1. Mental health is defined as: 5.

Primary level of prevention is exemplified

A. The ability to distinguish what is real from by:
what is not. A. Helping the client resume self-care.
B. A state of well-being where a person can B. Ensuring the safety of a suicidal client in the
realize his own abilities can cope with normal institution.
stresses of life and work productively. C. Teaching the client stress management
C. Is the promotion of mental health, prevention techniques
of mental disorders, nursing care of patients D. Case finding and surveillance in the
during illness and rehabilitation community
D. Absence of mental illness 6. Situation: In a home visit done by the
2. Which of the following describes the role of nurse, she suspects that the wife and her
a technician? child are victims of abuse. Which of the
A. Administers medications to a schizophrenic following is the most appropriate for the
patient. nurse to ask?
B. The nurse feeds and bathes a catatonic client A. “Are you being threatened or hurt by your
C. Coordinates diverse aspects of care rendered partner?
to the patient B. “Are you frightened of you partner.”
D. Disseminates information about alcohol and C. “Is something bothering you?”
its effects. D. “What happens when you and your partner
3. Letty says, “Give me ten (10) minutes to argue?”
recall the name of our college professor who 7. The wife admits that she is a victim of
failed many students in our anatomy class.” abuse and opens up about her persistent
She is operating on her: distaste for sex. This sexual disorder is:
A. Subconscious A. Sexual desire disorder
B. Conscious B. Sexual arousal disorder
C. Unconscious C. Orgasm disorder
D. Ego D. Sexual Pain Disorder
4. The superego is that part of the psyche 8. What would be the best approach for a wife
that: who is still living with her abusive husband?
A. Uses defensive function for protection. A. “Here’s the number of a crisis center that you
B. Is impulsive and without morals. can call for help .”
C. Determines the circumstances before making B. “It’s best to leave your husband.”
decisions. C. “Did you discuss this with your family?”
D. The censoring portion of the mind. D. “ Why do you allow yourself to be treated this
way.”
9. Which comment about a 3-year-old child if A. Ineffective individual coping
made by the parent may indicate child B. Alteration in comfort, pain
abuse? C. Altered role performance
A. “Once my child is toilet trained, I can still D. Impaired social interaction
expect her to have some.” 14. The following statements describe
B. “When I tell my child to do something once, I somatoform disorders:
don’t expect to have to tell.” A. Physical symptoms are explained by organic
C. “My child is expected to try to do things such causes
as dress and feed.” B. It is a voluntary expression of psychological
D. “My three (3)-year-old loves to say NO.” conflicts
10. The primary nursing intervention for a C. Expression of conflicts through bodily
victim of child abuse is: symptoms
A. Assess the scope of the problem D. Management entails a specific medical
B. Analyze the family dynamics treatment
C. Ensure the safety of the victim 15. What would be the best response to the
D. Teach the victim coping skills client’s repeated complaints of pain:
11. Situation: A 30-year-old male employee A. “I know the feeling is real tests revealed
frequently complains of low back pain that negative results.”
leads to frequent absences from work. B. “I think you’re exaggerating things a little bit.”
Consultation and tests reveal negative C. “Try to forget this feeling and have activities to
results. The client has which somatoform take it off your mind.”
disorder? D. “So tell me more about the pain.”
A. Somatization Disorder 16. Situation: A nurse may encounter children
B. Hypochondriasis with mental disorders. Her knowledge of
C. Conversion Disorder these various disorders is vital. When
D. Somatoform Pain Disorder planning school interventions for a child with
12. Freud explains anxiety as: a diagnosis of attention deficit hyperactivity
A. Strives to gratify the needs for satisfaction and disorder, a guide to remember is to:
security A. Provide as much structure as possible for the
B. Conflict between id and superego child
C. A hypothalamic-pituitary-adrenal reaction B. Ignore the child’s overactivity.
to stress C. Encourage the child to engage in any play
D. A conditioned response to stressors activity to dissipate energy
13. The following are the appropriate nursing D. Remove the child from the classroom when
diagnosis for the client EXCEPT: disruptive behavior occurs
17. The child with conduct disorder will likely A. Overprotection of the child
demonstrate: B. Patience, routine, and repetition
A. Easy distractibility to external stimuli. C. Assisting the parents set realistic goals
B. Ritualistic behaviors D. Giving reasonable compliments
C. Preference for inanimate objects. 22. The parents express apprehensions on
D. Serious violations of age related norms. their ability to care for their maladaptive
18. Ritalin is the drug of choice for children child. The nurse identifies what nursing
with ADHD. The side effects of the following diagnosis:
may be noted: A. Hopelessness
A. Increased attention span and concentration B. Altered parenting role
B. Increase in appetite C. Altered family process
C. Sleepiness and lethargy D. Ineffective coping
D. Bradycardia and diarrhea 23. A 5-year-old boy is diagnosed to have
19. School phobia is usually treated by: autistic disorder. Which of the following
A. Returning the child to the school immediately manifestations may be noted in a client with
with family support. autistic disorder?
B. Calmly explaining why attendance in school is A. Aargumentativeness, disobedience, angry
necessary outburst
C. Allowing the child to enter the school before B. Intolerance to change, disturbed relatedness,
the other children stereotypes
D. Allowing the parent to accompany the child in C. Distractibility, impulsiveness, and overactivity
the classroom D. Aggression, truancy, stealing, lying
20. A 10 year old child has very limited 24. The therapeutic approach in the care of
vocabulary and interaction skills. She has an an autistic child includes the following
I.Q. of 45. She is diagnosed to have Mental EXCEPT:
retardation of this classification: A. Engage in diversionary activities when acting -
A. Profound out
B. Mild B. Provide an atmosphere of acceptance
C. Moderate C. Provide safety measures
D. Severe D. Rearrange the environment to activate the
21. The nurse teaches the parents of a child
mentally retarded child regarding her care. 25. According to Piaget, a 5-year-old is at
The following guidelines may be taught what stage of development:
except: A. Sensorimotor stage
B. Concrete operations
C. Pre-operational C. LSD
D. Formal operation D. Marijuana
26. Situation: The nurse assigned to the 30. A client is admitted with needle tracks on
detoxification unit attends to various his arm, stuporous and with pin point pupil
patients with substance-related disorders. A will likely be managed with:
45 years old male revealed that he A. Naltrexone (Revia)
experienced a marked increase in his intake B. Narcan (Naloxone)
of alcohol to achieve the desired effect This C. Disulfiram (Antabuse)
indicates: D. Methadone (Dolophine)
A. Withdrawal 31. Situation: An old woman was brought for
B. Tolerance evaluation due to the hospital for evaluation
C. Intoxication due to increasing forgetfulness and
D. Psychological dependence limitations in daily function. The daughter
27. The client admitted for alcohol revealed that the client used her toothbrush
detoxification develops increased tremors, to comb her hair. She is manifesting:
irritability, hypertension, and fever. The A. Apraxia
nurse should be alert for impending: B. Aphasia
A. Delirium tremens C. Agnosia
B. Korsakoff’s syndrome D. Amnesia
C. Esophageal varices 32. She tearfully tells the nurse “I can’t take it
D. Wernicke’s syndrome when she accuses me of stealing her things.”
28. The care for the client places priority on Which response by the nurse will be most
which of the following: therapeutic?
A. Monitoring his vital signs every hour A. ”Don’t take it personally. Your mother does
B. Providing a quiet, dim room not mean it.”
C. Encouraging adequate fluids and nutritious B. “Have you tried discussing this with your
foods mother?”
D. Administering Librium as ordered C. “This must be difficult for you and your
29. Another client is brought to the mother.”
emergency room by friends who state that he D. “Next time ask your mother where her things
took something an hour ago. He is actively were last seen.”
hallucinating, agitated, with an 33. The primary nursing intervention in
irritated nasal septum. working with a client with moderate stage
A. Heroin dementia is ensuring that the client:
B. Cocaine
A. Receives adequate nutrition and hydration D. Call her mother on the phone and tell her how
B. Will reminisce to decrease isolation she feels
C. Remains in a safe and secure environment 38. The client with anorexia nervosa is
D. Independently performs self-care improving if:
34. She says to the nurse who offers her A. She eats meals in the dining room.
breakfast, “Oh no, I will wait for my husband. B. Weight gain
We will eat together” The therapeutic C. She attends ward activities.
response by the nurse is: D. She has a more realistic self-concept.
A. “Your husband is dead. Let me serve you your 39. The characteristic manifestation that will
breakfast.” differentiate bulimia nervosa from anorexia
B. “I’ve told you several times that he is dead. It’s nervosa is that bulimic individual
time to eat.” A. Have episodic binge eating and purging
C. “You’re going to have to wait a long time.” B. Have repeated attempts to stabilize their
D. “What made you say that your husband is weight
alive? C. Have peculiar food handling patterns
35. Dementia, unlike delirium, is D. Have threatened self-esteem
characterized by: 40. A nursing diagnosis for bulimia nervosa
A. Slurred speech is powerlessness related to feeling not in
B. Insidious onset control of eating habits. The goal for this
C. Clouding of consciousness problem is:
D. Sensory perceptual change A. Patient will learn problem-solving skills
36. Situation: A 17-year-old gymnast is B. Patient will have decreased symptoms of
admitted to the hospital due to weight loss anxiety.
and dehydration secondary to starvation. C. Patient will perform self-care activities daily.
Which of the following nursing diagnoses will D. Patient will verbalize how to set limits on
be given priority for the client? others.
A. Altered self-image 41. In the management of bulimic patients,
B. Fluid volume deficit the following nursing interventions will
C. Altered nutrition less than body requirements promote a therapeutic relationship EXCEPT:
D. Altered family process A. Establish an atmosphere of trust
37. What is the best intervention to teach the B. Discuss their eating behavior.
client when she feels the need to starve? C. Help patients identify feelings associated with
A. Allow her to starve to relieve her anxiety binge-purge behavior
B. Do a short term exercise until the urge passes D. Teach patient about bulimia nervosa
C. Approach the nurse and talk out her feelings
42. Situation: A 35-year-old male has an 46. Which of the following should be included
intense fear of riding an elevator. He claims “ in the health teachings among clients
As if I will die inside.” This has affected his receiving Valium:
studies The client is suffering from: A. Avoid taking CNS depressant like alcohol.
A. Agoraphobia B. There are no restrictions in activities.
B. Social phobia C. Limit fluid intake.
C. Claustrophobia D. Any beverage like coffee may be taken
D. Xenophobia 47. Situation: A 20-year-old college student is
43. Initial intervention for the client should admitted to the medical ward because of
be to: sudden onset of paralysis of both legs.
A. Encourage to verbalize his fears as much as he Extensive examination revealed no physical
wants. basis for the complaint. The nurse plans
B. Assist him to find meaning to his feelings in intervention based on which correct
relation to his past. statement about conversion disorder?
C. Establish trust through a consistent approach. A. The symptoms are conscious effort to control
D. Accept her fears without criticizing. anxiety
44. The nurse develops a countertransference B. The client will experience a high level of
reaction. This is evidenced by: anxiety in response to the paralysis.
A. Revealing personal information to the client C. The conversion symptom has symbolic
B. Focusing on the feelings of the client. meaning to the client
C. Confronting the client about discrepancies in D. A confrontational approach will be beneficial
verbal or non-verbal behavior for the client.
D. The client feels angry towards the nurse who 48. Nikki reveals that the boyfriend has been
resembles his mother. pressuring her to engage in premarital sex.
45. Which is the desired outcome in The most therapeutic response by the nurse
conducting desensitization: is:
A. The client verbalize his fears about the A. “I can refer you to a spiritual counselor if you
situation like.”
B. The client will voluntarily attend group therapy B. “You shouldn’t allow anyone to pressure you
in the social hall. into sex.”
C. The client will socialize with others willingly C. “It sounds like this problem is related to your
D. The client will be able to overcome his paralysis.”
disabling fear. D. “How do you feel about being pressured into
sex by your boyfriend?”
49. Malingering is different from somatoform  Option D: Mental health is not just the
disorder because the former: absence of mental illness.
A. Has evidence of an organic basis. 2. Answer: A. Administers medications to a
B. It is a deliberate effort to handle upsetting schizophrenic patient.
events Administration of medications and treatments,
C. Gratification from the environment are assessment, documentation are the activities of
obtained. the nurse as a technician.
D. Stress is expressed through physical
 Option B: Activities as a parent
symptoms.
surrogate.
50. Unlike psychophysiologic disorder Linda
 Option C: Refers to the ward manager
may be best managed with:
role.
A. Medical regimen
 Option D: Role as a teacher.
B. Milieu therapy
3. Answer: A. Subconscious
C. Stress management techniques
Subconscious refers to the materials that are
D. Psychotherapy
partly remembered partly forgotten but these
can be recalled spontaneously and voluntarily.
Answers and Rationale

 Option B: This functions when one is

1. Answer: B. A state of well-being where a
awake. One is aware of his thoughts,
person can realize his own abilities can cope
feelings actions and what is going on
with normal stresses of life and work
in the environment.
productively.
ADVERTISEMENT  Option C: The largest portion of the

Mental health is a state of emotional and mind that contains the memories of

psychosocial well being. A mentally healthy one’s past particularly the unpleasant.

individual is self-aware and self-directive has the It is difficult to recall the unconscious

ability to solve problems, can cope with the crisis content.

without assistance beyond the support of family  Option D: The conscious self that deals

and friends fulfill the capacity to love and work and tests reality.

and sets goals and realistic limits. 4. Answer: D. The censoring portion of the
mind.
 Option A: This describes the ego The critical censoring portion of one’s
function reality testing. personality; the conscience.
 Option C: This is the definition of
Mental Health and Psychiatric Nursing.
  Option A: This refers to the ego  Option B: Failure to maintain the
function that protects itself from physiologic requirements for sexual
anything that threatens it. intercourse.
 Option B: The Id is composed of the  Option C: Persistent and recurrent
untamed, primitive drives and inability to achieve an orgasm.
impulses.  Option D: Also called dyspareunia.
 Option C: This refers to the ego that Individuals with this disorder suffer
acts as the moderator of the struggle genital pain before, during and after
between the id and the superego. sexual intercourse.
5. Answer: C. Teaching the client stress 8. Answer: A. “Here’s the number of a crisis
management techniques center that you can call for help .”
Primary level of prevention refers to the Protection is a priority concern in abuse. Help
promotion of mental health and prevention of the victim to develop a plan to ensure safety.
mental illness. This can be achieved by rendering
 Option B: Do not give advice to leave
health teachings such as modifying one’s
the abuser. Making decisions for the
responses to stress.
victim further erodes her esteem.
 Option A: This is tertiary level of However, discuss options available.
prevention that deals with  Option C: The victim tends to isolate
rehabilitation. from friends and family.
 Options B and D. Secondary level of  Option D: This is judgmental. Avoid in
prevention which involves reduction of any way implying that she is at fault.
actual illness through early detection 9. Answer: B. “When I tell my child to do
and treatment of illness. something once, I don’t expect to have to
6. Answer: A. “Are you being threatened or tell.”
hurt by your partner? Abusive parents tend to have unrealistic
The nurse validates her observation by asking expectations on the child.
simple, direct question. This also shows
 Options A, B, and C are realistic
empathy.
expectations on a 3-year-old.
 Options B, C, and D are indirect 10. Answer: C. Ensure the safety of the victim
questions which may not lead to the The priority consideration is the safety of the
discussion of abuse. victim. Attend to the physical injuries to ensure
7. Answer: A. Sexual desire disorder the physiologic safety and integrity of the child.
Has little or no sexual desire or has a distaste for Reporting suspected case of abuse may deter
sex. recurrence of abuse.
  Options A, B, and D may be addressed  Option A: The client maladaptively
later. uses body symptoms to manage
11. Answer: D. Somatoform Pain Disorder anxiety.
This is characterized by severe and prolonged  Option B: The client will have
pain that causes significant distress. discomfort due to pain.
 Option C: The client may fail to meet
 Option A: This is a chronic syndrome
environmental expectations due to
of somatic symptoms that cannot be
pain.
explained medically and is associated
14. Answer: C. Expression of conflicts through
with psychosocial distress.
bodily symptoms
 Option B: This is an unrealistic
Bodily symptoms are used to handle conflicts.
preoccupation with a fear of having a
serious illness.  Option A: Manifestations do not have
 Option C: Characterized by alteration an organic basis.
or loss in sensory or motor function  Option B: This occurs unconsciously.
resulting from a psychological conflict.  Option D: Medical treatment is not
12. Answer: B. Conflict between id and used because the disorder does not
superego have a structural or organic basis.
Freud explains anxiety as due to opposing action 15. Answer: A. “I know the feeling is real tests
drives between the id and the superego. revealed negative results.”
Shows empathy and offers information.
 Option A: Sullivan identified 2 types of
needs, satisfaction and security.  Option B: This is a demeaning
Failure to gratify these needs may statement.
result in anxiety.  Option C: This belittles the client’s
 Option C: Biomedical perspective of feelings.
anxiety.  Option D: Giving undue attention to
 Option D: Explanation of anxiety using the physical symptom reinforces the
the behavioral model. complaint.
13. Answer: D. Impaired social interaction 16. Answer: A. provide as much structure as
The client may not have difficulty in social possible for the child
exchange. The cues do not support this Decrease stimuli for behavior control thru an
diagnosis. 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  Options C: Anxiety in school phobia is
from a lenient approach. not due to being in school but due to
 Option C: Dissipate energy through separation from parents/caregivers so
safe activities. these interventions are not applicable.
 Option D: This indicates that the  Option D: This will not help the child
classroom environment lacks overcome the fear
structure. 20. Answer: C. Moderate
17. Answer: D. Serious violations of age- The child with moderate mental retardation has
related norms. an I.Q. of 35-50
This is a disruptive disorder among children
 Option A: Profound Mental retardation
characterized by more serious violations of social
has an I.Q. of below 20.
standards such as aggression, vandalism,
 Option B: Mild mental retardation 50-
stealing, lying and truancy.
70.
 Option A: This is characteristic of  Option D: Severe mental retardation
attention deficit disorder. has an I.Q. of 20-35.
 Options B and C: These are noted 21. Answer: A. Overprotection of the child
among children with autistic disorder. The child with mental retardation should not be
18. Answer: A. increased attention span and overprotected but need protection from injury
concentration and the teasing of other children.
The medication has a paradoxical effect that
 Options B, C, and D Children with
decreases hyperactivity and impulsivity among
mental retardation have a learning
children with ADHD.
difficulty. They should be taught with
 Options B, C, D. Side effects of Ritalin patience and repetition, start from
include anorexia, insomnia, diarrhea, simple to complex, use visuals and
and irritability. compliment them for motivation.
19. Answer: A. Returning the child to the Realistic expectations should be set
school immediately with family support. and optimize their capability.
Exposure to the feared situation can help in 22. Answer: B. altered parenting role
overcoming anxiety. Altered parenting role refers to the inability to
create an environment that promotes optimum
 Option B: This will not help in relieving
growth and development of the child. This is
the anxiety due separation from a
reflected in the parent’s inability to care for the
significant other.
child.
  Option A: This refers to the lack of Preoperational stage (2-7 years) is the stage
choices or inability to mobilize one’s when the use of language, the use of symbols
resources. and the concept of time occur.
 Option C: Refers to change in family
 Option A: Sensorimotor stage (0-2
relationship and function.
years) is the stage when the child uses
 Option D: Ineffective coping is the
the senses in learning about the self
inability to form valid appraisal of the
and the environment through
stressor or inability to use available
exploration.
resources
 Option B: Concrete operations (7-12
23. Answer: B. intolerance to change,
years) when inductive reasoning
disturbed relatedness, stereotypes
develops.
These are manifestations of autistic disorder.
 Option D: Formal operations (2 till
 Option A: These manifestations are adulthood) is when abstract thinking
noted in Oppositional Defiant and deductive reasoning develop.
Disorder, a disruptive disorder among 26. Answer: B. Tolerance
children. Tolerance refers to the increase in the amount of
 Option C: These are manifestations of the substance to achieve the same effects.
Attention Deficit Disorder.
 Option A: Withdrawal refers to the
 Option D: These are the
physical signs and symptoms that
manifestations of Conduct Disorder
occur when the addictive substance is
24. Answer: D. Rearrange the environment to
reduced or withheld.
activate the child
 Option B: Intoxication refers to the
The child with autistic disorder does not want
behavioral changes that occur upon
change. Maintaining a consistent environment is
recent ingestion of substance.
therapeutic.
 Option D: Psychological dependence
 Option A: Angry outburst can be re- refers to the intake of the substance to
channelled through safe activities. prevent the onset of withdrawal
 Option B: Acceptance enhances a symptoms.
trusting relationship. 27. Answer: A. Delirium tremens
 Option C: Ensure safety from self- Delirium Tremens is the most extreme
destructive behaviors like head central nervous system irritability due to
banging and hair pulling. withdrawal from alcohol.
25. Answer: C. Pre-operational
  Option B: This refers to an amnestic Intoxication with Marijuana, a cannabinoid is
syndrome associated with chronic manifested by
alcoholism due to a deficiency in Vit. B.
 Option A: Intoxication with heroine is
 Option C: This is a complication of
manifested by euphoria then
liver cirrhosis which may be secondary
impairment in judgment, attention and
to alcoholism.
the presence of papillary constriction.
 Option D: This is a complication of
 Option C: Intoxication with
alcoholism characterized by
hallucinogen like LSD is manifested by
irregularities of eye movements and
grandiosity, hallucinations, synesthesia
lack of coordination.
and increase in vital signs.
28. Answer: A. Monitoring his vital signs every
 Option D: Intoxication with Marijuana,
hour
a cannabinoid is manifested by the
Pulse and blood pressure are usually elevated
sensation of slowed time, conjunctival
during withdrawal; Elevation may indicate
redness, social withdrawal, impaired
impending delirium tremens.
judgment, and hallucinations.
 Option B: Client needs quiet, well 30. Answer: B. Narcan (Naloxone)
lighted, consistent and secure Narcan is a narcotic antagonist used to manage
environment. Excessive stimulation the CNS depression due to overdose with heroin.
can aggravate anxiety and cause
 Option A: This is an opiate receptor
illusions and hallucinations.
blocker used to relieve the craving for
 Option C: Adequate nutrition with
heroin.
supplements of Vit. B should be
 Option C: Disulfiram is used as a
ensured.
deterrent in the use of alcohol.
 Option D: Sedatives are used to relieve
 Option D: Methadone is used as a
anxiety.
substitute in the withdrawal from
29. Answer: B. Cocaine
heroin
The manifestations indicate intoxication with
31. Answer: C. Agnosia
cocaine, a CNS stimulant. Option A: Intoxication
This is the inability to recognize objects.
with heroine is manifested by euphoria then
impairment in judgment, attention and the
 Option A: Apraxia is the inability to
presence of papillary constriction. Option C:
execute motor activities despite intact
Intoxication with hallucinogen like LSD is
comprehension.
manifested by grandiosity, hallucinations,
 Option B: Aphasia is the loss of ability
synesthesia and increase in vital signs. Option D:
to use or understand words.
  Option D: Amnesia is loss of memory.  Option D: The cognitive limitation of
32. Answer: C. “This must be difficult for you the client makes the client incapable of
and your mother.” giving an explanation.
This reflecting the feeling of the daughter that 35. Answer: B. Insidious onset
shows empathy. Dementia has a gradual onset and progressive
deterioration. It causes pronounced memory
 Options A and D. Giving advice does
and cognitive disturbances.
not encourage verbalization.
 Option B: This response does not  Options A, C, and D are all
encourage verbalization of feelings. characteristics of delirium.
33. Answer: C. Remains in a safe and secure 36. Answer: B. Fluid volume deficit
environment Fluid volume deficit is the priority over altered
Safety is a priority consideration as the client’s nutrition since the situation indicates that the
cognitive ability deteriorates. client is dehydrated.

 Option A is appropriate interventions  Options A and D are psychosocial

because the client’s cognitive needs of a client with anorexia nervosa
impairment can affect the client’s but they are not the priority.
ability to attend to his nutritional 37. Answer: C. Approach the nurse and talk
needs, but it is not the priority out her feelings
 Option B: Patient is allowed to The client with anorexia nervosa uses starvation
reminisce but it is not the priority. as a way of managing anxiety. Talking out
 Option D: The client in the moderate feelings with the nurse is an adaptive coping.
stage of Alzheimer’s disease will have
 Option A: Starvation should not be
difficulty in performing activities
encouraged. Physical safety is a
independently
priority. Without adequate nutrition, a
34. Answer: A. “Your husband is dead. Let me
life threatening situation exists.
serve you your breakfast.”
 Option B: The client with anorexia
The client should be reoriented to reality and be
nervosa is preoccupied with losing
focused on the here and now.
weight due to disturbed body image.
 Option B: This is not a helpful Limits should be set on attempts to
approach because of the short term lose more weight.
memory of the client.  Option D: The client may have a
 Option C: This indicates a pompous domineering mother which causes the
response. client to feel ambivalent. The client will
 not discuss her feelings with her  Option D: Setting limits to control
mother. imposed by others is a necessary skill
38. Answer: B. Weight gain but problem-solving skill is the priority.
ADVERTISEMENT 41. Answer: B. Discuss their eating behavior.
Weight gain is the best indication of the client’s The client is often ashamed of her eating
improvement. The goal is for the client to gain 1- behavior. Discussion should focus on feelings.
2 pounds per week.
 Options A, C, and D promote a
 Option A: The client may purge after therapeutic relationship
eating. 42. Answer: C. Claustrophobia
 Option C: Attending an activity does Claustrophobia is fear of closed space.
not indicate improvement in the
nutritional state.  Option A: Agoraphobia is fear of open
 Option D: Body image is a factor in space or being a situation where
anorexia nervosa, but it is not an escape is difficult.
indicator of improvement.  Option B: Social phobia is fear of
39. Answer: A. Have episodic binge eating and performing in the presence of others
purging in a way that will be humiliating or
Bulimia is characterized by binge eating which is embarrassing.
characterized by taking in a large amount of food  Option D: Xenophobia is fear of
over a short period of time. strangers.
43. Answer: D. Accept her fears without
 Options B and C are characteristics of criticizing.
a client with anorexia nervosa. The client cannot control her fears although the
 Option D: Low esteem is noted in both client knows it’s silly and can joke about it.
eating disorders
40. Answer: A. Patient will learn problem-  Option A: Allow expression of the
solving skills client’s fears but he should focus on
If the client learns problem-solving skills she will other productive activities as well.
gain a sense of control over her life.  Options B and C: These are not the
initial interventions.
 Option B: Anxiety is caused by 44. Answer: A. Revealing personal
powerlessness. information to the client
 Option C: Performing self-care Countertransference is an emotional reaction of
activities will not decrease one’s the nurse on the client based on her
powerlessness. unconscious needs and conflicts.
  Options B and C: These are  Option D: The client should not be
therapeutic approaches. confronted by the underlying cause of
 Option D: This is transference reaction his condition because this can
where a client has an emotional aggravate the client’s anxiety.
reaction towards the nurse based on 48. Answer: D. “How do you feel about being
her past. pressured into sex by your boyfriend?”
45. Answer: D. The client will be able to Focusing on the expression of feelings is
overcome his disabling fear. therapeutic. The central force of the client’s
The client will overcome his disabling fear by condition is anxiety.
gradual exposure to the feared object.
 Option A: This is not therapeutic
 Options A, B, and C are not the desired because the nurse passes the
outcome of desensitization. responsibility to the counselor.
46. Answer: A. Avoid taking CNS depressant  Option B: Giving advice is not
like alcohol. therapeutic.
Valium is a CNS depressant. Taking it with other  Option C: This is not therapeutic
CNS depressants like alcohol; potentiates its because it confronts the underlying
effect. cause.
49. Answer: B. It is a deliberate effort to
 Option B: The client should be taught
handle upsetting events
to avoid activities that require
Malingering is a conscious simulation of an
alertness.
illness while somatoform disorder occurs
 Option C: Valium causes dry mouth so
unconsciously.
the client must increase her fluid
intake.  Option A: Both disorders do not have
 Option D: Stimulants must not be an organic or structural basis.
taken by the client because it can  Option C: Both have primary gains.
decrease the effect of Valium.  Option D: This is a characteristic of the
47. Answer: C. The conversion symptom has somatoform disorder.
symbolic meaning to the client 50. Answer: C. stress management techniques
the client uses body symptoms to relieve anxiety. Stress management techniques is the best
management of somatoform disorder because
 Option A: The condition occurs
the disorder is related to stress and it does not
unconsciously.
have a medical basis. Option A: This disorder is
 Option B: The client is not distressed
not supported by organic pathology so no
by the lost or altered body function.
medical regimen is required. Options B and D: 3. The nurse observes a client pacing
Milieu therapy and psychotherapy may be used in the hall. Which statement by the
nurse may help the client recognize
 Option A: This disorder is not
his anxiety?
supported by organic pathology so no
medical regimen is required. A. “I guess you’re worried about
 Options B and D: Milieu therapy and something, aren’t you?
psychotherapy may be used b. “Can I get you some medication to help
therapeutic modalities but these are calm you?”
not the best. c. “Have you been pacing for a long
time?”
1. Which nursing intervention is best
d. “I notice that you’re pacing. How are
for facilitating communication with a
you feeling?”
psychiatric client who speaks a foreign
language?
4. A client with obsessive-compulsive
disorder is hospitalized on an
A. Rely on nonverbal communication.
inpatient unit. Which nursing
B. Select symbolic pictures as aids.
response is most therapeutic?
C. Speak in universal phrases.
D. Use the services of an interpreter.
A. Accepting the client’s obsessive-
compulsive behaviors
2. The nurse explains to a mental
B. Challenging the client’s obsessive-
health care technician that a client’s
compulsive behaviors
obsessive-compulsive behaviors are
C. Preventing the client’s obsessive-
related to an unconscious conflict
compulsive behaviors
between id impulses and the superego
D. Rejecting the client’s obsessive-
(or conscience). On which of the
compulsive behaviors
following theories does the nurse base
this statement?
5. A 45-year-old woman with a history
of depression tells a nurse in her
A. Behavioral theory
doctor’s office that she has difficulty
B. Cognitive theory
with sexual arousal and is fearful that
C. Interpersonal theory
her husband will have an affair. Which
D. Psychoanalytic theory
of the following factors would the
nurse identify as least significant in
contributing to the client’s sexual C. The client verbalizes that family meals
difficulty? are now enjoyable.
D. The client tells her parents about
A. Education and work history feelings of low self-esteem.
B. Medication used
C. Physical health status 8. The nurse is working with a client
D. Quality of spousal relationship with a somatoform disorder. Which
client outcome goal would the nurse
6. Which nursing intervention is most most likely establish in this situation?
appropriate for a client with anorexia
nervosa during initial hospitalization A. The client will recognize signs and
on a behavioral therapy unit? symptoms of physical illness.
B. The client will cope with physical
A. Emphasize the importance of good illness.
nutrition to establish normal weight. C. The client will take prescribed
B. Ignore the client’s mealtime behavior medications.
and focus instead on issues of D. The client will express anxiety verbally
dependence and independence. rather than through physical symptoms.
C. Help establish a plan using privileges
and restrictions based on compliance 9. Which method would a nurse use to
with refeeding. determine a client’s potential risk
D. Teach the client information about the for suicide?
long-term physical consequence of
anorexia. A. Wait for the client to bring up the
subject of suicide.
7. A nurse is evaluating therapy with B. Observe the client’s behavior for cues
the family of a client with anorexia of suicide ideation.
nervosa. Which of the following would C. Question the client directly about
indicate that the therapy was suicidal thoughts.
successful? D. Question the client about future plans.

A. The parents reinforce increased 10. A client with a bipolar disorder

decision making by the client. exhibits manic behavior. The nursing
B. The parents clearly verbalize their diagnosis is Disturbed thought
expectations for the client. processes related to difficulty
concentrating, secondary to flight of affecting every aspect of a person’s
ideas. Which of the following outcome functioning.
criteria would indicate improvement D. The distressing symptoms of this
in the client? disorder can respond to treatment with
medications.
A. The client verbalizes feelings directly
during treatment. 13. A nurse is working with a client
B. The client verbalizes positive “self” who has schizophrenia, paranoid type.
statement. Which of the following outcomes
C. The client speaks in coherent related to the client’s delusional
sentences. perceptions would the nurse
D. The client reports feelings calmer. establish?

11. A client tells a nurse. “Everyone A. The client will demonstrate realistic
would be better off if I wasn’t alive.” interpretation of daily events in the unit.
Which nursing diagnosis would be B. The client will perform daily hygiene
made based on this statement? and grooming without assistance.
C. The client will take prescribed
A. Disturbed thought processes medications without difficulty.
B. Ineffective coping D. The client will participate in unit
C. Risk for self-directed violence activities.
D. Impaired social interaction
14. A client with bipolar disorder,
12. Which information is the most manic type, exhibits extreme
essential in the initial teaching session excitement, delusional thinking, and
for the family of a young adult command hallucinations. Which of the
recently diagnosed with following is the priority nursing
schizophrenia? diagnosis?

A. Symptoms of this disease imbalance in A. Anxiety

the brain. B. Impaired social interaction
B. Genetic history is an important factor C. Disturbed sensory-perceptual
related to the development of alteration (auditory)
schizophrenia. D. Risk for other-directed violence
C. Schizophrenia is a serious disease
15. A client who abuses alcohol and A. Mental retardation.
cocaine tells a nurse that he only uses B. Heroin dependence.
substances because of his stressful C. Addiction in adulthood.
marriage and difficult job. Which D. Psychological disturbances.
defense mechanisms is this client
using? 18. The emergency department nurse
is assigned to provide care for a victim
A. Displacement of a sexual assault. When following
B. Projection legal and agency guidelines, which
C. Rationalization intervention is most important?
D. Sublimation
A. Determine the assailant’s identity.
16. An 11-year-old child diagnosed B. Preserve the client’s privacy.
with conduct disorder is admitted to C. Identify the extent of an injury.
the psychiatric unit for treatment. D. Ensure an unbroken chain of evidence.
Which of the following behaviors
would the nurse assess? 19. Which factor is least important in
the decision regarding whether a
A. Restlessness, short attention span, victim of family violence can safely
hyperactivity remain in the home?
B. Physical aggressiveness, low-
stress tolerance disregard for the rights A. The availability of appropriate
of others community shelters
C. Deterioration in social functioning, B. The non-abusing caretaker’s ability to
excessive anxiety, and worry, bizarre intervene on the client’s behalf
behavior C. The client’s possible response to
D. Sadness, poor appetite and relocation
sleeplessness, loss of interest in activities D. The family’s socioeconomic status

17. The nurse understands that if a 20. The nurse would expect a client
client continues to be dependent on with early Alzheimer’s disease to have
heroin throughout her pregnancy, her problems with:
baby will be at high risk for:
A. Balancing a checkbook.
B. Self-care measures.
C. Relating to family members. event and availability of situational
D. Remembering his own name supports
D. The client’s use of reality testing and
21. Which nursing intervention is most level of depression
appropriate for a client with
Alzheimer’s disease who has frequent 24. The nurse considers a client’s
episodes emotional lability? response to crisis intervention
successful if the client:
A. Attempt humor to alter the client
mood. A. Changes coping skills and behavioral
B. Explore reasons for the client’s altered patterns.
mood. B. Develops insight into reasons why the
C. Reduce environmental stimuli to crisis occurred.
redirect the client’s attention. C. Learns to relate better to others.
D. Use logic to point out reality aspects. D. Returns to his previous level of
functioning.
22. Which neurotransmitter has been
implicated in the development of 25. Two nurses are co-leading group
Alzheimer’s disease? therapy for seven clients in the
psychiatric unit. The leaders observe
A. Acetylcholine that the group members are anxious
B. Dopamine and look to the leaders for answers.
C. Epinephrine Which phase of development is this
D. Serotonin group in?

23. Which factors are the most A. Conflict resolution phase

essential for the nurse to assess when B. Initiation phase
providing crisis intervention foer a C. Working phase
client? D. Termination phase

A. The client’s communication and coping 26. Group members have worked very
skills hard, and the nurse reminds them
B. The client’s anxiety level and ability to that termination is approaching.
express feelings Termination is considered successful if
C. The client’s perception of the triggering group members:
A. Decide to continue. A. Aged cheese and red wine
B. Elevate group progress B. Milk and green, leafy vegetables
C. Focus on positive experience C. Carbonated beverages and tomato
D. Stop attending prior to termination. products
D. Lean red meats and fruit juices
27. The nurse is teaching a group of
clients about the mood-stabilizing 30. Prior to
medications lithium carbonate. Which administering chlorpromazine (Thoraz
medications should she instruct the ine) to an agitated client, the nurse
clients to avoid because of the should:
increased risk of lithium toxicity?
A. Assess skin color and sclera
A. Antacids B. Assess the radial pulse
B. Antibiotics C. Take the client’s blood pressure
C. Diuretics D. Ask the client to void
D. Hypoglycemic agents
31. The nurse understands that
28. When providing family therapy, electroconvulsive therapy is primarily
the nurse analyzes the functioning of used in psychiatric care for the
healthy family systems. Which treatment of:
situations would not
increase stress on a healthy family A. Anxiety disorders.
system? B. Depression.
C. Mania.
A. An adolescent’s going away to college D. Schizophrenia.
B. The birth of a child
C. The death of a grandparent 32. A client taking the MAOI
D. Parental disagreement phenelzine (Nardil) tells the nurse that
he routinely takes all of the
29. A client taking the monoamine medications listed below. Which
oxidase inhibitor (MAOI) medication would cause the nurse to
antidepressant isocarboxazid express concern and therefore initiate
(Marplan) is instructed by the nurse to further teaching?
avoid which foods and beverages?
A. Acetaminophen (Tylenol) C. Provide fellowship among members.
B. Diphenhydramine (Benadryl) D. Teach positive coping mechanisms.
C. Furosemide (Lasix)
D. Isosorbide dinitrate (Isordil) 36. Which client outcome is most
appropriately achieved in a
33. The nurse is administering a community approach setting in
psychotropic drug to an elderly client psychiatric nursing?
who has a history of benign prostatic
hypertrophy. It is most important for A. The client performs activities of daily
the nurse to teach this client to: living and learns about crafts.
B. The client is able to prevent aggressive
A. Add fiber to his diet. behavior and monitors his use of
B. Exercise on a regular basis. medications.
C. Report incomplete bladder emptying C. The client demonstrates self-reliance
D. Take the prescribed dose at bedtime. and social adaptation.
D. The client experience experiences
34. The nurse correctly teaches a anxiety relief and learns about his
client taking the Benzodiazepine symptoms.
Oxazepam (Serax) to avoid excessive
intake of: 37. A client with panic disorder
experiences an acute attack while the
A. Cheese nurse is completing an admission
B. Coffee assessment. List the following
C. Sugar interventions according to their level
D. Shellfish of priority.

35. The nurse provides a referral to A. Remain with the client.

Alcoholics Anonymous to a client who B. Encourage physical activity.
describes a 20-year history of alcohol C. Encourage low, deep breathing.
abuse. The primary function of this D. Reduce external stimuli.
group is to: E. Teach coping measures.

A. Encourage the use of a 12-step 38. The doctor has prescribed

program. haloperidol (Haldol) 2.5 mg. I.M. for an
B. Help members maintain sobriety. agitated client. The medication is
labeled haloperidol 10 mg/2 ml. The 41. A 75-year-old client has dementia
nurse prepares the correct dose by of the Alzheimer’s type and
drawing up how many milliliters in the confabulates. The nurse understands
syringe? that this client:

A. 0.3 A. Denies confusion by being jovial.

B. 0.4 B. Pretends to be someone else.
C. 0.5 C. Rationalizes various behaviors.
D. 0.6 D. Fills in memory gaps with fantasy.

39. The nurse enters the room of a 42. An elderly client with Alzheimer’s
client with a cognitive impairment disease becomes agitated and
disorder and asks what day of the combative when a nurse approaches
week it is: what the date, month, and to help with morning care. The most
year are; and where the client is. The appropriate nursing intervention in
nurse is attempting to assess: this situation would be to:

A. Confabulation A. Tell the client family that it is time to

B. Delirium get dressed.
C. Orientation B. Obtain assistance to restrain the client
D. Perseveration for safety.
C. Remain calm and talk quietly to the
40. Which of the following will the client.
nurse use when communicating with a D. Call the doctor and request an order
client who has a cognitive for sedation.
impairment?
43. In clients with a cognitive
A. Complete explanations with multiple impairment disorder, the
details phenomenon of increased confusion
B. Picture or gestures instead of words in the early evening hours is called:
C. Stimulating words and phrases to
capture the client’s attention A. Aphasia
D. Short words and simple sentences B. Agnosia
C. Sundowning
D. Confabulation
44. Which of the following outcome A. Acknowledge the parent’s
criteria is appropriate for the client responsibility.
with dementia? B. Explain the biological nature of
schizophrenia.
A. The client will return to an adequate C. Refer the family to a support group
level of self-functioning. D. Teach the parents various ways they
B. The client will learn new coping must change.
mechanisms to handle anxiety.
C. The client will seek out resources in 47. The nurse collecting family
the community for support. assessment data asks. “Who is in your
D. The client will follow an establishing family and where do they live?” which
schedule for activities of daily living. of the following is the nurse
attempting o identify?
45. The school guidance counselor
refers a family with an 8-year-old child A. Boundaries
to the mental health clinic because of B. Ethnicity
the child’s frequent fighting in school C. Relationships
and truancy. Which of the following D. Triangles
data would be a priority to the nurse
doing the initial family assessment? 48. According to the family systems
theory, which of the following best
A. The child’s performance in school describes the process of
B. Family education and work history differentiation?
C. The family’s perception of the current
problem A. Cooperative action among members of
D. The teacher’s attempt to solve the the family
problem B. Development of autonomy within the
family
46. The parents of a young man with C. Incongruent messages wherein the
schizophrenia express feelings of recipient is a victim
responsibility and guilt for their son’s D. Maintenance of system continuity or
problems. How can the nurse best equilibrium
educate the family?
49. The nurse is interacting with a
family consisting of a mother, a
father, and a hospitalized adolescent Answers and Rationale
who has a diagnosis of alcohol abuse.
The nurse analyzes the situation and
1. Answer: D. Use the services of an
agrees with the adolescent’s view
interpreter.
about family rules. Which intervention
is most appropriate? ADVERTISEMENT

An interpreter will enable the nurse to

A. The nurse should align with the better assess the client’s problems and
adolescent, who is the family scapegoat. concerns.
B. The nurse should encourage the
parents to adopt more realistic rules.  Option A: Nonverbal
C. The nurse should encourage the communication is important;
adolescent to comply with parental rules. however for the nurse to fully
D. The nurse should remain objective determine the client’s problems
and encourage mutual negotiation of and concerns, the assistance of
issues. an interpreter is essential.
 Options B and C: The use of
50. A 16-year-old girl symbolic pictures and universal
has returned home following phrases may assist the nurse in
hospitalization for treatment of understanding the basic needs
anorexia nervosa. The parents tell of the client; however these are
the family nurse performing a home insufficient to assess the client
visit that their child has always done with a psychiatric problem.
everything to please them and they
cannot understand her current 2. Answer: D. Psychoanalytic theory
stubbornness about eating. The nurse
analyzes the family situation and Psychoanalytic is based on Freud’s beliefs
determines it is characteristic of regarding the importance of unconscious
which relationship style? motivation for behavior and the role of
the id and superego in opposition to
A. Differentiation each other.
B. Disengagement
C. Enmeshment  Options A and B: Behavioral
D. Scapegoating cognitive and interpersonal
theories do not emphasize
 unconscious conflicts as the plan is developed, other nursing
basis for symptomatic behavior. responses may also be acceptable.

3. Answer: D. “I notice that you’re  Options B, C, and D: The

pacing. How are you feeling?” remaining answer choices will
increase the client’s anxiety and
By acknowledging the observed behavior therefore are inappropriate.
and asking the client to express his
feelings the nurse can best assist the 5. Answer: A. Education and work
client to become aware of his anxiety. history

 In option A, the nurse is offering Education and work history would have
an interpretation that may or the least significance in relation to the
may not be accurate; the nurse client’s sexual problem.
is also asking a question that
may be answered by a “yes” or  Options B, C, and D: Age, health
“no” response, which is not status, physical attributes and
therapeutic. relationship issues have great
 In option B, the nurse is influence on sexual expression.
intervening before accurately
6. Answer: C. Help establish a plan
assessing the problem.
using privileges and restrictions based
 Option C, which also encourages
on compliance with refeeding.
a “yes” or “no” response, avoids
focusing on the client’s anxiety,
Inpatient treatment of a client with
which is the reason for his
anorexia usually focuses initially on
pacing.
establishing a plan for refeeding to
4. Answer: A. Accepting the client’s combat the effects of self-induced
obsessive-compulsive behaviors starvation. Refeeding is accomplished
through behavioral therapy, which uses a
A client with obsessive-compulsive system of rewards and reinforcements to
behavior uses this behavior to decrease assist in establishing weight restoration.
anxiety. Accepting this behavior as the
client’s attempt to feel secure is  Options A and D: Emphasizing
therapeutic. When a specific treatment nutrition and teaching the client
about the long-term physical
 consequences of anorexia verbally indicates a positive change
maybe appropriate at a later toward improved health.
time in the treatment program.
 Option B: The nurse needs to  Options A, B, and C: The
assess the client’s mealtime remaining responses do not
behavior continually to evaluate indicate any positive change
treatment effectiveness. toward increased coping with
anxiety.
7. Answer: A. The parents reinforce
increased decision making by the 9. Answer: C. Question the client
client. directly about suicidal thoughts.

One of the core issues concerning the Directly questioning a client about
family of a client with anorexia is control. suicide is important to determine suicide
The family’s acceptance of the client’s risk.
ability to make independent decisions is
key to successful family intervention.  Option A: The client may not
bring up this subject for several
 Options B, C, and D: Although reasons, including guilt
the remaining options may occur regarding suicide, wishing not to
during the process of therapy be discovered, and his lack of
they would not necessarily trust in staff.
indicate a successful outcome;  Option B: Behavioral cues are
the central family issues of important, but direct
dependence and independence questioning is essential to
are not addressed in these determine suicide risk.
responses.  Option D: Indirect questions
convey to the client that the
8. Answer: D. The client will express nurse is not comfortable with
anxiety verbally rather than through the subject of suicide and,
physical symptoms. therefore, the client may be
reluctant to discuss the topic.
The client with a somatoform disorder
displaces anxiety into physical 10. Answer: C. The client speaks in
symptoms. The ability to express anxiety coherent sentences
A client exhibiting flight of ideas typically true, they do not provide the
has a continuous speech flow and jumps empathic response the family
from one topic to another. Speaking in needs after just learning about
coherent sentences is an indicator that the diagnosis. These facts can
the client’s concentration has improved become part of the ongoing
and his thoughts are no longer racing. teaching.

 Options A, B, and D: The 13. Answer: A. The client will

remaining options do not relate demonstrate realistic interpretation
directly to the stated nursing of daily events in the unit.
diagnosis.
A client with schizophrenia, paranoid
11. Answer: C. Risk for self-directed type, has distorted perceptions and views
violence people, institutions, and aspects of the
environment as plotting against him. The
The nurse should take any nurse desired outcome for someone with
statements indicating suicidal thoughts delusional perceptions would be to have
seriously and further assess for other risk a realistic interpretation of daily events.
factors.
 Option B: The client with a
 Options A, B, and D: The distorted perception of the
remaining diagnoses fail to environment would not
address the seriousness of the necessarily have impairments
client’s statement. affecting hygiene and grooming
skills.
12. Answer: D. The distressing
 Options C and D: Although
symptoms of this disorder can
taking medications and
respond to treatment with
participating in unit activities
medications.
may be appropriate outcomes
for nursing intervention; these
This statement provides accurate
responses are not related to
information and an element of hope for
client perceptions.
the family of a schizophrenic client.
14. Answer: D. Risk for other-directed
 Options A, B, and C: Although violence
the remaining statements are
A client with these symptoms would have Physical aggressiveness, low-stress
poor impulse control and would tolerance, and a disregard for the rights
therefore be prone to acting-out of others are common behaviors in
behavior that may be harmful to either clients with conduct disorders.
himself or others. All of the remaining
nursing diagnoses may apply to the client  Option A: Restlessness, short
with mania; however, the priority attention span, and hyperactivity
diagnosis would be risk for violence. are typical behaviors in a client
with attention deficit
 Options A, B, and C: All of the hyperactivity disorder.
remaining nursing diagnoses  Option C: Deterioration in social
may apply to the client with functioning, excessive anxiety
mania; however, the priority and worry and bizarre behaviors
diagnosis would be risk for are typical in schizophrenic
violence. disorders.
 Option D: Sadness, poor
15. Answer: C. Rationalization appetite, sleeplessness, and loss
of interest in activities are
Rationalization is the defense mechanism
behaviors commonly seen in
that involves offering excuses for
depressive disorders.
maladaptive behavior. The client is
defending his substance abuse by 17. Answer: B. Heroin dependence.
providing reasons related to life
stressors. This is a common defense Babies born to heroin-dependent women
mechanism used by clients with are also heroin-dependent and need to
substance abuse problems. go through withdrawal. There is no
evidence to support any of the remaining
 Options A, B, and D: None of the answer choices.
remaining defense mechanisms
involves making excuses for 18. Answer: D. Ensure an unbroken
behaviors. chain of evidence.

16. Answer: B. Physical aggressiveness, Establishing an unbroken chain of

low-stress tolerance disregard for the evidence is essential in order to ensure
rights of others that the prosecution of the perpetrator
can occur.
  Options A and D: The nurse will can help a client feel less like a
also need to preserve the client’s victim.
privacy and identify the extent of
an injury. However, it is essential 20. Answer: A. Balancing a checkbook.

that the nurse follows legal and

In the early stage of Alzheimer’s disease,
agency guidelines for preserving
complex tasks (such as balancing a
evidence.
checkbook) would be the first cognitive
 Option C: Identifying the
deficit to occur.
assailant is the job of law
enforcement, not the nurse.
 Options B, C, and D: The loss of
19. Answer: D. The family’s self-care ability, problems with
socioeconomic status relating to family members, and
difficulty remembering one’s
Socioeconomic status is not a reliable own name are all areas of
predictor of abuse in the home so that it cognitive decline that occur later
would be the least important in the disease process.
consideration in deciding issues of safety
21. Answer: C. Reduce environmental
for the victim of family violence.
stimuli to redirect the client’s

 Options A and B: The availability attention.

of appropriate community
The client with Alzheimer’s disease can
shelters and the ability of the
have frequent episode of labile mood,
non-abusing caretaker to
which can best be handled by decreasing
intervene on the client’s behalf
a stimulating environment and
are important factors when
redirecting the client’s attention.
making safety decisions.
 Option C: The client’s response
 Option A: The client with
to possible relocation (if the
Alzheimer’s disease loses the
client is a competent adult)
cognitive ability to respond to
would be the most important
either humor or logic.
factor to consider; feelings of
 Option B: An over stimulating
empowerment and being
environment may cause the
treated as a competent person
labile mood, which will be
 difficult for the client to 24. Answer: D. Returns to his previous
understand. level of functioning.
 Option D: The client lacks any
insight into his or her own Crisis intervention is based on the idea
behavior and therefore will be that a crisis is a disturbance
unaware of any causative in homeostasis (steady state). The goal is
factors. to help the client return to a previous
level of equilibrium in functioning.
22. Answer: A. Acetylcholine
 Options A, B, and C: The
A relative deficiency of acetylcholine is remaining answer choices are
associated with this disorder. The drugs not considered the primary
used in the early stages of Alzheimer’s outcome of crisis intervention,
disease will act to increase available although they may occur as a
acetylcholine in the brain. The remaining side benefit.
neurotransmitters have not been
implicated in Alzheimer’s disease. 25. Answer: B. Initiation phase

23. Answer: C. The client’s perception Increased anxiety and uncertainty

of the triggering event and availability characterize the initiation phase in group
of situational supports therapy. Group members are more self-
reliant during the working and
The most important factors to determine termination phases.
in this situations are the client’s
perception of the crisis event and the 26. Answer: A. Decide to continue.
availability of support (including family
and friends) to provide basic needs. As the group progresses into the working
phase, group members assume more
 Options A, B, and D: Although responsibility for the group. The leader
the nurse should assess the becomes more of a facilitator. Comments
other factors, they are not as about behavior in a group are indicators
essential as determining why the that the group is active and involved.
client considers this a crisis and
whether he can meet his present  Options B, C, and D: The
needs. remaining answer choices would
indicate the group progress has
 not advanced to the working with an MAOI, can precipitate a
phase. hypertensive crisis.

27. Answer: C. Diuretics Options B, C, and D: The other foods and

beverages do not contain significant
The use of diuretics would amounts of tyramine and, therefore, are
cause sodium and water excretion, which not restricted.
would increase the risk of lithium toxicity.
Clients taking lithium carbonate should 30. Answer: C. Take the client’s blood
be taught to increase their fluid intake pressure
and to maintain normal intake of sodium.
Because chlorpromazine (Thorazine) can
 Options A, B, and D: Concurrent cause a significant hypotensive effect
use of any of the remaining (and possible client injury), the nurse
medications will not increase the must assess the client’s blood pressure
risk of lithium toxicity. (lying, sitting, and standing) before
administering this drug.
28. Answer: D. Parental disagreement

 Option A: If the client had taken

In a functional family, parents typically do
the drug previously, the nurse
not agree on all issues and problems.
would also need to assess the
Open discussion of thoughts and feeling
skin color and sclera for signs of
is healthy, and parental disagreement
jaundice, a possible drug side
should not cause system stress.
affect; however, based on the
information given here, there is
 Options A, B, and C: The
no evidence that the client has
remaining answer choices are
received chlorpromazine before.
life transitions that are expected
 Option D: Although the drug can
to increase family stress.
cause urine retention, asking the
29. Answer: A. Aged cheese and red client to avoid will not alter this
wine anticholinergic effect.

31. Answer: B. Depression.

Aged cheese and red wines contain the
substance tyramine which, when taken
Electroconvulsive therapy (ECT) can
provide relief for patients with severe
depression who have not been able to regularly are measures to
feel better with other treatments. In counteract another
some severe cases where rapid response anticholinergic
is necessary or medications cannot be effect, constipation.
used safely, ECT can even be a first-line  Option D: Depending on the
intervention. ECT consists of a series of specific medication and how it is
sessions, typically three times a week, for prescribed, taking the
two to four weeks. medication at night may or may
not be important. However, it
32. Answer: B. Diphenhydramine would have nothing to do with
(Benadryl) urinary retention in this client.

Over-the-counter medications used for 34. Answer: B. Coffee

allergies and cold symptoms are
contraindicated because they will Coffee contains caffeine, which has a
increase the sympathomimetic effects of stimulating effect on the central nervous
MAOIs, possibly causing a hypertensive system that will counteract the effect of
crisis. the antianxiety medication oxazepam.
None of the remaining foods is
 Options A, C, and D: None of the contraindicated.
remaining medications will
increase the sympathomimetic 35. Answer: B. Help members maintain
response and, therefore, are not sobriety.
contraindicated.
The primary purpose of Alcoholics
33. Answer: C. Report incomplete Anonymous is to help members achieve
bladder emptying and maintain sobriety.

Urinary retention is a common  Options A, C, and D: Although

anticholinergic side effect of psychotic each of the remaining answer
medications, and the client with benign choices may be an outcome of
prostatic hypertrophy would have attendance at Alcoholics
increased risk for this problem. Anonymous, the primary
purpose is directed toward
 Options A and B: Adding fiber to sobriety of members.
one’s diet and exercising
36. Answer: C. The client demonstrates under control. Teaching coping measures
self-reliance and social adaptation. will help the client learn to handle
anxiety; however, this can only be
A therapeutic community is designed to accomplished when the client’s panic has
help individuals assume responsibility for dissipated and he is better able to focus.
themselves, to learn how to respect and
communicate with others, and to interact 38. Answer: C. 0.5
in a positive manner.
ADVERTISEMENT

 Options A, B, and D: The Set up the problem as follows:

remaining answer choices may 2.5mg/10mg = Xml/2ml X=0.5ml
be outcomes of psychiatric
treatment, but the use of a 39. Answer: C. Orientation
therapeutic community
approach is concerned with the The initial, most basic assessment of a
promotion of self-reliance and client with cognitive impairment involves
cooperative adaptation to being determining his level of orientation
with others. (awareness of time, place, and person).

37. Answer: A, D, C, B, then E.  Options A and D: The nurse may

also assess for confabulation
The nurse should remain with the client and perseveration in a client
to provide support and promote safety. with cognitive impairment, but
Reducing external stimuli, including the questions in this situation
dimming lights and avoiding crowded would not elicit the symptom
areas, will help decrease anxiety. response.
Encouraging the client to use slow, deep  Option B: Delirium is a type of
breathing will help promote the cognitive impairment; however,
body’s relaxation response, thereby other symptoms are necessary
interrupting stimulation from the to establish this diagnosis.
autonomic nervous system. Encouraging
physical activity will help him to release 40. Answer: D. Short words and simple
energy resulting from the heightened sentences
anxiety state; this should be done only
after the client has brought his breathing
Short words and simple sentence  Option B: Restraints are a last
minimize client confusion and enhance resort to ensure client safety and
communication. are inappropriate in this
situation.
 Options A and C: Complete  Option D: Sedation should be
explanations with multiple avoided, if possible, because it
details and stimulating words will interfere with CNS
and phrases would increase functioning and may contribute
confusion in a client with short to the client’s confusion.
attention span and difficulty with
comprehension. 43. Answer: C. Sundowning
 Option B: Although pictures and
gestures may be helpful, they Sundowning is a common phenomenon

would not substitute for verbal that occurs after daylight hours in a client

communication. with a cognitive impairment disorder.

The other options are incorrect
41. Answer: D. Fills in memory gaps responses, although all may be seen in
with fantasy. this client.

Confabulation is a communication device 44. Answer: D. The client will follow an

used by patients with dementia to establishing schedule for activities of
compensate for memory gaps. The daily living.
remaining answer choices are incorrect.
Following established activity schedules
42. Answer: C. Remain calm and talk is a realistic expectation for clients with
quietly to the client. dementia.

Maintaining a calm approach when  Options A, B, and C: All of the

intervening with an agitated client is remaining outcome statements
extremely important. require a higher level of
cognitive ability than can be
 Option A: Telling the client firmly realistically expected of clients
that it is time to get dressed may with this disorder.
increase his agitation, especially
if the nurse touches him. 45. Answer: C. The family’s perception
of the current problem
The family’s perception of the problem is making a referral for this
essential because change in any one part problem.
of a family system affects all other parts  Option D: Teaching the parents
and the system as a whole. Each member various ways to change would
of the family has been affected by the reinforce the parental
current problems related to the school assumption of blame; although
system and the nurse would be parents can learn about
interested in the data. Options A and D: schizophrenia and what is
The child’s performance in school and helpful and not helpful, the
the teacher’s attempts to solve the approach suggested in this
problem are relevant and may be option implies the parents’
assessed; however, priority would be behavior is at fault.
given to the family’s perception of the
problem. Option B: The family education 47. Answer: A. Boundaries

and work history may be relevant, but

Family boundaries are parameters that
are not a priority.
define who is inside and outside the

46. Answer: B. Explain the biological system. The best method of obtaining

nature of schizophrenia. this information is asking the family

directly who they consider to be
The parents are feeling responsible and members.
this inappropriate self-blame can be
limited by supplying them with the facts  Options B, C, and D: The

about the biologic basis of schizophrenia. question asked by the nurse

would not elicit information
 Option A: Acknowledging the about the family’s ethnicity or
patient’s responsibility is neither culture, nor does it address the
accurate nor helpful to the nature of the family relationship.
parents and would only
48. Answer: B. Development of
reinforce their feelings of guilt.
autonomy within the family
 Option C: Support groups are
useful; however, the nurse
Differentiation is the process of
needs to handle the parents’
becoming an individual developing
self-blame directly instead of
autonomy while staying in contact with
the family system.
  Option A: Cooperative action  Options B and C: Encouraging
among family members does the parents to adopt more
not refer to differentiation, realistic rules or the adolescent
although individuals who have a to comply with parental rules
high level of differentiation does not give the family an
would be able to accomplish opportunity to try to resolve
cooperative action. problems on their own.
 Option C: Incongruent messages
in which the recipient is a victim 50. Answer: C. Enmeshment

describe double-bind
Enmeshment is a fusion or over
communication.
involvement among family members
 Option D: Maintenance of
whereby the expectation exists that all
system continuity or equilibrium
members think and act alike. The child
is homeostasis.
who always acts to please her parents is
49. Answer: D. The nurse should an example of how enmeshment affects
remain objective and encourage development in many cases, a child who
mutual negotiation of issues. develops anorexia nervosa exerts control
only in the area of eating behavior.
The nurse who wishes to be helpful to
the entire family must remain neutral.  Options A, B, and D: The
Taking sides in a conflict situation in a remaining options are not
family will not encourage negotiation, appropriate to the situation
which is important for problem described.
resolution.  1. A client is struggling to explore
and solve a problem. Which
 Option A: If the nurse aligned nursing statement would
with the adolescent, then the verbalize the implication of the
nurse would be blaming the client’s actions?
parents for the child’s current  A. “You seem to be motivated to
problem; this would not help the change your behavior.”
family’s situation. Learning to B. “How will these changes affect
negotiate conflict is a function of your family relationships?”
a healthy family. C. “Why don’t you make a list of the
behaviors you need to change.”
 D. “The team recommends that you with clients diagnosed with
make only one behavioral change psychiatric disorders. Which
at a time.” statement by the instructor best
 2. The nurse asks a newly provides information about this
admitted client, “What can we do aspect of therapeutic
to help you?” What is the communication?
purpose of this therapeutic  A. “Touch carries a different
communication technique? meaning for different individuals.”
 A. To reframe the client’s thoughts B. “Touch is often used when
about mental health treatment deescalating volatile client
B. To put the client at ease situations.”
C. To explore a subject, idea, C. “Touch is used to convey interest
experience, or relationship and warmth.”
D. To communicate that the nurse D. “Touch is best combined with
is listening to the conversation empathy when dealing with
 3. A student nurse tells the anxious clients.”
instructor, “I’m concerned that  5. Which nursing statement is a
when a client asks me for advice good example of the therapeutic
I won’t have a good solution.” communication technique of
Which should be the nursing focusing?
instructor‘s best response?  A. “Describe one of the best things
 A. “It’s scary to feel put on the spot that happened to you this week.”
by a client. Nurses don’t always B. “I’m having a difficult time
have the answer.” understanding what you mean.”
B. “Remember, clients, not nurses, C. “Your counseling session is in 30
are responsible for their own minutes. I’ll stay with you until
choices and decisions.” then.”
C. “Just keep the client’s best D. “You mentioned your
interests in mind and do the best relationship with your father. Let’s
that you can.” discuss that further.”
D. “Set a goal to continue to work  6. After fasting from 10 p.m. the
on this aspect of your practice.” previous evening, a client finds
 4. A student nurse is learning out that the blood test has been
about the appropriate use canceled. The client swears at
of touch when communicating the nurse and states, “You are
 incompetent!” Which is the can change with time.”
nurse’s best response? C. “You’ve been feeling sad and
 A. “Do you believe that I was the alone for some time now?”
cause of your blood test being D. “It is great that you have come in
canceled?” for help.”
B. “I see that you are upset, but I  9. Which nursing response is an
feel uncomfortable when you example of the nontherapeutic
swear at me.” communication block of
C. “Have you ever thought about requesting an explanation?
ways to express anger  A. “Can you tell me why you said
appropriately?” that?”
D. “I’ll give you some space. Let me B. “Keep your chin up. I’ll explain
know if you need anything.” the procedure to you.”
 7. During a nurse-client C. “There is always an explanation
interaction, which nursing for both good and bad behaviors.”
statement may belittle the D. “Are you not understanding the
client’s feelings and concerns? explanation I provided?”
 A. “Don’t worry. Everything will be  10. A client states, “You won’t
alright.” believe what my husband said to
B. “You appear uptight.” me during visiting hours. He has
C. “I notice you have bitten your no right treating me that way.”
nails to the quick.” Which nursing response would
D. “You are jumping to best assess the situation that
conclusions.” occurred?
 8. A client on an in-patient  A. “Does your husband treat you
psychiatric unit tells the nurse, “I like this very often?”
should have died because I am B. “What do you think is your role
totally worthless.” In order to in this relationship?”
encourage the client to continue C. “Why do you think he behaved
talking about feelings, which like that?”
should be the nurse’s initial D. “Describe what happened during
response? your time with your husband.”
 A. “How would your family feel if  11. Which therapeutic
you died?” communication technique
B. “You feel worthless now, but that should the nurse use when
 communicating with a client communication technique has
who is experiencing auditory the nurse employed and what
hallucinations? defense mechanism is the client
 A. “My sister has the same unconsciously demonstrating?
diagnosis as you and she also hear  A. Making observations and the
voices.” defense mechanism of suppression
B. “I understand that the voices B. Verbalizing the implied and the
seem real to you, but I do not hear defense mechanism of denial
any voices.” C. Reflection and the defense
C. “Why not turn up the radio so mechanism of projection
that the voices are muted.” D. Encouraging descriptions of
D. “I wouldn’t worry about these perceptions and the defense
voices. The medication will make mechanism of displacement
them disappear.”  14. Which of the following
 12. Which nursing statement is a individuals are communicating a
good example of the therapeutic message? (Select all that apply.)
communication technique of  A. A mother spanking her son for
offering self? playing with matches
 A. “I think it would be great if you B. A teenage boy isolating himself
talked about that problem during and playing loud music
our next group session.” C. A biker sporting an
B. “Would you like me to eagle tattoo on his biceps
accompany you to your D. A teenage girl writing, “No one
electroconvulsive therapy understands me.”
treatment?” E. A father checking for new e-mail
C. “I notice that you are offering on a regular basis
help to other peers in the milieu.”  15. A mother rescues two of her
D. “After discharge, would you like four children from a house fire.
to meet me for lunch to review In the emergency department,
your outpatient progress?” she cries, “I should have gone
 13. A client slammed a door on back in to get them. I should
the unit several times. The nurse have died, not them.” What is
responds, “You seem angry.” The the nurse’s best response?
client states, “I’m not angry.”  A. “The smoke was too thick. You
What therapeutic couldn’t have gone back in.”
 B. “You’re feeling guilty because  3. Answer: B. “Remember,
you weren’t able to save your clients, not nurses, are
children.” responsible for their own choices
C. “Focus on the fact that you could and decisions.”
have lost all four of your children.”  Giving advice tells the client what to
D. “It’s best if you try not to think do or how to behave. It implies that
about what happened. Try to move the nurse knows what is best and
on.” that the client is incapable of any
self-direction. It discourages
 Answers and Rationale independent thinking.
  4. Answer: A. “Touch carries a
different meaning for different
 1. Answer: A. “You seem to be individuals.”
motivated to change your  Touch can elicit both negative and
behavior.” positive reactions, depending on
 ADVERTISEMENT the people involved and the
circumstances of the interaction.
 This is an example of the
 5. Answer: D. “You mentioned
therapeutic communication
your relationship with your
technique of verbalizing the
father. Let’s discuss that
implied. Verbalizing the implied
further.”
puts into words what the client has
 This is an example of the
only implied or said indirectly.
therapeutic communication
 2. Answer: C. To explore a
technique of focusing. Focusing
subject, idea, experience, or
takes notice of a single idea or even
relationship
a single word and works especially
 This is an example of the
well with a client who is moving
therapeutic communication
rapidly from one thought to
technique of exploring. The
another.
purpose of using exploring is to
 6. Answer: B. “I see that you are
delve further into the subject, idea,
upset, but I feel uncomfortable
experience, or relationship. This
when you swear at me.”
technique is especially helpful with
 This is an example of the
clients who tend to remain on a
appropriate use of feedback.
superficial level of communication.
Feedback should be directed
 toward behavior that the client has implies that the client must defend
the capacity to modify. his or her behavior or feelings.
 7. Answer: A. “Don’t worry.  10. Answer: D. “Describe what
Everything will be alright.” happened during your time with
 This nursing statement is an your husband.”
example of the nontherapeutic  This is an example of the
communication block of belittling therapeutic communication
feelings. Belittling feelings occur technique of exploring. The
when the nurse misjudges the purpose of using exploring is to
degree of the client’s discomfort. delve further into the subject, idea,
Thus a lack of empathy and experience, or relationship. This
understanding may be conveyed. technique is especially helpful with
 8. Answer: C. “You’ve been clients who tend to remain on a
feeling sad and alone for some superficial level of communication.
time now?”  11. Answer: B. “I understand that
 This nursing statement is an the voices seem real to you, but I
example of the therapeutic do not hear any voices.”
communication technique of  This is an example of the
reflection. When reflection is used, therapeutic communication
questions and feelings are referred technique of presenting reality.
back to the client so that they may Presenting reality is when the client
be recognized and accepted. has a misperception of the
 9. Answer: A. “Can you tell me environment. The nurse defines
why you said that?” reality or indicates his or her
 This nursing statement is an perception of the situation for the
example of the nontherapeutic client.
communication block of requesting  12. Answer: B. “Would you like
an explanation. Requesting an me to accompany you to your
explanation is when the client is electroconvulsive therapy
asked to provide the reason for treatment?”
thoughts, feelings, behaviors, and  This is an example of the
events. Asking “why” a client did therapeutic communication
something or feels a certain way technique of offering self. Offering
can be very intimidating and self-makes the nurse available on
an unconditional basis, increasing
 client’s feelings of self-worth. reflection which identifies a client’s
Professional boundaries must be emotional response and reflects
maintained when using the these feelings back to the client so
technique of offering self. that they may be recognized and
 13. Answer: B. Verbalizing the accepted.
implied and the defense
mechanism of denial 1. A man is admitted to the nursing
 This is an example of the care unit with a diagnosis of cirrhosis.
therapeutic communication He has a long history of alcohol
technique of verbalizing the dependence. During the late evening
implied. The nurse is putting into following his admission, he becomes
words what the client has only increasingly disoriented and agitated.
implied by words or actions. Denial Which of the following would the
is the refusal of the client to client be least likely to experience?
acknowledge the existence of a real
situation, the feelings associated A. Diaphoresis and tremors.
with it, or both. B. Increased blood pressure and heart
 ADVERTISEMENT rate.
C. Illusions.
 14. Answer: A, B, C, D
D. Delusions of grandeur.
 The nurse should determine that
spanking, isolating, getting tattoos,
2. Mr. Peterson, 35, is admitted for
and writing are all ways in which
bipolar illness, manic phase, after
people communicate messages to
assaulting his landlord in an argument
others. It is estimated that about
over Mr. Peterson is staying up all
70% to 90% of communication is
night playing loud music. Mr.
nonverbal.
Peterson is hyperactive, intrusive, and
 15. Answer: B. “You’re feeling
has rapid, pressured speech. He has
guilty because you weren’t able
not slept in three days and appears
to save your children.”
thin and disheveled. Which of the
 The best response by the nurse is,
following is the most essential nursing
“You’re experiencing feelings of
action at this time?
guilt because you weren’t able to
save your children.” This response
A. Providing a meal and beverage for Mr.
utilizes the therapeutic
Peterson to eat in the dining room.
communication technique of
B. Providing linens and toiletries for Mr. C. Changes in the sensory environment.
Peterson to attend to his hygiene. D. Fuctuating levels of oxygen exchange.
C. Consulting with the psychiatrist to
order a hypnotic to promote sleep. 5. The nurse is discussing
D. Providing for client safety by limiting electroconvulsive therapy (ECT) with a
his privileges. client who asks how long it will be
before she feels better. The nurse
3. Which of the following would best explains that the beneficial effects of
indicate to the nurse that a depressed ECT usually occur within
client is improving?
A. One week.
A. Reduced levels of anxiety. B. Three weeks.
B. Changes in vegetative signs. C. Four weeks.
C. Compliance with medications. D. Six weeks.
D. Requests to talk to the nurse.
6. The nurse is assessing a 17-year-old
4. An elderly man is admitted to the female who is admitted to the eating
hospital. He was alert and oriented disorders unit with a history of weight
during the admission interview. fluctuation, abdominal pain, teeth
However, his family states that he erosion, receding gums, and bad
becomes disruptive and disoriented breath. She states that her health has
around dinnertime. One night he was been a problem but there are no other
shouting furiously and didn’t know concerns in her life. Which of the
where he was. He was sedated and the following assessments will be the least
next morning he was fine. At useful as the nurse develops the care
dinnertime, the disruptive behavior plan?
returned. The client is diagnosed as
having sundown syndrome. The A. Information regarding recent mood
client’s son asks the nurse what changes.
causes sundown syndrome. The B. Family functioning using a genogram.
nurse’s best response is that it is C. Ability to socialize with peers.
attributed to D. Whether she has a sexual relationship
with a boyfriend.
A. An underlying depression.
B. Inadequate cerebral flow.
7. A 34-year-old woman is admitted for a. “These pills aren’t antacids since they
treatment of depression. Which of are all different.”
these symptoms would the nurse be b. “Some teenagers use pills to lose
least likely to find in the initial weight.”
assessment? c. “Tell me about your week prior to
being admitted.”
A. Inability to make decisions. d. “Are you taking pills to change your
B. Feelings of hopelessness. weight?”
C. Family history of depression.
D. Increased interest in sex. 10. A mother with a Roman Catholic
belief has given birth in an ambulance
8. The nurse is planning care for a on the way to the hospital. The
client who has a phobic disorder neonate is in very critical condition
manifested by a fear of elevators. with little expectation of surviving the
Which goal would need to be trip to the hospital. Which of these
accomplished first? The client requests should the nurse in the
ambulance anticipate and be prepared
A. Demonstrates the relaxation response to do?
when asked.
B. Verbalizes the underlying cause of the A. The refusal of any treatment for self
disorder. and the neonate until she talks to a
C. Rides the elevator in the company of reader
the nurse. B. The placement of a rosary necklace
D. Role plays the use of an elevator. around the neonate’s neck and not to
remove it unless absolutely necessary
9. A teenage female is admitted with C. Arrange for a church elder to be at the
the diagnosis of anorexia nervosa. emergency department when the
Upon admission, the nurse finds ambulance arrives so a “laying on hands”
a bottle of assorted pills in the client’s can be done
drawer. The client tells the nurse that D. Pour fluid over the forehead backward
they are antacids for stomach pains. towards the back of the head and say “I
The best response by the nurse would baptize you in the name of the father, the
be son and the holy spirit. Amen.”
11. Which statement by the client C. Achieve clients’ therapeutic goals
during the initial assessment in the D. Build skills of group participation
emergency department is most
indicative of suspected domestic 14. A client was admitted to the
violence? psychiatric unit for severe depression.
After several days, the client
a. “I am determined to leave my house in continues to withdraw from other
a week.” clients. Which of the following would
b. “No one else in the family has been be the MOST appropriate statement
treated like this.” by the nurse to promote interaction
c. “I have only been married for two (2) with other clients?
months.”
d. “I have tried leaving, but have always a. “Your doctor thinks its good for you to
gone back.” spend time with others.”
b. “It is important for you to participate in
12. Which of these statements by the group activities.”
nurse reflects the best use of c. “Painting this picture will help you feel
therapeutic interaction techniques? better.”
d. “Come play Chinese Checkers with
a. “You look upset. Would you like to talk Gerry and me.”
about it?”
b. “I’d like to know more about your 15. The nurse can BEST ensure the
family. Tell me about them.” safety of a demented client who
c. “I understand that you lost your wanders from the room by
partner. I don’t think I could go on if that
happened to me.” A. Repeatedly reminding the client of
d. “You look very sad. How long have you time and place
been this way?” B. Explaining the risks of becoming lost
C. Using soft restraints
13. When planning the therapeutic D. Attaching a wander guard sensor band
milieu, it is MOST important to select to the client’s wrist
group activities which

A. Match the clients’ preferences

B. Are consistent with clients’ skills
16. A client with paranoid thoughts D. Significant others are important to
refuses to eat because he believes the provide care and concern.
food has poisoned. The MOST
appropriate initial action is to 19. A student nurse is caring for a 75-
year-old client who is very confused.
A. Taste the food in the client’s presence The student’s communication tools
B. Suggest that food be brought from should include:
home
C. Simply state the food is not poisoned A. Written directions for bathing.
D. Inform the client he will be tube fed if B. Speaking very loudly.
he does not eat C. Gentle touch while guiding ADLs
(activities of daily living).
17. The nurse is caring for a severely D. Flat facial expression.
depressed client who has just been
admitted to the in-client psychiatric 20. When a husband takes out his
unit. Which of the following is a work frustrations and anger by
PRIORITY of care? abusing his wife at home, the nurse
will identify this crisis as which type?
A. Nutrition
B. Elimination A. Psychiatric emergency crisis
C. Rest B. Developmental crisis
D. Safety C. Anticipated life transition
D. Dispositional crisis
18. A nurse is teaching a stress-
management program for a client. Answers and Rationale
Which of the following beliefs will the
nurse advocate as a method of coping
1. Answer D. Delusions of grandeur
with stressful life events?
ADVERTISEMENT

A. Avoidance of stress is an important Delusions of grandeur are symptomatic

goal for living. of manic clients, not clients withdrawing
B. Control over one’s response to stress from alcohol. The symptoms and history
is possible. of alcohol abuse suggest this client is in
C. Most people have no control over their alcohol withdrawal.
level of stress.
  Option A: Diaphoresis and Peterson’s. regarding hygiene
tremors occur in the first phase and grooming needs.
of alcohol withdrawal.  Option C: Medications will be
 Option B: The blood ordered. However, a thorough
pressure and heart rate increase evaluation must be done first.
in the first phase of alcohol
withdrawal. 3. Answer B. Changes in vegetative

 Option C: Illusions are common signs.

in persons withdrawing from

Vegetative signs such as insomnia,
alcohol. Illusions occur most
anorexia, psychomotor
often in dim artificial lighting
retardation, constipation, diminished
where the environment is not
libido, and poor concentration are
perceived accurately.
biological responses to depression.
2. Answer D. Providing for client safety Improvement in these signs indicates a
by limiting his privileges. lifting of the depression.

Mr. Peterson has been assaultive with  Option A: Reduced levels of

the landlord, and it is reasonable to anxiety do not indicate an
expect that he may be with peers and improvement in depressive
staff. His mental illness produces a symptoms.
hyperactive state and poor judgment and  Option C: Compliance with
impulse control. External controls such medications does not indicate
as limiting of unit privileges will assist in improvement in depression.
feelings of security and safety.  Option D: Requests to talk to the
nurse vary. Requests may show
 Option A: Food and fluids are trust in the nurse but are not a
necessary. However, Mr. sign that depression has
Peterson’s hyperactivity does not diminished.
allow him to sit quietly to eat.
Finger foods “on the run” will 4. Answer C. Changes in the sensory

provide needed nourishment. environment.

 Option B: When hyperactivity

Because the confusion occurs at
decreases, then approach Mr.
sundown, the cause probably changes in
the sensory environment. Sundown
syndrome is related to environmental It is inappropriate to ask about her
and sensory abnormalities that lead sexual relationships.
to acute confusion.
 Option A: Information about
 Option A: An underlying mood changes is important to
depression does not cause assess, as bulimia is often
sundown syndrome. associated with affective
 Option B: There is not sufficient disorders.
evidence to suggest he has  Option B: Family functioning is
inadequate cerebral blood flow. the most essential point to
 Option D: Fluctuating levels of assess, as it reveals if binge
oxygen exchange do not cause eating is triggered by conflict
sundown syndrome. within the family.
 Option C: Information about the
5. Answer A. One (1) week. ability to socialize with peers is
important to assess, as it is
Beneficial effects of ECT usually are
possible the problem initiated
evident after the first several treatments.
with peer relationships.
Since treatments are administered at
intervals of 48 hours, these effects are 7. Answer D. Increased interest in sex.
apparent after one week of therapy.
Beneficial effects of ECT therapy are Interest in sex is markedly decreased in
usually seen before three weeks. It takes depression.
three to four weeks for tricyclic
antidepressants to take effect. Beneficial  Option A: Indecisiveness and
effects of ECT therapy are usually seen fear of being wrong are common
before four weeks. It takes three to four in depression.
weeks for tricyclic antidepressants to  Option B: Depression creates
take effect. Beneficial effects of ECT feelings that nothing will ever
therapy are usually seen after the first improve.
few treatments.  Option C: The risk of depression
is increased when there is a
6. Answer D. Whether she has a sexual family history.
relationship with a boyfriend.
8. Answer A. Demonstrates the
relaxation response when asked.
The ability to use relaxation is basic to  Option A refers to the Christian
treatment of phobia. Science belief.
 Option B is a belief of Russian
 Option B: Clients with phobias Orthodoxy.
are resistant to insight therapy.  Option C: Mormons believe in
 Option C: Riding the elevator divine healing with the laying on
accompanied by the nurse is an of hands.
appropriate long-term goal.
 Option D: Role playing may be 11. Answer D. “I have tried leaving, but
appropriate after the client has have always gone back.”
learned relaxation.
Victims develop a high tolerance for
9. Answer C. “Tell me about your week abuse. They blame themselves for being
prior to being admitted.” victimized. All members of the family
suffer from the effects of abuse, even if
This is an open-ended question which is they are not the actual victims. For these
non-judgemental and allows for further reasons, victims often have an extensive
discussion. The topic is also history of abuse and struggle for a long
nonthreatening yet will give the nurse time before they can leave permanently.
insight into the client’s view of events
leading up to admission. It is the only 12. Answer A. “You look upset. Would
option that is client centered. The other you like to talk about it?”
options focus on the pills.
Giving broad opening statements and
10. Answer D. Pour fluid over the making observations are examples
forehead backward towards the back of therapeutic communication. The other
of the head and say “I baptize you in options are too specific or focused on
the name of the father, the son and being therapeutic.
the holy spirit. Amen.”
13. Answer C. Achieve clients’
Infant baptism is mandatory in the therapeutic goals
Roman Catholic belief especially if a
neonate is not expected to live. Anyone
may perform this if an infant or child is
gravely ill.
Activity groups are used to enhance the When learning to manage stress, it is
therapeutic milieu and to meet the helpful to believe that one has the ability
clinical and social needs of clients, e.g., to to control one’s response to stress.
minimize withdrawal and regression, to
develop self-care skills, etc.  Option A: It is impossible to
avoid stress, which is a normal
14. Answer D. “Come play Chinese experience.
Checkers with Gerry and me.”  Options C and D: Stress can be
positive and growth enhancing
This gradually engages the client in as well as harmful. The belief
interactions with others and uses positive that one has some control can
behavioral expectation. minimize the stress response.

15. Answer D. Attaching a wander 19. Answer C. Gentle touch while

guard sensor band to the client’s wrist guiding ADLs (activities of daily living).

This type of identification band easily Nonverbal, gentle touch is an important

tracks the client’s movements and tool here. Providing appropriate forms of
ensures safety while wandering on the touch to reinforce caring feelings.
unit. Because tactile contacts vary
considerably among individuals, families,
16. Answer C. Simply state the food is and cultures, the nurse must be sensitive
not poisoned to the differences in attitudes and
practices of clients and self.
This action presents reality.
20. Answer D. Dispositional crisis
17. Answer D. Safety
A dispositional crisis is a response to an
ADVERTISEMENT
external situational crisis. External anger
Safety is a priority of care for the at work is the dispositional crisis
depressed client. Precautions to displaced to his wife through abuse.
prevent suicidemust be a part of the
plan.  Option A: Psychiatric emergency
crisis is when the individual’s
18. Answer B. Control over one’s general functioning has been
response to stress is possible. severely impaired, and the
 7.Biofeedback: Form of behavior therapy and is
individual has been rendered
successfully used today, esp. for controlling body's
incompetent. physiological response to stress and anxiety
 Option B: Developmental crisis 8.Biological theories: focus on neurological, chemical,
occurs in response to triggering biological, and genetic; how body and brain interact to
create emotions, memories, and perceptual experiences
emotions related to unresolved
9.Biological theories and nursing: Social, environmental,
conflict in one’s life. This is called
cultural, and economic all play a role in treatment and
a developmental crisis based on development of mental disorders; focuses on qualities of
a therapeutic relationship, understanding pt's
Freudian psychology.
perspective, communicating to facilitate recovery
 Option C: An anticipated life
10.Classical responses are...: involuntary
transition crisis is a crisis that is
11.Cognitive-Behavioral therapy (beck): test distorted
normal in the life cycle;
beliefs and change way of thinking; reduce symptoms
transitional is one over which (schemata, automatic thoughts, and cognitive
distortions)
the person has no control.
12.Cognitivetheory: Dynamic interplay b/w individuals and
Mental Ch. 2 environment; thoughts come before feelings and actions;
thoughts about work and our place in it are based on
Study online at quizlet.com/_2jjeee own UNIQUE perspectives which may or may not be
1.3 paradigms for aversive techniques: 1. paring based on reality
maladaptive behavior w/ noxious stimuli so anxiety/fear
13.Conditioning: pairing a behavior with a condition that
becomes ass. w/ once-pleasurable stimulus
2. punishment reinforces or diminishes the behavior's occurence
3. avoidance training
14.Conscious: Tip of iceberg; all material a person is aware
2.According to Freud, which aspect of the personality of at one time such as perceptions, memories, thoughts,
motivates an individual to seek perfection? fantasies, and feelings
A. Id
15.Countertransference: Unconscious feelings that the
B. Ego
health care worker has toward patient
C. Superego: C. Superego
16.Defense mechanisms: Automatic coping sytles that
3.The art of nursing: Provide care, compassion, and
protect people from anxiety and maintain self-image by
advocacy; enhance comfort and well-being
blocking feeling, conflicts, and memory (ex. denial,
4.Automatic thoughts/cognitive distortions: rapid, regression)
unthinking responses based on schemas; intense and
17.Developmental model is important part of nursing
frequent in psychiatric disorders such as depression and
assessment: helps determine what types of
anxiety; irrational and lead to false assumptions and
interventions are most likely to be effective (age-
misinterpretations
appropriate interventions)
5.Aversion thearpy: Punishment; used to treat addictions,
18.Ego: Problem solver and reality tester; able to
hallucinations, etc; treatment of choice when other less
differentiate subjective experiences, memory images,
drastic measures have failed to produce desired effects
and objective reality and attempts to negotiate with the
6.Behavior therapy: Based on assumption that changes in outside world (ex. hungry adult knows to seek where he
maladaptive behavior can occur without insight into can go eat and do it)
underlying cause
19.Erikson'seight stages of psychosocial
development: Infancy (0-1.5y), early childhood (1.5-3),
preschool (3-6), school age (6-12), adolescence (12-20),
 early adulthood (20-35), middle adulthood (35-65), later 30.MilieuTherapy: Use of total environment; people,
years (65-death) setting, structure, and emotional climate are all important
to healing
20.Extinction:Absence of reinforcement; decreases
behavior by withholding a reward that has become 31.Modeling: therapist provides role model for specific
habitual identified behaviors and pt learns through imitation

21.Foundation for Hildegard Peplau's theory: Participant 32.Negative reinforcement: removal of an objectionable or
observer; mutuality, respect for patient, unconditional aversive stimulus (ex. walking through park once viscous
acceptance, empathy dog is pickedup)

22.Freud's Psychoanalytic theory: Personality structure, 33.Operantconditioning: bases for behavior modification
level of awareness, anxiety, role of defense and uses positive reinforcement to increases desired
mechanisms, and psychosexual development behaviors (ex. kid throwing fit for candy)

23.Freud's Psychosexual stages of development: oral, 34.Operant conditioning is...: voluntary

anal, phallic, latency, genital
35.Apatient is admitted to your unit who has an
24.Hierarchy levels: Physiological (basic needs - food, uncanny resemblance to your older sister. As a
oxygen, water, sex), safety (security, law, order, freedom child, your older sister bossed you around and
from fear), belonging and love needs (intimate criticized you constantly. You realize that you are
relationships, love, overcoming loneliness), esteem responding negatively to this patient. What is going
needs (high self-regard and can beel confident, on?
valuable), self-actualization (striving to everything person What should the nurse do?: Countertransference
is capable of becoming) Nurse should realize importance of maintaining self-
awareness and seeking supervisory guidance as the
25.Hildegard Peplau's Theory of Interpersonal therapeutic relationship progresses
Relationships in Nursing: Influenced by Sullivan's work
(mother of psychiatric nursing) 36.Pavlov's classical conditioning theory: noticed dogs
were able to anticipate when food would be coming and
26.Id:Source of all drives, instincts, reflexes, needs, genetic would salivate before tasting meat (psychic secretion);
inheritance, and capacity to respond as well as the theory found that when neutral stimulus was paired with
wishes that motivate us; cannot tolerate frustration and another stimulus, the neutral could stimulate the other
seeks to discharge tension and return to a more
comfortable level of energy; lacks ability to problem 37.Positivereinforcement: causes behavior to occur more
solve (it is not logical and operates according to pleasure frequently (ex. 3.8 GPA after studying hard)
principle); only needs that counts are its own (ex.
38.Preconscious: Below surface of awareness; contains
hungry, screaming infant)
material that can be retrieved easily through conscious
27.Implicationof nursing for behavioral effort
theories: modifying or replacing behaviors and behavior
39.Punishment: unpleasant consequence;
management
positive - give; negative - take away
28.Interpersonalpsychotherapy has approved
40.Purpose of theories: help us explain behavior;
successfully in the treatment of
A. Depression foundation of mental health and mental health nursing;
B. Bipolar treatment therapies are based on these
C. Schizophrenia
41.Rational-Emotive Behavior Therapy (ellis): aims to
D. OCD: A. Depression
eradicate irrational beliefs; recognize thoughts that are
29.Maslow's Hierarchy of Needs: Human beings are active not accurate (thoughts tend to take form of shoulds,
participants in life, striving for self-actualization; when oughts, and musts)
needs are met, higher needs are able to emerge; when
42.Schemata, automatic thoughts, and cognitive
lower level needs are met, then higher needs can
distortions are terms that relate to
emerge
A. rational-emotive behavioral therapy
 B. cognitive-behavioral therapy 53.Whois the first nurse theorist to describe the nurse-
C. operant conditioning therapy patient relationship as the foundation of nursing
D. biofeedback: B. Cognitive-behavioral therapy practice?
A. Florence Nightingale
43.The science of nursing: Application of knowledge to: B. Jean Watson
understand broad range of human problems and C. Hildegard Peplau
psychosocial phenomena; intervene in relieving pt's D. Erik Erikson: C. Hildegard Peplau
suffering and promote growth

44.Skinner'soperant conditioning theory: voluntary

behaviors are learned through consequences and
behavioral responses are elicited through reinforcement

45.Sullivan's Interpersonal Theory: Purpose of all

behavior is to get needs met through interpersonal
interactions and to reduce or avoid anxiety

46.Superego: Moral component of personality; has

conscious and ideas of reality; ideal rather than real,
seeks perfection as opposed to seeking pleasure or
engaging reason

47.Systematic desensitization: involves the development

of behavior tasks customized to the pt's specific fears;
four steps (break down fear, exposure to fear, design
hierarchy of fears, practice techniques to reduce fear)

48.The therapy that used total environment to treat

disturbed children created by Bruno Bettlehein in
1948 is called
A. Cognition-Behavior Therapy
B. Milieu Therapy
C. Psychoanalytic Therapy
D. Interpersonal Therapy: B. Milieu Therapy

49.Transference: Feelings that the patient has toward

health care workers that were originally held toward
significant others in life

50.Unconscious: repressed memories, passions, and

unacceptable urges lying deep below surface; exerts a
powerful yet unseen effect on the conscious thoughts
and feelings of the individual; person is usually unable to
retrieve unconscious material w/out help of therapist

51.Watson's behaviorism theory: developed school of

thought (behaviorism); personality traits and responses
were socially learned through classical conditioning

52.Which theorist most influenced the professional

practice of psychiatric nursing?
A. Harry Stack Sullivan
B. Hildegard Peplau
C. Erik Erikson
D. Ivan Pavlov: B. Hildegard Peplau