Professional Documents
Culture Documents
Psychiatric Nursing
Psychiatric Nursing
1. 60 year old post CVA patient is taking TPA for his disease, the nurse understands that this
is an example of what level of prevention?
a. primary
b. secondary
c. tertiary
d. nota
C. Tertiary
The client already had stroke, TPA stands for TRANSPLASMINOGEN ACTIVATOR which
are thrombolytics, dissolving clots formed in the vessels of the brain. We are just preventing
COMPLICATIONS here.
a. primary
b. secondary
c. tertiary
d. nota
b. secondary
: The client is never sick of anything but we are detecting the POSSIBILITY by giving yearly
mammography. Remember that all kinds of tests, case findings and treatment belongs to the
secondary
level of prevention.
3. A Diabetic patient was amputated following an unexpected necrosis on the right leg, he
sustained and undergone BKA. He then underwent therapy on how to use his new prosthetic
leg. this is a type of what level of prevention?
a. primary
b. secondary
c. tertiary
d. nota
c. tertiary
: Tertiary prevention involves rehabilitation. Client is now being assisted to perform ADLs at
his
optimum functioning. Remember that all kinds of rehabilitatory and palliative management is
included in tertiary prevention.
ASSESSMENT involves early recognition of clients needs. A,B,C are all involve in the
intervention phase of the nursing process.
A,B,C are not specific of a nurse manager. They can be done by an ordinary R.N.
: An advocate role is shown when the nurse defends the rights of the
client. Interceding in behalf of the patient should not be done by a nurse. Counter
transference can
develop in that case and we should avoid that. Only the family and the health attorney of the
patient can
7. which is the following is the most appropriate during the orientation phase ?
ESTABLISHMENT. Here, the nurse will establish regular meeting of schedule, agreements
and giving the
client information that there is a TERMINATION. Letter A and B assesses the client’s coping
skills, which is
in the working phase and so is letter B. In working phase, The nurse assesses the coping skills
of the
client and formulate plans and intervention to correct deficiencies. Although assessment is
also made in
the orientation phase, COPING SKILLS are assessed in the working phase.
b. orientation
c. working
d. termination
c. working :
Telling the client that there is a TERMINATION PHASE should be in the ORIENTATION
PHASE,
however, in preparing the client for the TERMINATION, it should be done in the working
phase. The nurse will start to lessen the number of meetings to prevent development of
transference or counter
transference.
a. recovery promoting
b. mutual interaction
c. growth facilitating
d. health enhancing
c. growth facilitating :
In psychiatric nursing, The epitome of all nursing goal should focus on facilitating
10. During the nurse patient interaction, the nurse assess the ff: to determine the patients
coping strategy
the problem on the client and the ways she is dealing with it. Letter A can only be answered
by FINE and
close further communication. B is unrelated to coping strategies. Letter C, asking the client
what do you
think can help you right now is INAPPROPRIATE for the nurse to ask. The client is in the
hospital because
she needs help. If she knows something that can help her with her problem she shouldn’t be
there.
speaker. She encourage the client to express feelings and concerns as to formulate necessary
response
b. Moral arm of the personality that strives for perfection than pleasure.
a characteristic of the SUPER EGO which is the CONTROLLER of instincts and drives and
serve as our
CONSCIENCE or the MORAL ARM. The ID is our DRIVES and INSTINCTS that is
mediated by the EGO and
13. A 16 year old child is hospitalized, according to Erik Erikson, what is an appropriate
intervention?
CONFUSION. The most significant persons in this group are the PEERS. B refers to children
in the school
age while C refers to the young adulthood stage of INTIMACY VS. ISOLATION. The child
is not dying and
the situation did not even talk about the child’s belief therefore, calling the priest is
unnecessary.
b. Clozaril
immune function is severely impaired. The first presenting sign of agranulocytosis is SORE
THROAT.
15. Which of the following drugs needs a WBC level checked regularly?
a. Lithane
b. Clozaril
c. Tofranil
d. Diazepam
b. Clozaril
depression, agranulocytosis, infection and sore throat. WBC count is important to assess if
the clients
immune function is severely impaired. The first presenting sign of agranulocytosis is SORE
THROAT.
Angelo, an 18 year old out of school youth was caught shoplifting in a department store. He
has history of being quarrelsome and involving physical fight with his friends. He has been
out of jail for the past two years
16. Initially, The nurse identifies which of the ff: Nursing diagnosis:
altered thought process or sensory alteration, It is not anymore a personality disorder but
rather, a sign
functioning. They are much more of SOCIAL Disturbances rather than PSYCHOLOGICAL.
18. the most effective treatment modality for persons if anti social PD is
a. hypnotherapy
b. gestalt therapy
c. behavior therapy
d. crisis intervention
c. behavior therapy
: The problem of the patient is his behavior. A is done for patient who has insomnia
or severe anxiety. B is a therapy that promotes growth by providing a contact, either a person
or an
approach. D is done on clients who are in crisis like trauma, post traumatic disorders, raped
or accidents.
b. flight of ideas
c. illusion
d. hallucination
b. flight of ideas
: Flight of ideas is a condition in which patient talks continuously and then switching to
unrelated topic. An example is “ Ang ganda ng bulaklak na ito no budek? Rose ito hindi ba?
Kilala mo ba si
jack yung boyfriend ni rose? Grabe yung barko no ang laki laki tapos lumubog lang. Dapat
sana nag
seaman ako eh, gusto kasi ng nanay ko. “. Loose association is somewhat similar but the
switch in topic is more obvious and completely unrelated. Example “ Ang cute nung rabbit,
paano si paul kasi tanga eh,
papapatay ko yan kay albert. Ang ganda nung bag na binigay ni jenny, tanga nga lang yung
aswang dun
sa kanto. Pero bakit ka ba andito? Wala akong pagkain, Penge ako kotse aakyat ako everest.”
A,C,D are all alteration in perception. A refers to a person thinking that everyone is talking
about him. C
and D are all sensory alterations. The difference is that, in hallucination, there is no need for a
stimuli. In
illusion, a stimuli [ A phone cord ] is mistakenly identified by the client as something else [
Snake ]
d. panic
21. A client is admitted to the hospital. Twelve hours later the nurse observes hand tremors,
This question will give the nurse idea WHEN will the
withdrawal occur. Withdrawal occurs 5 to 10 hours after the last intake of alcohol. This is a
crucial and
mortality is very high during this period. Client will undergo delirium tremens, seizures and
DEATH if not
recognize earlier by the nurse. B is very judgmental, C is non specific, whether it is a beer or
a wine It is
still alcohol and has the same effects. D is a valuable question to determine the chronic
effects of alcohol
ingestion but asking letter A can broaden the line between life and death.
22. client with a history of schizophrenia has been admitted for suicidal ideation. The client
states "God is telling me to kill myself right now." The nurse's best response is:
a. I understand that god’s voice are real to you, But I don’t hear anything. I will stay with
you.
b. The voices are part of your illness, it will stop if you take medication
c. The voices are all in your imagination, think of something else and itll go away
a. I understand that god’s voice are real to you, But I don’t hear anything. I will stay
with you.
: The nurse should first ACKNOWLEDGE that the voices are real to the patient and then,
PRESENT
REALITY by telling the patient that you do not hear anything. The third part of the nursing
intervention in
hallucination is LESSENING THE STIMULI by either staying with the patient or removing
the patient from a
Telling the client that the voices is part of his illness is not therapeutic. People with
schizophrenia do not
think that they are ILL. Letter C and D disregards the client’s concern and therefore, not
therapeutic.
23. In assessing a client's suicide potential, which statement by the client would give the
nurse the
c. I’ve thought about taking pills and alcohol till I pass out
c. I’ve thought about taking pills and alcohol till I pass out
that contains a specific and technical plan. B,D are all indicative of suicidal ideation but it
contains no
specific plans to carry out the objective. Letter A admits the client thinks of hurting himself,
but not doing
24. A client with paranoid schizophrenia has persecutory delusions and auditory
hallucinations and is
extremely agitated. He has been given a PRN dose of Thorazine IM. Which of the following
would indicate to the nurse that the medication is having the desired effect?
controlling the client’s psychoses. Letter A is the side effect of the drug, which is not desired.
B and D
indicates that the drug is not effective in controlling the client’s agitation, restlessness and
disorders of
perception.
25. A client who was wandering aimlessly around the streets acting inappropriately and
appeared
disheveled and unkempt was admitted to a psychiatric unit and is experiencing auditory and
visual
b. anxiety disorder
c. schizophrenia
d. depression
c. schizophrenia
: When disorders of perception and thoughts came in, The only feasible diagnosis a
doctor can make is among the choices is schizophrenia. A,B and D can occur in normal
individuals without
26. A decision is made to not hospitalize a client with obsessive-compulsive disorder. Of the
following abilities the client has demonstrated, the one that probably most influenced the
decision not to hospitalize him is his ability to:
a. Hold a job.
b. Relate to his peers.
hospitalized.
27. A client is admitted to the inpatient psychiatric unit. He is unshaven, has body odor, and
has spots on his shirt and pants. He moves slowly, gazes at the floor, and has a flat affect. The
nurse's highest priority in assessing the client on admission would be to ask him:
DEPRESSION. Moving slowly, gazes on the floor, blank stares and showing flat affect. The
highest priority
among depressed client is assessing any suicide plans or ideation for the nurse to establish a
no suicide
contract early on or, in any case client do not participate in a no suicide contract, a 24 hour
continuous
monitoring is established.
28. The nurse should know that the normal therapeutic level of lithium is :
a. .6 to 1.2 meq/L
b. 6 to 12 meq/L
c. .6 to .12 cc/ml
d. .6 to .12 cc3/L
a. .6 to .12 meq/L
29. The patient complaint of vomiting, diarrhea and restlessness after taking lithane. The
nurse’s initial
intervention is :
a. Recognize that this is a sign of toxicity and withhold the next medication.
d. Recognize that this is a normal side effects of lithium and still continue the drug.
a. Recognize that this is a sign of toxicity and withhold the next medication
recognize that this is an early s/s of lithium toxicity. Taking the clients vital signs will not
confirm diarrhea,vomiting or restlessness. Notifying the physician is unnecessary at this point
and the physician will likely to withhold the medication.
30. The client is taking TOFRANIL. The nurse should closely monitor the patient for :
a. Hypertension
b. Hypothermia
antipsychotic that increases the IOP and contraindicated in patients with glaucoma.
Hypertension is not specific with TOFRANIL. All neuroleptics can cause NMS or the
neuroleptic malignant syndrome.
31. A client was hospitalized with major depression with suicidal ideation for 1 week. He is
taking
venlafaxine (Effexor), 75 mg three times a day, and is planning to return to work. The nurse
asks the
client if he is experiencing thoughts of self-harm. The client responds, "I hardly think about it
anymore and wouldn't do anything to hurt myself." The nurse judges:
d. The presence of suicidal ideation to warrant a telephone call to the client's physician
: too obvious, no
need to rationalize.
32. The client is taking sertraline (Zoloft), 50 mg q AM. The nurse includes which of the
following in the
d. It may take 3-4 weeks before client will start feeling better.
Because it causes erectile dysfuntion and decrease libido. Letter B and C are specific of
TCAs. Zoloft will
33. After 3 days of taking haloperidol, the client shows an inability to sit still, is restless and
fidgety, and paces around the unit. Of the following extrapyramidal adverse reactions, the
client is showing signs of:
a. Dystonia.
b. Akathisia.
c. Parkinsonism.
d. Tardive dyskinesia.
b. Akathisia :
The client shows sign of motor restlessness, which is specific for Akathisia or MAKATI
SYA.
34. After 10 days of lithium therapy, the client's lithium level is 1.0 mEq/L. The nurse knows
that this
a. A laboratory error.
d. A toxic level.
35. When caring for a client receiving haloperidol (Haldol), the nurse would assess for which
of the following?
a. Hypertensive episodes.
b. Extrapyramidal symptoms.
c. Hypersalivation.
d. Oversedation.
b. Extrapyramidal symptoms
client will likely be hypotensive than hypertensive because neuroleptics causes postural
hypotension, The client will complaint of dry mouth due to its anticholinergic properties.
Dizziness and drowsiness are side effects of neuroleptics but not oversedation.
36. A client is brought to the hospital’s emergency room by a friend, who states, "I guess he
had some bad junk (heroin) today." In assessing the client, the nurse would likely find which
of the following symptoms?
a. Increased heart rate, dilated pupils, and fever.
morphine, meperidine, codeine and opiods, they are DEPRESSANTS and will cause decrease
respiration,
37. The client has been taking the monoamine oxidase inhibitor (MAOI) phenelzine (Nardil),
10 mg bid.The physician orders a selective serotonin reuptake inhibitor (SSRI), paroxetine
(Paxil), 20 mg given every morning. The nurse:
d. Asks the physician to order benztropine (Cogentin) for the side effects.
unless the other one is tapered while the other one is given gradually.
38. Which of the following client statements about clozapine (Clozaril) indicates that the
client needs additional teaching?
a. "I need to have my blood checked once every several months while I’m taking this drug."
b. "I need to sit on the side of the bed for a while when I wake up in the morning."
d. "I need to call my doctor whenever I notice that I have a fever or sore throat."
d. "I need to call my doctor whenever I notice that I have a fever or sore throat."
: Clozapine
causes AGRANULOCYTOSIS and bone marrow depression. Early s/s includes fever and
sore throat. The
medication is to be withheld this time or the patient might develop severe infection leading to
death.
39. A client has been taking lithium carbonate (Lithane) for hyperactivity, as prescribed by
his physician.
While the client is taking this drug, the nurse should ensure that he has an adequate intake of:
a. Sodium.
b. Iron.
c. Iodine.
d. Calcium.
a. Sodium
: The levels of lithium in the body are dependent on sodium. The higher the sodium, The
lower
the levels of lithium. Clients should have an adequate intake of sodium to prevent sudden
increase in the
40. The client has been taking clomipramine (Anafranil) for his obsessive-compulsive
disorder. He tells the nurse, "I'm not really better, and I've been taking the medication
faithfully for the past 3 days just like it says on this prescription bottle." Which of the
following actions would the nurse do first?
a. Tell the client to continue taking the medication as prescribed because it takes 5 to 10
weeks for a full therapeutic effect.
b. Tell the client to stop taking the medication and to call the physician.
a. Tell the client to continue taking the medication as prescribed because it takes 5 to 10
weeks
for a full therapeutic effect
weeks.
41. The nurse judges correctly that a client is experiencing an adverse effect from
amitriptyline
b. Insomnia.
c. Hypertension.
d. Urinary retention.
d. Urinary retention :
specific of MAOI anti depressants when tyramine is ingested. Due to the anticholinergic s/e
of TCAs,
42. Which of the following health status assessments must be completed before the client
starts taking
imipramine (Tofranil)?
a. Electrocardiogram (ECG).
c. Thyroid scan.
a. Electrocardiogram (ECG).
regular ECG schedule. Most TCAs causse tachycardias and ECG changes, an ECG should be
done before
The client was given a 1-week supply of clozapine (Clozaril). The nurse reviews information
about
clozapine with the client. Which client statement indicates an accurate understanding of the
nurse's
b."I need to keep my appointment here at the hospital this week for a blood test."
b."I need to keep my appointment here at the hospital this week for a blood test."
: Regular blood check up is required for patients taking clozaril. As frequent as every 2
weeks. Clozapine can cause bone marrow depression, therefore, frequent blood counts are
necessary.
44. The client is taking risperidone (Risperdal) to treat the positive and negative symptoms of
c. Bizarre behaviour.
45. The nurse would teach the client taking tranylcypromine sulfate (Parnate) to avoid which
food because of its high tyramine content?
a. Nuts.
b. Aged cheeses.
c. Grain cereals.
d. Reconstituted milk.
b. Aged cheeses.
: This is high in tyramine, and therefore, removed from patients diet to prevent
hypertensive crisis.
46. Which of the following clinical manifestations would alert the nurse to lithium toxicity?
47. The client with depression has been hospitalized for 3 days on the psychiatric unit. This is
the second hospitalization during the past year. The physician orders a different drug,
tranylcypromine sulfate (Parnate), when the client does not respond positively to a tricyclic
antidepressant. Which of the following reactions should the client be cautioned about if her
diet includes foods containing tryaminetyramine?
a. Heart block.
c. Respiratory arrest.
d. Hypertensive crisis.
d. Hypertensive crisis.
48. After the nurse has taught the client who is being discharged on lithium (Eskalith) about
the drug, which of the following client statements would indicate that the teaching has been
successful?
b. "If I forget a dose, I can double the dose the next time I take it."
c. "I'll call my doctor right away for any vomiting, severe hand tremors, or muscle
weakness."
c."I'll call my doctor right away for any vomiting, severe hand tremors, or muscle
weakness."
:This is a sign of light lithium toxicity. Increasing fluid intake will cause dilutional decrease
of lithium level. Restriction of sodium will cause dilutional increase in lithium level.
49. A nurse is caring for a client with Parkinson's disease who has been taking
carbidopa/levodopa
(Sinemet) for a year. Which of the following adverse reactions will the nurse monitor the
client for?
a. dykinesia
b. glaucoma
c. hypotension
d. respiratory depression
c. hypotension
: Hypotension, dizziness and lethargy are side effects of anti parkinson drugs like
50. A client is taking fluoxetine hydrochloride (Prozac) for treatment of depression. The
client asks thenurse when the maximum therapeutic response occurs. The nurse's best
response is that the maximum therapeutic response for fluoxetine hydrochloride may occur in
the:
a. 10-14 days
b. First week
c. Third week
d. Fourth week
c. Third week
: A and B are similar, therefore , removed them first. Recognizing that most
antidepressants exerts their effects within 2-3 weeks will lead you to letter C.
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
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.
3. Liza says, “Give me 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
Subconscious refers to the materials that are partly remembered partly forgotten but these can
be 4. The superego is that part of the psyche that:
a. Uses defensive function for protection.
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?
7. The wife admits that she is a victim of abuse and opens up about her persistent distaste for
sex. This sexual disorder is:
c. Orgasm Disorder
a. “Here’s the number of a crisis center that you can call for help .”
Answer: (A) “Here’s the number of a crisis center that you can call for help .”
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"
c. “My child is
Answer: (B) “When I tell my child to do something once, I don’t expect to have to tell"
10. The primary nursing intervention for a victim of child abuse is:
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. Hypochondriaisis
c. Conversion Disorder
15. What would be the best response to the client’s repeated compla ints of pain:
c. “Try to forget this feeling and have activities to take it off your mind”
Answer: (A) “I know the feeling is real tests revealed negative results.”
16. Situation: A nurse may encounter children with mental disorders. Her knowledge of these
various disorders is vital. When planning school interventions for a child with a diagnosis of
attention deficit hyperactivity disorder, a guide to remember is to:
d. remove the child from the classroom when disruptive behavior occurs
Answer: (A) provide as much structure as possible for the child
b. Ritualistic behaviors
18. Ritalin is the drug of choice for chidren with ADHD. The side effects of the following
may be noted:
b. increase in appetite
c. Allowing the child to enter the school before the other children
Answer: (A) Returning the child to the school immediately with family support.
20. A 10 year old child has very limited vocabulary and interaction skills. She has an I.Q. of
45. She is diagnosed to have Mental retardation of this classification:
a. Profound
b. Mild
c. Moderate
d. Severe
The child with moderate mental retardation has an I.Q. of 35-50 Profound Mental retardation
has an I.Q. of below 20; Mild mental retardation 50-70 and
21. The nurse teaches the parents of a mentally retarded child regarding her care. The
following guidelines may be taught except:
22. The parents express apprehensions on their ability to care for their maladaptive child. The
nurse identifies what nursing diagnosis:
a. hopelessness
d. ineffective coping
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 disorder?
These are manifestations of Attention Deficit Disorder D. These are the manifestations of
Conduct Disorder
24. The therapeutic approach in the care of an autistic child include the following EXCEPT:
b. Concrete operations
c. Pre-operational
d. Formal operation
Francis who is addicted to cocaine withdraws from the drug. Nurse Ron should
expect to observe:
a. Hyperactivity
b. Depression
c. Suspicion
d. Delirium
d. Esophageal varices
hospitalized client for signs of opiate withdrawal. These signs would include:
4. A 48 year old male client is brought to the psychiatric emergency room after
attempting to jump off a bridge. The client’s wife states that he lost his job several
months ago and has been unable to find another job. The primary nursing
5. Before helping a male client who has been sexually assaulted, nurse Maureen
b. Inadequacy
c. Incompetence
d. Passion
6. When working with children who have been sexually abused by a family member it
is important for the nurse to understand that these victims usually are
a. Humiliation
b. Confusion
c. Self blame
d. Hatred
7. Joy who has just experienced her second spontaneous abortion expresses anger
towards her physician, the hospital and the “rotten nursing care”. When assessing
the situation, the nurse recognizes that the client may be using the coping
mechanism of:
a. Projection
b. Displacement
c. Denial
d. Reaction formation
8. The most critical factor for nurse Linda to determine during crisis intervention
c. Developmental theory
problem
10. Nurse Ronald could evaluate that the staff’s approach to setting limits for a
b. Understands the reason why frequent calls to the staff were made
12. When nurse Hazel considers a client’s placement on the continuum of anxiety, a
a. Perceptual field
b. Delusional system
c. Memory state
d. Creativity level
nurse would find it most unusual for a 3 year old child to demonstrate:
a. An interest in music
c. Ritualistic behavior
14. Malou with schizophrenia tells Nurse Melinda, “My intestines are rotted from
a. Jealous delusion
b. Somatic delusion
c. Delusion of grandeur
d. Delusion of persecution
15. Andy is admitted to the psychiatric unit with a diagnosis of borderline personality
b. Somatic symptoms
16. PROPRANOLOL (Inderal) is used in the mental health setting to manage which of
17. Which medication can control the extra pyramidal effects associated with
antipsychotic agents?
a. Clorazepate (Tranxene)
b. Amantadine (Symmetrel)
c. Doxepin (Sinequan)
d. Perphenazine (Trilafon)
18. Which of the following statements should be included when teaching clients about
physician
19. Kris periodically has acute panic attacks. These attacks are unpredictable and
a. Heightened concentration
20. Initial interventions for Marco with acute anxiety include all except which of the
following?
21. Nurse Jessie is assessing a client suffering from stress and anxiety. A common
a. Uticaria
b. Vertigo
c. Sedation
d. Diarrhea
22. When performing a physical examination on a female anxious client, nurse Nelli
would expect to find which of the following effects produced by the
parasympathetic system?
a. Muscle tension
d. Constipation
23. Which of the following drugs have been known to be effective in treating
24. Tony with agoraphobia has been symptom-free for 4 months. Classic signs and
25. Which nursing action is most appropriate when trying to diffuse a client’s
b. Leaving the client alone until he can talk about his feelings
pain. Which question by Nurse Jenny would best elicit information about the pain?
a. General anesthesia
c. Neurologic examination
d. Physical therapy
28. Jose who is receiving monoamine oxidase inhibitor antidepressant should avoid
29. Erlinda, age 85, with major depression undergoes a sixth electroconvulsive
therapy (ECT) treatment. When assessing the client immediately after ECT, the
30. Barbara with bipolar disorder is being treated with lithium for the first time. Nurse
Clint should observe the client for which common adverse effect of lithium?
a. Polyuria
b. Seizures
c. Constipation
d. Sexual dysfunction
31. Nurse Fred is assessing a client who has just been admitted to the ER
32. Discharge instructions for a male client receiving tricyclic antidepressants include
33. Important teaching for women in their childbearing years who are receiving
inpatient psychiatric unit. Which information should the community health nurse
35. The nurse understands that the therapeutic effects of typical antipsychotic
c. Stabilization of serotonin
d. Stimulation of GABA
36. Which of the following best explains why tricyclic antidepressants are used with
37. A client with depressive symptoms is given prescribed medications and talks with
his therapist about his belief that he is worthless and unable to cope with life.
a. Behavioral framework
b. Cognitive framework
c. Interpersonal framework
d. Psychodynamic framework
38. A nurse who explains that a client’s psychotic behavior is unconsciously motivated
understands that the client’s disordered behavior arises from which of the
following?
a. Abnormal thinking
b. Altered neurotransmitters
c. Internal needs
d. Response to stimuli
39. A client with depression has been hospitalized for treatment after taking a leave
of absence from work. The client’s employer expects the client to return to work
following inpatient treatment. The client tells the nurse, “I’m no good. I’m a
a. Learned behavior
40. The nurse describes a client as anxious. Which of the following statement about
anxiety is true?
41. A client with a phobic disorder is treated by systematic desensitization. The nurse
42. Which client outcome would best indicate successful treatment for a client with an
43. The nurse is caring for a client with an autoimmune disorder at a medical clinic,
information should the nurse teach the client to help foster a sense of control over
his symptoms?
45. Which nursing diagnosis is most appropriate for a client with anorexia nervosa
a. Anxiety
c. Defensive coping
d. Powerlessness
46. 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?
47. A client with dysthymic disorder reports to a nurse that his life is hopeless and
will never improve in the future. How can the nurse best respond using a cognitive
approach?
48. A client with major depression has not verbalized problem areas to staff or peers
since admission to a psychiatric unit. Which activity should the nurse recommend
49. The home health psychiatric nurse visits a client with chronic schizophrenia who
was recently discharged after a prolong stay in a state hospital. The client lives in
a boarding home, reports no family involvement, and has little social interaction.
The nurse plan to refer the client to a day treatment program in order to help him
with:
b. Medication teaching
d. Vocational training
50. Which activity would be most appropriate for a severely withdrawn client?
Marco approached Nurse Trish asking for advice on how to deal with his
alcohol addiction. Nurse Trish should tell the client that the only
a.
Psychotherapy
b.
c.
Total abstinence
d.
Aversion Therapy
Nurse Hazel is caring for a male client who experience false sensory
a.
Hallucinations
b.
Delusions
c.
Loose associations
d.
Neologisms
Nurse Monet is caring for a female client who has suicidal tendency. When
a.
b.
c.
Open the window and allow her to get some fresh air
d.
Observe her
Nurse Maureen is developing a plan of care for a female client with anorexia
a.
b.
Set-up a strict eating plan for the client
c.
d.
a.
b.
Leaving the client alone
c.
d.
a.
Being Killed
b.
c.
d.
a.
b.
Avoiding relationship
c.
d.
a.
Paranoid thoughts
b.
Emotional affect
c.
Independence need
d.
Aggressive behavior
Nurse Claire is caring for a client diagnosed with bulimia. The most
a.
b.
c.
d.
Nurse Tony was caring for a 41 year old female client. Which behavior by the
a.
c.
d.
a.
Respiratory difficulties
b.
c.
Dizziness
d.
Seizures
A 75 year old client is admitted to the hospital with the diagnosis of dementia
of the Alzheimer’s type and depression. The symptom that is unrelated to
a.
b.
c.
d.
Nurse Trish is working in a mental health facility; the nurse priority nursing
intervention for a newly admitted client with bulimia nervosa would be to?
a.
b.
c.
Observe client during meals
d.
Nurse Patricia is aware that the major health complication associated with
a.
b.
c.
d.
a.
Increasing stimulation
b.
limiting unnecessary interaction
c.
d.
immobilized by her elaborate hand washing and walking rituals. Nurse Trish
a.
b.
c.
d.
Mario is complaining to other clients about not being allowed by staff to keep
food in his room. Which of the following interventions would be most
appropriate?
a.
b.
c.
d.
a.
temporarily
b.
d.
member asks Joey, “Do you know why people find you repulsive?” this
statement most likely would elicit which of the following client reaction?
a.
Defensiveness
b.
Embarrassment
c.
Shame
d.
Remorsefulness
Rationalization
b.
Supportive confrontation
c.
Limit setting
d.
Consistency
a.
Naloxone (Narcan)
b.
Benzlropine (Cogentin)
c.
Lorazepam (Ativan)
d.
Haloperidol (Haldol)
Which of the following foods would the nurse Trish eliminate from the diet of a
a.
Milk
b.
Orange Juice
c.
Soda
d.
Regular Coffee
Which of the following would Nurse Hazel expect to assess for a client who is
a.
b.
Restlessness & Irritability
c.
d.
To establish open and trusting relationship with a female client who has been
a.
b.
c.
d.
to:
a.
behavior
b.
be involved in activities
c.
d.
disorder to:
a.
Have more positive relation with the father than the mother
b.
c.
Be able to develop only superficial relation with the others
d.
When teaching parents about childhood depression Nurse Trina should say?
a.
b.
c.
d.
a.
Scanning speech
b.
Speech lag
c.
Shuttering
d.
Echolalia
A 60 year old female client who lives alone tells the nurse at the community
health center “I really don’t need anyone to talk to”. The TV is my best friend.
The nurse recognizes that the client is using the defense mechanism known
as?
a.
Displacement
b.
Projection
c.
Sublimation
d.
Denial
When working with a male client suffering phobia about black cats, Nurse
Trish should anticipate that a problem for this client would be?
a.
b.
c.
d.
Linda is pacing the floor and appears extremely anxious. The duty nurse
a.
b.
c.
Are you feeling upset now?
d.
Nurse Penny is aware that the symptoms that distinguish post traumatic
a.
stress
b.
situation
c.
d.
persisting dementia; the client cannot remember facts and fills in the gaps
with imaginary information. Nurse Benjie is aware that this is typical of?
a.
Flight of ideas
b.
Associative looseness
c.
Confabulation
d.
Concretism
Nurse Joey is aware that the signs & symptoms that would be most specific
a.
b.
c.
d.
Excessive activity, memory lapses & an increased pulse
a.
b.
c.
d.
a.
Multiple stimuli
b.
Routine Activities
c.
d.
Varied Activities
a.
b.
c.
d.
A nursing care plan for a male client with bipolar I disorder should include:
a.
Providing a structured environment
b.
c.
d.
When planning care for a female client using ritualistic behavior, Nurse Gina
a.
b.
c.
d.
Is used by the client primarily for secondary gains
A 32 year old male graduate student, who has become increasingly withdrawn
and neglectful of his work and personal hygiene, is brought to the psychiatric
a.
b.
Concrete thinking
c.
d.
Weak ego
A 23 year old client has been admitted with a diagnosis of schizophrenia says
to the nurse “Yes, its march, March is little woman”. That’s literal you know”.
a.
Neologisms
b.
Echolalia
c.
Flight of ideas
d.
Loosening of association
A long term goal for a paranoid male client who has unjustifiably accused his
wife of having many extramarital affairs would be to help the client develop:
a.
b.
c.
d.
a.
b.
c.
d.
Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor.
When Nurse Nina enters the client’s room, the client is found lying on the bed
a.
b.
c.
Sit beside the client in silence and occasionally ask open-ended
question
d.
Leave the client alone and continue with providing care to the
other clients
Nurse Tina is caring for a client with delirium and states that “look at the
spiders on the wall”. What should the nurse respond to the client?
a.
at all”
b.
“I can see the spiders on the wall, but they are not going to
hurt you”
c.
d.
a.
b.
c.
d.
During electroconvulsive therapy (ECT) the client receives oxygen by mask via
positive pressure ventilation. The nurse assisting with this procedure knows
a.
b.
Decrease oxygen to the brain increases confusion and
disorientation
c.
d.
When planning the discharge of a client with chronic anxiety, Nurse Chris
evaluation?
a.
b.
c.
d.
The client maintains contact with a crisis counselor
Nurse Tina is caring for a client with depression who has not responded to
a.
Neuroleptic medication
b.
c.
Psychosurgery
d.
Electroconvulsive therapy
a.
b.
Name of the ingested medication & the amount ingested
c.
d.