may cause the labile mood,
which will be difficult for the client to understand.
Option D: The client lacks any insight into his or her own behavior and
therefore will be unaware of any causative factors.
22. Answer: A. Acetylcholine
A relative deficiency of acetylcholine is associated with this disorder.
The drugs used in the early stages of Alzheimer’s disease will act to
increase available acetylcholine in the brain. The remaining
neurotransmitters have not been implicated in Alzheimer’s disease.
23. Answer: C. The client’s perception of the triggering event and
availability of situational supports
The most important factors to determine in this situations are the
client’s perception of the crisis event and the availability of support
(including family and friends) to provide basic needs.
Options A, B, and D: Although the nurse should assess the other
factors, they are not as essential as determining why the client
considers this a crisis and whether he can meet his present needs.
24. Answer: D. Returns to his previous level of functioning.
Crisis intervention is based on the idea that a crisis is a disturbance in
homeostasis (steady state). The goal is to help the client return to a
previous level of equilibrium in functioning.
Options A, B, and C: The remaining answer choices are not considered
the primary outcome of crisis intervention, although they may occur as
a side benefit.
25. Answer: B. Initiation phase
Increased anxiety and uncertainty characterize the initiation phase in
group therapy. Group members are more self-reliant during the
working and termination phases.
26. Answer: A. Decide to continue.
As the group progresses into the working phase, group members
assume more responsibility for the group. The leader becomes more of
a facilitator. Comments about behavior in a group are indicators that
the group is active and involved.
Options B, C, and D: The remaining answer choices would indicate the
group progress has not advanced to the working phase.
27. Answer: C. Diuretics
The use of diuretics would cause sodium and water excretion, which
would increase the risk of lithium toxicity. Clients taking lithium
carbonate should be taught to increase their fluid intake and to
maintain normal intake of sodium.
Options A, B, and D: Concurrent use of any of the remaining
medications will not increase the risk of lithium toxicity.
28. Answer: D. Parental disagreement
In a functional family, parents typically do not agree on all issues and
problems. Open discussion of thoughts and feeling is healthy, and
parental disagreement should not cause system stress.
Options A, B, and C: The remaining answer choices are life transitions
that are expected to increase family stress.
29. Answer: A. Aged cheese and red wine
Aged cheese and red wines contain the substance tyramine which,
when taken with an MAOI, can precipitate a hypertensive crisis.
Options B, C, and D: The other foods and beverages do not contain
significant amounts of tyramine and, therefore, are not restricted.
30. Answer: C. Take the client’s blood pressure
Because chlorpromazine (Thorazine) can cause a significant
hypotensive effect (and possible client injury), the nurse must assess
the client’s blood pressure (lying, sitting, and standing) before
administering this drug.
Option A: If the client had taken the drug previously, the nurse would
also need to assess the skin color and sclera for signs of jaundice, a
possible drug side affect; however, based on the information given
here, there is no evidence that the client has received chlorpromazine
before.
Option D: Although the drug can cause urine retention, asking the
client to avoid will not alter this anticholinergic effect.
31. Answer: B. Depression.
Electroconvulsive therapy (ECT) can provide relief for patients with
severe depression who have not been able to feel better with other
treatments. In some severe cases where rapid response is necessary
or medications cannot be used safely, ECT can even be a first-line
intervention. ECT consists of a series of sessions, typically three times
a week, for two to four weeks.
32. Answer: B. Diphenhydramine (Benadryl)
Over-the-counter medications used for allergies and cold symptoms
are contraindicated because they will increase the sympathomimetic
effects of MAOIs, possibly causing a hypertensive crisis.
Options A, C, and D: None of the remaining medications will increase
the sympathomimetic response and, therefore, are not contraindicated.
33. Answer: C. Report incomplete bladder emptying
Urinary retention is a common anticholinergic side effect of psychotic
medications, and the client with benign prostatic hypertrophy would
have increased risk for this problem.
Options A and B: Adding fiber to one’s diet and exercising regularly are
measures to counteract another anticholinergic effect, constipation.
Option D: Depending on the specific medication and how it is
prescribed, taking the medication at night may or may not be important.
However, it would have nothing to do with urinary retention in this
client.
34. Answer: B. Coffee
Coffee contains caffeine, which has a stimulating effect on the central
nervous system that will counteract the effect of the antianxiety
medication oxazepam. None of the remaining foods is contraindicated.
35. Answer: B. Help members maintain sobriety.
The primary purpose of Alcoholics Anonymous is to help members
achieve and maintain sobriety.
Options A, C, and D: Although each of the remaining answer choices
may be an outcome of attendance at Alcoholics Anonymous, the
primary purpose is directed toward sobriety of members.
36. Answer: C. The client demonstrates self-reliance and social
adaptation.
A therapeutic community is designed to help individuals assume
responsibility for themselves, to learn how to respect and communicate
with others, and to interact in a positive manner.
Options A, B, and D: The remaining answer choices may be outcomes
of psychiatric treatment, but the use of a therapeutic community
approach is concerned with the promotion of self-reliance and
cooperative adaptation to being with others.
37. Answer: A, D, C, B, then E.
The nurse should remain with the client to provide support and
promote safety. Reducing external stimuli, including dimming lights and
avoiding crowded areas, will help decrease anxiety. Encouraging the
client to use slow, deep breathing will help promote the body’s
relaxation response, thereby interrupting stimulation from the
autonomic nervous system. Encouraging physical activity will help him
to release energy resulting from the heightened anxiety state; this
should be done only after the client has brought his breathing under
control. Teaching coping measures will help the client learn to handle
anxiety; however, this can only be accomplished when the client’s
panic has dissipated and he is better able to focus.
38. Answer: C. 0.5
Set up the problem as follows: 2.5mg/10mg = Xml/2ml X=0.5ml
39. Answer: C. Orientation
The initial, most basic assessment of a client with cognitive impairment
involves determining his level of orientation (awareness of time, place,
and person).
Options A and D: The nurse may also assess for confabulation and
perseveration in a client with cognitive impairment, but the questions in
this situation would not elicit the symptom response.
Option B: Delirium is a type of cognitive impairment; however, other
symptoms are necessary to establish this diagnosis.
40. Answer: D. Short words and simple sentences
Short words and simple sentence minimize client confusion and
enhance communication.
Options A and C: Complete explanations with multiple details and
stimulating words and phrases would increase confusion in a client
with short attention span and difficulty with comprehension.
Option B: Although pictures and gestures may be helpful, they would
not substitute for verbal communication.
41. Answer: D. Fills in memory gaps with fantasy.
Confabulation is a communication device used by patients with
dementia to compensate for memory gaps. The remaining answer
choices are incorrect.
42. Answer: C. Remain calm and talk quietly to the client.
Maintaining a calm approach when intervening with an agitated client is
extremely important.
Option A: Telling the client firmly that it is time to get dressed may
increase his agitation, especially if the nurse touches him.
Option B: Restraints are a last resort to ensure client safety and are
inappropriate in this situation.
Option D: Sedation should be avoided, if possible, because it will
interfere with CNS functioning and may contribute to the client’s
confusion.
43. Answer: C. Sundowning
Sundowning is a common phenomenon that occurs after daylight hours
in a client with a cognitive impairment disorder. The other options are
incorrect responses, although all may be seen in this client.
44. Answer: D. The client will follow an establishing schedule for
activities of daily living.
Following established activity schedules is a realistic expectation for
clients with dementia.
Options A, B, and C: All of the remaining outcome statements require a
higher level of cognitive ability than can be realistically expected of
clients with this disorder.
45. Answer: C. The family’s perception of the current problem
The family’s perception of the problem is essential because change in
any one part of a family system affects all other parts and the system
as a whole. Each member of the family has been affected by the
current problems related to the school system and the nurse would be
interested in the data. Options A and D: The child’s performance in
school and the teacher’s attempts to solve the problem are relevant
and may be assessed; however, priority would be given to the family’s
perception of the problem. Option B: The family education and work
history may be relevant, but are not a priority.
46. Answer: B. Explain the biological nature of schizophrenia.
The parents are feeling responsible and this inappropriate self-blame
can be limited by supplying them with the facts about the biologic basis
of schizophrenia.
Option A: Acknowledging the patient’s responsibility is neither accurate
nor helpful to the parents and would only reinforce their feelings of
guilt.
Option C: Support groups are useful; however, the nurse needs to
handle the parents’ self-blame directly instead of making a referral for
this problem.
Option D: Teaching the parents various ways to change would
reinforce the parental assumption of blame; although parents can learn
about schizophrenia and what is helpful and not helpful, the approach
suggested in this option implies the parents’ behavior is at fault.
47. Answer: A. Boundaries
Family boundaries are parameters that define who is inside and
outside the system. The best method of obtaining this information is
asking the family directly who they consider to be members.
Options B, C, and D: The question asked by the nurse would not elicit
information about the family’s ethnicity or culture, nor does it address
the nature of the family relationship.

48. Answer: B. Development of autonomy within the family

Differentiation is the process of becoming an individual developing

autonomy while staying in contact with the family system.

Option A: Cooperative action among family members does not refer to

differentiation, although individuals who have a high level of
differentiation would be able to accomplish cooperative action.
Option C: Incongruent messages in which the recipient is a victim
describe double-bind communication.
Option D: Maintenance of system continuity or equilibrium is
homeostasis.

49. Answer: D. The nurse should remain objective and encourage

mutual negotiation of issues.

The nurse who wishes to be helpful to the entire family must remain
neutral. Taking sides in a conflict situation in a family will not
encourage negotiation, which is important for problem resolution.

Option A: If the nurse aligned with the adolescent, then the nurse
would be blaming the parents for the child’s current problem; this would
not help the family’s situation. Learning to negotiate conflict is a
function of a healthy family.
Options B and C: Encouraging the parents to adopt more realistic rules
or the adolescent to comply with parental rules does not give the family
an opportunity to try to resolve problems on their own.

50. Answer: C. Enmeshment

Enmeshment is a fusion or over involvement among family members

whereby the expectation exists that all members think and act alike.
The child who always acts to please her parents is an example of how
enmeshment affects development in many cases, a child who develops
anorexia nervosa exerts control only in the area of eating behavior.

Options A, B, and D: The remaining options are not appropriate to the

situation described.
SET D PSYCH PRACTICE TEST
1. A man is admitted to the nursing care unit with a diagnosis of
cirrhosis. He has a long history of alcohol dependence. During the late
evening following his admission, he becomes increasingly disoriented
and agitated. Which of the following would the client be least likely to
experience?
A. Diaphoresis and tremors.
B. Increased blood pressure and heart rate.
C. Illusions.
D. Delusions of grandeur.
2. Mr. Peterson, 35, is admitted for bipolar illness, manic phase, after
assaulting his landlord in an argument over Mr. Peterson is staying up
all night playing loud music. Mr. Peterson is hyperactive, intrusive, and
has rapid, pressured speech. He has not slept in three days and
appears thin and disheveled. Which of the following is the most
essential nursing action at this time?
A. Providing a meal and beverage for Mr. Peterson to eat in the dining
room.
B. Providing linens and toiletries for Mr. Peterson to attend to his
hygiene.
C. Consulting with the psychiatrist to order a hypnotic to promote
sleep.
D. Providing for client safety by limiting his privileges.
3. Which of the following would best indicate to the nurse that a
depressed client is improving?
A. Reduced levels of anxiety.
B. Changes in vegetative signs.
C. Compliance with medications.
D. Requests to talk to the nurse.
4. An elderly man is admitted to the hospital. He was alert and oriented
during the admission interview. However, his family states that he
becomes disruptive and disoriented around dinnertime. One night he
was shouting furiously and didn’t know where he was. He was sedated
and the next morning he was fine. At dinnertime, the disruptive
behavior returned. The client is diagnosed as having sundown
syndrome. The client’s son asks the nurse what causes sundown
syndrome. The nurse’s best response is that it is attributed to
A. An underlying depression.
B. Inadequate cerebral flow.
C. Changes in the sensory environment.
D. Fuctuating levels of oxygen exchange.
5. The nurse is discussing electroconvulsive therapy (ECT) with a
client who asks how long it will be before she feels better. The nurse
explains that the beneficial effects of ECT usually occur within
A. One week.
B. Three weeks.
C. Four weeks.
D. Six weeks.
6. The nurse is assessing a 17-year-old female who is admitted to the
eating disorders unit with a history of weight fluctuation, abdominal
pain, teeth erosion, receding gums, and bad breath. She states that
her health has been a problem but there are no other concerns in her
life. Which of the following assessments will be the least useful as the
nurse develops the care plan?
A. Information regarding recent mood changes.
B. Family functioning using a genogram.
C. Ability to socialize with peers.
D. Whether she has a sexual relationship with a boyfriend.
7. A 34-year-old woman is admitted for treatment of depression. Which
of these symptoms would the nurse be least likely to find in the initial
assessment?
A. Inability to make decisions.
B. Feelings of hopelessness.
C. Family history of depression.
D. Increased interest in sex.
8. The nurse is planning care for a client who has a phobic disorder
manifested by a fear of elevators. Which goal would need to be
accomplished first? The client
A. Demonstrates the relaxation response when asked.
B. Verbalizes the underlying cause of the disorder.
C. Rides the elevator in the company of the nurse.
D. Role plays the use of an elevator.
9. A teenage female is admitted with the diagnosis of anorexia
nervosa. Upon admission, the nurse finds a bottle of assorted pills in
the client’s drawer. The client tells the nurse that they are antacids for
stomach pains. The best response by the nurse would be
a. “These pills aren’t antacids since they are all different.”
b. “Some teenagers use pills to lose weight.”
c. “Tell me about your week prior to being admitted.”
d. “Are you taking pills to change your weight?”
10. A mother with a Roman Catholic belief has given birth in an
ambulance on the way to the hospital. The neonate is in very critical
condition with little expectation of surviving the trip to the hospital.
Which of these requests should the nurse in the ambulance anticipate
and be prepared to do?
A. The refusal of any treatment for self and the neonate until she talks
to a reader
B. The placement of a rosary necklace around the neonate’s neck and
not to remove it unless absolutely necessary
C. Arrange for a church elder to be at the emergency department when
the ambulance arrives so a “laying on hands” can be done
D. Pour fluid over the forehead backward towards the back of the head
and say “I baptize you in the name of the father, the son and the holy
spirit. Amen.”
11. Which statement by the client during the initial assessment in the
emergency department is most indicative of suspected domestic
violence?
a. “I am determined to leave my house in a week.”
b. “No one else in the family has been treated like this.”
c. “I have only been married for two (2) months.”
d. “I have tried leaving, but have always gone back.”
12. Which of these statements by the nurse reflects the best use of
therapeutic interaction techniques?
a. “You look upset. Would you like to talk about it?”
b. “I’d like to know more about your family. Tell me about them.”
c. “I understand that you lost your partner. I don’t think I could go on if
that happened to me.”
d. “You look very sad. How long have you been this way?”
13. When planning the therapeutic milieu, it is MOST important to
select group activities which
A. Match the clients’ preferences
B. Are consistent with clients’ skills
C. Achieve clients’ therapeutic goals
D. Build skills of group participation
14. A client was admitted to the psychiatric unit for severe depression.
After several days, the client continues to withdraw from other clients.
Which of the following would be the MOST appropriate statement by
the nurse to promote interaction with other clients?
a. “Your doctor thinks its good for you to spend time with others.”
b. “It is important for you to participate in group activities.”
c. “Painting this picture will help you feel better.”
d. “Come play Chinese Checkers with Gerry and me.”
15. The nurse can BEST ensure the safety of a demented client who
wanders from the room by
A. Repeatedly reminding the client of time and place
B. Explaining the risks of becoming lost
C. Using soft restraints
D. Attaching a wander guard sensor band to the client’s wrist
16. A client with paranoid thoughts refuses to eat because he believes
the food has poisoned. The MOST appropriate initial action is to
A. Taste the food in the client’s presence
B. Suggest that food be brought from home
C. Simply state the food is not poisoned
D. Inform the client he will be tube fed if he does not eat
17. The nurse is caring for a severely depressed client who has just
been admitted to the in-client psychiatric unit. Which of the following is
a PRIORITY of care?
A. Nutrition
B. Elimination
C. Rest
D. Safety
18. A nurse is teaching a stress-management program for a client.
Which of the following beliefs will the nurse advocate as a method of
coping with stressful life events?
A. Avoidance of stress is an important goal for living.
B. Control over one’s response to stress is possible.
C. Most people have no control over their level of stress.
D. Significant others are important to provide care and concern.
19. A student nurse is caring for a 75-year-old client who is very
confused. The student’s communication tools should include:
A. Written directions for bathing.
B. Speaking very loudly.
C. Gentle touch while guiding ADLs (activities of daily living).
D. Flat facial expression.
20. When a husband takes out his work frustrations and anger by
abusing his wife at home, the nurse will identify this crisis as which
type?
A. Psychiatric emergency crisis
B. Developmental crisis
C. Anticipated life transition
D. Dispositional crisis
SET D PSYCH ANSWER KEY
1. Answer D. Delusions of grandeur
Delusions of grandeur are symptomatic of manic clients, not clients
withdrawing from alcohol. The symptoms and history of alcohol abuse
suggest this client is in alcohol withdrawal.
Option A: Diaphoresis and tremors occur in the first phase of alcohol
withdrawal.
Option B: The blood pressure and heart rate increase in the first phase
of alcohol withdrawal.
Option C: Illusions are common in persons withdrawing from alcohol.
Illusions occur most often in dim artificial lighting where the
environment is not perceived accurately.
2. Answer D. Providing for client safety by limiting his privileges.
Mr. Peterson has been assaultive with the landlord, and it is
reasonable to expect that he may be with peers and staff. His mental
illness produces a hyperactive state and poor judgment and impulse
control. External controls such as limiting of unit privileges will assist in
feelings of security and safety.
Option A: Food and fluids are necessary. However, Mr. Peterson’s
hyperactivity does not allow him to sit quietly to eat. Finger foods “on
the run” will provide needed nourishment.
Option B: When hyperactivity decreases, then approach Mr.
Peterson’s. regarding hygiene and grooming needs.
Option C: Medications will be ordered. However, a thorough evaluation
must be done first.
3. Answer B. Changes in vegetative signs.
Vegetative signs such as insomnia, anorexia, psychomotor retardation,
constipation, diminished libido, and poor concentration are biological
responses to depression. Improvement in these signs indicates a lifting
of the depression.
Option A: Reduced levels of anxiety do not indicate an improvement in
depressive symptoms.
Option C: Compliance with medications does not indicate improvement
in depression.
Option D: Requests to talk to the nurse vary. Requests may show trust
in the nurse but are not a sign that depression has diminished.
4. Answer C. Changes in the sensory environment.
Because the confusion occurs at sundown, the cause probably
changes in the sensory environment. Sundown syndrome is related to
environmental and sensory abnormalities that lead to acute confusion.
Option A: An underlying depression does not cause sundown
syndrome.
Option B: There is not sufficient evidence to suggest he has
inadequate cerebral blood flow.
Option D: Fluctuating levels of oxygen exchange do not cause
sundown syndrome.
5. Answer A. One (1) week.
Beneficial effects of ECT usually are evident after the first several
treatments. Since treatments are administered at intervals of 48 hours,
these effects are apparent after one week of therapy. Beneficial effects
of ECT therapy are usually seen before three weeks. It takes three to
four weeks for tricyclic antidepressants to take effect. Beneficial effects
of ECT therapy are usually seen before four weeks. It takes three to
four weeks for tricyclic antidepressants to take effect. Beneficial effects
of ECT therapy are usually seen after the first few treatments.
6. Answer D. Whether she has a sexual relationship with a
boyfriend.
It is inappropriate to ask about her sexual relationships.
Option A: Information about mood changes is important to assess, as
bulimia is often associated with affective disorders.
Option B: Family functioning is the most essential point to assess, as it
reveals if binge eating is triggered by conflict within the family.
Option C: Information about the ability to socialize with peers is
important to assess, as it is possible the problem initiated with peer
relationships.
7. Answer D. Increased interest in sex.
Interest in sex is markedly decreased in depression.
Option A: Indecisiveness and fear of being wrong are common in
depression.
Option B: Depression creates feelings that nothing will ever improve.
Option C: The risk of depression is increased when there is a family
history.
8. Answer A. Demonstrates the relaxation response when asked.
The ability to use relaxation is basic to treatment of phobia.
Option B: Clients with phobias are resistant to insight therapy.
Option C: Riding the elevator accompanied by the nurse is an
appropriate long-term goal.
Option D: Role playing may be appropriate after the client has learned
relaxation.
9. Answer C. “Tell me about your week prior to being admitted.”
This is an open-ended question which is non-judgemental and allows
for further discussion. The topic is also nonthreatening yet will give the
nurse insight into the client’s view of events leading up to admission. It
is the only option that is client centered. The other options focus on the
pills.
10. Answer D. Pour fluid over the forehead backward towards the
back of the head and say “I baptize you in the name of the father,
the son and the holy spirit. Amen.”
Infant baptism is mandatory in the Roman Catholic belief especially if a
neonate is not expected to live. Anyone may perform this if an infant or
child is gravely ill.
Option A refers to the Christian Science belief.
Option B is a belief of Russian Orthodoxy.
Option C: Mormons believe in divine healing with the laying on of
hands.
11. Answer D. “I have tried leaving, but have always gone back.”
Victims develop a high tolerance for abuse. They blame themselves for
being victimized. All members of the family suffer from the effects of
abuse, even if they are not the actual victims. For these reasons,
victims often have an extensive history of abuse and struggle for a long
time before they can leave permanently.
12. Answer A. “You look upset. Would you like to talk about it?”
Giving broad opening statements and making observations are
examples of therapeutic communication. The other options are too
specific or focused on being therapeutic.
13. Answer C. Achieve clients’ therapeutic goals
Activity groups are used to enhance the therapeutic milieu and to meet
the clinical and social needs of clients, e.g., to minimize withdrawal and
regression, to develop self-care skills, etc.
14. Answer D. “Come play Chinese Checkers with Gerry and me.”
This gradually engages the client in interactions with others and uses
positive behavioral expectation.
15. Answer D. Attaching a wander guard sensor band to the
client’s wrist
This type of identification band easily tracks the client’s movements
and ensures safety while wandering on the unit.
16. Answer C. Simply state the food is not poisoned
This action presents reality.
17. Answer D. Safety
Safety is a priority of care for the depressed client. Precautions to
prevent suicide must be a part of the plan.
18. Answer B. Control over one’s response to stress is possible.
When learning to manage stress, it is helpful to believe that one has
the ability to control one’s response to stress.
Option A: It is impossible to avoid stress, which is a normal experience.
Options C and D: Stress can be positive and growth enhancing as well
as harmful. The belief that one has some control can minimize the
stress response.

19. Answer C. Gentle touch while guiding ADLs (activities of daily

living).

Nonverbal, gentle touch is an important tool here. Providing

appropriate forms of touch to reinforce caring feelings. Because tactile
contacts vary considerably among individuals, families, and cultures,
the nurse must be sensitive to the differences in attitudes and practices
of clients and self.

20. Answer D. Dispositional crisis

A dispositional crisis is a response to an external situational crisis.

External anger at work is the dispositional crisis displaced to his wife
through abuse.

Option A: Psychiatric emergency crisis is when the individual’s general

functioning has been severely impaired, and the individual has been
rendered incompetent.
Option B: Developmental crisis occurs in response to triggering
emotions related to unresolved conflict in one’s life. This is called a
developmental crisis based on Freudian psychology.
Option C: An anticipated life transition crisis is a crisis that is normal in
the life cycle; transitional is one over which the person has no control.
SET E PSYCH PRACTICE TEST
1. A psychotic client reports to the evening nurse that the day nurse put
something suspicious in his water with his medication. The nurse
replies, “You’re worried about your medication?” The nurse’s
communication is:
A. an example of presenting reality.
B. reinforcing the client’s delusions.
C. focusing on emotional content.
D. a nontherapeutic technique called mind reading.
2. A client is admitted to the inpatient unit of the mental health center
with a diagnosis of paranoid schizophrenia. He’s shouting that the
government of France is trying to assassinate him. Which of the
following responses is most appropriate?
A. “I think you’re wrong. France is a friendly country and an ally of the
United States. Their government wouldn’t try to kill you.”
B. “I find it hard to believe that a foreign government or anyone else is
trying to hurt you. You must feel frightened by this.”
C. “You’re wrong. Nobody is trying to kill you.”
D. “A foreign government is trying to kill you? Please tell me more
about it.”
3. A client receiving haloperidol (Haldol) complains of a stiff jaw and
difficulty swallowing. The nurse’s first action is to:
A. reassure the client and administer as needed lorazepam (Ativan)
I.M.
B. administer as needed dose of benztropine (Cogentin) I.M. as
ordered.
C. administer as needed dose of benztropine (Cogentin) by mouth as
ordered.
D. administer as needed dose of haloperidol (Haldol) by mouth.
4. The nurse is caring for a client with schizophrenia who experiences
auditory hallucinations. The client appears to be listening to someone
who isn’t visible. He gestures, shouts angrily, and stops shouting in
mid-sentence. Which nursing intervention is the most appropriate?
A. Approach the client and touch him to get his attention.
B. Encourage the client to go to his room where he’ll experience fewer
distractions.
C. Acknowledge that the client is hearing voices but make it clear that
the nurse doesn’t hear these voices.
D. Ask the client to describe what the voices are saying.
5. A client with paranoid schizophrenia has been experiencing auditory
hallucinations for many years. One approach that has proven to be
effective for hallucinating clients is to:
A. take an as-needed dose of psychotropic medication whenever they
hear voices.
B. practice saying “Go away” or “Stop” when they hear voices.
C. sing loudly to drown out the voices and provide a distraction.
D. go to their room until the voices go away.
6. A client with catatonic schizophrenia is mute, can’t perform activities
of daily living, and stares out the window for hours. What is the nurse’s
first priority?
A. Assist the client with feeding.
B. Assist the client with showering.
C. Reassure the client about safety.
D. Encourage socialization with peers.
7. A client tells the nurse that the television newscaster is sending a
secret message to her. The nurse suspects the client is experiencing:
A. a delusion.
B. flight of ideas.
C. ideas of reference.
D. a hallucination.
8. The nurse knows that the physician has ordered the liquid form of
the drug chlorpromazine (Thorazine) rather than the tablet form
because the liquid:
A. has a more predictable onset of action.
B. produces fewer anticholinergic effects.
C. produces fewer drug interactions.
D. has a longer duration of action.
9. A client who has been hospitalized with disorganized type
schizophrenia for 8 years can’t complete activities of daily living (ADLs)
without staff direction and assistance. The nurse formulates a nursing
diagnosis of Self-care deficient: Dressing/grooming related to inability
to function without assistance. What is an appropriate goal for this
client?
A. “Client will be able to complete ADLs independently within 1 month.”
B. “Client will be able to complete ADLs with only verbal
encouragement within 1 month.”
C. “Client will be able to complete ADLs with assistance in organizing
grooming items and clothing within 1 month.”
D. “Client will be able to complete ADLs with complete assistance
within 1 month.”
10. The nurse is planning care for a client admitted to the psychiatric
unit with a diagnosis of paranoid schizophrenia. Which nursing
diagnosis should receive the highest priority?
A. Risk for violence toward self or others
B. Imbalanced nutrition: Less than body requirements
C. Ineffective family coping
D. Impaired verbal communication
11. The nurse is preparing for the discharge of a client who has been
hospitalized for paranoid schizophrenia. The client’s husband
expresses concern over whether his wife will continue to take her daily
prescribed medication. The nurse should inform him that:
A. his concern is valid but his wife is an adult and has the right to make
her own decisions.
B. he can easily mix the medication in his wife’s food if she stops
taking it.
C. his wife can be given a long-acting medication that is administered
every 1 to 4 weeks.
D. his wife knows she must take her medication as prescribed to avoid
future hospitalizations.
12. Benztropine (Cogentin) is used to treat the extrapyramidal effects
induced by antipsychotics. This drug exerts its effect by:
A. decreasing the anxiety causing muscle rigidity.
B. blocking the cholinergic activity in the central nervous system
(CNS).
C. increasing the level of acetylcholine in the CNS.
D. increasing norepinephrine in the CNS.
13. A dopamine receptor agonist such as bromocriptine (Parlodel)
relieves muscle rigidity caused by antipsychotic medication by:
A. Blocking dopamine receptors in the central nervous system (CNS).
B. Blocking acetylcholine in the CNS.
C. Activating norepinephrine in the CNS.
D. Activating dopamine receptors in the CNS.
14. Most antipsychotic medications exert which of following effects on
the central nervous system (CNS)?
A. Stimulate the CNS by blocking postsynaptic dopamine,
norepinephrine, and serotonin receptors.
B. Sedate the CNS by stimulating serotonin at the synaptic cleft.
C. Depress the CNS by blocking the postsynaptic transmission of
dopamine, serotonin, and norepinephrine.
D. Depress the CNS by stimulating the release of acetylcholine.
15. A client is admitted to the psychiatric unit of a local hospital with
chronic undifferentiated schizophrenia. During the next several days,
the client is seen laughing, yelling, and talking to herself. This behavior
is characteristic of:
A. delusion.
B. looseness of association.
C. illusion.
D. hallucination.
16. Which of the following medications would the nurse expect the
physician to order to reverse a dystonic reaction?
A. prochlorperazine (Compazine)
B. diphenhydramine (Benadryl)
C. haloperidol (Haldol)
D. midazolam (Versed)
17. A schizophrenic client states, “I hear the voice of King Tut.” Which
response by the nurse would be most therapeutic?
A. “I don’t hear the voice, but I know you hear what sounds like a
voice.”
B. “You shouldn’t focus on that voice.”
C. “Don’t worry about the voice as long as it doesn’t belong to anyone
real.”
D. “King Tut has been dead for years.”
18. A client has been receiving chlorpromazine (Thorazine), an
antipsychotic, to treat his psychosis. Which findings should alert the
nurse that the client is experiencing pseudoparkinsonism?
A. Restlessness, difficulty sitting still, and pacing
B. Involuntary rolling of the eyes
C. Tremors, shuffling gait, and masklike face
D. Extremity and neck spasms, facial grimacing, and jerky movements

19. For several years, a client with chronic schizophrenia has received
10 mg of fluphenazine hydrochloride (Prolixin) by mouth four times per
day. Now the client has a temperature of 102° F (38.9° C), a heart rate
of 120 beats/minute, a respiratory rate of 20 breaths/minute, and a
blood pressure of 210/140 mm Hg. Because the client also is confused
and incontinent, the nurse suspects malignant neuroleptic syndrome.
What steps should the nurse take?
A. Give the next dose of fluphenazine, call the physician, and monitor
vital signs.
B. Withhold the next dose of fluphenazine, call the physician, and
monitor vital signs.
C. Give the next dose of fluphenazine and restrict the client to the room
to decrease stimulation.
D. Withhold the next dose of fluphenazine, administer an antipyretic
agent, and increase the client’s fluid intake.
20. A schizophrenic client with delusions tells the nurse, “There is a
man wearing a red coat who’s out to get me.” The client exhibits
increasing anxiety when focusing on the delusions. Which of the
following would be the best response?
A. “This subject seems to be troubling you. Let’s walk to the activity
room.”
B. “Describe the man who’s out to get you. What does he look like?”
C. “There is no reason to be afraid of that man. This hospital is very
secure.”
D. “There is no need to be concerned with a man who isn’t even real.”
21. Important teaching for women in their childbearing years who are
receiving antipsychotic medications includes which of the following?
A. Occurrence of increased libido due to medication adverse effects
B. Increased incidence of dysmenorrhea while taking the drug
C. Continuing previous use of contraception during periods of
amenorrhea
D. Instruction that amenorrhea is irreversible
22. A client is admitted to a psychiatric facility with a diagnosis of
chronic schizophrenia. The history indicates that the client has been
taking neuroleptic medication for many years. Assessment reveals
unusual movements of the tongue, neck, and arms. Which condition
should the nurse suspect?
A. Tardive dyskinesia
B. Dystonia
C. Neuroleptic malignant syndrome
D. Akathisia
23. What medication would probably be ordered for the acutely
aggressive schizophrenic client?
A. chlorpromazine (Thorazine)
B. haloperidol (Haldol)
C. lithium carbonate (Lithonate)
D. amitriptyline (Elavil)
24. A client is admitted with a diagnosis of schizotypal personality
disorder. Which signs would this client exhibit during social situations?
A. Aggressive behavior
B. Paranoid thoughts
C. Emotional affect
D. Independence needs
25. During the initial interview, a client with schizophrenia suddenly
turns to the empty chair beside him and whispers, “Now just leave. I
told you to stay home. There isn’t enough work here for both of us!”
What is the nurse’s best initial response?
A. “When people are under stress, they may see things or hear things
that others don’t. Is that what just happened?”
B. “I’m having a difficult time hearing you. Please look at me when you
talk.”
C. “There is no one else in the room. What are you doing?”
D. “Who are you talking to? Are you hallucinating?”
26. The definition of nihilistic delusions is:
A. a false belief about the functioning of the body.
B. belief that the body is deformed or defective in a specific way.
C. false ideas about the self, others, or the world
D. the inability to carry out motor activities.
27. A client who’s taking antipsychotic medication develops a very high
temperature, severe muscle rigidity, tachycardia, and rapid
deterioration in mental status. The nurse suspects what complication of
antipsychotic therapy?
A. Agranulocytosis
B. Extrapyramidal effects
C. Anticholinergic effects
D. Neuroleptic malignant syndrome (NMS)
28. The nurse formulates a nursing diagnosis of Impaired social
interaction related to disorganized thinking for a client with schizotypal
personality disorder. Based on this nursing diagnosis, which nursing
intervention takes highest priority?
A. Helping the client to participate in social interactions
B. Establishing a one-on-one relationship with the client
C. Exploring the effects of the client’s behavior on social interactions
D. Developing a schedule for the client’s participation in social
interactions
29. A client with schizophrenia hears a voice telling him he is evil and
must die. The nurse understands that the client is experiencing:
A. a delusion.
B. flight of ideas.
C. ideas of reference.
D. a hallucination.
30. A client with delusional thinking shows a lack of interest in eating at
meal times. She states that she is unworthy of eating and that her
children will die if she eats. Which nursing action would be most
appropriate for this client?
A. Telling the client that she may become sick and die unless she eats
B. Paying special attention to the client’s rituals and emotions
associated with meals
C. Restricting the client’s access to food except at specified meal and
snack times
D. Encouraging the client to express her feelings at meal times
31. Which of the following groups of characteristics would the nurse
expect to see in the client with schizophrenia?
A. Loose associations, grandiose delusions, and auditory
hallucinations
B. Periods of hyperactivity and irritability alternating with depression
C. Delusions of jealousy and persecution, paranoia, and mistrust
D. Sadness, apathy, feelings of worthlessness, anorexia, and weight
loss
32. The nurse must administer a medication to reverse or prevent
Parkinson-type symptoms in a client receiving an antipsychotic. The
medication the client will likely receive is:
A. Benztropine (Cogentin).
B. diphenhydramine (Benadryl).
C. propranolol (Inderal).
D. haloperidol (Haldol).
33. A client is receiving haloperidol (Haldol) to reduce psychotic
symptoms. As he watches television with other clients, the nurse notes
that he has trouble sitting still. He seems restless, constantly moving
his hands and feet and changing position. When the nurse asks what is
wrong, he says he feels jittery. How should the nurse manage this
situation?
A. Ask the client to sit still or leave the room because he is distracting
the other clients.
B. Ask the client if he is nervous or anxious about something.
C. Give an as needed dose of a prescribed anticholinergic agent to
control akathisia.
D. Administer an as needed dose of haloperidol to decrease agitation.
34. A man is brought to the hospital by his wife, who states that for the
past week her husband has refused all meals and accused her of
trying to poison him. During the initial interview, the client’s speech,
only partly comprehensible, reveals that his thoughts are controlled by
delusions that he is possessed by the devil. The physician diagnoses
paranoid schizophrenia. Schizophrenia is best described as a disorder
characterized by:
A. disturbed relationships related to an inability to communicate and
think clearly.
B. severe mood swings and periods of low to high activity.
C. multiple personalities, one of which is more destructive than the
others.
D. auditory and tactile hallucinations.
35. A client has a history of chronic undifferentiated schizophrenia.
Because she has a history of noncompliance with antipsychotic
therapy, she’ll receive fluphenazine decanoate (Prolixin Decanoate)
injections every 4 weeks. Before discharge, what should the nurse
include in her teaching plan?
A. Asking the physician for droperidol (Inapsine) to control any
extrapyramidal symptoms that occur
B. Sitting up for a few minutes before standing to minimize orthostatic
hypotension
C. Notifying the physician if her thoughts don’t normalize within 1 week
D. Expecting symptoms of tardive dyskinesia to occur and to be
transient
36. A client with chronic schizophrenia who takes neuroleptic
medication is admitted to the psychiatric unit. Nursing assessment
reveals rigidity, fever, hypertension, and diaphoresis. These findings
suggest which life-threatening reaction:
A. tardive dyskinesia.
B. dystonia.
C. neuroleptic malignant syndrome.
D. akathisia.
37. While looking out the window, a client with schizophrenia remarks,
“That school across the street has creatures in it that are waiting for
me.” Which of the following terms best describes what the creatures
represent?
A. Anxiety attack
B. Projection
C. Hallucination
D. Delusion
38. A client with schizophrenia tells the nurse, “My intestines are rotted
from the worms chewing on them.” This statement indicates a:
A. delusion of persecution.
B. delusion of grandeur.
C. somatic delusion.
D. jealous delusion.
ADVERTISEMENTS
39. During the assessment stage, a client with schizophrenia leaves
his arm in the air after the nurse has taken his blood pressure. His
action shows evidence of:
A. somatic delusions.
B. waxy flexibility.
C. neologisms.
D. nihilistic delusions.
40. A client with paranoid-type schizophrenia becomes angry and tells
the nurse to leave him alone. The nurse should
A. tell him that she’ll leave for now but will return soon.
B. ask him if it’s okay if she sits quietly with him.
C. ask him why he wants to be left alone.
D. tell him that she won’t let anything happen to him
41. Nursing care for a client with schizophrenia must be based on valid
psychiatric and nursing theories. The nurse’s interpersonal
communication with the client and specific nursing interventions must
be:
A. clearly identified with boundaries and specifically defined roles.
B. warm and non-threatening.
C. centered on clearly defined limits and expression of empathy.
D. flexible enough for the nurse to adjust the plan of care as the
situation warrants.
42. When discharging a client after treatment for a dystonic reaction,
the emergency department nurse must ensure that the client
understands which of the following?
A. Results of treatment are rapid and dramatic but may not last.
B. Although uncomfortable, this reaction isn’t serious.
C. The client shouldn’t buy drugs on the street.
D. The client must take benztropine (Cogentin) as prescribed to
prevent a return of symptoms.
43. Upon evaluation of the patient’s record, the nurse sees the
admission was voluntary. Based on this data, the nurse expects which
patient behavior?
A. Fearfulness regarding treatment measures.
B. Anger and aggressiveness directed toward others.
C. An understanding of the pathology and symptoms of the diagnosis.
D. A willingness to participate in the planning of the care and treatment
plan.
44. A clinical instructor is correcting a nursing student‘s worksheet.
Which instructor statement is the best example of effective feedback?
A. “Why did you use the client’s name on your clinical worksheet?”
B. “You were very careless to refer to your client by name on your
clinical worksheet.”
C. “Surely you didn’t do this deliberately, but you breached
confidentiality by using the client’s name.”
D. “It is disappointing that after being told, you’re still using client
names on your worksheet.”
45. Which nursing statement is a good example of the therapeutic
communication technique of focusing?
A. “Describe one of the best things that happened to you this week.”
B. “I’m having a difficult time understanding what you mean.”
C. “Your counseling session is in 30 minutes. I’ll stay with you until
then.”
D. “You mentioned your relationship with your father. Let’s discuss that
further.”
46. A person with antisocial personality disorder has toughness relating
to others because of never having learned to:
A. Count on others
B. Empathize with others
C. Be dependent on others
D. Communicate with others socially
47. Which of the following behaviors by a client with dependent
personality disorder shows the client has made progress toward the
goal of increasing problem-solving skills?
A. The client is courteous
B. The client asks questions
C. The client stops acting out
D. The client controls emotions
48. Which is the best indicator of success in the long-term
management of the client?
A. His symptoms are replaced by indifference to his feelings
B. He participates in diversionary activities.
C. He learns to verbalize his feelings and concerns
D. He states that his behavior is irrational.
49. The nurse asks a client to roll up his sleeves so she can take his
blood pressure. The client replies “If you want I can go naked for you.”
The most therapeutic response by the nurse is:
A. “You’re attractive, but I’m not interested.”
B. “You wouldn’t be the first that I will see naked.”
C. “I will report you to the guard if you don’t control yourself.”
D. “I only need access to your arm. Putting up your sleeve is fine.”
50. Which goal is a priority for a client with a DSM-IV-TR diagnosis of
delirium and the nursing diagnosis Acute confusion related to recent
surgery secondary to traumatic hip fracture?
A. The client will complete activities of daily living.
B. The client will maintain safety.
C. The client will remain oriented.
D. The client will understand communication.
SET E PSYCH ANSWER KEY
1. Answer: C. focusing on emotional content.
Option C: The nurse should help the client focus on the emotional
content rather than delusional material.
Option A: Presenting reality isn’t helpful because it can lead to
confrontation and disengagement.
Option B: Agreeing with the client and supporting his beliefs are
reinforcing delusions.
Option D: Mind reading isn’t therapeutic.
2. Answer: B. “I find it hard to believe that a foreign government or
anyone else is trying to hurt you. You must feel frightened by this.”
Option B: Responses should focus on reality while acknowledging the
client’s feelings.
Option A: Arguing with the client or denying his belief isn’t therapeutic.
Option C: Arguing can also inhibit development of a trusting
relationship. Continuing to talk about delusions may aggravate the
psychosis.
Option D: Asking the client if a foreign government is trying to kill him
may increase his anxiety level and can reinforce his delusions.
3. Answer: B. administer as needed dose of benztropine (Cogentin)
I.M. as ordered.
Option B: The client is most likely suffering from muscle rigidity due to
haloperidol. I.M. benztropine should be administered to prevent
asphyxia or aspiration.
Option A: Lorazepam treats anxiety, not extrapyramidal effects.
Option D: Another dose of haloperidol would increase the severity of
the reaction.
4. Answer: C. Acknowledge that the client is hearing voices but make it
clear that the nurse doesn’t hear these voices.
Option C: By acknowledging that the client hears voices, the nurse
conveys acceptance of the client. By letting the client know that the
nurse doesn’t hear the voices, the nurse avoids reinforcing the
hallucination.
Option A: The nurse shouldn’t touch the client with schizophrenia
without advance warning. The hallucinating client may believe that the
touch is a threat or act of aggression and respond violently.
Option B: Being alone in his room encourages the client to withdraw
and may promote more hallucinations. The nurse should provide an
activity to distract the client.
Option D: By asking the client what the voices are saying, the nurse is
reinforcing the hallucination. The nurse should focus on the client’s
feelings, rather than the content of the hallucination.
5. Answer: B. practice saying “Go away” or “Stop” when they hear
voices.
Option B: Researchers have found that some clients can learn to
control bothersome hallucinations by telling the voices to go away or
stop.
Option A: Taking an as needed dose of psychotropic medication
whenever the voices arise may lead to overmedication and put the
client at risk for adverse effects. Because the voices aren’t likely to go
away permanently, the client must learn to deal with the hallucinations
without relying on drugs.
Option C: Although distraction is helpful, singing loudly may upset
other clients and would be socially unacceptable after the client is
discharged.
Option D: Hallucinations are most bothersome in a quiet environment
when the client is alone, so sending the client to his room would
increase, rather than decrease, the hallucinations.
6. Answer: A. Assist the client with feeding.
Option A: According to Maslow’s hierarchy of needs, the need for food
is among the most important.
Options B, C, and D: Other needs, in order of decreasing importance,
include hygiene, safety, and a sense of belonging.
7. Answer: C. ideas of reference.
Option C: Ideas of reference refers to the mistaken belief that neutral
stimuli have special meaning to the individual such as the television
newscaster sending a message directly to the individual.
Option A: A delusion is a false belief.
Option B: Flight of ideas is a speech pattern in which the client skips
from one unrelated subject to another.
Option D: A hallucination is a sensory perception, such as hearing
voices and seeing objects, that only the client experiences.
8. Answer: A. has a more predictable onset of action.
Option A: A liquid phenothiazine preparation will produce effects in 2 to
4 hours. The onset of tablets is unpredictable.
9. Answer: C. “Client will be able to complete ADLs with assistance in
organizing grooming items and clothing within 1 month.”
Option C: The client’s disorganized personality and history of
hospitalization have affected the ability to perform self-care activities.
Option A: Interventions should be directed at helping the client
complete ADLs with the assistance of staff members, who can provide
needed structure by helping the client select grooming items and
clothing. This goal promotes realistic independence.
Option B: As the client improves and achieves the established goal, the
nurse can set new goals that focus on the client completing ADLs with
only verbal encouragement and, ultimately, completing them
independently.
Option D: The client’s condition doesn’t indicate a need for complete
assistance, which would only foster dependence.
10. Answer: A. Risk for violence toward self or others
Option A: Because of such factors as suspiciousness, anxiety, and
hallucinations, the client with paranoid schizophrenia is at risk for
violence toward himself or others.
Options B, C, and D: The other options are also appropriate nursing
diagnoses but should be addressed after the safety of the client and
those around him is established.
11. Answer: C. his wife can be given a long-acting medication that is
administered every 1 to 4 weeks.
Option C: Long-acting psychotropic drugs can be administered by
depot injection every 1 to 4 weeks. These agents are useful for
noncompliant clients because the client receives the injection at the
outpatient clinic.
Option A: A client has the right to refuse medication, but this issue isn’t
the focus of discussion at this time.
Option B: Medication should never be hidden in food or drink to trick
the client into taking it; besides destroying the client’s trust, doing so
would place the client at risk for overmedication or undermedication
because the amount administered is hard to determine.
Option D: Assuming the client knows she must take the medication to
avoid future hospitalizations would be unrealistic.
12. Answer: B. blocking the cholinergic activity in the central nervous
system (CNS).
Option B: This is the action of Cogentin.
Option A: Anxiety doesn’t cause extrapyramidal effects.
Option C: Overactivity of acetylcholine and lower levels of dopamine
are the causes of extrapyramidal effects.
Option D: Benztropine doesn’t increase norepinephrine in the CNS.
13. Answer: D. activating dopamine receptors in the CNS.
Option D: Extrapyramidal effects and the muscle rigidity induced by
antipsychotic medications are caused by a low level of dopamine.
Option A: Dopamine receptor agonists stimulate dopamine receptors
and thereby reduce rigidity.
Options B and C: They don’t affect norepinephrine or acetylcholine.
14. Answer: C. Depress the CNS by blocking the postsynaptic
transmission of dopamine, serotonin, and norepinephrine.
Option C: The exact mechanism of antipsychotic medication action is
unknown, but appear to depress the CNS by blocking the transmission
of three neurotransmitters: dopamine, serotonin, and norepinephrine.
Options A, B, and D: They don’t sedate the CNS by stimulating
serotonin, and they don’t stimulate neurotransmitter action or
acetylcholine release.
15. Answer: D. hallucination.
Option D: Auditory hallucination, in which one hears voices when no
external stimuli exist, is common in schizophrenic clients. Such
behaviors as laughing, yelling, and talking to oneself suggest such a
hallucination.
Option A: Delusions, also common in schizophrenia, are false beliefs
or ideas that arise without external stimuli.
Option B: Clients with schizophrenia may exhibit looseness of
association, a pattern of thinking and communicating in which ideas
aren’t clearly linked to one another.
Option C: Illusion is a less severe perceptual disturbance in which the
client misinterprets actual external stimuli. Illusions are rarely
associated with schizophrenia.
16. Answer: B. diphenhydramine (Benadryl)
Option B: Diphenhydramine, 25 to 50 mg I.M. or I.V., would quickly
reverse this condition.
Options A and C: Prochlorperazine and haloperidol are both capable of
causing dystonia, not reversing it.
Option D: Midazolam would make this client drowsy.
17. Answer: A. “I don’t hear the voice, but I know you hear what
sounds like a voice.”
Option A: This response states reality about the client’s hallucination.
Options B, C, and D: The other options are judgmental, flippant, or
dismissive.
18. Answer: C. Tremors, shuffling gait, and mask-like face
Option C: Pseudoparkinsonism may appear 1 to 5 days after starting
an antipsychotic and may also include drooling, rigidity, and “pill
rolling.”
Option A: Akathisia may occur several weeks after starting
antipsychotic therapy and consists of restlessness, difficulty sitting still,
and fidgeting.
Option B: An oculogyric crisis is recognized by uncontrollable rolling
back of the eyes and, along with dystonia, should be considered an
emergency.
Option D: Dystonia may occur minutes to hours after receiving an
antipsychotic and may include extremity and neck spasms, jerky
muscle movements, and facial grimacing.
19. Answer: B. Withhold the next dose of fluphenazine,
call the physician, and monitor vital signs.
Option B: Malignant neuroleptic syndrome is a dangerous adverse
effect of neuroleptic drugs such as fluphenazine. The nurse should
withhold the next dose, notify the physician, and continue to monitor
vital signs. Although an antipyretic agent may be used to reduce fever,
increased fluid intake is contraindicated because it may increase the
client’s fluid volume further, raising blood pressure even higher.
20. Answer: A. “This subject seems to be troubling you. Let’s walk to
the activity room.”
Option A: This remark distracts the client from the delusion by
engaging the client in a less threatening or more comforting activity at
the first sign of anxiety. The nurse should reinforce reality and
discourage the false belief.
Options B, C, and D: The other options focus on the content of the
delusion rather than the meaning, feeling, or intent that it provokes.
21. Answer: C. Continuing previous use of contraception during
periods of amenorrhea
Option C: Women may experience amenorrhea, which is reversible,
while taking antipsychotics. Amenorrhea doesn’t indicate cessation of
ovulation; therefore, the client can still become pregnant. The client
should be instructed to continue contraceptive use even when
experiencing amenorrhea.
Option A: Dysmenorrhea isn’t an adverse effect of antipsychotics, and
libido generally decreases because of the depressant effect.
22. Answer: A. Tardive dyskinesia
Option A: Unusual movements of the tongue, neck, and arms suggest
tardive dyskinesia, an adverse reaction to neuroleptic medication.
Option B: Dystonia is characterized by cramps and rigidity of the
tongue, face, neck, and back muscles.
Option C: Neuroleptic malignant syndrome causes rigidity, fever,
hypertension, and diaphoresis.
Option D: Akathisia causes restlessness, anxiety, and jitteriness.
23. Answer: B. haloperidol (Haldol)
Option B: Haloperidol administered I.M. or I.V. is the drug of choice for
acute aggressive psychotic behavior.
Option A: Chlorpromazine is also an antipsychotic drug; however, it
causes more pronounced sedation than haloperidol.
Options C and D: Lithium carbonate is used in bipolar or manic
disorder, and amitriptyline is used for depression.
24. Answer: B. Paranoid thoughts
Option B: Clients with schizotypal personality disorder experience
excessive social anxiety that can lead to paranoid thoughts.
Option A: Aggressive behavior is uncommon, although these clients
may experience agitation with anxiety.
Option C: Their behavior is emotionally cold with a flattened affect,
regardless of the situation.
Option D: These clients demonstrate a reduced capacity for close or
dependent relationships.
25. Answer: A. “When people are under stress, they may see things or
hear things that others don’t. Is that what just happened?”
Option A: This response makes the client feel that experiencing
hallucinations is acceptable and promotes an open, therapeutic
relationship.
Option B: Directing the client to look at the nurse wouldn’t address the
obvious issue of the hallucination.
Options C and D: Confrontational approaches are likely to elicit an
uninformative or negative response.
26. Answer: C. false ideas about the self, others, or the world
Option C: Nihilistic delusions are false ideas about the self, others, or
the world.
Option A: Somatic delusions involve a false belief about the functioning
of the body.
Option B: Body dysmorphic disorder is characterized by a belief that
the body is deformed or defective in a specific way.
Option D: Apraxia is the inability to carry out motor activities.
27. Answer: D. Neuroleptic malignant syndrome (NMS)
Option D: A rare but potentially fatal condition of antipsychotic
medication is called NMS. It generally starts with an elevated
temperature and severe extrapyramidal effects.
Option A: Agranulocytosis is a blood disorder.
Option B: Symptoms of extrapyramidal effects include tremors,
restlessness, muscle spasms, and pseudoparkinsonism.
Option C: Anticholinergic effects include blurred vision, drowsiness,
and dry mouth.
28. Answer: B. Establishing a one-on-one relationship with the client
Option B: By establishing a one-on-one relationship, the nurse helps
the client learn how to interact with people in new situations.
Options A, C, and D: The other options are appropriate but should take
place only after the nurse-client relationship is established.
29. Answer: D. a hallucination.
Option D: A hallucination is a sensory perception, such as hearing
voices and seeing objects, that only the client experiences.
Option A: A delusion is a false belief.
Option B: Flight of ideas refers to a speech pattern in which the client
skips from one unrelated subject to another.
Option C: Ideas of reference refers to the mistaken belief that someone
or something outside the client is controlling the client’s ideas or
behavior.
30. Answer: C. Restricting the client’s access to food except at
specified meal and snack times
Option C: Restricting access to food except at specified times prevents
the client from eating when she feels anxious, guilty, or depressed;
this, in turn, decreases the association between these emotions and
food.
Option A: Telling the client she may become sick or die may reinforce
her behavior because illness or death may be her goal.
Option B: Paying special attention to rituals and emotions associated
with meals also would reinforce undesirable behavior.
Option D: Encouraging the client to express feelings at meal times
would increase the association between emotions and food; instead,
the nurse should encourage her to express feelings at other times.
31. Answer: A. Loose associations, grandiose delusions, and auditory
hallucinations
Option A: Loose associations, grandiose delusions, and auditory
hallucinations are all characteristic of the classic schizophrenic client.
These clients aren’t able to care for their physical appearance. They
frequently hear voices telling them to do something either to
themselves or to others. Additionally, they verbally ramble from one
topic to the next.
Option B: Periods of hyperactivity and irritability alternating with
depression are characteristic of bipolar or manic disease.
Option C: Delusions of jealousy and persecution, paranoia, and
mistrust are characteristics of paranoid disorders.
Option D: Sadness, apathy, feelings of worthlessness, anorexia, and
weight loss are characteristics of depression.
32. Answer: A. Benztropine (Cogentin).
Option A: Benztropine, trihexyphenidyl, or amantadine are prescribed
for a client with Parkinson-type symptoms.
Option B: Diphenhydramine provides rapid relief for dystonia.
Option C: Propranolol relieves akathisia.
Option D: Haloperidol can cause Parkinson-type symptoms.
33. Answer: C. Give an as needed dose of a prescribed anticholinergic
agent to control akathisia.
Option C: Akathisia, characterized by restlessness, is a common but
often overlooked adverse reaction to haloperidol and other
antipsychotic agents; it may be confused with psychotic agitation. To
control akathisia, the nurse should give an as needed dose of a
prescribed anticholinergic agent.
Option A: The client can’t control the movements, so asking him to sit
still would be pointless.
Option B: Asking him to leave the room wouldn’t address the
underlying cause of the problem. Encouraging him to talk about the
symptoms wouldn’t stop them from occurring.
Option D: Giving more antipsychotic medication would worsen
akathisia.
34. Answer: A. disturbed relationships related to an inability to
communicate and think clearly.
Option A: Schizophrenia is best described as one of a group of
psychotic reactions characterized by disturbed relationships with others
and an inability to communicate and think clearly. Schizophrenic
thoughts, feelings, and behavior commonly are evidenced by
withdrawal, fluctuating moods, disordered thinking, and regressive
tendencies.
Option B: Severe mood swings and periods of low to high activity are
typical of bipolar disorder.
Option C: Multiple personality, sometimes confused with
schizophrenia, is a dissociative personality disorder, not a psychotic
illness.
Option D: Many schizophrenic clients have auditory hallucinations;
tactile hallucinations are more common in organic or toxic disorders
35. Answer: B. Sitting up for a few minutes before standing to minimize
orthostatic hypotension
Option B: The nurse should teach the client how to manage common
adverse reactions, such as orthostatic hypotension and anticholinergic
effects.
Option A: Droperidol increases the risk of extrapyramidal effects when
given in conjunction with phenothiazines such as fluphenazine.
Options C: Antipsychotic effects of the drug may take several weeks to
appear.
Option D: Tardive dyskinesia is a possible adverse reaction and should
be reported immediately
36. Answer: C. neuroleptic malignant syndrome.
Option C: The client’s signs and symptoms suggest neuroleptic
malignant syndrome, a life-threatening reaction to neuroleptic
medication that requires immediate treatment.
Option A: Tardive dyskinesia causes involuntary movements of the
tongue, mouth, facial muscles, and arm and leg muscles.
Option B: Dystonia is characterized by cramps and rigidity of the
tongue, face, neck, and back muscles.
Option D: Akathisia causes restlessness, anxiety, and jitteriness.
37. Answer: D. Delusion
Option D: A delusion is a false belief based on a misrepresentation of a
real event or experience.
Option A: Although anxiety can increase delusional responses, it isn’t
considered the primary symptom.
Option B: Projection is falsely attributing to another person one’s own
unacceptable feelings.
Option C: Hallucinations, which characterize most psychoses, are
perceptual disorders of the five senses; the client may see, taste, feel,
smell, or hear something in the absence of external stimulation
38. Answer: C. somatic delusion.
communication to help others consider a modification of behavior.
Feedback should be descriptive, specific, and directed toward a
behavior that the person has the capacity to modify and should impart
information rather than offer advice or criticize the individual.
45. Answer: D. “You mentioned your relationship with your father. Let’s
discuss that further.”
Option D: This is an example of the therapeutic communication
technique of focusing. Focusing takes notice of a single idea or even a
single word and works especially well with a client who is moving
rapidly from one thought to another.
46. Answer: B. Empathize with others.
Option B: The lack of superego control allows the ego and the id to
control the behavior. Self-motivation and self-satisfaction are of
paramount concern.

Option C: Somatic delusions focus on bodily functions or systems and
commonly include delusions about foul odor emissions, insect
infestations, internal parasites, and misshapen parts.
Option A: Delusions of persecution are morbid beliefs that one is being
mistreated and harassed by unidentified enemies.
Option B: Delusions of grandeur are gross exaggerations of one’s
importance, wealth, power, or talents.
Option D: Jealous delusions are delusions that one’s spouse or lover is
unfaithful.
39. Answer: B. waxy flexibility.
Option B: The correct answer is waxy flexibility, which is defined as
retaining any position that the body has been placed in.
Option A: Somatic delusions involve a false belief about the functioning
of the body.
Option C: Neologisms are invented meaningless words.
Option D: Nihilistic delusions are false ideas about self, others, or the
world.
40. Answer: A. tell him that she’ll leave for now but will return soon.
Option A: If the client tells the nurse to leave, the nurse should leave
but let the client know that she’ll return so that he doesn’t feel
abandoned.
Option B: Not heeding the client’s request can agitate him further.
Option C: Also, challenging the client isn’t therapeutic and may
increase his anger.
Option D: False reassurance isn’t warranted in this situation
41. Answer: D. flexible enough for the nurse to adjust the plan of care
as the situation warrants.
Option D: A flexible plan of care is needed for any client who behaves
in a suspicious, withdrawn, or regressed manner or who has a thought
disorder. Because such a client communicates at different levels and is
in control of himself at various times, the nurse must be able to adjust
nursing care as the situation warrants.
Option A: The nurse’s role should be clear; however, the boundaries or
limits of this role should be flexible enough to meet client needs.
Option B: Because a client with schizophrenia fears closeness and
affection, a warm approach may be too threatening.
Option C: Expressing empathy is important, but centering interventions
on clearly defined limits is impossible because the client’s situation
may change without warning.
47. Answer: B. The client asks questions.
Option B: The client with a dependent personality disorder is passive
and tries to please others. By asking questions, the client is beginning
to gather information, the first step of decision making.
48. Answer: C. He learns to verbalize his feelings and concerns
Option C: The client is encouraged to talk about his feelings and
concerns instead of using body symptoms to manage his stressors.
Option A: The client is encouraged to acknowledge feelings rather than
being indifferent to her feelings.
Option B: Participation in activities diverts the client’s attention away
from his bodily concerns but this is not the best indicator of success.
Option D: Help the client recognize that his physical symptoms occur
because of or are exacerbated by specific stressor, not as irrational.
49. Answer: D. “I only need access to your arm. Putting up your sleeve
is fine.”
Option D: The nurse needs to deal with the client with sexually
connotative behavior in a casual, matter of fact way.
Options A and B: These responses are not therapeutic because they
are challenging and rejecting.
Option C: Threatening the client is not therapeutic.
50. Answer: B. The client will maintain safety.
Option B: Maintaining safety is the priority goal for an acutely confused
client who recently had surgery. All measures to promote physiologic
safety and psychosocial wellbeing would be implemented.
Option A: This client would not be able of completing activities of daily
living, and safety is a priority over these tasks.
Options C and D: The goals of remaining oriented and understanding
communication would be appropriate only after the client’s acute
confusion has resolved.

42. Answer: D. The client must take benztropine (Cogentin) as

prescribed to prevent a return of symptoms.

Option D: An oral anticholinergic agent such as benztropine (Cogentin)

is commonly prescribed to control and prevent the return of symptoms.
Option A: Dystonic reactions are typically acute and reversible.
Option B: Dystonic reactions can be life-threatening when airway
patency is compromised.
Option C: Lecturing the client about buying drugs on the street isn’t
appropriate.

43. Answer: D. A willingness to participate in the planning of the care

and treatment plan.

Option D: In general, patients seek voluntary admission. If a patient

seeks voluntary admission, the most likely expectation is the patient
will participate in the treatment program since they are actively seeking
help.
Options A, B, and C: The remaining options are not characteristics of
this type of admission. Fearfulness, anger, and aggressiveness are
more characteristic of an involuntary admission. Voluntary admission
does not guarantee a patient’s understanding of their illness, only of
their desire for help.

44. Answer: C. “Surely you didn’t do this deliberately, but you breached
confidentiality by using the client’s name.”

Option C: The instructor’s statement, “Surely you didn’t do this

deliberately, but you breached confidentiality by using the client’s
name.” is an example of effective feedback. Feedback is a method of
COGNITIVE IMPAIRMENT
1. Nurse Isabelle enters the room of a client with a cognitive
impairment disorder and asks what day of the week it is; what the date,
month, and year are; and where the client is. The nurse is attempting
to assess:
A. confabulation.
B. delirium.
C. orientation.
D. perseveration.
2. A student nurse was asked which of the following best describes
dementia. Which of the following best describes the condition?
A. Memory loss occurring as part of the natural consequence of aging
B. Difficulty coping with physical and psychological change
C. Severe cognitive impairment that occurs rapidly
D. Loss of cognitive abilities, impairing ability to perform activities of
daily living
3. Which of the following will Nurse Dory use when communicating with
a client who has cognitive impairment.
A. Complete explanations with multiple details
B. Pictures or gestures instead of words
C. Stimulating words and phrases to capture the client’s attention
D. Short words and simple sentences
4. Mrs. Mendoza is a 75-year-old client who has dementia of the
Alzheimer’s type and confabulates. The nurse understands that this
client:
A. Denies confusion by being jovial.
B. Pretends to be someone else.
C. Rationalizes various behaviors.
D. fills in memory gaps with fantasy.
5. Which ability should Nurse Rebecca expect from a client in the mild
stage of dementia of the Alzheimer’s type?
A. Remembering the daily schedule
B. Recalling past events
C. Coping the anxiety
D. Solving problems of daily living
6. 82-year-old Mr. Robeson together with his daughter arrived at the
medical-surgical unit for diagnostic confirmation and management of
probable delirium. Which statement by the client’s daughter best
supports the diagnosis?
A. “Maybe it’s just caused by aging. This usually happens by age 82.”
B. “The changes in his behavior came on so quickly! I wasn’t sure what
was happening.”
C. “Dad just didn’t seem to know what he was doing. He would forget
what he had for breakfast.”
D. “Dad has always been so independent. He’s lived alone for years
since mom died.”
7. Mrs. Jordan is an elderly client diagnosed with Alzheimer’s disease.
She becomes agitated and combative when a nurse approaches to
help with morning care. The most appropriate nursing intervention in
this situation would be to:
A. tell the client firmly that it is time to get dressed.
B. obtain assistance to restrain the client for safety.
C. remain calm and talk quietly to the client.
D. call the doctor and request an order for sedation.
8. Which goal is a priority for a client with a DSM-IV-TR diagnosis of
delirium and the nursing diagnosis Acute confusion related to recent
surgery secondary to traumatic hip fracture?
A. The client will complete activities of daily living.
B. The client will maintain safety.
C. The client will remain oriented.
D. The client will understand communication.
9. Which of the following is not included in the care of plan of a client
with a moderate cognitive impairment involving dementia of the
Alzheimer’s type?
A. Daily structured schedule
B. Positive reinforcement for performing activities of daily living
C. Stimulating environment
D. Use of validation techniques
10. In clients with a cognitive impairment disorder, the phenomenon of
increased confusion in the early evening hours is called:
A. Aphasia.
B. Agnosia.
C. Sundowning.
D. Confabulation.
11. 80-year-old Mr. Stevens is accompanied to the clinic by his son,
who tells the nurse that the client’s constant confusion, incontinence,
and tendency to wander are intolerable. The client was diagnosed with
chronic cognitive impairment disorder. Which nursing diagnosis is most
appropriate for the client’s son?
A. Risk for other-directed violence
B. Disturbed sleep pattern
C. Caregiver role strain
D. Social isolation
12. Which of the following outcome criteria is appropriate for the client
with dementia?
A. The client will return to an adequate level of self-functioning.
B. The client will learn new coping mechanisms to handle anxiety.
C. The client will seek out resources in the community for support.
D. The client will follow an established schedule for activities of daily
living.
13. A family member expresses concern to a nurse about behavioral
changes in an elderly aunt. Which would cause the nurse to suspect a
cognitive impairment disorder?
A. Decreased interest in activities that she once enjoyed
B. Fearfulness of being alone at night
C. Increased complaints of physical ailments
D. Problems with preparing a meal or balancing her checkbook
14. During the home visit of a client with dementia, the nurse notes that
an adult daughter persistently corrects her father’s misperceptions of
reality, even when the father becomes upset and anxious. Which
intervention should the nurse teach the caregiver?
A. Anxiety-reducing measures
B. Positive reinforcement
C. Reality orientation techniques
D. Validation techniques
15. Mr. Lim who is diagnosed with moderate dementia has frequent
catastrophic reactions during shower time. Which of the following
interventions should be implemented in the plan of care? Select all that
apply.
A. Assign consistent staff members to assist the client.
B. Accomplish the task quickly, with several staff members assisting.
C. Schedule the client’s shower at the same time of day.
D. Sedate the client 30 minutes prior to showering.
E. Tell the client to remain calm while showering.
F. Use a calm, supportive, quiet manner when assisting the client.
PHYSICAL SEXUAL ABUSE VIOLENCE
1. Nurse Sharie is assessing a parent who abused her child. Which of
the following risk factors would the nurse expect to find in this case?
A. Flexible role functioning between parents
B. History of the parent having been abused as a child
C. Single-parent home situation
D. Presence of parental mental illness
2. A group of nursing students at Nurseslabs University is currently
learning about family violence. Which of the following is true about the
topic mentioned?
A. Family violence affects every socioeconomic level.
B. Family violence is caused by drugs and alcohol abuse.
C. Family violence predominantly occurs in lower socioeconomic
levels.
D. Family violence rarely occurs during pregnancy.
3. During a well-child checkup, a mother tells the Nurse Rio about a
recent situation in which her child needed to be disciplined by her
husband. The child was slapped in the face for not getting her husband
breakfast on Saturday, despite being told on Thursday never to
prepare food for him. Nurse Rio analyzes the family system and
concludes it is dysfunctional. All of the following factors contribute to
this dysfunction except:
A. Conflictual relationships of parents.
B. Inconsistent communication patterns.
C. Rigid, authoritarian roles.
D. Use of violence to establish control.
4. During a home visit to a family of three: a mother, father, and their
child, The mother tells the community nurse that the father (who is not
present) had hit the child on several occasions when he was drinking.
The mother further explains that she has talked her husband into going
to Alcoholics Anonymous and asks the nurse not to interfere, so her
husband won’t get angry and refuse treatment. Which of the following
is the best response of the nurse?

A. The nurse agrees not to interfere if the husband attends an
Alcoholics Anonymous meeting that evening.
B. The nurse commends the mother’s efforts and agrees to let her
handle things.
C. The nurse commends the mother’s efforts and also contacts
protective services.
D. The nurse confronts the mother’s failure to protect the child.
5. Joseph, a 12-year-old child, complains to the school nurse about
nausea and dizziness. While assessing the child, the nurse notices a
black eye that looks like an injury. This is the third time in 1 month that
the child has visited the nurse. Each time, the child provides vague
explanations for various injuries. Which of the following is the school
nurse’s priority intervention?
A. Contact the child’s parents and ask about the child’s injury.
B. Encourage the child to be truthful with her.
C. Question the teacher about the parent’s behavior.
D. Report suspicion of abuse to the proper authorities.
6. Nurse Meredith is observing 8-year-old Anna during a community
visit. Which of the following findings would lead the nurse to suspect
that Anna is a victim of sexual abuse?
A. The child is fearful of the caregiver and other adults.
B. The child has a lack of peer relationships.
C. The child has self-injurious behavior.
D. The child has an interest in things of a sexual nature.
7. Nurse Angela is working in the emergency department of
Nurseslabs Medical Center. She is conducting an interview with a
victim of spousal abuse. Which step should the nurse take first?
A. Contact the appropriate legal services.
B. Ensure privacy for interviewing the victim away from the abuser.
C. Establish a rapport with the victim and the abuser.
D. Request the presence of a security guard.
8. Mariefer is studying about abuse for the upcoming exam. For her to
fully instill the topic, she should know that the priority nursing
intervention for a child or elder victim of abuse is:
A. Assess the scope of the abuse problem.
B. Analyze family dynamics.
C. Implement measures to ensure the victim’s safety.
D. Teach appropriate coping skills.
9. A community nurse conducts a primary prevention, home-visit
assessment for a newborn and mother. Mrs. Smith has three other
children, the oldest of whom is age 12. She tells the nurse that her 12-
year-old daughter is expected to prepare family meals, to look after the
young children, and to clean the house once a week. Which of the
following is the most appropriate nursing diagnosis for this family
situation?
A. Delayed growth and development, related to performance
expectations of the child.
B. Anxiety (moderate), related to difficulty managing the home
situation.
C. Impaired parenting, related to the role reversal of mother and child.
D. Social isolation, related to lack of extended family assistance.
10. Mrs. Smith was admitted to the emergency department of
Nurseslabs Medical Center with a fractured arm. She explains to the
nurse that her injury resulted when she provoked her drunken
husband, Mr. Smith, who then pushed her. Which of the following best
describes the nurse’s understanding of the wife’s explanation?
A. Mrs. Smith’s explanation is appropriate acceptance of her
responsibility.
B. Mrs. Smith’s explanation is an atypical reaction of an abused
woman.
C. Mrs. Smith’s explanation is evidence that the woman may be an
abuser as well as a victim.
D. Mrs. Smith’s explanation is a typical response of a victim accepting
blame for the abuser.
11. Sheila tells the community nurse that her boyfriend has been
abusive and she is afraid of him, but she doesn’t want to leave. The
client asks the nurse for assistance. Which nursing interventions are
appropriate in this situation? Select all that apply.
A. Help Sheila to develop a plan to ensure safety, including phone
numbers for emergency help.
B. Help Sheila to get her boyfriend into an appropriate treatment
program.
C. Communicate acceptance, avoiding any implication that Sheila is at
fault for not leaving.
D. Help Sheila to explore available options, including shelters and legal
protection.
E. Tell Sheila that she should leave because things will not improve.
F. Reinforce concern for Sheila’s safety and her right to be free of
abuse.
12. Which nursing assessment findings are physical signs of sexual
abuse of a female child? Select all that apply.
A. Enuresis
B. Red and swollen labia and rectum
C. Vaginal tears
D. Injuries in different stages of healing
E. Cigarette burns
F. Lice infestation
13. During a prenatal assessment, the clinic nurse suspects that her
client was abused. Which of the following questions would be most
appropriate?
A. “Are you being threatened or hurt by your partner?”
B. “Are you frightened of your partner?”
C. “Is something bothering you?”
D. “What happens when you and your partner argue?”
14. Which situation would Nurse Sally identify as placing a client at
high risk for caregiver abuse?
A. Antonia, an adult child, quits her job to move in and care for a parent
with severe dementia.
B. Mr. Wright, an elderly man with severe heart disease, resides in a
personal care home and is frequently visited by his adult child.
C. Mrs. Hale, an elderly parent with limited mobility, lives alone and
receives help from several adult children.
D. Antoinette cares for her husband who is in early stages of
Alzheimer’s disease and has a network of available support persons.
15. The interventions common to treatment plans for survivors include
which of the following? Select all that apply.
A. Establish trust and rapport.
B. Identify areas of control.
C. Remove the client from home.
D. Support the client in the decisions he/she makes.
E. Encourage the client to pursue legal action.
STRESS ANXIETY MIND BODY DO
1. Chuck is a 20-year-old student diagnosed of having obsessive-
compulsive behavior. A psychiatrist prescribes clomipramine
(Anafranil) to treat his condition. Nurse Nicolette understands the
rationale for this treatment is that the clomipramine:
A. Increases dopamine levels.
B. Increases serotonin levels.
C. Decreases norepinephrine levels.
D. Decreases GABA levels.
2. A nurse at Nurseslabs Medical Center is developing a care plan for
a female client with post-traumatic stress disorder. Which of the
following would she do initially?
A. Instruct the client to use distraction techniques to cope with
flashbacks.
B. Encourage the client to put the past in proper perspective.
C. Encourage the client to verbalize thoughts and feelings about the
trauma.
D. Avoid discussing the traumatic event with the client.
3. A group of community nurses sees and plans care for various clients
with different types of problems. Which of the following clients would
they consider the most vulnerable to post-traumatic stress disorder?
A. An eight (8)-year-old boy with asthma who has recently failed a
grade in school
B. A 20-year-old college student with DM who experienced date rape
C. A 40-year-old widower who has recently lost his wife to cancer
D. A wife of an individual with a severe substance abuse problem
4. Which outcome is most appropriate for Francis who has a
dissociative disorder?
A. Francis will deal with uncomfortable emotions on a conscious level.
B. Francis will modify stress with the use of relaxation techniques.
C. Francis will identify his anxiety responses.
D. Francis will use problem-solving strategies when feeling stressed.
5. The psychiatric nurse uses cognitive-behavioral techniques when
working with a client who experiences panic attacks. Which of the
following techniques are common to this theoretical framework? Select
all that apply.
A. Administering anti-anxiety medication as prescribed
B. Encouraging the client to restructure thoughts
C. Helping the client to use controlled relaxation breathing
D. Helping the client examine evidence of stressors
E. Questioning the client about early childhood relationships
F. Teaching the client about anxiety and panic
6. Marty is pacing and complains of racing thoughts. Nurse Lally asks
the client if something upsetting happened, and Marty’s response is
vague and not focused on the question. Nurse Lally assess Marty’s
level of anxiety as:
A. Mild.
B. Moderate.
C. Severe.
D. Panic.
7. Nurse Martha is teaching her students about anxiety medications;
she explains that benzodiazepines affect which brain chemical?
A. Acetylcholine
B. Gamma-aminobutyric acid (GABA)
C. Norepinephrine
D. Serotonin
8. Mandy, a nurse who works at Nurseslabs Rehabilitation Center is
assessing a client for recent stressful life events. She recognizes that
stressful life events are both:
A. Desirable and growth-promoting.
B. Positive and negative.
C. Undesirable and harmful.
D. Predictable and controllable.
9. During a community visit, volunteer nurses teach stress
management to the participants. The nurses will most likely advocate
which belief as a method of coping with stressful life events?
A. Avoidance of stress is an important goal for living.
B. Control over one’s response to stress is possible.
C. Most people have no control over their level of stress.
D. Significant others are important to provide care and concern.
10. Genevieve only attends social events when a family member is
also present. She exhibits behavior typical of which anxiety disorder?
A. Agoraphobia
B. Generalized anxiety disorder
C. Obsessive-compulsive disorder
D. Post-traumatic stress disorder
11. Mr. Johnson is newly admitted to a psychiatric unit because of
severe obsessive-compulsive behavior. Which initial response by the
nurse would be most therapeutic for him?
A. Accepting the client’s ritualistic behaviors
B. Challenging the client’s need for rituals
C. Expressing concern about the harmfulness of the client’s rituals
D. Limiting the client’s rituals that are excessive
12. Nurse Vicky is assessing a newly admitted client for symptoms of
post-traumatic stress disorder (PTSD). Which symptoms are typically
seen with this diagnosis? Select all that apply.
A. Anger with numbing of other emotions
B. Exaggerated startle response
C. Feeling that one is having a heart attack
D. Frequent thoughts about contamination
E. Frequent nightmares
F. Survivor’s guilt
13. Jordanne is a client with a fear of air travel. She is being treated in
a mental institution for phobic disorder. The treatment method involves
systematic desensitization. The nurse would consider the treatment
successful if:
A. Jordanne plans a trip requiring air travel.
B. Jordanne takes a short trip in an airplane.
C. Jordanne recognizes the unrealistic nature of the fear of riding on
airplanes.
D. Jordanne verbalizes a decreased fear about air travel.
14. Nurse Kerrick observes Toni who is hospitalized on an eating
disorder unit during mealtimes and for 1 hour after eating. An
explanation for this intervention is:
A. To develop a trusting relationship.
B. To maintain focus on the importance of nutrition.
C. To prevent purging behaviors.
D. To reinforce the behavioral contact.
15. Marlyn is diagnosed with anorexia nervosa and is admitted to the
special eating disorder unit. The initial treatment priority for her is:
A. To determine her current body image.
B. To identify family interaction patterns.
C. To initiate a refeeding program.
D. To promote the client’s independence.
16. The nurse evaluates the treatment of Mrs. Montez with somatoform
disorder as successful if:
A. Mrs. Montez practices self-medication rather than changing health
care providers.
B. Mrs. Montez recognizes that physical symptoms increase anxiety
level.
C. Mrs. Montez researches treatment protocols for various illnesses.
D. Mrs. Montez verbalizes anxiety directly rather than displacing it.
17. Which of the following attitudes from a nurse would hinder a
discussion with an adolescent client about sexuality?
A. Accepting
B. Matter-of-fact
C. Moralistic
D. Nonjudgemental
18. Nurse Wayne is planning a psychoeducational discussion for a
group of adolescent clients with anorexia nervosa. Which of the
following topics would Nurse Wayne select to enhance understanding
about central issues in this disorder?
A. Anger management
B. Parental expectations
C. Peer pressure and substance abuse
D. Self-control and self-esteem
19. Nurse Ginia understands that her client Glenda who is bulimic feels
shame and guilt over binge eating and purging. This disorder is
therefore considered:
A. Ego-distorting.
B. Ego-dystonic.
C. Ego-enhancing.
D. Ego-syntonic.
20. The psychoanalytic theory explains the etiology of anorexia
nervosa as:
A. The achievement of secondary gain through control of eating.
B. A conflict between mother and child over separation and
individualization.
C. Family dynamics that lead to enmeshment of members.
D. The incorporation of thinness as an ideal body image.
21. The school nurse assesses for anorexia nervosa in an adolescent
girl. Which of the following findings are characteristic of this disorder?
Select all that apply.
A. Bradycardia
B. Hypotension
C. Chronic pain in one or more sites
D. Fear of having a serious illness
E. Irregular or absent menses
F. Refusal to maintain minimally normal weight
22. Mr. Bartowski who is newly diagnosed with rheumatoid arthritis
asks the community nurse how stress can affect his disease. The
nurse would explain that:
A. The psychological experience of stress will not affect symptoms of
physical disease.
B. Psychological stress can cause painful emotions, which are harmful
to a person with an illness.
C. Stress can overburden the body’s immune system, and therefore
one can experience increased symptoms.
D. The body’s stress response is stimulated when there are major
disruptions in one’s life.
23. During a mother’s class, the nurse who is teaching the participants
on stress management is questioned about the use of alternative
treatments, such as herbal therapy and therapeutic touch. She
explains that the advantage of these methods would include all of the
following except:
A. They are congruent with many cultural belief systems.
B. They encourage the consumer to take an active role in health
management.
C. They promote interrelationships within the mind-body-spirit.
D. They usually work better than traditional medical practice.
24. David is preoccupied with numerous bodily complaints even after a
careful diagnostic workup reveals no physiologic problems. Which
nursing intervention would be therapeutic for him?
A. Acknowledge that the complaints are real to the client, and refocus
the client on other concerns and problems.
B. Challenge the physical complaints by confronting the client with the
normal diagnostic findings.
C. Ignore the client’s complaints, but request that the client keeps a list
of all symptoms.
D. Listen to the client’s complaints carefully, and question him about
specific symptoms.
25. Nurse Kenzo is teaching a client about sertraline (Zoloft), which
has been prescribed for depression. A significant side effect is an
interference with sexual arousal by inhibiting erectile function. How
should the Nurse Kenzo approach this topic?
A. Nurse Kenzo should avoid mentioning the sexual side effects to
prevent the client from having anxiety about potential erectile
problems.
B. Nurse Kenzo should advise the client to report any changes in
sexual functioning in case medication adjustments are needed.
C. Nurse Kenzo should explain that the client’s sexual desire will
probably decrease while on this medication.
D. Nurse Kenzo should tell the client that sexual side effects are
expected, but that they will decrease when his depression lifts.
PERSONALITY MOOD SUICIDE DO
1. Mrs. B is diagnosed with borderline personality disorder has a
nursing diagnosis of Risk for self-directed violence, which is related to
the client’s self-mutilation behavior (burning arms with cigarettes).
Which client behavior would indicate a positive outcome of
intervention?
A. Mrs. B denies feelings of wanting to harm anyone.
B. Mrs. B expresses feelings of anger towards others.
C. Mrs. B requests cigarettes at appropriate times.
D. Mrs. B tells the nurse about wanting to burn herself.
2. Nurse Aldrich is working with the family of Mary Ann, a client with a
personality disorder. Which of the following should Nurse Aldrich
encourage the family members to work on?
A. Avoiding direct expressions of problems with family
B. Changing Mary Ann’s problem behaviors
C. Improving self-functioning
D. Supporting Mary Ann’s defenses.
3. Nurse Florence assesses Mrs. B with borderline personality
disorder. Which of the following behaviors are common to this
diagnosis? Select all that apply.
A. Intense fear of being alone
B. Evidence of self-mutilating attempts
C. Evidence of suspiciousness and mistrust of others
D. Indifferent attitude toward approval of criticism
E. Unstable moods with impulsive behaviors
F. Presence of odd mannerisms, speech, and behaviors
4. When a client with personality disorder begins demonstrating
manipulative behavior, which of the following nursing actions are most
appropriate? Select all that apply.
A. Ask the client to think about the consequences of behavior.
B. Allow the client time to perform specific rituals.
C. Develop a consistent team approach to handle the client’s
behaviors.
D. Help the client to express anxiety verbally rather than with specific
symptoms.
E. Provide immediate feedback concerning the client’s specific
behaviors.
F. Set limits in a clear, direct manner.
5. Barbara is a client with borderline personality disorder. She is
defensive and emotionally labile and often becomes suddenly and
explosively angry. When interacting with her, you as a nurse would:
A. point out how angry Barbara is becoming, and confront the
behavior.
B. take a calm, quiet, and nonconfrontational approach, and avoid
arguing with Barbara.
C. tell Barbara to calm down and to avoid becoming explosive or
restraints will be used.
D. Use a gentle touch and a caring approach to calm Barbara.
6. Nurse Danita is working with clients who have personality disorders.
Which of the following techniques would the nurse use to deal with her
own feelings that interfere with therapeutic performance?
A. Active listening techniques
B. Challenging the client’s assertions
C. Forming social relations
D. Seeking peer or supervisor direction
7. A client with antisocial personality disorder was admitted in a unit at
Nurseslabs Hospital. The newly admitted client stole money from an
elderly in the unit. Which of the following is the most appropriate for the
nurse to say to this client?
A. “Why did you take the money?”
B. “Let’s talk about how you felt when you took the money.”
C. “The consequences of stealing are a loss of privileges.”
D. “This client is defenseless against you.”
8. Angela has a history of conflict-filled relationships. Despite an
expressed desire for friends, she acts in ways that tend to alienate
people. Which nursing intervention would be important for Angela?
A. Establish a therapeutic relationship in which the nurse uses role-
modeling and role-playing for appropriate behaviors.
B. Help the client to select friends who are kind and extra caring.
C. Point out that the client acts in ways that alienate others.
D. Recognize that this client is unlikely to change and therefore
intervention is inappropriate.
9. Tyrion describes himself as “very religious, with strong opinions
about what is right and what is wrong.” He is quite judgmental about
beliefs and lifestyles that are “unacceptable.” Which statement
supports the nurse’s analysis that this client’s behavior is typical of
someone with a personality disorder?
A. Inflexible behaviors, along with the use of rigid defense
mechanisms, are characteristic.
B. Judgmental behavior, including self-insight, is common.
C. Religious fanatics often have personality disorders.
D. Strong belief systems are common and can help identify evidence of
instability.
10. Which statement about an individual with a personality disorder is
true?
A. Psychotic behavior is common during acute episodes.
B. Prognosis for recovery is good with therapeutic intervention.
C. The individual typically remains in the mainstream of society,
although he has problems in social and occupational roles.
D. The individual usually seeks treatment willingly for symptoms that
are personally distressful.
11. Kyle is a client with an anxious, fearful personality who has
difficulty accomplishing work assignments because of his fear of
failure. He has been referred to the employee assistance program
because of repeated absences from work and evidence of an alcohol
problem. Which nursing diagnosis would be most appropriate?
A. Ineffective coping
B. Decisional conflict
C. Disturbed thought process
D. Risk for self-directed violence
12. Tekla is hospitalized at Nurseslabs Medical Center following a
suicide attempt. His history reveals a previous diagnosis of schizoid
personality disorder. Which of the following behaviors would be
atypical of a client with this disorder?
A. Actions designed to please the nurse
B. Limited expressions of feelings and emotions
C. Odd ideas and mannerisms
D. Reluctance to join group activities
13. The community nurse is following up on Mrs. Jenner who was
hospitalized at Nurseslabs Medical Center due to depressive disorder,
not otherwise specified, following the death of her spouse. In reviewing
the client’s chart, the nurse notes that Mrs. Jenner has an Axis II
diagnosis of dependent personality disorder. Which behavior would the
nurse anticipate in this client?
A. Difficulty making decisions, lack of self-confidence
B. Grandiose thinking, attention-seeking behaviors
C. Odd mannerisms, speech, and behaviors
D. Unstable moods and impulsive behaviors
14. Ralph is admitted at Nurseslabs Medical Center with the diagnosis
of bipolar disorder, single manic episode. Which of the following
behaviors would the nurse expect to assess?
A. Apathy, poor insight, and poverty of ideas
B. Anxiety, somatic complaints, and insomnia
C. Elation, hyperactivity, and impaired judgment
D. Social isolation, delusional thinking, and clang associations
15. In a day treatment program, a manic client is creating considerable
chaos, behaving in a dominating and manipulative way. Which nursing
intervention is most appropriate?
A. Allow the peer group to intervene.
B. Describe acceptable behavior and set realistic limits with the client.
C. Recommend that the client is hospitalized for treatment.
D. Tell the client that his behavior is inappropriate.
16. An individual with depression has a deficiency in which
neurotransmitters, based on the biogenic amine theory?
A. Dopamine and thyroxin
B. GABA and acetylcholine
C. Cortisone and epinephrine
D. Serotonin and norepinephrine
17. Nurse Rica is teaching a client and her family about the causes of
depression. Which of the following causative factors should the nurse
emphasize as the most significant?
A. Brain structure abnormalities
B. Chemical imbalance
C. Social environment
D. Recessive gene transmission
18. Clara is under evaluation for imminent suicide risk, which
information given by her would be most significant?
A. At least a 2-year history of feeling depressed more days than not
B. Divorced from spouse six (6) months ago
C. Feeling loss of energy and appetite
D. Reference to suicide as best solution to identified problems
19. Rendell is admitted in an acute psychiatric unit at Nurseslabs
Medical Center. He suddenly tells Nurse Matt about his plans for
suicide. The nurse’s priority is to:
A. Allow the client time alone for reflection.
B. Encourage the client to use problem solving.
C. Follow agency protocol for suicide precautions.
D. Stimulate the client’s interest in activities.
20. Which mood disorder is characterized by the client feeling
depressed most of the day for a 2-year period?
A. Cyclothymia
B. Dysthymia
C. Melancholic depressive disorder
D. Seasonal affective disorder
21. Using cognitive-behavioral therapy, which treatment would be
appropriate for a client with depression?
A. Challenging negative thinking
B. Encouraging analysis of dreams
C. Prescribing antidepressant medications
D. Using ultraviolet light therapy
22. Nurse Nadine is assessing James who is diagnosed with bipolar
disorder. The nurse would expect to find a history of:
A. A depressive episode followed by prolonged sadness.
B. A series of depressive episodes that recur periodically.
C. Symptoms of mania that may or may not be followed by depression.
D. Symptoms of mania that include delusional thoughts.
23. A client completing requirements for student teaching reports to the
nurse an incident in which a student was rude and disrespectful. The
client states, “None of the students respects my teaching ability.” The
nurse identifies this as an example of which common negative
cognition?
A. Labeling
B. Fortune telling
C. Overgeneralization
D. “Should” statement
24. The community nurse is speaking to a group of new mothers as
part of a primary prevention program. Which self-measures would be
most helpful as a strategy to decrease the occurrence of mood
disorders?
A. Keeping busy, so as not to confront problem areas
B. Medication with antidepressants
C. Use of crisis intervention services
D. Verbalizing rather than internalizing feelings
25. Nurse Marge teaches the family of a client with major depression
disorder. Which of the following information should be included in the
teaching? Select all that apply.
A. Depression is characterized by sadness, feelings of hopelessness,
and decreased self-worth
B. It is common for a pressed individual to have thoughts of suicide.
C. Attempts to cheer up a person with depression are often helpful.
D. Talk therapy, along with antidepressant medications, is usually the
treatment.
E. Someone with depression may be preoccupied with spending
money and too busy to sleep.
F. Encourage a person with depression to keep a regular routine of
activity and rest.
SCHIZOPHRENIA
1. Nurse Dorothy is evaluating care of a client with schizophrenia; the
nurse should keep which point in mind?
A. Frequent reassessment is needed and is based on the client’s
response to treatment.
B. The family does not need to be included in the care because the
client is an adult.
C. The client is too ill to learn about his illness.
D. Relapse is not an issue for a client with schizophrenia.
2. Gio told his nurse that the FBI is monitoring and recording his every
movement and that microphones have been plated in the unit walls.
Which action would be the most therapeutic response?
A. Confront the delusional material directly by telling Gio that this
simply is not so.
B. Tell Gio that this must seem frightening to him but that you believe
he is safe here.
C. Tell Gio to wait and talk about these beliefs in his one-on-one
counseling sessions.
D. Isolate Gio when he begins to talk about these beliefs.
3. Which of the following client behaviors documented in Gio’s chart
would validate the nursing diagnosis of Risk for other-directed
violence?
A. Gio’s description of being endowed with superpowers
B. Frequent angry outburst noted toward peers and staff
C. Refusal to eat cafeteria food
D. Refusal to join in group activities
4. Nurse Winona educates the family about symptom management for
when the schizophrenic client becomes upset or anxious. Which of the
following would Nurse Winona state is helpful?
A. Call the therapist to request a medication change.
B. Encourage the use of learned relaxation techniques.
C. Request that the client be hospitalized until the crisis is over.
D. Wait before the anxiety worsens before intervening.
5. Drogo who has had auditory hallucinations for many years tells
Nurse Khally that the voices prevent his participation in a social skills
training program at the community health center. Which intervention is
most appropriate?
A. Let Drogo analyze the content of the voices.
B. Advise Drogo to participate in the program when the voices cease.
C. Advise Drogo to take his medications as prescribed.
D. Teach Drogo to use thought stopping techniques.
6. Cersei is diagnosed as having disorganized schizophrenia. Which
behaviors would Nurse Sansa most likely assess in the client?
A. Absence of acute symptoms impaired role function
B. Extreme social withdrawal, odd mannerisms, and behavior
C. Psychomotor immobility; presence of waxy flexibility
D. Suspiciousness toward others increased hostility
7. Jaime has a diagnosis of schizophrenia with negative symptoms. In
planning care for the client, Nurse Brienne would anticipate a problem
with:
A. Auditory hallucinations.
B. Bizarre behaviors.
C. Ideas of reference.
D. Motivation for activities.
8. The family of a schizophrenic client asks the nurse if there is a
genetic cause of this disorder. To answer the family, which fact would
the nurse cite?
A. Conclusive evidence indicates a specific gene transmits the
disorder.
B. Incidence of this disorder is variable in all families.
C. There is a little evidence that genes play a role in transmission.
D. Genetic factors can increase the vulnerability for this disorder.
9. Ramsay is diagnosed with schizophrenia paranoid type and is
admitted to the psychiatric unit of Nurseslabs Medical Center. Which of
the following nursing interventions would be most appropriate?
A. Establishing a non-demanding relationship
B. Encouraging involvement in group activities
C. Spending more time with Ramsay
D. Waiting until Ramsay initiates interaction
10. A client tells the nurse that psychotropic medicines are dangerous
and refuses to take them. Which intervention should the nurse use
first?
A. Ask the client about any previous problems with psychotropic
medications.
B. Ask the client if an injection is preferable.
C. Insist that the client takes medication as prescribed.
D. Withhold the medication until the client is less suspicious.
11. Upon Sam’s admission for acute psychiatric hospitalization, Nurse
Jona documents the following: Client refuses to bathe or dress,
remains in room most of the day, speaks infrequently to peers or staff.
Which nursing diagnosis would be the priority at this time?
A. Anxiety
B. Decisional conflict
C. Self-care deficit
D. Social isolation
12. Which statement is correct about a 25-year-old client with newly
diagnosed schizophrenia?
A. Age of onset is typical for schizophrenia.
B. Age of onset is later than usual for schizophrenia.
C. Age of onset is earlier than usual for schizophrenia.
D. Age of onset follows no predictable pattern in schizophrenia.
13. Which factor is associated with increased risk for schizophrenia?
A. Alcoholism
B. Adolescent pregnancy
C. Overcrowded schools
D. Poverty
14. Nurse Arya assesses for evidence of positive symptoms of
schizophrenia in a newly admitted client. Which of the following
symptoms are considered positive evidence? Select all that apply.
A. Anhedonia
B. Delusions
C. Flat affect
D. Hallucinations
E. Loose associations
F. Social withdrawal
15. A client with schizophrenia is referred for psychosocial
rehabilitation. Which of the following are typical of this type of
program? Select all that apply.
A. Analyzing family issues and past problems
B. Developing social skills and supports
C. Learning how to live independently in a community
D. Learning job skills for employment
E. Treating family members affected by the illness
F. Participating in in-depth psychoanalytical counseling
MOOD DO SUBSTANCE ABUSE
1. The nurse is planning activities for a client who has bipolar disorder
with aggressive social behavior. Which of the following activities would
be most appropriate for this client?
1. Ping pong
2. Writing
3. Chess
4. Basketball
2. A client is admitted to the hospital with a diagnosis of major
depression, severe, single episode. The nurse assesses the client and
identifies a nursing diagnosis of imbalanced nutrition related to poor
nutritional intake. The most appropriate nursing intervention related to
this diagnosis is:
1. Explain to the client the importance of a good nutritional intake
2. Weight the client 3 times per week before breakfast
3. Report the nutritional concern to the psychiatrist and obtain a
nutritional consultation as soon as possible.
4. Consult with the nutritionist, offer the client several small meals per
day, and schedule brief nursing interactions with the client during these
times.
3. In planning activities for the depressed client, especially during the
early stages of hospitalization, which of the following plans is best?
1. Provide an activity that is quiet and solitary to avoid increased
fatigue, such as working on a puzzle or reading a book.
2. Plan nothing until the client asks to participate in milieu.
3. Offer the client a menu of daily activities and insist the client
participate in all of them
4. Provide a structured daily program of activities and encourage the
client to participate.
4. The depressed client verbalizes feelings of low self-esteem and self-
worth typified by statements such as “I’m such a failure… I can’t do
anything right!” The best nursing response would be:
1. To tell the client this is not true; that we all have a purpose in life.
2. To remain with the client and sit in silence; this will encourage the
client to verbalize feelings
3. To reassure the client that you know how the client is feeling and
that things will get better
4. To identify recent behaviors or accomplishments that demonstrates
skill ability.
5. A client with a diagnosis of major depression, recurrent with
psychotic features is admitted to the mental health unit. To create a
safe environment for the client, the nurse most importantly devises a
plan of care that deals specifically with the client’s:
1. Disturbed thought processes
2. Imbalanced nutrition
3. Self-care deficit
4. Deficient knowledge
6. A depressed client is ready for discharge. The nurse feels
comfortable that the client has a good understanding of the disease
process when the client states:
1. “I’ll never let this happen to me again. I won’t let my boss or my job
or my family get to me!”
2. “It’s important for me to eat well, exercise, and to take my
medication. If I begin to lose my appetite or not sleep well, I’ve got to
get in to see my doctor.”
3. “I’ve learned that I’m a good person and that I am worthy of giving
and receiving love. I don’t need anyone; I have myself to rely on!”
4. “I don’t know what happened to me. I’ve always been able to make
decisions for myself and for my business. I don’t ever want to feel so
weak or vulnerable again!”
7. The nurse assesses a client with the admitting diagnosis of bipolar
affective disorder, mania. The symptom presented by the client that
requires the nurse’s immediate intervention is the client’s:
1. Outlandish behaviors and inappropriate dress
2. Grandiose delusions of being a royal descendant of King Arthur.
3. Nonstop physical activity and poor nutritional intake
4. Constant, incessant talking that includes sexual innuendoes and
teasing the staff
8. The nurse reviews the activity schedule for the day and plans which
activity for the manic client?
1. Brown-bag luncheon and book review
2. Tetherball
3. Paint-by-number activity
4. Deep breathing and progressive relaxation group
9. A hospitalized client is being considered for ECT. The client appears
calm, but the family is anxious. The client’s mother begins to cry and
states “My son’s brain will be destroyed. How can the doctor do this to
him?” The nurses best response is:
1. “It sounds as though you need to speak with the psychiatrist”
2. “Your son has decided to have this treatment. You should be
supportive of him.”
3. “Perhaps you’d like to see the ECT room and speak to the staff.”
4. “It sounds as though you have some concerns about the ECT
procedure. Why don’t we sit down together and discuss any concerns
you may have.”
10. The manic client announces to everyone in the dayroom that a
stripper is coming to perform this evening. When the nurse firmly states
that this will not happen, the manic client becomes verbally abusive
and threatens physical violence to the nurse. Based on the analysis of
this situation, the nurse determines that the most appropriate action
would be to:
1. With assistance, escort the manic client to her room and administer
Haldol as prescribed if needed
2. Tell the client that smoking privileges are revoked for 24 hours
3. Orient the client to time, person, and place
4. Tell the client that the behavior is not appropriate.
11. Select all nursing interventions for a hospitalized client with mania
who is exhibiting manipulative behavior.
1. Communicate expected behaviors to the client
2. Enforce rules and inform the client the he or she will not be allowed
to attend group therapy sessions.
3. Ensure that the client knows that he or she is not in charge of the
nursing unit
4. Be clear with the client regarding the consequences of exceeding
limits set regarding behavior.
5. Assist the client in testing out alternative behaviors for obtaining
needs
12. A woman comes into the ER in a severe state of anxiety following a
car accident. The most appropriate nursing intervention is to:
1. Remain with the client
2. Put the client in a quiet room
3. Teach the client deep breathing
4. Encourage the client to talk about their feelings and concern.
13. When planning the discharge of a client with chronic anxiety, the
nurse directs the goals at promoting a safe environment at home. The
most appropriate maintenance goal should focus on which of the
following?
1. Continued contact with a crisis counselor
2. Identifying anxiety-producing situations
3. Ignoring feelings of anxiety
4. Eliminating all anxiety from daily situations
14. The nurse is monitoring a client who abuses alcohol for signs of
alcohol withdrawal. Which of the following would alert the nurse to the
potential for delirium tremors?
1. Hypertension, changes in LOC, hallucinations
2. Hypotension, ataxia, hunger
3. Stupor, agitation, muscular rigidity
4. Hypotension, coarse hand tremors, agitation
3. Work with the client to take steps to move on with his life
4. Help the client accept positive and negative feelings
21. Which of the following psychological symptoms would the nurse
expect to find in a hospitalized client who is the only survivor of a train
accident?
1. Denial
2. Indifference
3. Perfectionism
4. Trust
22. Which of the following communication guidelines should the nurse
use when talking with a client experiencing mania?
1. Address the client in a light and joking manner
2. Focus and redirect the conversation as necessary
3. Allow the client to talk about several different topic
4. Ask only open ended questions to facilitate conversations
23. What information is important to include in the nutritional
counseling of a family with a member who has bipolar disorder?

15. The spouse of a client admitted to the mental health unit for alcohol 1. If sufficient roughage isn’t eaten while taking lithium, bowel problems
withdrawal says to the nurse “I should get out of this bad situation.” will occur.
The most helpful response by the nurse would be: 2. If the intake of carbohydrates increases, the lithium level increases.
3. If the intake of calories is reduced, the lithium level will increase
1. “I agree with you. You should get out of this situation.” 4. If the intake of sodium increases, the lithium level will decrease.
2. “What do you find difficult about this situation?”
3. “Why don’t you tell your husband about this?” 24. In conferring with the treatment team, the nurse should make which
4. “This is not the best time to make that decision.” of the following recommendations for a client who tells the nurse that
everyday thoughts of suicide are present?
16. The nurse determines that the wife of an alcoholic client is
benefiting from attending Al-Anon group when she hears the wife say: 1. A no-suicide contract
2. Weekly outpatient therapy
1. “My attendance at the meetings has helped me to see that I provoke 3. A second psychiatric opinion
my husband’s violence.” 4. Intensive inpatient treatment
2. “I no longer feel that I deserve the beatings my husband inflicts on
me.” 25. Which of the following short term goals is most appropriate for a
3. “I can tolerate my husband’s destructive behavior now that I know client with bipolar disorder who is having difficulty sleeping?
they are common with alcoholics.”
4. “I enjoy attending the meetings because they get me out of the 1. Obtain medication for sleep
house and away from my husband.” 2. Work on solving a problem
3. Exercise before bedtime
17. The client has been hospitalized and is participating in a substance 4. Develop a sleep ritual
abuse therapy group sessions. On discharge, the client has consented
to participate in AA community groups. The nurse is monitoring the PERSONALITY DO 1
client’s response to the substance abuse sessions. Which statement
by the client best indicates that the client has developed effective 1. The nursing diagnosis that would be most appropriate for a 22-year
coping response styles and has processed information effectively for old client who uses ritualistic behavior would be:
self use?
1. Ineffective coping
1. “I know I’m ready to be discharged. I feel I can say ‘no’ and leave a 2. Impaired adjustment
group of friends if they are drinking… ‘No Problem.’” 3. Personal identity disturbance
2. “This group has really helped a lot. I know it will be different when I 4. Sensory/perceptual alterations
go home. But I’m sure that my family and friends will all help me like
the people in this group have… They’ll all help me… I know they will… 2. A psychiatrist prescribes an anti-obsessional agent for a client who
They won’t let me go back to my old ways.” is using ritualistic behavior. A common anti-anxiety medication used for
3. “I’m looking forward to leaving here. I know that I will miss all of you. this type of client would be:
So, I’m happy and I’m sad, I’m excited and I’m scared. I know that I
have to work hard to be strong and that everyone isn’t going to be as 1. Fluvoxamine (Luvox)
helpful as you people.” 2. Benztropine (Cogentin)
4. “I’ll keep all my appointments; go to all my AA groups; I’ll do 3. Amantadine (Symmetrel)
everything I’m supposed to… Nothing will go wrong that way.” 4. Diphenhydramine (Benadryl)

18. A hospitalized client with a history of alcohol abuse tells the nurse, 3. A 20-year old college student has been brought to the psychiatric
“I am leaving now. I have to go. I don’t want anymore treatment. I have hospital by her parents. Her admitting diagnosis is borderline
things that I have to do right away.” The client has not been personality disorder. When talking with the parents, which information
discharged. In fact, the client is scheduled for an important diagnostic would the nurse expect to be included in the client’s history? Select all
test to be performed in 1 hour. After the nurse discusses the client’s that apply.
concerns with the client, the client dresses and begins to walk out of
the hospital room. The most important nursing action is to: 1. Impulsiveness
2. Lability of mood
1. Restrain the client until the physician can be reached 3. Ritualistic behavior
2. Call security to block all areas 4. psychomotor retardation
3. Tell the client that the client cannot return to this hospital again if the 5. Self-destructive behavior
client leaves now.
4. Call the nursing supervisor. 4. A hospitalized client, diagnosed with a borderline personality
disorder, consistently breaks the unit’s rules. This behavior should be
19. Select the appropriate interventions for caring for the client in confronted because it will help the client:
alcohol withdrawal.
1. Control anger
1. Monitor vital signs 2. Reduce anxiety
2. Provide stimulation in the environment 3. Set realistic goals
3. Maintain NPO status 4. Become more self-aware
4. Provide reality orientation as appropriate
5. Address hallucinations therapeutically 5. When working with the nurse during the orientation phase of the
relationship, a client with a borderline personality disorder would
20. Which of the following nursing actions would be included in a care probably have the most difficulty in:
plan for a client with PTSD who states the experience was “bad luck”?
1. Controlling anxiety
1. Encourage the client to verbalize the experience 2. Terminating the session on time
2. Assist the client in defining the experience 3. Accepting the psychiatric diagnosis
4. Setting mutual goals for the relationship
6. A client with a diagnosis of borderline personality disorder has
negative feelings toward the other clients on the unit and considers
them all to be “bad.” The nurse understands this defense is known as:
1. Splitting
2. Ambivalence
3. Passive aggression
4. Reaction formation
7. The client with antisocial personality disorder:
1. Suffers from a great deal of anxiety
2. Is generally unable to postpone gratification
3. Rapidly learns by experience and punishment
4. Has a great sense of responsibility toward others
8. A person with antisocial personality disorder has difficulty relating to
others because of never having learned to:
1. Count on others
2. Empathize with others
3. Be dependent on others
4. Communicate with others socially
9. A young, handsome man with a diagnosis of antisocial personality
disorder is being discharged from the hospital next week. He asks the
nurse for her phone number so that he can call her for a date. The
nurse’s best response would be:
1. “We are not permitted to date clients.”
2. “No, you are a client and I am a nurse.”
3. “I like you, but our relationship is professional.”
4. “It’s against my professional ethics to date clients.”
10. When caring for a client with a diagnosis of schizotypal personality
disorder, the nurse should:
1. Set limits on manipulative behavior
2. Encourage participation in group therapy
3. Respect the client’s needs for social isolation
4. Understand that seductive behavior is expected.
11. A nurse is orienting a new client to the unit when another client
rushes down the hallway and asks the nurse to sit down and talk. The
client requesting the nurse’s attention is extremely manipulative and
uses socially acting-out behaviors when demands are unmet. The
nurse should:
1. Suggest that the client requesting attention speak with another staff
member
2. Leave the new client and talk with the other client to avoid
precipitating acting out behavior
3. Tell the interrupting client to sit down and be patient, stating, “I’ll be
back as soon as possible.”
4. Introduce the two clients and suggest that the client join the new
client and the nurse on the tour
12. A client with a diagnosis of narcissistic personality disorder has
been given a day pass from the psychiatric hospital. The client is due
to return at 6pm. At 5pm the client telephones the nurse in charge of
the unit and says “6 o’clock is too early. I feel like coming back at 7:30.”
The nurse would be most therapeutic by telling the client to:
1. Return immediately, to demonstrate control
2. Return on time or restrictions will be imposed
3. Come back at 6:45, as a compromise to set limits
4. Come back as soon as possible or the police will be sent
13. An adult client with a borderline personality disorder become
nauseated and vomits immediately after drinking after drinking 2
ounces of shampoo as a suicide gesture. The most appropriate initial
response by the nurse would be to:
1. Promptly notify the attending physician
2. Immediately initiate suicide precautions
3. Sit quietly with the client until nausea and vomiting subsides
4. Assess the client’s vital signs and administer syrup of ipecac
14. A nurse notices that a client is mistrustful and shows hostile
behavior. Which of the following types of personality disorder is
associated with these characteristics?
1. Antisocial
2. Avoidant
3. Borderline
4. Paranoid
15. Which of the following statements is typical for a client diagnosed
with a personality disorder?
1. “I understand you’re the one to blame.”
2. “I must be seen first; it’s not negotiable.”
3. “I see nothing humorous in this situation.”
4. “I wish someone would select the outfit for me.”
16. Which of the following characteristics is expected for a client with
paranoid personality disorder who receives bad news?
1. The client is overly dramatic after hearing the facts
2. The client focuses on self to not become over-anxious
3. The client responds from a rational, objective point of view
4. The client doesn’t spend time thinking about the information.
17. Which of the following types of behavior is expected from a client
diagnosed with a paranoid personality disorder?
1. Eccentric
2. Exploitative
3. Hypersensitive
4. Seductive
18. Which of the following interventions is important for a client with
paranoid personality disorder taking olanzapine (Zyprexa)?
1. Explain effects of serotonin syndrome
2. Teach the client to watch for extrapyramidal adverse reactions
3. Explain that the drug is less effective if the client smokes
4. Discuss the need to report paradoxical effects such as euphoria.
19. A client with antisocial personality is trying to convince a nurse that
he deserves special privileges and that an exception to the rules
should be made for him. Which of the following responses is the most
appropriate?
1. “I believe we need to sit down and talk about this.”
2. “Don’t you know better than to try to bend the rules?”
3. “What you’re asking me to do is unacceptable.”
4. “Why don’t you bring this request to the community meeting?”
20. A nurse notices other clients on the unit avoiding a client diagnosed
with antisocial personality disorder. When discussing appropriate
behavior in group therapy, which of the following comments is
expected about this client by his peers?
1. Lack of honesty
2. Belief in superstitions
3. Show of temper tantrums
4. Constant need for attention
21. Which of the following characteristics or client histories
substantiates a diagnosis of antisocial personality disorder?
1. Delusional thinking
2. Feelings of inferiority
3. Disorganized thinking
4. Multiple criminal charges
22. A client with borderline personality disorder is admitted to the unit
after slashing his wrist. Which of the following goals is most important
after promoting safety?
1. Establish a therapeutic relationship with the client
2. Identify whether splitting is present in the client’s thoughts
3. Talk about the client’s acting out and self-destructive tendencies.
4. Encourage the client to understand why he blames others
23. Which of the following characteristics or situations is indicated
when a client with borderline personality disorder has a crisis?
1. Antisocial behavior
2. Suspicious behavior
3. Relationship problems
4. Auditory hallucinations
24. Which of the following assessment findings is seen in a client
diagnosed with borderline personality disorder?
1. Abrasions in various healing stages
2. Intermittent episodes of hypertension
3. Alternating tachycardia and bradycardia
4. Mild state of euphoria with disorientation
25. In planning care for a client with borderline personality disorder, a
nurse must be aware that this client is prone to develop which of the
following conditions?
1. Binge eating
2. Memory loss
3. Cult membership
4. Delusional thinking
26. Which of the following statements is expected from a client with
borderline personality disorder with a history of dysfunctional
relationships?
1. “I won’t get involved in another relationship.”
2. “I’m determined to look for the perfect partner.”
3. “I’ve decided to use better communication skills.”
4. “I’m going to be an equal partner in a relationship.”
27. Which of the following conditions is likely to coexist in clients with a
diagnosis of borderline personality disorder?
1. Avoidance
2. Delirium
3. Depression
4. Disorientation
28. Which of the following nursing interventions has priority for a client
with borderline personality disorder?
1. Maintain consistent and realistic limits
2. Give instructions for meeting basic self-care needs
3. Engage in daytime activities to stimulate wakefulness
4. Have the client attend group therapy on a daily basis
29. A nurse is assessing a client diagnosed with dependent personality
disorder. Which of the following characteristics is a major component to
this disorder?
1. Abrasive to others
2. Indifferent to others
3. Manipulative of others
4. Over-reliance on others
30. Which of the following information must be included for the family
of a client diagnosed with dependent personality disorder?
1. Address coping skills
2. Explore panic attacks
3. Promote exercise programs
4. Decrease aggressive outbursts
31. Which of the following behaviors by a client with dependent
personality disorder shows the client has made progress toward the
goal of increasing problem solving skills?
1. The client is courteous
2. The client asks questions
3. The client stops acting out
4. The client controls emotions
32. A client with schizotypal personality disorder is sitting in a puddle of
urine. She’s playing in it, smiling, and softly singing a child’s song.
Which action would be best?
1. Admonish the client for not using the bathroom
2. Firmly tell the client that her behavior is unacceptable
3. Ask the client if she’s ready to get cleaned up now
4. Help the client to the shower, and change the bedclothes.
33. A client with avoidant personality disorder says occupational
therapy is boring and doesn’t want to go. Which action would be best?
1. State firmly that you’ll escort him to OT.
2. Arrange with OT for the client to do a project on the unit.
3. Ask the client to talk about why OT is boring
4. Arrange for the client not to attend OT until he is feeling better
34. A nurse discusses job possibilities with a client with schizoid
personality disorder. Which suggestion by the nurse would be helpful?
1. “You can work in a family restaurant part-time on the weekend and
holidays.”
2. “Maybe your friend could get you that customer service job where
you work only on the weekends.”
3. “Your idea of applying for the position of filing and organizing
records is worth pursuing.”
4. “Being an introvert limits the employment opportunities you can
pursue.”
35. When assessing a client diagnosed with impulse control disorder,
the nurse observes violent, aggressive, and assaultive behavior. Which
of the following assessment data is the nurse also likely to find? Select
all that apply.
1. The client functions well in other areas of his life.
2. The degree of aggressiveness is out of proportion to the stressor.
3. The violent behavior is most often justified by the stressor.
4. The client has a history of parental alcoholism and chaotic, abusive
family life.
5. The client has no remorse about the inability to control his anger.
PERSONALITY DO 2
1. Which is the best indicator of success in the long term management
of the client?
A. His symptoms are replaced by indifference to his feelings
B. He participates in diversionary activities.
C. He learns to verbalize his feelings and concerns
D. He states that his behavior is irrational.
2. Situation: A young woman is brought to the emergency room
appearing depressed. The nurse learned that her child died a year ago
due to an accident. The initial nursing diagnosis is dysfunctional
grieving. The statement of the woman that supports this diagnosis is:
A. “I feel envious of mothers who have toddlers”
B. “I haven’t been able to open the door and go into my baby’s room “
C. “I watch other toddlers and think about their play activities and I cry.”
D. “I often find myself thinking of how I could have prevented the death.
3. The client said “I can’t even take care of my baby. I’m good for
nothing.” Which is the appropriate nursing diagnosis?
A. Ineffective individual coping related to loss.
B. Impaired verbal communication related to inadequate social skills.
C. Low esteem related to failure in role performance
D. Impaired social interaction related to repressed anger.
4. The following medications will likely be prescribed for the client
EXCEPT:
A. Prozac
B. Tofranil
C. Parnate
D. Zyprexa
5. Which is the highest priority in the post-ECT care?
A. Observe for confusion
B. Monitor respiratory status
C. Reorient to time, place and person
D. Document the client’s response to the treatment
6. Situation: A 27-year-old writer is admitted for the second time
accompanied by his wife. He is demanding, arrogant, talked fast and
hyperactive. Initially, the nurse should plan this for a manic client:
A. Set realistic limits to the client’s behavior
B. Repeat verbal instructions as often as needed
C. Allow the client to get out feelings to relieve tension
D. Assign a staff to be with the client at all times to help maintain
control
7. An activity appropriate for the client is:
A. Table tennis
B. Painting
C. Chess
D. Cleaning
8. The client is arrogant and manipulative. In ensuring a therapeutic
milieu, the nurse does one of the following:
A. Agree on a consistent approach among the staff assigned to the
client.
B. Suggest that the client take a leading role in the social activities
C. Provide the client with extra time for one on one sessions
D. Allow the client to negotiate the plan of care
9. The nurse exemplifies an awareness of the rights of a client whose
anger is escalating by:
A. Taking a directive role in verbalizing feelings
B. Using an authoritarian, confrontational approach
C. Putting the client in a seclusion room
D. Applying mechanical restraints
10. A client on Lithium has diarrhea and vomiting. What should the
nurse do first:
A. Recognize this as a drug interaction
B. Give the client Cogentin
C. Reassure the client that these are common side effects of lithium
therapy
D. Hold the next dose and obtain an order for a stat serum lithium level
11. Situation: A widow age 28, whose husband died one (1) year ago
due to AIDS, has just been told that she has AIDS. Panky says to the
nurse, “Why me? How could God do this to me?” This reaction is one
of:
A. Depression
B. Denial
C. anger
D. bargaining
12. The nurse’s therapeutic response is:

A. “I will refer you to a clergy who can help you understand what is
happening to you.”
B. “ It isn’t fair that an innocent like you will suffer from AIDS.”
C. “That is a negative attitude.”
D. ”It must really be frustrating for you. How can I best help you?”
13. One morning the nurse sees the client in a depressed mood. The
nurse asks her “What are you thinking about?” This communication
technique is:
A. Focusing
B. Validating
C. Reflecting
D. Giving broad opening
14. The client says to the nurse “Pray for me” and entrusts her wedding
ring to the nurse. The nurse knows that this may signal which of the
following:
A. Anxiety
B. Suicidal ideation
C. Major depression
D. Hopelessness
15. Which of the following interventions should be prioritized in the care
of the suicidal client?
A. Remove all potentially harmful items from the client’s room.
B. Allow the client to express feelings of hopelessness.
C. Note the client’s capabilities to increase self-esteem.
D. Set a “no suicide” contract with the client.
16. Situation: A 14-year-old male was admitted to a medical ward due
to bronchial asthma after learning that his mother was leaving soon for
U.K. to work as a nurse. The client has which of the following
developmental focus:
A. Establishing a relationship with the opposite sex and career
planning.
B. Parental and societal responsibilities.
C. Establishing one’s sense of competence in school.
D. Developing initial commitments and collaboration in work
17. The personality type of Ryan is:
A. Conforming
B. Dependent
C. Perfectionist
D. Masochistic
18. The nurse ensures a therapeutic environment for the client. Which
of the following best describes a therapeutic milieu?
A. A therapy that rewards adaptive behavior
B. A cognitive approach to change behavior
C. A living, learning or working environment.
D. A permissive and congenial environment
19. Included as a priority of care for the client will be:
A. Encourage verbalization of concerns instead of demonstrating them
through the body
B. Divert attention toward activities
C. Place in semi-fowlers position and render O2 inhalation as ordered
D. Help her recognize that her physical condition has an emotional
component
20. The client is concerned about his coming discharge, manifested by
being unusually sad. Which is the most therapeutic approach by the
nurse?
A. “You are much better than when you were admitted so there’s no
reason to worry.”
B. “What would you like to do now that you’re about to go home?”
C. “You seem to have concerns about going home.”
D. “Aren’t you glad that you’re going home soon?”
21. Situation: The nurse may encounter clients with concerns on
sexuality. The most basic factor in the intervention with clients in the
area of sexuality is:
A. Knowledge about sexuality.
B. Experience in dealing with clients with sexual problems
C. Comfort with one’s sexuality
D. Ability to communicate effectively
22. Which of the following statements is true for gender identity
disorder?
A. It is a sexual pleasure derived from inanimate objects.
B. It is a pleasure derived from being humiliated and made to suffer
C. It is a pleasure of shocking the victim with exposure of the genitalia
D. It is the desire to live or involve in reactions of the opposite sex
23. The sexual response cycle in which the sexual interest continues to
build:
A. Sexual Desire
B. Sexual arousal
C. Orgasm
D. Resolution
24. The inability to maintain the physiologic requirements in sexual
intercourse is:
A. Sexual Desire Disorder
B. Sexual Arousal Disorder
C. Orgasm Disorder
D. Sexual Pain Disorder
25. The nurse asks a client to roll up his sleeves so she can take his
blood pressure. The client replies “If you want I can go naked for you.”
The most therapeutic response by the nurse is:
A. “You’re attractive, but I’m not interested.”
B. “You wouldn’t be the first that I will see naked.”
C. “I will report you to the guard if you don’t control yourself.”
D. “I only need access to your arm. Putting up your sleeve is fine.”
26. Situation: Knowledge and skills in the care of violent clients is vital
in the psychiatric unit. A nurse observes that a client with a potential for
violence is agitated, pacing up and down the hallway and making
aggressive remarks. Which of the following statements is most
appropriate to make to this patient?
A. What is causing you to become agitated?
B. You need to stop that behavior now.
C. You will need to be restrained if you do not change your behavior.
D. You will need to be placed in seclusion.
27. The nurse closely observes the client who has been displaying
aggressive behavior. The nurse observes that the client’s anger is
escalating. Which approach is least helpful for the client at this time?
A. Acknowledge the client’s behavior
B. Maintain a safe distance from the client
C. Assist the client to an area that is quiet
D. Initiate confinement measures
28. The charge nurse of a psychiatric unit is planning the client
assignment for the day. The most appropriate staff to be assigned to a
client with a potential for violence is which of the following:
A. A timid nurse
B. A mature, experienced nurse
C. an inexperienced nurse
D. a soft-spoken nurse
29. The nurse exemplifies an awareness of the rights of a client whose
anger is escalating by:
A. Taking a directive role in verbalizing feelings
B. Using an authoritarian, confrontational approach
C. Putting the client in a seclusion room
D. Applying mechanical restraints
30. The client jumps up and throws a chair out of the window. He was
restrained after his behavior can no longer be controlled by the staff.
Which of these documentations indicates the safeguarding of the
patient’s rights?
A. There was a doctor’s order for restraints/seclusion
B. The patient’s rights were explained to him.
C. The staff observed confidentiality
D. The staff carried out less restrictive measures but were
unsuccessful.
31. Situation: Clients with personality disorders have difficulties in their
social and occupational functions.
Clients with a personality disorder will most likely:
A. Recover with therapeutic intervention
B. Respond to antianxiety medication
C. Manifest enduring patterns of inflexible behaviors
D. Seek treatment willingly from some personally distressing symptoms
32. A client tends to be insensitive to others, engages in abusive
behaviors and does not have a sense of remorse. Which personality
disorder is he likely to have?
A. Narcissistic
B. Paranoid
C. Histrionic
D. Antisocial
33. The client joins a support group and frequently preaches against 44. Crisis intervention carried out to the client has this primary goal:
abuse, is demonstrating the use of:
A. Assist the client to express her feelings
A. Denial B. Help her identify her resources
B. Reaction formation C. Support her adaptive coping skills
C. Rationalization D. Help her return to her pre-rape level of function
D. Projection
45. Five months after the incident the client complains of difficulty to
34. A teenage girl is diagnosed to have borderline personality disorder. concentrate, poor appetite, inability to sleep and guilt. She is likely
Which manifestations support the diagnosis? suffering from:

A. Lack of self-esteem, strong dependency needs, and impulsive A. Adjustment disorder

behavior
B. Social withdrawal, inadequacy, sensitivity to rejection and criticism
C. Suspicious, hypervigilance and coldness
D. Preoccupation with perfectionism, orderliness, and need for control
35. The plan of care for clients with borderline personality should
include:
B. Somatoform Disorder
C. Generalized Anxiety Disorder
D. Post traumatic disorder
46. Situation: A 29-year-old client newly diagnosed with breast cancer
is pacing, with rapid speech headache and inability to focus on what
the doctor was saying. The nurse assesses the level of anxiety as:

A. Limit setting and flexibility in schedule A. Mild

B. Giving medications to prevent acting out B. Moderate
C. Restricting her from other clients C. Severe
D. Ensuring she adheres to certain restrictions D. Panic

36. Situation: A 42-year-old male client, is admitted to the ward 47. Anxiety is caused by:
because of bizarre behaviors. He was given a diagnosis of
schizophrenia paranoid type. The client should have achieved the A. An objective threat
developmental task of: B. A subjectively perceived threat
C. Hostility turned to the self
A. Trust vs. mistrust D. Masked depression
B. Industry vs. Inferiority
C. Generativity vs. stagnation 48. It would be most helpful for the nurse to deal with a client with
D. Ego integrity vs. despair severe anxiety by:

37. Clients who are suspicious primarily use projection for which A. Give specific instructions using speak in concise statements.
purpose: B. Ask the client to identify the cause of her anxiety.
C. Explain in detail the plan of care developed
A. Deny reality D. Urge the client to focus on what the nurse is saying
B. To deal with feelings and thoughts that are not acceptable
C. To show resentment towards others 49. Which of the following medications will likely be ordered for the
D. Manipulate others client?”

38. The client says “ the FBI is out to get me.” The nurse’s best A. Prozac
response is: B. Valium
C. Risperdal
A. “The FBI is not out to catch you.” D. Lithium
B. “I don’t believe that.”
C. “I don’t know anything about that. You are afraid of being harmed.” 50. Which of the following is included in the health teachings among
D. “ What made you think of that.” clients receiving Valium?:

39. The client on Haldol has pill rolling tremors and muscle rigidity. He A. Avoid foods rich in tyramine.
is likely manifesting: B. Take the medication after meals.
C. It is safe to stop it anytime after long term use.
A. Tardive dyskinesia D. Double up the dose if the client forgets her medication.
B. Pseudoparkinsonism
C. Akinesia CHILDHOOD PSYCH DO
D. Dystonia
1. Martin Sanchez is a nine (9)-year-old child admitted to a psychiatric
40. The client is very hostile toward one of the staff for no apparent treatment unit accompanied by Mr. and Mrs. Sanchez. To establish
reason. The client is manifesting: trust and position of neutrality, which action would the nurse take?

A. Splitting A. Encourage Mr. and Mrs. Sanchez to leave while Martin is being
B. Transference interviewed.
C. Countertransference B. Interview Martin with his parents together, observing their
D. Resistance interaction.
C. Provide diversion for Martin, and interview Mr. and Mrs. Sanchez
41. Situation: An 18-year-old female is sexually attacked while on her alone.
way home from work. She was brought to the hospital by her mother. D. Review the clinical record prior to interviewing Mr. and Mrs.
Rape is an example of which type of crisis: Sanchez.

A. Situational 2. Nurse Bennet is a community nurse practicing primary prevention for

B. Adventitious
C. Developmental
D. Internal
42. During the initial care of rape victims, the following are to be
considered EXCEPT:
A. Assure privacy.
B. Touch the client to show acceptance and empathy
C. Accompany the client to the examination room.
D. Maintain a non-judgmental approach.
43. The nurse acts as a patient advocate when she does one of the
following:
A. She encourages the client to express her feeling regarding her
experience.
B. She assesses the client for injuries.
C. She postpones the physical assessment until the client is calm
D. Explains to the client that her reactions are normal
psychiatric disorders in children. On which of the following risk factors
would he focus?
A. Being raised in a single-parent home
B. Family history of mental illness
C. Lack of peer friendship
D. Family culture
3. Nurse Daya, a school nurse, is meeting with the school and health
treatment team about a child who has been receiving methylphenidate
(Ritalin) for two (2) months. The meeting is to evaluate the results of
the child’s medication use. Which behavior change noted by the
teacher will help determine the medication’s effectiveness.
A. Decrease repetitive behaviors
B. Decreased signs of anxiety
C. Increased depressed mood
D. Increased ability to concentrate on tasks
4. Which behavioral assessment in a child is most consistent with a
diagnosis of conduct disorder?

A. Arguing with adults
B. Gross impairment in communication
C. Physical aggression toward others
D. Refusal to separate from caretaker
5. Alexi who has separation anxiety disorder has not attended school
for three (3) weeks, and she cries and exhibits clinging behaviors when
her mother encourages attendance. The priority nursing action by the
home-care psychiatric nurse would be to:
A. Assist the child in returning to school immediately with family
support.
B. Arrange for a home-school teacher to visit for two (2) weeks
C. Encourage family discussion of various problem areas.
D. Use play therapy to help the child express her feelings.
6. A 15-year-old boy was hospitalized in a psychiatric unit because he
initiates frequent fights with peers. Which implementation is most
appropriate?
A. Anticipate and neutralize potentially explosive situations.
B. Ignore minor infractions of rules against fighting.
C. Isolate the adolescent from contact with peers.
D. Talk to the adolescent each time fighting occurs.
7. The community nurse visits the home of George, a child recently
diagnosed with autism. The parents express feelings of shame and
guilt about having somehow caused this problem. Which statement by
the nurse would best help alleviate parental guilt?
A. “Autism is a rare disorder. Your other children shouldn’t be affected.”
B. “The specific cause of autism is unknown. However, it is known to
be associated with problems in the structure of and chemicals in the
brain.”
C. “Sometimes a lack of prenatal care can be cause of autism.”
D. “Although autism is genetically inherited if you didn’t have testing
you could not have known this would happen.”
8. An adolescent with a depressive disorder is more likely than an adult
with the same disorder to exhibit:
A. Negativism and acting out.
B. Sadness and crying.
C. Suicidal thoughts.
D. Weight gain.
9. The parents of Suzanne, a child with attention deficit hyperactivity
disorder, tell the nurse they have tried everything to calm their child
and nothing has worked. Which action by the nurse is most appropriate
initially?
A. Actively listen to the parents’ concern before planning interventions.
B. Encourage the parents to discuss these issues with the mental
health team.
C. Provide literature regarding the disorder and its management.
D. Tell the parents they are overacting to the problem.
10. Nurse Gloria questions the parents of a child with oppositional
defiant disorder about the roles of each parent in setting rules of
behavior. The purpose for this type of questioning is to assess which
element of the family system?
A. Anxiety levels
B. Generational boundaries
C. Knowledge of growth and development
D. Quality of communication
11. Nurse Tiffany reinforces the behavioral contract for a child having
difficulty controlling aggressive behaviors on the psychiatric unit. Which
of the following is the best rationale for this method of treatment?
A. It will assist the child to develop more adaptive coping methods.
B. It will avoid having the nurse be responsible for setting the rules.
C. It will maintain the nurse’s role in controlling the child’s behavior.
D. It will prevent the child from manipulating the nurse.
12. Nurse Sophia is teaching the parents of a child with pervasive
developmental disorder about how to deal with the child when his
behavior escalates and he begins throwing things and screaming.
Which guideline would be most helpful for the parents to deal with the
situation?
A. Accept the child’s limitations, and ignore this behavior.
B. Decrease stimulation in the environment, and provide a time-out.
C. Seek help when feeling overwhelmed by the child’s behavior.
D. Tell the child to calm down, and encourage quiet activity.
13. The school nurse assesses Brook, a child newly diagnosed with
attention deficit hyperactivity disorder (ADHD). Which of the following
symptoms are characteristic of the disorder? Select all that apply.
A. Constant fidgeting and squirming
B. Excessive fatigue and somatic complaints
C. Difficulty paying attention to details
D. Easily distracted
E. Running away
F. Talking constantly, even when inappropriate
14. The psychiatric nurse is alert to warning signs of suicide in the
adolescent population. From the following list, select those behaviors
that are indicative of adolescent suicidal thinking. Select all that apply.
A. Giving away prized possessions
B. Associating with friends who are substance abusers
C. Sudden withdrawal from friends and family
D. Having difficulty concentrating on one thing at a time
E. Being easily distracted by environmental events
F. Verbal hints or threats about suicide
15. Which of the following statements about ADHD in children is false?
A. Black parents tend to be less sure of potential causes of and
treatments for ADHD than white parents, and they are less likely to
connect ADHD to their child’s school experiences.
B. Because of its frequent genetic etiology, ADHD in a child is likely
foreshadowed by ADHD in other family members.
C. The chances of successful treatment are adversely affected if the
parent responsible for implementing the treatment has untreated
ADHD.
D. More than 40% of respondents in the recent National Stigma Study-
Children (NSS-C) believe that children will face rejection in school for
receiving mental health treatment and that negative ramifications will
continue into adulthood. More than half expected psychiatric
medications to cause a zombie-like effect.
E. The Multimodal Treatment Study of Children with ADHD suggests
that pharmacological treatment of ADHD is as effective as behavioral
therapy alone.
THERAPEUTIC COMMUNICATION 1
1. A patient with a diagnosis of major depression who has attempted
suicide says to the nurse, “I should have died! I’ve always been a
failure. Nothing ever goes right for me.” Which response demonstrates
therapeutic communication?
A. “You have everything to live for.”
B. “Why do you see yourself as a failure?”
C. “Feeling like this is all part of being depressed.”
D. “You’ve been feeling like a failure for a while?”
2. When the community health nurse visits a patient at home, the
patient states, “I haven’t slept the last couple of nights.” Which
response by the nurse illustrates a therapeutic communication
response to this patient?
A. “I see.”
B. “Really?”
C. “You’re having difficulty sleeping?”
D. “Sometimes, I have trouble sleeping too.”
3. A patient experiencing disturbed thought processes believes that his
food is has been poisoned. Which communication technique should the
use to encourage the patient to eat?
A. Using open-ended questions and silence
B. Sharing personal preference regarding food choices
C. Documenting reasons why the patient does not want to eat
D. Offering opinions about the necessity of adequate nutrition
4. A patient admitted to a mental health unit for treatment of psychotic
behavior spends hours at the locked exit door shouting. “Let me out.
There’s nothing wrong with me. I don’t belong here.” What defense
mechanism is the patient implementing?
A. Denial
B. Projection
C. Regression
D. Rationalization
5. A patient diagnosed with terminal cancer says to the nurse “I’m
going to die, and I wish my family would stop hoping for a cure! I get so
angry when they carry on like this. After all, I’m the one who’s dying.”
Which response by the nurse is therapeutic?
A. “Have you shared your feelings with your family?”
B. “I think we should talk more about your anger with your family.”
C. “You’re feeling angry that your family continues to hope for you to
be cured?”
D. “You are probably very depressed, which is understandable with
such a diagnosis.”
6. On review of the patient’s record, the nurse notes the admission was
voluntary. Based on this information, the nurse anticipates which
patient behavior?
A. Fearfulness regarding treatment measures.
B. Anger and aggressiveness directed toward others.
C. An understanding of the pathology and symptoms of the diagnosis.
D. A willingness to participate in the planning of the care and treatment
plan.
7. A patient admitted voluntarily for the treatment of an anxiety disorder
demands to be released from the hospital. Which action should the
nurse take INITIALLY?
A. Contact the patient’s health care provider (HCP).
B. Call the patient’s family to arrange for transportations.
C. Attempt to persuade the patient to stay for only a few more days.
D. Tell the patient that leaving would likely result in an involuntary
commitment.
8. When reviewing the admission assessment, the nurse notes that a
patient was admitted to the mental health unit involuntarily. Based on
this type of admission, the nurse should provide which intervention for
this patient?
A. Monitor closely for harm to self or others.
B. Assist in completing an application for admission.
C. Supply the patient with written information about their mental illness.
D. Provide an opportunity for the family to discuss why they felt the
admission was needed.
9. The nurse is preparing a patient for the termination phase of the
nurse-patient relationship. The nurse prepares to implement which
nursing task that is MOST APPROPRIATE for this phase?
A. Planning short-term goals
B. Making appropriate referrals
C. Developing realistic solutions
D. Identifying expected outcomes
10. The nurse employed in a mental health clinic is greeted by a
neighbor in a local grocery store. The neighbors ask the nurse, “How is
Mary doing? She is my best friend and is seen at your clinic every
week.” Which is the MOST APPROPRIATE nursing response?
A. “I can not discuss any patient situation with you.”
B. “If you want to know about Mary, you need t ask her yourself.”
C. “Only because you’re worried about a friend, I’ll tell you that she is
improving.”
D. “Being her friend, you know she is having a difficult time and
deserves her privacy.”
11. The nurse calls security and has physical restraints applied when a
client who admitted voluntarily becomes both physically and verbally
abusive while demanding to be discharged from the hospital. Which
represents the possible legal ramifications for the nurse associated
with these interventions? Select all that apply.
A. Libel
B. Battery
C. Assault
D. Slander
E. False Imprisonment
12. The nurse in the mental health unit recognizes which of the
following as therapeutic communication techniques? Select all that
apply.
A. Restating
B. Listening
C. Asking the patient “Why?”
D. Maintaining neutral responses
E. Providing acknowledgment and feedback
F. Giving advice and approval or disapproval
13. A patient being seen in the emergency department immediately
after being sexually assaulted appears calm and controlled. The nurse
analyzes this behavior as indicating which defense mechanism?
A. Denial
B. Projection
C. Rationalization
D. Intellectualization
14. A patient’s unresolved feelings related to loss would be MOST
LIKELY observed during which phase of the therapeutic nurse-patient
relationship?
A. Trusting
B. Working
C. Orientation
D. Termination
15. Which statement demonstrates the BEST understanding of the
nurse’s role regarding ensuring that each client’s rights are respected?
A. “Autonomy is the fundamental right of each and every client.”
B. “A patient’s rights are guaranteed by both state and federal laws.”
C. “Being respectful and concerned will ensure that I’m attentive to my
patient’s rights.”
D. “Regardless of the patient’s conditions, all nurses have the duty to
respect patient rights.”
THERAPEUTIC COMM 2
1. Which therapeutic communication technique is being used in this
nurse-client interaction?
Client: “When I get angry, I get into a fistfight with my wife, or I take it
out of the kids.”
Nurse: “I notice that you are smiling as you talk about this physical
violence.”
A. Encouraging comparison
B. Exploring
C. Formulating a plan of action
D. Making observations
2. Which therapeutic communication technique is being used in this
nurse-client interaction?
Client: “My father spanked me often.”
Nurse: “Your father was a harsh disciplinarian.”
A. Restatement
B. Offering general leads
C. Focusing
D. Accepting
3. Which therapeutic communication technique is being used in this
nurse-client interaction?
Client: “When I am anxious, the only thing that calms me down is
alcohol.”
Nurse: “Other than drinking, what alternatives have you explored to
decrease anxiety?”
A. Reflecting
B. Making observations
C. Formulating a plan of action
D. Giving recognition
4. Nurse Patrick is interviewing a newly admitted psychiatric client.
Which nursing statement is an example of offering a “general lead”?
A. “Do you know why you are here?”
B. “Are you feeling depressed or anxious?”
C. “Yes, I see. Go on.”
D. “Can you chronologically order the events that led to your
admission?”
5. A nurse states to a client, “Things will look better tomorrow after a
good night’s sleep.” This is an example of which communication
technique?
A. The therapeutic technique of “giving advice”
B. The therapeutic technique of “defending”
C. The nontherapeutic technique of “presenting reality”
D. The nontherapeutic technique of “giving false reassurance”
6. A client diagnosed with post-traumatic stress disorder is admitted to
an inpatient psychiatric unit for evaluation and medication stabilization.
Which therapeutic communication technique used by the nurse is an
example of a broad opening?
A. “What occurred prior to the rape, and when did you go to the
emergency department?”
B. “What would you like to talk about?”
C. “I notice you seem uncomfortable discussing this.”
D. “How can we help you feel safe during your stay here?”
7. A nurse is assessing a client diagnosed with schizophrenia for the
presence of hallucinations. Which therapeutic communication
technique used by the nurse is an example of making observations?
A. “You appear to be talking to someone I do not see.”
B. “Please describe what you are seeing.”
C. “Why do you continually look in the corner of this room?”
D. “If you hum a tune, the voices may not be so distracting.”
8. A nurse maintains an uncrossed arm and leg posture. This
nonverbal behavior is reflective of which letter of the SOLER acronym
for active listening?
A. S
B. O
C. L
D. E
E. R
9. An instructor is correcting a nursing student‘s clinical worksheet.
Which instructor statement is the best example of effective feedback?

A. “Why did you use the client’s name on your clinical worksheet?”
B. “You were very careless to refer to your client by name on your
clinical worksheet.”
C. “Surely you didn’t do this deliberately, but you breached
confidentiality by using the client’s name.”
D. “It is disappointing that after being told, you’re still using client
names on your worksheet.”
10. After assertiveness training, a formerly passive client appropriately
confronts a peer in group therapy. The group leader states, “I’m so
proud of you for being assertive. You are so good!” Which
communication technique has the leader employed?
A. The nontherapeutic technique of giving approval
B. The nontherapeutic technique of interpreting
C. The therapeutic technique of presenting reality
D. The therapeutic technique of making observations
11. What is the purpose of a nurse providing appropriate feedback?
A. To give the client good advice
B. To advise the client on appropriate behaviors
C. To evaluate the client’s behavior
D. To give the client critical information
12. A client who frequently exhibits angry outbursts is diagnosed with
antisocial personality disorder. Which appropriate feedback should a
nurse provide when this client experiences an angry outburst?
A. “Why do you continue to alienate your peers by your angry
outbursts?”
B. “You accomplish nothing when you lose your temper like that.”
C. “Showing your anger in that manner is very childish and insensitive.”
D. “During group, you raised your voice, yelled at a peer, left, and
slammed the door.”
13. A client diagnosed with dependent personality disorder states, “Do
you think I should move from my parent’s house and get a job?” Which
nursing response is most appropriate?
A. “It would be best to do that in order to increase independence.”
B. “Why would you want to leave a secure home?”
C. “Let’s discuss and explore all of your options.”
D. “I’m afraid you would feel very guilty leaving your parents.”
14. When interviewing a client, which nonverbal behavior should a
nurse employ?
A. Maintaining indirect eye contact with the client
B. Providing space by leaning back away from the client
C. Sitting squarely, facing the client
D. Maintaining open posture with arms and legs crossed
15. A mother rescues two of her four children from a house fire. In the
emergency department, she cries, “I should have gone back in to get
them. I should have died, not them.” What is the nurse’s best
response?
A. “The smoke was too thick. You couldn’t have gone back in.”
B. “You’re feeling guilty because you weren’t able to save your
children.”
C. “Focus on the fact that you could have lost all four of your children.”
D. “It’s best if you try not to think about what happened. Try to move
on.”
16. A newly admitted client diagnosed with obsessive-compulsive
disorder (OCD) washes hands continually. This behavior prevents unit
activity attendance. Which nursing statement best addresses this
situation?
A. “Everyone diagnosed with OCD needs to control their ritualistic
behaviors.”
B. “It is important for you to discontinue these ritualistic behaviors.”
C. “Why are you asking for help if you won’t participate in unit
therapy?”
D. “Let’s figure out a way for you to attend unit activities and still wash
your hands.”
17. Which example of a therapeutic communication technique would
be effective in the planning phase of the nursing process?
A. “We’ve discussed past coping skills. Let’s see if these coping skills
can be effective now.”
B. “Please tell me in your own words what brought you to the hospital.”
C. “This new approach worked for you. Keep it up.”
D. “I notice that you seem to be responding to voices that I do not
hear.”
18. A client tells the nurse, “I feel bad because my mother does not
want me to return home after I leave the hospital.” Which nursing
response is therapeutic?
A. “It’s quite common for clients to feel that way after a lengthy
hospitalization.”
B. “Why don’t you talk to your mother? You may find out she doesn’t
feel that way.”
C. “Your mother seems like an understanding person. I’ll help you
approach her.”
D. “You feel that your mother does not want you to come back home?”
19. A client’s younger daughter is ignoring curfew. The client states,
“I’m afraid she will get pregnant.” The nurse responds, “Hang in there.
Don’t you think she has a lot to learn about life?” This is an example of
which communication block?
A. Requesting an explanation
B. Belittling the client
C. Making stereotyped comments
D. Probing
20. Which nursing statement is a good example of the therapeutic
communication technique of giving recognition?
A. “You did not attend group today. Can we talk about that?”
B. “I’ll sit with you until it is time for your family session.”
C. “I notice you are wearing a new dress and you have washed your
hair.”
D. “I’m happy that you are now taking your medications. They will really
help.”
THERAPEUTIC COMM 3
1. A client is struggling to explore and solve a problem. Which nursing
statement would verbalize the implication of the client’s actions?
A. “You seem to be motivated to change your behavior.”
B. “How will these changes affect your family relationships?”
C. “Why don’t you make a list of the behaviors you need to change.”
D. “The team recommends that you make only one behavioral change
at a time.”
2. The nurse asks a newly admitted client, “What can we do to help
you?” What is the purpose of this therapeutic communication
technique?
A. To reframe the client’s thoughts about mental health treatment
B. To put the client at ease
C. To explore a subject, idea, experience, or relationship
D. To communicate that the nurse is listening to the conversation
3. A student nurse tells the instructor, “I’m concerned that when a client
asks me for advice I won’t have a good solution.” Which should be the
nursing instructor‘s best response?
A. “It’s scary to feel put on the spot by a client. Nurses don’t always
have the answer.”
B. “Remember, clients, not nurses, are responsible for their own
choices and decisions.”
C. “Just keep the client’s best interests in mind and do the best that
you can.”
D. “Set a goal to continue to work on this aspect of your practice.”
4. A student nurse is learning about the appropriate use of touch when
communicating with clients diagnosed with psychiatric disorders.
Which statement by the instructor best provides information about this
aspect of therapeutic communication?
A. “Touch carries a different meaning for different individuals.”
B. “Touch is often used when deescalating volatile client situations.”
C. “Touch is used to convey interest and warmth.”
D. “Touch is best combined with empathy when dealing with anxious
clients.”
5. Which nursing statement is a good example of the therapeutic
communication technique of focusing?
A. “Describe one of the best things that happened to you this week.”
B. “I’m having a difficult time understanding what you mean.”
C. “Your counseling session is in 30 minutes. I’ll stay with you until
then.”
D. “You mentioned your relationship with your father. Let’s discuss that
further.”
6. After fasting from 10 p.m. the previous evening, a client finds out
that the blood test has been canceled. The client swears at the nurse
and states, “You are incompetent!” Which is the nurse’s best
response?
A. “Do you believe that I was the cause of your blood test being
canceled?”
B. “I see that you are upset, but I feel uncomfortable when you swear
at me.”
C. “Have you ever thought about ways to express anger
appropriately?”
D. “I’ll give you some space. Let me know if you need anything.”
7. During a nurse-client interaction, which nursing statement may
belittle the client’s feelings and concerns?

A. “Don’t worry. Everything will be alright.”

B. “You appear uptight.”
C. “I notice you have bitten your nails to the quick.”
D. “You are jumping to conclusions.”

8. A client on an in-patient psychiatric unit tells the nurse, “I should

have died because I am totally worthless.” In order to encourage the
client to continue talking about feelings, which should be the nurse’s
initial response?

A. “How would your family feel if you died?”

B. “You feel worthless now, but that can change with time.”
C. “You’ve been feeling sad and alone for some time now?”
D. “It is great that you have come in for help.”

9. Which nursing response is an example of the nontherapeutic

communication block of requesting an explanation?

A. “Can you tell me why you said that?”

B. “Keep your chin up. I’ll explain the procedure to you.”
C. “There is always an explanation for both good and bad behaviors.”
D. “Are you not understanding the explanation I provided?”

10. A client states, “You won’t believe what my husband said to me

during visiting hours. He has no right treating me that way.” Which
nursing response would best assess the situation that occurred?

A. “Does your husband treat you like this very often?”

B. “What do you think is your role in this relationship?”
C. “Why do you think he behaved like that?”
D. “Describe what happened during your time with your husband.”

11. Which therapeutic communication technique should the nurse use

when communicating with a client who is experiencing auditory
hallucinations?

A. “My sister has the same diagnosis as you and she also hear voices.”
B. “I understand that the voices seem real to you, but I do not hear any
voices.”
C. “Why not turn up the radio so that the voices are muted.”
D. “I wouldn’t worry about these voices. The medication will make them
disappear.”

12. Which nursing statement is a good example of the therapeutic

communication technique of offering self?

A. “I think it would be great if you talked about that problem during our
next group session.”
B. “Would you like me to accompany you to your electroconvulsive
therapy treatment?”
C. “I notice that you are offering help to other peers in the milieu.”
D. “After discharge, would you like to meet me for lunch to review your
outpatient progress?”

13. A client slammed a door on the unit several times. The nurse
responds, “You seem angry.” The client states, “I’m not angry.” What
therapeutic communication technique has the nurse employed and
what defense mechanism is the client unconsciously demonstrating?

A. Making observations and the defense mechanism of suppression

B. Verbalizing the implied and the defense mechanism of denial
C. Reflection and the defense mechanism of projection
D. Encouraging descriptions of perceptions and the defense
mechanism of displacement

14. Which of the following individuals are communicating a message?

(Select all that apply.)

A. A mother spanking her son for playing with matches

B. A teenage boy isolating himself and playing loud music
C. A biker sporting an eagle tattoo on his biceps
D. A teenage girl writing, “No one understands me.”
E. A father checking for new e-mail on a regular basis

15. A mother rescues two of her four children from a house fire. In the
emergency department, she cries, “I should have gone back in to get
them. I should have died, not them.” What is the nurse’s best
response?

A. “The smoke was too thick. You couldn’t have gone back in.”
B. “You’re feeling guilty because you weren’t able to save your
children.”
C. “Focus on the fact that you could have lost all four of your children.”
D. “It’s best if you try not to think about what happened. Try to move
on.”