Which behavior indicates to the nurse that a client with paranoid ideas is improving?
A. Arrives on time for all activities
B. Talks more openly about plans to protect his possessions
C. Aggressively uses the punching bag in the gym
D. Discusses his feeli
Answer: D
Rationale: Anxious feelings increase paranoid ideation. If the client is able to discuss feelings (D), then the client is improving because of fewer paranoid ideas. (A) would indicate that a client with depression or one who is passive-aggressiv
The nurse notes multiple burns of the arms and chest of a 2 year old Vietnamese child who is being treated for dehydration. When questioned, the child's father states that he treated the child's vomiting with the cultural practice termed coining, which re
Answer: A
Rationale: The nurse's highest priority is to ensure that no further harm befalls the child (A). (B,C,D) are also important objectives but are secondary to (A).
A 25 year old client has suffered extensive burns and is crying during dressing change treatment. The client tells the nurse, "Please let me die. Why are you all torturing me like this? I just want to die." Which response by the nurse is best?
A. "We aren
Answer: B
Rationale: (B) offers empathetic response without sounding patronizing. (A) is not empathetic and is actually somewhat argumentative. The client is not asking for information as much as pleading for understanding. (C) appears as scolding and pla
A 22 year old client is admitted to the psychiatric unit from the medical unit following a suicide attempt with an overdose of diazepam (Valium). When developing the nursing care plan for this patient, which intervention would be most important for the nu
Answer: A
Rationale: Encouraging the client to focus on his or her strengths (A) helps the client become aware of positive qualities, assists in improving self-image, and aids in coping with past and present situations. Although nursing actions should ass
A client in an acute care facility has been taking antipsychotic medications for the past 3 days with a decrease in psychotic behaviors and no adverse reactions. On the fourth day, the client experiences an increase in blood pressure and temperature and d
Answer: B
Rationale: This is an emergency situation, and the client requires immediate management in a critical care setting (B). These symptoms are descriptive of neuroleptic malignant syndrome (NMS), an extremely serious and life-threatening reaction to
A 38 year old client is admitted with a diagnosis of paranoid schizophrenia. When the lunch tray is brought to the room, the client refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response by the nurse is the
Answer: A
Rationale: (A) is the best choice because the nurse does not argue with the client or demand that the client eat but offers support by agreeing to be there if needed, which provides open, rather than closed, response to the client's statement. (
A 35 year old client admitted to the psychiatric unit of an acute care hospital tell the nurse that someone is trying to poison her. The client's delusions are most likely related to which factor?
A. Authority issues in childhood
B. Anger about being hosp
Answer: C
Rationale: Delusional clients have difficulty with trust and have low self-esteem (C). Nursing care should be directed at building trust and promoting positive self-esteem. Activities with limited concentration and no competition should be encou
The nurse is caring for a client who is taking the mood stabilizer divalproex sodium (Depakote). Which laboratory finding is most important to include in this client's record?
A. Liver function test results
B. Creatinine clearance
C. Complete blood count
Answer: A
Rationale: Depakote is metabolized by the liver and cause hepatotoxicity, so lab findings of liver function tests (A) should be included in the client's record. (B) should be in the client record of those who are receiving lithium because it is
A middle-aged client tells the nurse, "I'm again starting to feel overwhelmed and anxious with all my responsibilities. I don't know what to do." Which is the best response for the nurse to make?
A. "Describe in more detail your feelings of being overwhel
Answer: C
Rationale: A nurse can help the client solve problems by identifying past coping mechanisms that could be transferred into current situations that the client finds to be overwhelming (C). The client has already expressed some degree of hopelessn
A 45 year old male client tells the nurse that he used to believe he was Jesus Christ, but now knows he is not. Which response is best for the nurse to make?
A. "Did you really believe you were Jesus Christ?"
B. "I think you're getting well."
C. "Others h
Answer: C
Rationale: (C) offers support by assuring the client that other have experienced similar situations. (A) is belittling. (B) is making an inappropriate judgement. You may have narrowed your choices to (C and D). However, you should eliminate (D)
The nurse is assessing a young client admitted to the psychiatric unit for acute depression related to a recent divorce. Which statement is most indicative of a client suffering from depression?
A. "I'm not very pretty or likable."
B. "I've lost 20 lbs in
Answer: A
Rationale: Feelings of hopelessness (A) are characteristics of one who is depressed. Although (B) might be indicative of depression, further assessment may be required to rule out an organic cause before attributing the statement to depression.
Which ego defense mechanism is exhibited by a client with a phobia related to refusal to leave home?
A. Denial
B. Symbolization
C. Fantasy
D. Intellectualization
Answer: B
Rationale: Symbolization (B) allows external objects to carry the internal emotional feeling through some act such as refusing to leave a safe harbour. (A) is the unconscious failure to acknowledge an event, thought, or feeling. (C) is pretendin
An individual with a known history of alcohol abuse is admitted for emergency surgery following a motor vehicle accident. The nurse includes in the client's plan of care, "Observe for signs of delirium tremens."" Which early signs indicate that the client
Answer: C
Rationale: A client experiencing alcohol withdrawal often has delirium tremens (DTs), which is characterized by progressive disorientation. Initially the client appears restless and confused (C) and develop tachycardia, tachypnea, and diaphoresi
A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad. No one can help me." Which response would be best for the nurse to make?
A. "How can I help me? Tell me more about your problems."
B. "Things probably aren't
Answer: A
Rationale: Offering self shows empathy and caring (A) and gives the client the opportunity to talk while the nurse listens. (B) dismisses the client's perception that things are really bad and potentially stops further communication with the cli
On admission, a depressed client tells the nurse, "I can't eat because my tongue is rubber." Which is the best action for the nurse to implement?
A. Provide packaged foods for the client to eat
B. Begin the client on total parenteral nutritional therapy
C
Answer: C
Rationale: The nurse should strive to provide a safe environment (adequate nutrition is part of a safe environment) and should not argue with the client's delusions. (C) is the least invasive while providing nutrition that doesn't argue with the
The nurse admits a client with depression to the mental health unit. The client reports difficulty concentrating, has lost 10 lbs in 2 weeks, and is sleeping 12 hours a day. Which outcome is most important for the client to meet by discharge?
A. Tries to
Answer: B
Rationale: The client is experiencing symptoms of depression, and the outcome by discharge for this client would be that the client reports feeling better and less depressed (B). The client may interact with peers and staff (A) and sit attentive
Clients are preparing to leave the mental health unit for an outdoor smoke break. A client on constant observation cannot leave and becomes agitated and demands to smoke a cigarette. Which action should the nurse take first?
A. Remind the client to wear t
Answer: B
Rationale: The nurse should continually reassess the need for constant observation (B) so that the client can have unit privileges such as outdoor breaks. (A and C) do not meet the client's needs and desire to smoke. (D) will cause more agitatio
A women brings her 48 year old husband to the outpatient psychiatric unit and tells the nurse that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. These behaviors are often associated with which condition?
A. Diss
Answer: A
Rationale: Sleepwalking, amnesia, and multiple personalities are examples of detaching emotional conflict from one's consciousness (A). (B) is characterized by persistent, recurrent intrusive thought or urges that are unwilled and cannot be igno
During a home visit, a client with schizophrenia reports hearing voices that tell the client to walk in the middle of the street. The nurse records several statements made by the client. Based on which statement should the nurse determine that the client
Answer: C
Rationale: Hospitalization is needed if the client continues to hear voices telling the client to do things that can cause self harm (C). (A or B) do not require hospitalization unless symptoms become severe. The client should continue symptom m
Physical examination of a 6 year old boy reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. What initial response by th
Answer: B
Rationale: (B) seeks more information using an open-ended, non threatening statement. (A) might be appropriate but is not the best answer because the nurse is being somewhat sarcastic and is also avoiding the situations by referring to the healt
A client on the psychiatric unit, diagnosed with bipolar disorder, becomes loud and shouts at one of the nurses, "You fat tub of lard, get something done around here!" What is the best initial action for the nurse to take?
A. Have the staff escort the cli
Answer: C
Rationale: Distracting the client, or redirecting him toward a constructive activity (C) prevents further escalation of the inappropriate behavior. (A) could result in escalating the abuse and might unnecessarily involve another staff member in
The nurse develops a plan of care for a client with symptoms of paranoia and psychosis. The priority nursing diagnosis is Impaired social interactions related to inability to trust. Which intervention is most important for the nurse to implement?
A. Greet
Answer: A
Rationale: The most important nursing intervention is to greet the client by name (A) and provide short frequent contact to establish trust. The presence of auditory hallucinations can affect social interactions (B) but is not a priority interve
A client is admitted with a diagnosis of depression. Which of the following characteristics is most indicative of depression?
A. Grandiose ideation
B. Self-destructive thoughts
C. Suspiciousness of others
D. Negative self image
Answer: D
Rationale: A negative self image (D) is a specific indicator for depression. (A) occurs with paranoia or paranoia ideation (C). (B) may be seen in depressed clients but not always
A client on the psychiatric unit seeks out a particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client?
A. Sublimination
B. Identification
C. Introjection
D. Repression
Answer: B
Rationale: Identification (B) is an attempt to be like someone or emulate the personality traits of another. (A) is substituting an unacceptable feeling for one that is more socially acceptable. (C) is incorporating the values or qualities of an
On admission, a highly anxious client is described as delusional. Delusions are most likely to occur with which disorder?
A. Dissociative disorders
B. Personality disorders
C. Anxiety disorders
D. Psychotic disorders
Answer: D
Rationale: Delusions are false beliefs characteristic of psychosis (D). Delusions are generally not characteristic of (A, B, and C)
A nurse working in the emergency department of a children's hospital admits a child whose injuries could have been the result of abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse?
A. Obtain objec
Answer: C
Rationale: It is the nurse's legal responsibility to report all suspected cases of child abuse (C) and notifying the nurse manager or charge nurse starts the legal reporting process. (A, B, and D) delay the first step in reporting the abuse.
A schizophrenic client who is taking fluphenazine decanoate (Prolixin decanoate) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse about a planned vacation and will return
Answer: A
Rationale: Photosensitivity is a side effect of Prolixin, so the client should be instructed to avoid the sun (A). (B, C, and D) indicate accurate knowledge. Alcohol acts synergistically with Prolixin (B). A sore throat and flulike symptoms (C)
A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. Which action should the nurse take?
A. Notify the healthcare provider immediately and force fluids
B. Prior to giving the next
Answer: B
Rationale: Although these are expected symptoms, the healthcare provider should be notified prior to the next administration of the drug (B). Early side effects of lithium carbonate (occurring with serum lithium levels below 2 mEq/L) generally f
A child is brought to the emergency department with a broken arm. Because of other injuries, the nurse suspects that the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts,
Answer: C
Rationale: Projection is attributing one's own thoughts, impulses, or behaviors onto another; it is the mother who is probably harming the child, and she attributing her actions to the nurse (C). The mother may be immature, but (A) is not the be
At the first meeting of a group at a daycare center for older adults, the nurse asks one of the members what kinds of things the client would like to do with the group. The older adult shrugs and says, "You tell me. You're the leader." What would be the b
Answer: B
Rationale: Anxiety over participation in a group and testing of the leader characteristically occur in the initial phase of the group dynamics. (B) provides information and refocuses the group defining its function. (A) is manipulative bargainin
A client in the critical care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant change and the nurse formulates the diagnosis, "Confusion related to ICU psych
Answer: C
Rationale: The critical care environment confronts clients with an environment which provides stressors heightened by treatment modalities that may prove to be lifesaving. These stressors can result in isolation and confusion. The best intervent
What instructions should the nurse include in the discharge teaching plan of a client who has recently been prescribed oxazepam (Serax)? (Select all that apply)
A. Take the medication in the morning for the best results
B. Do not combine this medication w
Answer: B, C, E
Rationale: Harm can occur if oxazepam is taken with alcohol or other central nervous system depressants (B). Oxazepam is a benzodiazepine used for the short-term treatment of anxiety (C). Sleepiness is an expected side effect; therefore dr
A client who recently retired is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of guilt." What is true about the goal statement referrin
Answer: C
Rationale: Depression is associated with feelings of guilt, and clients are often not aware of these feelings (C). Awareness is the first step in dealing with guilt, so the nurse's efforts should be directed toward increasing the client's awaren
A client who has been hospitalized for two weeks for paranoia continuously complains to the staff that someone is trying to steal his clothing. What is the correct action for the nurse to take?
A) Enroll the client in an exercise class to promote positive
Answer: A
Rationale: Diverting the client's attention from paranoid ideation and encouraging him to complete assignments can be helpful in assisting him to develop a positive self-image (A). The client's problem is not security, and (B) actually supports
A 25-year-old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to
Correct Answer(s): D
Rationale: (D) is the best response because it offers support without judgment or demands. (A) is arguing with the client's delusion. (B) is offering false reassurance. (C) is a violation of therapeutic communication in that the nurse
Over a period of several weeks, one male participant of a socialization group at a community day care center for the elderly monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in
Correct Answer(s): C
Rationale: After several weeks, the group is in the working phase and the group members should be allowed to determine the direction of the group. The nurse should ignore the client's comments and allow the group to handle the situati
The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning the group?
A. Each resident's length of stay at the nursing home
B. A brief description
Answer: D
Rationale: An older person's level of activity (D) is a determining factor in adjustment to aging as described in (A, B, and C) might be useful to the nurse but is not as helpful during the initiation of the socialization group. The most useful
A client who was admitted 2 days earlier to a drug rehab unit tells the nurse, "I'm going to do what you people tell me to so I can get out of here and get a job." What is the most accurate interpretation of this client's statement?
A. The treatment progr
Answer: C
Rationale: Drug abusers tend to be manipulative so (C) is the best interpretation of the client's statement at this time in the client's treatment. He has been in treatment only 2 days which is not enough time to benefit from the program, so (A
The nurse reviews the lab findings for a client's urine drug screen that is positive for cocaine. Which client behavior should be expected during cocaine withdrawal?
A. Psychomotor impairment
B. Agitation and hyperactivity
C. Detachment from reality and d
Answer: A
Rationale: During cocaine withdrawal, the nurse should expect (A) and a pattern of withdrawal symptoms similar to those of one who uses amphetamines. (B, C, and D) are signs and symptoms of a person high on cocaine rather than one who is experie
A client mumbles out loud whether anyone is talking to her or not and the client also mumbles in group when others are talking. The nurse determines that the client is experiencing hallucinations. What intervention should the nurse implement?
A. Respond t
Answer: D
Rationale: The nurse should promote symptom management and determine how the client previously managed the voices (D). (A and B) are interventions that are useful with clients who are experiencing delusions. (C) is important but the most importa
A client begins taking an atypical antipsychotic medication. The nurse must provide informed consent and education about common medication side effects. Which client education will be most important?
A. Maintain a balanced diet and adequate exercise
B. Be
Answer: A
Rationale: Several atypical antipsychotic medications can cause significant weight gain, so the client should be advised to maintain a balanced diet and adequate exercise (A). (B) is important with lithium, a mood stabilizer. (C and D) are less
A client believes that his healthcare provider is an FBI agent and that his apartment is a site for slave trading. The client believe that the FBI has cameras in the apartment, so it is not safe to return there. Based on these symptoms, which class of med
Answer: C
Rationale: An antipsychotic (C) will most likely be prescribed because the client's thoughts are delusional. The client needs an antipsychotic to promote rational thought. (A) may lessen anxiety associated with the delusions, but is not the trea
While in group therapy, a client who is diagnosed with PTSD is processing an experience from the war in Iraq when another client tips over a chair. What action should the nurse take when the client with PTSD falls to the floor in fetal position?
A. Confro
Answer: C
Rationale: The client who is diagnosed with PTSD is reexperiencing the traumatic experience and needs reality reassurance (confirmation that there is no danger at this time) and reduced stimuli (C). (A, B, and D) do not consider the needs of the
Which topics should the nurse include in a education program for clients with schizophrenia and their families? (SATA)
A. Importance of adherence to medication regimen
B. Current treatment measures for substance abuse
C. Signs and symptoms of an exacerbat
Answer: A, C, F
Rationale: Medication adherence is an important component of successful rehab (A). Clients and their families also need to know the S/S of an exacerbation or relapse of the disease (C), which is frequently associated with poor medication c
A middle-aged adult was discharged from a treatment center 6 weeks ago following treatment for suicide ideation and alcohol abuse. In a follow up visit to the mental health clinic, the client complains of lethargy, apathy, irritability, and anxiety. Which
Answer: B
Rationale: First, and most importantly, the client's use of alcohol should be determined (B) because further treatment is dependent on the client's sobriety and asking how much alcohol is being consumed is a better question than asking if the cl
An adult client who lives in a residential facility is mentally retarded and has a history of bipolar disorder. During the past week, the client has refused to wear clothing and frequently exposed their body to other residents. Which intervention should t
Answer: B
Rationale: The client is exhibiting manic behavior related to bipolar disorder, and the nurse should redirect the client to activities that are physically demanding (B) so that energy can be expended in a socially acceptable way. Psychotic clien
When planning care for the client undergoing ECT, which equipment should the nurse make available? (SATA)
A. Oxygen
B. Suction equipment
C. Continuous passive ROM machine
D. Crash Cart
E. Chest tube drainage system
Answer: A, B, D
Rationale: Because aspiration is a potential complication, emergency equipment such as oxygen, suction, and crash cart should be available (A, B, D). The client is only unconscious for a short period therefore there is no need for a CMP ma