Prelim Ca 5 1
Prelim Ca 5 1
Prelim Ca 5 1
ideation. The psychiatric-mental health nurse knows that an important outcome has been met when the
patient states:
Select one:
a. "I can't wait to get home and forget that this ever happened."
b. "I feel so much better. If I continue to feel this way, I can probably stop taking my medications soon."
c. "I have a list of support groups and a crisis line that I can call, if I feel suicidal."
d. "I have to leave here soon, if I want to make it to the shelter before they run out of beds."
A 17-year old client whose boyfriend has recently broke up with her is brought into the ER after taking a
handful of lorazepam (ativan). Which nursing intervention would take priority in this situation?
Select one:
Which of the following if elicited from the patient may classify him under personality cluster B?
Select one:
b. anxiety attack after a person has taken his stuffed toy from its usual place
A person diagnosed with paranoid personality disorder should be approached using which of the
following techniques?
Select one:
a. Matter of fact
d. Firmness of voice
Patient GwaGwa has been admitted for observation from the clinic of Dr. Ferrer for potassium
replacement infusion.
The patient has a history of psychosis on home meds and verbalized feelings of palpitations and
weakness. Which of the following will the nurse prioritize to investigate about?
Select one:
Select one:
a. Summon another nurse to help ensure that the client takes her medicine.
b. Tell the client that she can take the medication either orally or by injection.
c. Tell the client that she needs to take her "vitamin" to stay healthy.
Od. Withhold the medication until it is determined why the client is refusing to take it.
A client who is taking sertraline hydrochloride (Zoloft), says, "I'm having trouble sleeping at night with
this medication." Which response should the nurse make to the client?
Select one:
a. "Try taking your medicine in the morning and limiting all liquids after 9:00 pm. Also change your
evening exercise to morning or early afternoon. If these measures don't help, notify me."
b. "This is a serious side effect. Let's take your temperature and stop your medication immediately."
c. "Try taking your medicine in the evening so the sedative effects can aid sleep. Also change your
morning exercise to early afternoon. If these measures do not help, notify you provider."
A client being treated for hypertension is also taking tranylcypromine (Parnate). The nurse should teach
the client to avoid eating which foods?
Select one:
a. Carrots
b. Steak
c. Ripe bananas
d. Baked potatoes
The nurse performs an assessment on a client who is taking an antipsychotic medication. Which
assessment data should the nurse identify as indicating neuroleptic malignant syndrome?
Select one:
A client who has been started on fluphenazine decanoate (Prolixin) is being taught about the
medication. The nurse tells the client to immediately report which statement by the client?
Select one:
a. "Bukod sa madami ako umihi, medyo lumalabo minsan ang paningin ko"
c. "Maayos naman po ako. Medyo sinisinat lang kagabi pero nagpapawis nako ngayon"
d. "Siguradong tatagal
Which of the following is the most appropriate therapy for a client with agoraphobia?
Select one:
a. 10 mg Valium qid
O c. Hypnosis
d. Group therapy with other agoraphobics
You are caring for a group of clients who are adversely affected with phobias. Which form of group
therapy will you most likely employ to treat these clients?
Select one:
a. Psychoanalysis
b. Cognitive psychotherapy
d. Behavioral psychotherapy
Select one:
a. diarrhea
b. Oculogyric crisis
c. Teary eyes
d. Excessive diaphoresis
What would be the best response to the client's repeated complaints of pain:
Select one:
c. "Try to forget this feeling and have activities to take it off your mind"
d. "I know the feeling is real but tests revealed negative results."
Which intervention is a nurse's priority when working with a client suspected of having a conversion
disorder?
Select one:
a. Teach the client alternative coping skills to use during times of stress
d. Confront the client with the fact that anxiety is the cause of physical symptoms
A client who has been prescribed Parnate is asking Nurse Berna about herbal remedies. Which of the
following statements by the client alerts the nurse to indicate a need for further teaching?
Select one
a. 'I understand that I will need to consult my physician for every herbal medications before taking them'
O b. 'I have been having a difficult time choosing the proper food and herbal supplements because
tyramine can be contained with them'
d. 'My sister has brought me St John's Wort yesterday and I found very effective at soothing my
pressures, especially giving me calmness at night.'
A neuromuscular blocking agent is administered to a client before ECT therapy. The Nurse should
carefully observe the client for?
Select one:
a. Dizziness
b. Seizures
c. Respiratory difficulties
Patient Kim is admitted for alcohol detoxification. Which of the following medications is Nurse Willy
most likely to administer to reduce the symptoms of alcohol withdrawal?
Select one:
a. naloxone (Narcan)
b. haloperidol (Haldol)
c. magnesium sulfate
d. chlordiazepoxide (Librium)
SOLER is an acronym used for therapeutic non-verbal communications. This includes all, except:
Select one:
c. Open-ended question
Select one:
b. Presented with massive exposure to a variety of stimuli associated with the phobic object/situation
The nurse is caring for a hospitalized client who has been taking clozapine (Clozaril) for the treatment of
a schizophrenic disorder. The nurse reviews the laboratory studies that have been prescribed for the
client. Which laboratory study should the nurse specifically review to monitor for an adverse effect
associated with the use of this medication?
Select one:
enzymes
Select one:
Ms. T. has been diagnosed with agoraphobia. Which behavior would be most characteristic of this
disorder?
Select one:
a. Ms. T. stays in her home for fear of being in a place from which she cannot escape.
Select one:
b. Rigidity and paralysis of the lips and unilateral portion of the face
d. Pill rolling
Select one:
The nurse is providing medication instructions to a client with depression who has just been placed on
phenelzine (Nardil). Which instruction is the priority?
Select one:
c. "Report severe, sudden, or unusual headache to your health care provider immediately."
Which of the following signals incidence of delirium tremens for a patient suffering from alcohol
withdrawal?
Select one:
a. Delusion of grandeur
c. Psychosis
d. Panic attack
The primary focus of family therapy for clients with schizophrenia and their families is:
Select one:
b. To discuss concrete problem solving and adaptive behaviors for coping with stress
d. To keep the client and family in touch with the health care system
Sertraline (Zoloft) is ordered for Patient Kim for the treatment of depression. During rounds, the doctor
was concerned the patient was having serotonine syndrome. Which of the following would alert the
nurse in relation to the doctor's suspicion?
Select one:
Select one:
doors
Terry with mania is skipping up and down the hallway practically running into other clients. Which of the
following activities would the nurse in charge expect to include in Terry's plan care?
Select one:
a. Reading a book
c. Watching TV
Nurse Booby has provided home-care educations to Patient Roma who has been prescribed with lithium
carbonate (Lithobid). Which statement by the client indicates that he understands the prescribed
regimen?
Select one:
Select one:
Ob. The client shouldn't be made aware of the conflicts underlying the symptoms
c. The client is aware of the psychological conflict
Select one:
To further assess a client's suicidal potential. Nurse Katrina should be especially alert to the client
expression of:
Select one:
Select one:
a. Anhedonia
b. Anergia
c. Insomnia
d. Anorexia
Fluoxetine hydrochloride (Prozac) has been prescribed for Aling Mila. When the nurse provides
instructions, which statement indicates an understanding about the administration of the drug?
Select one:
d. "I should take the medication right before bedtime with a snack."
Patient Jethro, has been admitted to the emergency unit with a diagnosis of Alcohol Intoxication. Labs
have confirmed it. Which of the following should the nurse prioritize to monitor?
Select one:
a. Hypoglycemia
b. Amonia level
c. Hypertensive episodes
d. Vomiting episodes
On assessment, which clinical manifestations should lead the nurse to suspect that a client was
experiencing a disulfiram (Antabuse)-alcohol reaction?
Select one:
b. Flushing, throbbing in the head and neck, difficulty breathing, sweating, dizziness, and weakness
c. Dry skin, tachycardia, vomiting, diarrhea, tremors, ataxia, and muscle stiffness
A client has been prescribed diazepam (Valium). Which assessment finding indicates an adverse effect of
the medication?
Select one:
a. Hypercapnic Hypoxemia
b. Fatigue
c. Drowsiness
d. Slurred Speech
A client with major depressive disorder has been prescribed citalopram (Celexa), and the nurse provides
discharge instructions to the client. Which client statement indicates a need for further teaching?
Select one:
a. "I will not stop taking this medication or alter the dosage in any way without first consulting my health
care provider."
O b. "If I experience dizziness, drowsiness, or a fast heartbeat, I will contact my health care provider
right away."
c. "A controlled very little amount of alcohol should not harm me if everything is in moderation"
d. "I will be sure to have my blood tests done whenever my health care provider prescribes them."
Margaret, age 68, is diagnosed with bipolar I disorder, current episode manic. She is extremely
hyperactive and has lost weight. One way to promote adequate nutritional intake for Margaret is to:
Select one:
a. Tell Margaret that she will be on room restriction until she starts gaining weight.
b. Sit with her during meals to ensure that she eats everything on her tray.
c. Have her sister-in-law bring all her food from home because she knows Margaret's likes and dislikes.
d. Provide high-calorie, nutritious finger foods and snacks that Margaret can eat "on the run.”
A 23 year old woman is admitted to the post partum unit following a miscarriage. The next day the nurse
finds the woman crying while looking at the babies in the newborn nursery. What would be MOST
appropriate?
Select one:
d. Assure the woman that the loss was "for the best."
It is a disorder of mood and affect wherein the patient is markedly depressed mood, excessive anxiety,
mood swing and decreased interest in activities during the week prior to menses improving shortly after
the onset of menstruation
Select one:
a. Dysthymia
b. Major depressive disorder
c. Cyclothymia
Clear my choice
When planning care for a female client using ritualistic behavior, Nurse Gina must recognize that the
ritual:
Select one:
Which of the options indicate proper dietary regimen for a patient taking up Nardil?
Select one:
a. Pork adobo, Boiled Eggs, Cabbage salad, apple fruit, sourdough bread
b. Pork binagoongan, Tender juicy hotdogs, peperoni pizza, tyramine free swiss cheese
c. Boiled egg sandwich, ginataang tilapia, pork giniling, ginisang pechay, jumping salad
O d. liverwurst, sauerkraut, fresh caviar, Argentina corned beef, healthy bugnay wine
Based on the fact that you family unit client is experiencing a situational crisis that has led to
dysfunctional communication within the family unit, you have recommended that the entire nuclear
family and members of the extended family who live in the family's home begin family therapy. The
grandparents tell you that it is their grandson, rather than their son, who is addicted to prescription pain
killers, is the cause of the problem; therefore, they do not have to participate in this group therapy. How
should you respond to these grandparents?
Select one:
a. "Despite the fact that it is your grandson's drug addiction, situations such as this affect all members of
the family including grandparent who live in the home."
A psychotic patient who has been receiving haloperidol visit the clinic for pain and rigidity in the neck.
Which of the following assessment findings will the nurse give the highest priority?
Select one:
a. the client has been taking a prescribed metoclopramide for his vomiting 3-5 days ago.
c. a data in patient's history record that the patient has been having hallucinations, delusions, and
illusions
A client says to the nurse, "Since I started taking this disulfiram (Antabuse), I feel like I've been eating
garlic. I always have a metallic-like taste in my mouth. Is this normal?" Which response should the nurse
make?
Select one:
a. "This is a harmless side effect that will usually disappear after you've taken the medicine for about 2
weeks. Meanwhile, chewing sugarless gum or sucking on sugar free hard candy will help."
b. "This is a harmless side effect that will usually disappear after you've taken the medicine for about 1
year. Meanwhile, chewing sugarless gum or sucking on sugar free hard candy will help."
c. "This is a dangerous side effect that will necessitate immediately stopping the medicine. The taste
your mouth will disappear in
A patient who has been abusing a barbiturate was admitted to the ICU. Which of the following will the
nurse note 10-12 hours after the patient's last intake of the drug?
Select one:
A 17-year old client whose boyfriend has recently broke up with her is brought into the ER after taking a
handful of lorazepam (ativan). Which nursing intervention would take priority in this situation?
Select one:
A patient is being discharged after spending six days in the hospital, due to depression with suicidal
ideation. The psychiatric-mental health nurse knows that an important outcome has been met when the
patient states:
Select one:
a. "I can't wait to get home and forget that this ever happened."
b. "I feel so much better. If I continue to feel this way, I can probably stop taking my medications soon."
c. "I have a list of support groups and a crisis line that I can call, if I feel suicidal."
d. "I have to leave here soon, if I want to make it to the shelter before they run out of beds."
A client receiving haloperidol (Haldol) complains of a stiff jaw and difficulty swallowing. The nurse's first
action is to:
Select one:
A patient suffering from alcohol withdrawal was rushed to the hospital. Which of the following should
the nurse plan to do?
Select one:
Delirium Tremens
Select one:
a. Hyperthermia
b. Myoclonus tremor
c. Bradyreflexia
d. Mydriasis
Select one:
a. clonazepam (Klonopin)
b. haloperidol (Haldol)
c. amitriptyline (Elavil)
d. diazepam (Valium)
The patient has been admitted for treatment of NMS. Which of the following should the nurse
prioritize?
Select one:
d. Maintenance of a patent
The nurse is interviewing a client on the psychiatric unit. The client tilts his head to the side, stops
talking in midsentence, and listens intently. The nurse recognizes these behaviors as a symptom of the
client's illness. The most appropriate nursing intervention for this symptom is to:
Select one:
A client with a diagnosis of paranoid schizophrenia comments to the nurse, "How do I know what is
really in those pills?" Which of the following is the best response?
Select one:
a. Say, "Don't worry about what is in the pills. It's what is ordered."
An 84 year old man is hospitalized with Alzheimer's disease. His daughter tells the nurse that caring for
him is too hard, and that she feels guilty placing him in a nursing home. Which of the following
statements by the nurse is MOST appropriate?
Select one:
a. "I think I would feel guilty too if I had placed my father in a nursing home."
b. "Don't feel guilty. The only solution is to place your father in a nursing home."
d. "It's hard to be caught between taking care of your needs and your father's needs.
Which of the following is not a sign or symptom of depression?
Select one:
a. Insomnia
b. Anhedonia
c. Akathisia
d. Anergia
A female patient reports an intense, overwhelming fear of driving a car. The fear has disrupted all
elements of the patient's life. The patient does not go to the grocery store unless someone transports
her, has relinquished her job, and has few social contacts. The patient's treatment plan includes:
Select one:
a. Assertiveness training.
c. Biofeedback.
d. Systematic desensitization
Tony, age 21, has been diagnosed with schizophrenia. He has been socially isolated and hearing voices
telling him to kill his parents. He has been admitted to the psychiatric unit from the emergency
department. The initial nursing intervention for Tony is to:
Select one:
Thorazine.
A client with bipolar II disorder is experiencing hypomania. The client is not hostile but is talking nonstop
and is disrupting an educational session. The client is forcibly taken to his room and is placed on
restraints. Which legal issue is applicable in this scenario?
Select one:
a. Slander
b. Battery
c. Libel
d. False imprisonment
Which of these is a form of therapeutic communication?
Select one:
Select one:
a. Open ended
volunteers information
When working with a male client suffering phobia about black cats, Nurse Trish should anticipate that a
problem for this client would be?
Select one:
A client with chronic schizophrenia who takes an antidepressant is admitted to the psychiatric unit.
Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. These findings suggest which
life-threatening reaction:
Select one:
a. Serotonine syndrome
d. Hypertensive crisis
Select one:
a. Dependent
b. Schizotypal
c. Histrionic
d. Hypochondraisis
The best goal for a client learning a relaxation technique is that the client will
Select one:
feeling overwhelmed
Peter James, a homosexual, is unwilling to go to his church with his barkada because his ex-boyfriend
goes there and he feels that he will laugh at him if he sees him. Because of this, the decides to remain
homebound. As his nurse, you develop a plan of care knowing that you need to address which of the
following personality disorder?
Select one:
a. Avoidant
b. Borderline
c. Schizotypal
d. Obsessive-compulsive
day and night washing his or her hands. On the third hospital day, the patient reports feeling better and
more comfortable with the staff and other patients. The psychiatric-mental health nurse knows that the
most appropriate nursing intervention is to:
Select one:
a. Collaborate with the patient to reduce the amount of time he or she engages in ritualistic behavior
b. Acknowledge the ritualistic behavior each time and point out that it is inappropriate
c. Allow the patient to carry out the ritualistic behavior, since it is helping him or her
d. Ignore the ritualistic behaviors, and the behaviors will be eliminated due to lack of reinforcement.
A patient who is admitted to the psychiatric unit with a diagnosis of obsessive-compulsive disorder
spends a significant amount of time during the day and night washing his or her hands. On the third
hospital day, the patient reports feeling better and more comfortable with the staff and other patients.
The psychiatric-mental health nurse knows that the most appropriate nursing intervention is to:
Select one:
a. Collaborate with the patient to reduce the amount of time he or she engages in ritualistic behavior
b. Acknowledge the ritualistic behavior each time and point out that it is inappropriate
Select one:
Select one:
b. Hopelessness
d. Decisional conflict
Jon a suspicious client states that "I know you nurses are spraying my food with poison as you take it out
of the cart." Which of the following would be the best response of the nurse?
Select one:
b. Allowing the client to be the first to open the cart and get a tray
The initial care plan for a client with OCD who washes her hands obsessively would include which of the
following nursing interventions?
Select one:
a. Keep the client's bathroom locked so she cannot wash her hands all the time.
b. Structure the client's schedule so that she has plenty of time for washing her hands.
c. Place the client in isolation until she promises to stop washing her hands so much.
Select one:
a. Before bedtime
b. Before Breakfast
c. With dinner
d. After lunch
A client diagnosed with a panic disorder has been treated with alprazolam (Xanax). The nurse
determines that the client is experiencing a side effect of this medication when the client exhibits which
sign/symptom?
Select one:
a. Heightened alertness
b. Enhanced coordination
c. Disorientation
d. Heightened anxiety
Nurse Akihiro has found Patient Rodie, a psychotic patient, in his room seemingly talking to some
unseen forces. When trying to initiate a conversation, the patient interrupted him saying, "Huwag kang
maingay, magagalit sila, baka mapano tayo dito." Which action is the best response by the patient?
Select one:
a. "May naririnig kang boses? Sabihin mo sakin kung ano ang sinasabi nila."
Select one:
a. Granulocytopenia
b. Systemic dermatitis
c. Infection
d. Hepatitis
A client begins clozapine (Clozaril) therapy after several other antipsychotic agents fail to relieve her
psychotic symptoms. The nurse instructs her to return for weekly white blood cell (WBC) counts to
assess for which adverse reaction?
Select one:
a. Granulocytopenia
b. Systemic dermatitis
c. Infection
d. Hepatitis
A 39 year old mother with obsessive compulsive disorder has become immobilized by her elaborate
hand washing and walking rituals. Nurse Trish recognizes that the basis of O.C. disorder is often:
Select one:
conscientious
A client has been prescribed phenelzine (Nardil), and the nurse is providing instructions to the client
regarding this medication. Which of the following client statement indicates the need for further
teaching?
Select one:
a. "Taking over-the-counter medications for cold symptoms should not cause any problems."
c. "The maximum benefit of this medication will be noticed within 2 to 6 weeks after initiation of
therapy."
d. "I need to avoid foods that require bacteria and molds for preparation."
Margaret, a 68-year-old widow, is brought to the emergency department by her sister-in-law. Margaret
has a history of bipolar disorder and has been maintained on medication for many years. Her sister-in-
law reports that Margaret quit taking her medication a few months ago, thinking she didn't need it
anymore. She is agitated, pacing, demanding, and speaking very loudly. Her sister-in-law reports that
Margaret eats very little, is losing weight, and almost never sleeps. "I'm afraid she's going to just
collapse!" Margaret is admitted to the psychiatric unit. The priority nursing diagnosis for Margaret is:
Select one:
Select one:
Select one:
a. Flumazenil (Romazicon)
b. Benzodiazepine
c. Narcan
d. Magnesium Sulfate
A newborn baby is being monitored in the unit after having been admitted due to distress. Which of the
following would indicate that the newborn baby is suffering from meta-amphatamine withdrawal?
Select one:
b. hyperthermia
A supervisor observes inconsistency in the psychiatric-mental health nurse's behavior toward a patient;
the nurse is unreasonably concerned, overly kind, or irrationally hostile. The most appropriate
explanation is that the nurse is displaying:
Select one:
a. Splitting behavior
b. Lability
c. Transference
d. Countertransference
Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of
prescribed antipsychotic medication. The most important piece of information the nurse in charge
should obtain initially is the:
Select one:
Select one:
a. "The team needs to know when something important occurs in treatment. I need to tell the others,
but let's talk about it first."
c. "Tell me what type of instrument you used. I'm concerned about infection."
d. "I'm going to tell your physician. Do you want to tell me why you did that?"
A patient was rushed to the ER due to narcotic overdose. The patient was initially unconscious but
regained his consciousness after NARCAN has been given in the ER. Which of the following should the
nurse monitor the patient for after Narcan administration?
Select one:
a. Respiratory acidosis
b. Respiratory depression
c. Metabolic acidosis
d. Suicidal ideations
Danny who is diagnosed with bipolar disorder and acute mania, states the nurse, "Where is my
daughter? I love Louis. Rain, rain go away. Dogs eat dirt." The nurse interprets these statements as
indicating which of the following?
Select one:
a. Echolalia
b. Neologism
c. Clang associations
d. Flight of ideas
A client who is experiencing a panic attack has just arrived at the emergency department. Which is the
priority nursing intervention for this client?
Select one:
b. Leave the client alone in a quiet room so that she can calm down.
The nurse is assessing an older client who was newly prescribed trazodone (Desyrel) for side effects of
the medication. Which baseline assessment measurement is the priority for this client?
Select one:
a. BP
b. Temperature
c. Suicidal ideations
d. Heart rate
A client with a psychotic disorder is being treated with haloperidol (Haldol). The nurse monitors the
client for which finding that indicates the presence of an adverse effect of this medication?
Select one:
a. Blurred vision.
b. Hypotension
c. Excessive salivation
d. Nausea
Which of the following nursing interventions is appropriate for a client diagnosed with hypochondriasis?
Select one:
b. Confront the client with the statement, "it's all in your head"
Select one:
Select one:
a. Avoidant-Histrionic
b. Anti-social-Boarderline
c. Narcissistic-Anti-social
d. Histrionic-Narcissistic
Clint, a client on the psychiatric unit, has been diagnosed with schizophrenia. He begins to tell the nurse
about how the CIA is looking for him and will kill him if they find him. Clint's belief is an example of a:
Select one:
a. Delusion of reference
b. Delusion of grandeur
c. Delusion of persecution
The nurse is interviewing a client on the psychiatric unit. The client tilts his head to the side, stops
talking in midsentence, and listens intently. The nurse recognizes from these signs that the client is likely
experiencing:
Select one:
a. Pseudoparkinsonism
b. Somatic delusions
c. Catatonic stupor
d. Auditory hallucinations
An alcoholic patient has been admitted to unit. Which of the following indicates that the patient has
developed delirium tremens?
Select one:
d. mental clouding 1-2 hours after the patient's last alcohol ingestion
A patient was rushed to ER due to hypoventilation and loss of consciousness. Which of the following
indicates that the patient is suffering from benzodiazepine toxicity?
Select one:
a. Ataxia
b. Seizure
c. Diarrhea
d. Irritability
A patient was rushed to ER due to hypoventilation and loss of consciousness. Which of the following
indicates that the patient is suffering from benzodiazepine toxicity?
Select one:
a. Ataxia
b. Seizure
c. Diarrhea
d. Irritability
A patient was rushed to ER due to hypoventilation and loss of consciousness. Which of the following
indicates that the patient is suffering from benzodiazepine toxicity?
Select one:
a. Ataxia
b. Seizure
c. Diarrhea
d. Irritability