Psychiatric Nursing Exam Quiz! Trivia

1. The nurse employed in a mental health unit is assigned to care for a client admitted to the unit 2 days ago. On review of the client's record, the nurse notes that the admission was a voluntary admission. Based on this type of admission, the nurse anticipates which of the following?

The client will resist treatment measures.

The client will be angry and will refuse care.

The client's family will resist treatment measures.

The client will participate in the planning of the care and treatment plan

Generally, the client seeks voluntary admission. A voluntary admission permits a client to make a written application for admission. If the client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program. Options 1, 2, and 3 are not characteristics of this type of admission.
Test-Taking Strategy: Use the process of admission. Note the strategic words voluntary admission. This should direct you to option 4. Additionally, note that options 1, 2, and 3 are comparative or alike. Review the various types of hospital admission processes if you had difficulty with this question.

Explanation

Generally, the client seeks voluntary admission. A voluntary admission permits a client to make a written application for admission. If the client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program. Options 1, 2, and 3 are not characteristics of this type of admission.
Test-Taking Strategy: Use the process of admission. Note the strategic words voluntary admission. This should direct you to option 4. Additionally, note that options 1, 2, and 3 are comparative or alike. Review the various types of hospital admission processes if you had difficulty with this question.

2. A home health nurse is talking to the spouse of a client taking an antidepressant. The spouse says, "Now that my husband is responding to the antidepressant, the suicidal risk is over and you can stop making these home visits." After analyzing this statement, which of the following is the appropriate nursing response?

“I need to continue with my visits. Your comment reflects a lack of knowledge that this disease runs in families.”

Most suicides occur within 3 months after the beginning of the improvement, when the client has the energy to carry out the suicidal intentions. Options 1, 2, and 3 are incorrect because they fail to address safety and involve giving false information. Test-Taking Strategy: Use the process of elimination and knowledge regarding the facts about suicide to answer the question. Recalling that a critical time for a suicidal client is when the client has energy will direct you to option 4. Review the concepts related
to suicide and therapeutic communication techniques if you had difficulty with this question.

Explanation

Most suicides occur within 3 months after the beginning of the improvement, when the client has the energy to carry out the suicidal intentions. Options 1, 2, and 3 are incorrect because they fail to address safety and involve giving false information. Test-Taking Strategy: Use the process of elimination and knowledge regarding the facts about suicide to answer the question. Recalling that a critical time for a suicidal client is when the client has energy will direct you to option 4. Review the concepts related
to suicide and therapeutic communication techniques if you had difficulty with this question.

3. The supervisor reprimands the nurse in charge of the nursing unit because the charge nurse has not adhered to the unit budget. Later that afternoon, the charge nurse accuses the nursing staff of wasting supplies. This behavior is an example of:

Denial

Repression

Suppression

Displacement

Ego defense mechanisms are operations outside of a person's awareness that the ego calls into play to protect against anxiety. Displacement is the discharging of pent-up feelings on persons less threatening than those who initially aroused the emotion. Denial is the blocking out of painful or anxiety-inducing events or feelings. Repression is unconsciously keeping unacceptable feelings out of awareness. Suppression is consciously keeping unacceptable feelings and thoughts out of awareness. Test-Taking Strategy: Use the process of elimination. Read the behavior identified in the question to assist you in determining the type of ego defense mechanism or behavior used. Remember that displacement is the discharging of pent-up feelings on persons less threatening than those who initially aroused the emotion. If you had difficulty with this question, review defense mechanisms

Explanation

Ego defense mechanisms are operations outside of a person's awareness that the ego calls into play to protect against anxiety. Displacement is the discharging of pent-up feelings on persons less threatening than those who initially aroused the emotion. Denial is the blocking out of painful or anxiety-inducing events or feelings. Repression is unconsciously keeping unacceptable feelings out of awareness. Suppression is consciously keeping unacceptable feelings and thoughts out of awareness. Test-Taking Strategy: Use the process of elimination. Read the behavior identified in the question to assist you in determining the type of ego defense mechanism or behavior used. Remember that displacement is the discharging of pent-up feelings on persons less threatening than those who initially aroused the emotion. If you had difficulty with this question, review defense mechanisms

4. The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." The appropriate nursing response is which of the following?

“I cannot discuss any client situation with you.”

“If you want to know about Carol, you need to ask her yourself.”

A nurse is required to maintain confidentiality regarding the client and the client's care. Confidentiality is basic to the therapeutic relationship and is a client's right. The most appropriate response to the neighbor is option 1. Option 2 is a rather blunt statement and does not acknowledge the issue that the nurse cannot reveal if the named person is or was a client. Options 3 and 4 identify statements that do not maintain client confidentiality.
Option 1 is the most direct and correct.
Test-Taking Strategy: Focus on the subject of the question, maintaining confidentiality. This should assist you easily in eliminating options 3 and 4. From the remaining options, select option 1 over option 2 because it is the most direct and correct. Option 2 is a rather blunt and rude statement. Review confidentiality issues if you had difficulty with this question.

Explanation

A nurse is required to maintain confidentiality regarding the client and the client's care. Confidentiality is basic to the therapeutic relationship and is a client's right. The most appropriate response to the neighbor is option 1. Option 2 is a rather blunt statement and does not acknowledge the issue that the nurse cannot reveal if the named person is or was a client. Options 3 and 4 identify statements that do not maintain client confidentiality.
Option 1 is the most direct and correct.
Test-Taking Strategy: Focus on the subject of the question, maintaining confidentiality. This should assist you easily in eliminating options 3 and 4. From the remaining options, select option 1 over option 2 because it is the most direct and correct. Option 2 is a rather blunt and rude statement. Review confidentiality issues if you had difficulty with this question.

5. The client is preparing to attend a Gambler's Anonymous meeting for the first time. The prototype used by this group is the 12-step program developed by Alcoholics Anonymous. The nurse tells the client that the first step in the 12-step program is which of the following?

Admitting to having a problem

Substituting other activities for gambling

Stating that the gambling will be stopped

Discontinuing relationships with friends who are gamblers

The first step in the 12-step program is to admit that a problem exists. Options 3 and 4 are unrealistic as a first step in the process to recovery. Although option 2 may be a strategy, it is not the first step.
Test-Taking Strategy: Use the process of elimination and note the strategic words first step in the question. This will assist in directing you to option 1. If you are unfamiliar with the 12-step program, review this content.

Explanation

The first step in the 12-step program is to admit that a problem exists. Options 3 and 4 are unrealistic as a first step in the process to recovery. Although option 2 may be a strategy, it is not the first step.
Test-Taking Strategy: Use the process of elimination and note the strategic words first step in the question. This will assist in directing you to option 1. If you are unfamiliar with the 12-step program, review this content.

6. When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. The appropriate maintenance goal should focus on which of the following?

Ignoring feelings of anxiety

Identifying anxiety-producing situations

Continued contact with a crisis counselor

Eliminating all anxiety from daily situations

Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing
situations, and this option does not encourage the development of internal strengths. Ignoring feelings will not resolve anxiety. Elimination of all anxiety from life is impossible.
Test-Taking Strategy: Use the process of elimination. Eliminate option 4 first because of the word all. Eliminate option 1 next, because feelings should not be ignored. From the remaining options, select option 2 because this option is more client-centered and helps prepare the client to deal with anxiety should it occur. Review home care planning for the client with chronic anxiety if you had
difficulty with this question.

Explanation

Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing
situations, and this option does not encourage the development of internal strengths. Ignoring feelings will not resolve anxiety. Elimination of all anxiety from life is impossible.
Test-Taking Strategy: Use the process of elimination. Eliminate option 4 first because of the word all. Eliminate option 1 next, because feelings should not be ignored. From the remaining options, select option 2 because this option is more client-centered and helps prepare the client to deal with anxiety should it occur. Review home care planning for the client with chronic anxiety if you had
difficulty with this question.

7. A nurse is conducting a group therapy session. During the session, a client with mania consistently talks and dominates the group session, and her behavior is disrupting group interactions. The nurse would initially:

Ask the client to leave the group session.

Ask another nurse to escort the client out of the group session.

Tell the client that she will not be able to attend any future group sessions.

Tell the client that she needs to allow other clients in the group time to talk.

Manic clients may be talkative and can dominate group meetings or therapy sessions by their excessive talking. If this occurs, the nurse initially would set limits on the client's behavior. Initially, asking the client to leave the session or asking another person to escort the client out of the session is inappropriate. This may agitate the client and further escalate the client's behavior. Option 2 is also an inappropriate initial action because it violates the client's right to receive treatment and is a threatening action. Test-Taking Strategy: Use the process of elimination and note the strategic word initially. Eliminate options 1 and 2 first because they are comparative or alike. Next, eliminate option 3 because it
violates the client's right to receive treatment and is a threatening action. Remember that setting firm limits with the client initially is best. Review care of a client with mania if you had difficulty with this question.

Explanation

Manic clients may be talkative and can dominate group meetings or therapy sessions by their excessive talking. If this occurs, the nurse initially would set limits on the client's behavior. Initially, asking the client to leave the session or asking another person to escort the client out of the session is inappropriate. This may agitate the client and further escalate the client's behavior. Option 2 is also an inappropriate initial action because it violates the client's right to receive treatment and is a threatening action. Test-Taking Strategy: Use the process of elimination and note the strategic word initially. Eliminate options 1 and 2 first because they are comparative or alike. Next, eliminate option 3 because it
violates the client's right to receive treatment and is a threatening action. Remember that setting firm limits with the client initially is best. Review care of a client with mania if you had difficulty with this question.

8. A client has been admitted to the mental health unit. On admission assessment, the nurse notes that the client was admitted by involuntary status. Based on this type of admission, the nurse would most likely expect that the client:

Presents a harm to self

Requested the admission

Consented to the admission

Provided written application to the facility for admission

Involuntary admission is made without the client's consent. Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment. Options 2, 3, and 4 describe the process of voluntary admission. Test-Taking Strategy: Use the process of elimination and note the strategic words involuntary status. This should direct you easily to option 1. Also, note that options 2, 3, and 4 are comparative or alike. Review the process of involuntary admission if you had difficulty with this question.

Explanation

Involuntary admission is made without the client's consent. Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment. Options 2, 3, and 4 describe the process of voluntary admission. Test-Taking Strategy: Use the process of elimination and note the strategic words involuntary status. This should direct you easily to option 1. Also, note that options 2, 3, and 4 are comparative or alike. Review the process of involuntary admission if you had difficulty with this question.

9. The nurse is conducting a group therapy session, and a client with a manic disorder is monopolizing the group. The appropriate nursing action is which of the following?

Ask the client to leave.

Refer the client to another group.

Tell the client to stop monopolizing

Thank the client for the contribution and tell him or her to allow others a chance to contribute

f a client is monopolizing the group, the nurse must be direct and decisive. The best action is to thank the client and suggest that the client stop talking and try listening to others. Although
option 3 may be a direct response, option 4 is a more specific and direct statement. Options 1 and 2 are inappropriate.
Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are comparative or alike. Use therapeutic communication techniques to assist in directing you to option 4. If you had difficulty with this question, review therapeutic communication techniques for the client with a manic disorder.

Explanation

f a client is monopolizing the group, the nurse must be direct and decisive. The best action is to thank the client and suggest that the client stop talking and try listening to others. Although
option 3 may be a direct response, option 4 is a more specific and direct statement. Options 1 and 2 are inappropriate.
Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are comparative or alike. Use therapeutic communication techniques to assist in directing you to option 4. If you had difficulty with this question, review therapeutic communication techniques for the client with a manic disorder.

10. An 18-year-old woman is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa. A cognitive behavioral approach is used as part of her treatment plan. The nurse understands that the purpose of this approach is to:

Provide a supportive environment.

Examine intrapsychic conflicts and past issues.

Emphasize social interaction with clients who withdraw.

Help the client identify and examine dysfunctional thoughts and beliefs.

Cognitive behavioral therapy is used to help the client identify and examine dysfunctional thoughts and to identify and examine values and beliefs that maintain these thoughts. Options 1, 2, and 3 are incorrect.
Test-Taking Strategy: Use the process of elimination and note the strategic words cognitive behavioral. Focusing on these words should direct you to option 4. If you are unfamiliar with this type of therapy and its purpose, review this content.

Explanation

Cognitive behavioral therapy is used to help the client identify and examine dysfunctional thoughts and to identify and examine values and beliefs that maintain these thoughts. Options 1, 2, and 3 are incorrect.
Test-Taking Strategy: Use the process of elimination and note the strategic words cognitive behavioral. Focusing on these words should direct you to option 4. If you are unfamiliar with this type of therapy and its purpose, review this content.

11. The community health nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse illustrates a therapeutic communication technique for this client?

“Go on.”

“Sleeping?”

“You're having difficulty sleeping?”

“Sometimes, I have trouble sleeping too.”

Option 3 uses the therapeutic communication technique of restatement. Although restatement is a technique that has a prompting component to it, it repeats the client's major theme,
which assists the nurse to obtain a more specific perception of the problem from the client. Options 1, 2, and 4 are not therapeutic responses.
Test-Taking Strategy: Use the process of elimination. Option 1 is a general lead and allows the client to direct the discussion. Option 2 uses reflection, which simply repeats the client's last words to prompt further discussion. Option 4 focuses on the nurse's problem. Option 3 will provide the perception of the problem from the
client's perspective. Review therapeutic communication techniques if you had difficulty with this question.

Explanation

Option 3 uses the therapeutic communication technique of restatement. Although restatement is a technique that has a prompting component to it, it repeats the client's major theme,
which assists the nurse to obtain a more specific perception of the problem from the client. Options 1, 2, and 4 are not therapeutic responses.
Test-Taking Strategy: Use the process of elimination. Option 1 is a general lead and allows the client to direct the discussion. Option 2 uses reflection, which simply repeats the client's last words to prompt further discussion. Option 4 focuses on the nurse's problem. Option 3 will provide the perception of the problem from the
client's perspective. Review therapeutic communication techniques if you had difficulty with this question.

12. A client is admitted to a mental health unit for treatment of psychotic behavior. The client is at the locked exit door and is shouting, "Let me out. There's nothing wrong with me. I don't belong here." The nurse analyzes this behavior as:

Denial

Projection

Regression

Rationalization

Denial is refusal to admit to a painful reality, which is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other persons, objects, or situations. In regression, the client returns to an earlier, more comforting, although less mature, way of behaving. Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller and the listener.
Test-Taking Strategy: Use the process of elimination. The strategic words in the question that should direct you to the correct option are “There's nothing wrong with me. ” Select the option that recognizes the client's attempt to avoid looking at the reality of the situation. If you had difficulty with this question, review defense mechanisms.

Explanation

Denial is refusal to admit to a painful reality, which is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other persons, objects, or situations. In regression, the client returns to an earlier, more comforting, although less mature, way of behaving. Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller and the listener.
Test-Taking Strategy: Use the process of elimination. The strategic words in the question that should direct you to the correct option are “There's nothing wrong with me. ” Select the option that recognizes the client's attempt to avoid looking at the reality of the situation. If you had difficulty with this question, review defense mechanisms.

13. The nurse is performing an assessment on a client with dementia. Which data gathered during the assessment indicate a manifestation associated with dementia?

Confabulation

Improvement in sleeping

Absence of sundown syndrome

Presence of personal hygienic care

The clinical picture of dementia varies from the development of mild cognitive defects to severe, life-threatening alterations in neurological functioning. For the client to use confabulation or the fabrication of events or experiences to fill in memory gaps is not unusual. Often, lack of inhibitions on the part of the client may constitute the first indication of anything being “wrong” to the client's significant others (the client may undress in front of others or demonstrate slovenly table manners but was formerly well mannered). As the dementia progresses, the client will have episodes of wandering or sundowning.
Test-Taking Strategy: Use the process of elimination and focus on the client's diagnosis. Noting the subject, a manifestation, will direct you to option 1. If you had difficulty with this question, review the manifestations associated with dementia.

Explanation

The clinical picture of dementia varies from the development of mild cognitive defects to severe, life-threatening alterations in neurological functioning. For the client to use confabulation or the fabrication of events or experiences to fill in memory gaps is not unusual. Often, lack of inhibitions on the part of the client may constitute the first indication of anything being “wrong” to the client's significant others (the client may undress in front of others or demonstrate slovenly table manners but was formerly well mannered). As the dementia progresses, the client will have episodes of wandering or sundowning.
Test-Taking Strategy: Use the process of elimination and focus on the client's diagnosis. Noting the subject, a manifestation, will direct you to option 1. If you had difficulty with this question, review the manifestations associated with dementia.

14. A client is admitted to the mental health unit with a diagnosis of depression. The nurse develops a plan of care for the client and includes which appropriate activity in the plan?

Reading and writing most of the day

Several activities from which the client can choose

Nothing, until the client asks to participate in milieu

A structured program of activities in which the client can participate

A client with depression often suffers a depressed mood and is withdrawn. The person also experiences difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. Options 1, 2, and 3 are too “restrictive” and offer little or no structure and stimulation.
Test-Taking Strategy: Use the process of elimination. Recall that the depressed client requires a structured and stimulating program in a safe environment. Option 4 is the only option that will provide a safe and effective environment. Review care of the client with depression if you had difficulty with this question.

Explanation

A client with depression often suffers a depressed mood and is withdrawn. The person also experiences difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. Options 1, 2, and 3 are too “restrictive” and offer little or no structure and stimulation.
Test-Taking Strategy: Use the process of elimination. Recall that the depressed client requires a structured and stimulating program in a safe environment. Option 4 is the only option that will provide a safe and effective environment. Review care of the client with depression if you had difficulty with this question.

15. He spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse would be:

“Why don't you tell your husband about this?”

“What do you find difficult about this situation?”

“This is not the best time to make that decision.”

“I agree with you. You should get out of this situation.”

The most helpful response is one that encourages the client to solve problems. Giving advice implies that the nurse knows what is best and also can foster dependency. The nurse should not agree with the client, nor should the nurse request that the client provide explanations.
Test-Taking Strategy: Use therapeutic communication techniques. Eliminate option 1 because of the word why, which should be avoided in communication. Eliminate option 4 because the nurse is agreeing with the client. Eliminate option 3 because this option places the client's feelings on hold. Option 2 is the only option that addresses the client's feelings. Review therapeutic communication techniques if you had difficulty with this question.

Explanation

The most helpful response is one that encourages the client to solve problems. Giving advice implies that the nurse knows what is best and also can foster dependency. The nurse should not agree with the client, nor should the nurse request that the client provide explanations.
Test-Taking Strategy: Use therapeutic communication techniques. Eliminate option 1 because of the word why, which should be avoided in communication. Eliminate option 4 because the nurse is agreeing with the client. Eliminate option 3 because this option places the client's feelings on hold. Option 2 is the only option that addresses the client's feelings. Review therapeutic communication techniques if you had difficulty with this question.

16. The client was admitted involuntarily to the mental health unit because of episodes of extremely violent behavior. The client is demanding to be discharged from the hospital and the nurse does not allow the client to leave. Which of the following represents the legal ramifications associated with the nurse's behavior?

The nurse will be charged with assault.

The nurse will be charged with slander.

The nurse will be charged with imprisonment.

No charge will be made against the nurse because the nurse's actions are reasonable.

False imprisonment is an act with the intent to confine a person to a specific area. A nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the
hospital if the client has been admitted voluntarily and if no agency or legal policies exist for detaining the client. However, if the client has been admitted involuntarily or had agreed to an evaluation before discharge, the nurse's actions are reasonable.
Test-Taking Strategy: Noting the strategic words admitted involuntarily will assist you in eliminating option 3 and direct you
to option 4. Options 1 and 2 are unrelated to the subject of the question and can be eliminated easily. Review the subjects related to false imprisonment and hospital admission if you had difficulty with this question.

Explanation

False imprisonment is an act with the intent to confine a person to a specific area. A nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the
hospital if the client has been admitted voluntarily and if no agency or legal policies exist for detaining the client. However, if the client has been admitted involuntarily or had agreed to an evaluation before discharge, the nurse's actions are reasonable.
Test-Taking Strategy: Noting the strategic words admitted involuntarily will assist you in eliminating option 3 and direct you
to option 4. Options 1 and 2 are unrelated to the subject of the question and can be eliminated easily. Review the subjects related to false imprisonment and hospital admission if you had difficulty with this question.

17. The nurse is discharging a client with a history of command hallucinations to harm self or others. The nurse provides instructions to the client about interventions for hallucinations and anxiety and determines that the client understands the instructions if the client states:

“My medications won't make me anxious.”

“I'll go to support group and talk so that I don't hurt anyone.”

“I won't get anxious or hear things if I get enough sleep and eat well.”

The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. The nurse should ask the client whether he or she has intentions to hurt himself or herself or others. Talking about auditory hallucinations can interfere with subvocal muscular
activity associated with a hallucination. Options 1, 2, and 3 will aid in wellness but are not specific interventions for hallucinations, if they occur.
Test-Taking Strategy: Use the process of elimination. Options 1, 2, and 3 are interventions that a client can carry out to aid wellness. Option 4 is a specific agreement to seek help and evidences self-responsible commitment and control over one's own behavior. Review teaching points for a client with a history of hallucinations
if you had difficulty with this question.

Explanation

The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. The nurse should ask the client whether he or she has intentions to hurt himself or herself or others. Talking about auditory hallucinations can interfere with subvocal muscular
activity associated with a hallucination. Options 1, 2, and 3 will aid in wellness but are not specific interventions for hallucinations, if they occur.
Test-Taking Strategy: Use the process of elimination. Options 1, 2, and 3 are interventions that a client can carry out to aid wellness. Option 4 is a specific agreement to seek help and evidences self-responsible commitment and control over one's own behavior. Review teaching points for a client with a history of hallucinations
if you had difficulty with this question.

18. A client with a diagnosis of major depression, recurrent, with psychotic features, is admitted to the mental health unit. To create a safe environment for the client, the nurse most importantly devises a plan of care that deals specifically with the client's:

Self-care deficit.

Imbalanced nutrition.

Deficient knowledge.

Disturbed thought processes.

Major depression, recurrent, with psychotic features, alerts the nurse that in addition to the criteria that designates the diagnosis of major depression, one also must deal with the client's psychosis. Psychosis is defined as a state in which a person's mental capacity to recognize reality and to communicate and relate to
others is impaired, thus interfering with the person's ability to deal with the demands of life. Disturbed thought processes generally indicate a state of increased anxiety in which hallucinations and delusions prevail. Although all the nursing diagnoses may be appropriate because the client is experiencing psychosis, option 4 is the correct option.
Test-Taking Strategy: Use the process of elimination. All the nursing diagnoses listed may be appropriate for a client diagnosed with major depression. The strategic words leading to the correct option are psychotic features, in which the client often suffers with disturbed thought processes, such as hallucinations and delusions. Review appropriate nursing diagnoses for major depression and psychotic features if you had difficulty with this question.

Explanation

Major depression, recurrent, with psychotic features, alerts the nurse that in addition to the criteria that designates the diagnosis of major depression, one also must deal with the client's psychosis. Psychosis is defined as a state in which a person's mental capacity to recognize reality and to communicate and relate to
others is impaired, thus interfering with the person's ability to deal with the demands of life. Disturbed thought processes generally indicate a state of increased anxiety in which hallucinations and delusions prevail. Although all the nursing diagnoses may be appropriate because the client is experiencing psychosis, option 4 is the correct option.
Test-Taking Strategy: Use the process of elimination. All the nursing diagnoses listed may be appropriate for a client diagnosed with major depression. The strategic words leading to the correct option are psychotic features, in which the client often suffers with disturbed thought processes, such as hallucinations and delusions. Review appropriate nursing diagnoses for major depression and psychotic features if you had difficulty with this question.

19. The home health nurse visits a client at home and determines that the client is dependent on drugs. Which of the following assessment questions would assist the nurse to provide appropriate nursing care?

“Why did you get started on these drugs?”

“How much do you use and what effect does it have on you?”

“How long did you think you could take these drugs without someone finding out?”

Whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental and off focus and reflects the nurse's bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques to answer the question. Also, focus on the subject, provide appropriate nursing care. Review assessment of a client who is a substance abuser if you had difficulty with this question.

Explanation

Whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental and off focus and reflects the nurse's bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques to answer the question. Also, focus on the subject, provide appropriate nursing care. Review assessment of a client who is a substance abuser if you had difficulty with this question.

20. The client with schizophrenia has been started on medication therapy with clozapine (Clozaril). The nurse assesses the results of which laboratory study to monitor for adverse effects from this medication?

Platelet count

Blood glucose level

White blood cell count

Liver function studies

The client taking clozapine (Clozaril) may experience agranulocytosis, which is monitored by reviewing the results of the white blood cell count. Treatment is interrupted if the white blood cell count drops below 3000/mm3. Agranulocytosis could be fatal if undetected and untreated. The other options are not related specifically to the use of this medication.
Test-Taking Strategy: Use the process of elimination. Recalling that this medication causes agranulocytosis will direct you to option 3. Review the adverse effects of this medication if you had
difficulty with this question

Explanation

The client taking clozapine (Clozaril) may experience agranulocytosis, which is monitored by reviewing the results of the white blood cell count. Treatment is interrupted if the white blood cell count drops below 3000/mm3. Agranulocytosis could be fatal if undetected and untreated. The other options are not related specifically to the use of this medication.
Test-Taking Strategy: Use the process of elimination. Recalling that this medication causes agranulocytosis will direct you to option 3. Review the adverse effects of this medication if you had
difficulty with this question

21. A client with major depression is considering cognitive therapy. The client asks the nurse, "How does this treatment work?" The nurse responds and tells the client that:

“This type of treatment will help you relax and develop newcoping skills.”

“This type of treatment helps you confront your fears by gradually exposing you to them.”

“This type of treatment helps you examine how your past life has contributed to your problems.”

This type of treatment helps you examine how your thoughts and feelings contribute to your difficulties.”

Cognitive therapy frequently is used for clients with depression. This type of therapy is based on exploring the client's subjective experience. Cognitive therapy includes examining the client's thoughts and feelings about situations and how these thoughts and feelings contribute to and perpetuate the client's difficulties and mood.
Test-Taking Strategy: Focusing on the word cognitive will assist you in selecting the correct option. Look for a similar word used in the question and repeated in one of the options. Note the relationship of the word cognitive in the question and thoughts in option 4. Review this form of therapy if you had difficulty with this question.

Explanation

Cognitive therapy frequently is used for clients with depression. This type of therapy is based on exploring the client's subjective experience. Cognitive therapy includes examining the client's thoughts and feelings about situations and how these thoughts and feelings contribute to and perpetuate the client's difficulties and mood.
Test-Taking Strategy: Focusing on the word cognitive will assist you in selecting the correct option. Look for a similar word used in the question and repeated in one of the options. Note the relationship of the word cognitive in the question and thoughts in option 4. Review this form of therapy if you had difficulty with this question.

22. A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. The appropriate nursing action is to:

Call the nursing supervisor.

Call security to block all exit areas.

Restrain the client until the physician can be reached.

Tell the client that the client cannot return to this hospital again if the client leaves now.

A nurse can be charged with false imprisonment if a client is made to believe wrongfully that he or she cannot leave the hospital. Most health care facilities have documents that the client is asked to sign relating to the client's responsibilities when the client leaves against medical advice. The client should be asked to sign this document before leaving. The nurse should request that the client wait to speak to the physician before leaving, but if the client refuses to do so, the nurse cannot hold the client against the client's will. Restraining the client and calling security to block exits constitutes false imprisonment. All clients have a right to health care and cannot be told otherwise.
Test-Taking Strategy: Use the process of elimination. Keeping the concept of false imprisonment in mind, eliminate options 2 and 3 because they are comparative or alike. Eliminate option 4, knowing that all clients have a right to health care. From the options presented, the best action is option 1. Review the points related to false imprisonment if you had difficulty with this question.

Explanation

A nurse can be charged with false imprisonment if a client is made to believe wrongfully that he or she cannot leave the hospital. Most health care facilities have documents that the client is asked to sign relating to the client's responsibilities when the client leaves against medical advice. The client should be asked to sign this document before leaving. The nurse should request that the client wait to speak to the physician before leaving, but if the client refuses to do so, the nurse cannot hold the client against the client's will. Restraining the client and calling security to block exits constitutes false imprisonment. All clients have a right to health care and cannot be told otherwise.
Test-Taking Strategy: Use the process of elimination. Keeping the concept of false imprisonment in mind, eliminate options 2 and 3 because they are comparative or alike. Eliminate option 4, knowing that all clients have a right to health care. From the options presented, the best action is option 1. Review the points related to false imprisonment if you had difficulty with this question.

23. The nurse is caring for a client with a phobia who is being treated for the condition. The client is introduced to short periods of exposure to the phobic object while in a relaxed state. The nurse understands that this form of behavior modification can best be described as:

Milieu therapy

Aversion therapy

Self-control therapy

Systematic desensitization

Systematic desensitization is a form of therapy used when the client is introduced to short periods of exposure to the phobic
object while in a relaxed state. Gradually exposure is increased until the anxiety about or fear of the object or situation has ceased.
Options 1, 2, and 3 are incorrect.
Test-Taking Strategy: Use the process of elimination. Focus on the strategic words introduced to short periods of exposure. This will direct you to the correct option. If you had difficulty with this question, review systematic desensitization.

Explanation

Systematic desensitization is a form of therapy used when the client is introduced to short periods of exposure to the phobic
object while in a relaxed state. Gradually exposure is increased until the anxiety about or fear of the object or situation has ceased.
Options 1, 2, and 3 are incorrect.
Test-Taking Strategy: Use the process of elimination. Focus on the strategic words introduced to short periods of exposure. This will direct you to the correct option. If you had difficulty with this question, review systematic desensitization.

24. The nurse is planning activities for a client who has bipolar disorder with aggressive social behavior. Which of the following activities would be most appropriate for this client?

Chess

Writing

Ping pong

Basketball

Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks
with staff, and finger painting are activities that minimize stimuli
and provide a constructive release for tension. Competitive games should be avoided because they can stimulate aggression and increase psychomotor activity.
Test-Taking Strategy: Use the process of elimination. Options 1, 3, and 4 are comparative or alike in that they are activities that the client cannot do alone. Option 2 identifies a solitary activity.
Review care of the client with aggressive behavior if you had difficulty with this question.

Explanation

Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks
with staff, and finger painting are activities that minimize stimuli
and provide a constructive release for tension. Competitive games should be avoided because they can stimulate aggression and increase psychomotor activity.
Test-Taking Strategy: Use the process of elimination. Options 1, 3, and 4 are comparative or alike in that they are activities that the client cannot do alone. Option 2 identifies a solitary activity.
Review care of the client with aggressive behavior if you had difficulty with this question.

25. A client with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." The therapeutic response to the client is:

“I don't see you as a failure.”

“You have everything to live for.”

“Feeling like this is all part of being ill.”

“You've been feeling like a failure for a while?”

Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. Options 1, 2, and 3 block communication because they minimize the client's experience and do not facilitate exploration of the client's expressed feelings. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques to direct you to the option that directly addresses the client's feelings and concerns. Also, option 4 is the only option stated in the form of a question and is open-ended; thus, it will encourage the verbalization of feelings. Review therapeutic communication techniques if you had difficulty with this question.

Explanation

Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. Options 1, 2, and 3 block communication because they minimize the client's experience and do not facilitate exploration of the client's expressed feelings. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques to direct you to the option that directly addresses the client's feelings and concerns. Also, option 4 is the only option stated in the form of a question and is open-ended; thus, it will encourage the verbalization of feelings. Review therapeutic communication techniques if you had difficulty with this question.

26. The client with schizophrenia has been started on medication therapy with clozapine (Clozaril). The nurse assesses the results of which laboratory study to monitor for adverse effects from this medication?

Platelet count

Blood glucose level

White blood cell count

Liver function studies

The client taking clozapine (Clozaril) may experience agranulocytosis, which is monitored by reviewing the results of the white blood cell count. Treatment is interrupted if the white blood cell count drops below 3000/mm3. Agranulocytosis could be fatal if undetected and untreated. The other options are not related specifically to the use of this medication.
Test-Taking Strategy: Use the process of elimination. Recalling that this medication causes agranulocytosis will direct you to option 3. Review the adverse effects of this medication if you had
difficulty with this question

Explanation

The client taking clozapine (Clozaril) may experience agranulocytosis, which is monitored by reviewing the results of the white blood cell count. Treatment is interrupted if the white blood cell count drops below 3000/mm3. Agranulocytosis could be fatal if undetected and untreated. The other options are not related specifically to the use of this medication.
Test-Taking Strategy: Use the process of elimination. Recalling that this medication causes agranulocytosis will direct you to option 3. Review the adverse effects of this medication if you had
difficulty with this question

27. A client who has just been sexually assaulted is quiet and calm. The nurse analyzes this behavior as indicating which defense mechanism?

Denial

Projection

Rationalization

Intellectualization

Denial is a refusal to admit to a painful reality and maybe a response by a victim of sexual abuse. Projection is transferring one's internal feelings, thoughts, and unacceptable ideas and traits to someone else. Rationalization is justifying the unacceptable attributes of oneself. Intellectualization is the excessive use of abstract thinking or generalizations to decrease painful thinking. Test-Taking Strategy: Use the process of elimination and note the strategic words calm and quiet. These behaviors indicate denial in a sexually abused victim. If you had difficulty with this question, review content related to the sexually abused victim and defense mechanisms.

Explanation

Denial is a refusal to admit to a painful reality and maybe a response by a victim of sexual abuse. Projection is transferring one's internal feelings, thoughts, and unacceptable ideas and traits to someone else. Rationalization is justifying the unacceptable attributes of oneself. Intellectualization is the excessive use of abstract thinking or generalizations to decrease painful thinking. Test-Taking Strategy: Use the process of elimination and note the strategic words calm and quiet. These behaviors indicate denial in a sexually abused victim. If you had difficulty with this question, review content related to the sexually abused victim and defense mechanisms.

28. The nurse is providing care to a client admitted to the hospital with a diagnosis of acute anxiety disorder. While conversing with the client, the client says to the nurse, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" The appropriate nursing response is which of the following?

“No, I won't tell anyone.”

“I cannot promise to keep a secret.”

“If you tell me the secret, I will tell it to your doctor.”

“If you tell me the secret, I will need to document it in your record.”

The nurse should never promise to keep a secret. Secrets are appropriate in a social relationship but not in a therapeutic one.
The nurse needs to be honest with the client and tell the client that a promise cannot be made to keep the secret. Options 1, 3, and 4 are inappropriate responses.
Test-Taking Strategy: Use the process of elimination. Option 1 can be eliminated easily because it is inappropriate. Options 3 and 4 are not only inappropriate but are also somewhat threatening and may even block further communication. Review therapeutic communication techniques and the nurse-client relationship if you had difficulty with this question.

Explanation

The nurse should never promise to keep a secret. Secrets are appropriate in a social relationship but not in a therapeutic one.
The nurse needs to be honest with the client and tell the client that a promise cannot be made to keep the secret. Options 1, 3, and 4 are inappropriate responses.
Test-Taking Strategy: Use the process of elimination. Option 1 can be eliminated easily because it is inappropriate. Options 3 and 4 are not only inappropriate but are also somewhat threatening and may even block further communication. Review therapeutic communication techniques and the nurse-client relationship if you had difficulty with this question.

29. The nurse is caring for a male client diagnosed with catatonic stupor. The client is lying on the bed with his body pulled into a fetal position. The appropriate nursing intervention is which of the following?

Ask direct questions to encourage talking.

Leave the client alone and intermittently check on him.

Sit beside the client in silence with occasional open-ended questions.

Take the client into the dayroom with other clients so that they can help watch him.

Clients who are withdrawn may be immobile and mute and may require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to respond.
Test-Taking Strategy: Eliminate option 2 because the client would not be left alone. Option 4 relies on other clients to care for this client, which is an inappropriate expectation. Asking direct questions of this client is not therapeutic. Option 3 provides for client supervision and communication as appropriate. Review care of the client with catatonic stupor if this question was difficult.

Explanation

Clients who are withdrawn may be immobile and mute and may require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to respond.
Test-Taking Strategy: Eliminate option 2 because the client would not be left alone. Option 4 relies on other clients to care for this client, which is an inappropriate expectation. Asking direct questions of this client is not therapeutic. Option 3 provides for client supervision and communication as appropriate. Review care of the client with catatonic stupor if this question was difficult.

30. A female client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes were much too tight and has reduced her calorie intake to 800 calories daily. The nurse analyzes this behavior as:

Normal behavior

Evidence of the client's disturbed body image

Regression as the client is moving toward the community

Indicative of the client's ambivalence about hospital discharge

Disturbed body image is a concern with clients with anorexia nervosa. Although the client may struggle with
ambivalence and show regressed behavior, the client's coping pattern relates to the basic issue of disturbed body image. The nurse should address this need in the support group.
Test-Taking Strategy: Use the process of elimination, focusing on the information provided in the question, which is related directly to an altered body image. This should direct you to the correct option. Review the needs of the client with anorexia nervosa if you had difficulty with this question.

Explanation

Disturbed body image is a concern with clients with anorexia nervosa. Although the client may struggle with
ambivalence and show regressed behavior, the client's coping pattern relates to the basic issue of disturbed body image. The nurse should address this need in the support group.
Test-Taking Strategy: Use the process of elimination, focusing on the information provided in the question, which is related directly to an altered body image. This should direct you to the correct option. Review the needs of the client with anorexia nervosa if you had difficulty with this question.

31. The nurse is preparing the client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task appropriate for this phase?

Planning short-term goals

Making appropriate referrals

Developing realistic solutions

Identifying expected outcomes

Tasks of the termination phase include evaluating client performance, evaluating achievement of expected outcomes, evaluating future needs, making appropriate referrals, and dealing with the common behaviors associated with termination. Options 1, 3, and 4 identify the tasks of the working phase of the relationship. Test-Taking Strategy: Use the process of elimination. Noting the strategic words termination phase should direct you easily to option 2. If you are unfamiliar with the appropriate tasks of the phases of the nurse-client relationship, review this content.

Explanation

Tasks of the termination phase include evaluating client performance, evaluating achievement of expected outcomes, evaluating future needs, making appropriate referrals, and dealing with the common behaviors associated with termination. Options 1, 3, and 4 identify the tasks of the working phase of the relationship. Test-Taking Strategy: Use the process of elimination. Noting the strategic words termination phase should direct you easily to option 2. If you are unfamiliar with the appropriate tasks of the phases of the nurse-client relationship, review this content.

32. A nurse enters a client's room, and the client is demanding release from the hospital. The nurse reviews the client's record and notes that the client was admitted 2 days ago for treatment of an anxiety disorder and that the admission was a voluntary admission. Which of the following actions will the nurse take?

Contact the physician.

Call the client's family.

Persuade the client to stay a few more days.

Tell the client that discharge is not possible at this time.

Generally, the client seeks voluntary admission. Voluntary clients have the right to demand and obtain release. If the client is a minor, the release may be contingent on the consent of the parent(s) or guardian. The nurse needs to be familiar with the state and facility policies and procedures. Many states require that the client submit a written release notice to the facility staff members, who reevaluate the client's condition for possible conversion to involuntary status, according to criteria established by laws. The best nursing action is to contact the physician. Test-Taking Strategy: Use the process of elimination. Noting the type of hospital admission will assist in eliminating option 4. To “persuade” a client to stay in the hospital is inappropriate. Option 2 should be eliminated simply based on the subjects of client rights and confidentiality. Review the various types of hospital admission and discharge processes if you had difficulty with this question.

Explanation

Generally, the client seeks voluntary admission. Voluntary clients have the right to demand and obtain release. If the client is a minor, the release may be contingent on the consent of the parent(s) or guardian. The nurse needs to be familiar with the state and facility policies and procedures. Many states require that the client submit a written release notice to the facility staff members, who reevaluate the client's condition for possible conversion to involuntary status, according to criteria established by laws. The best nursing action is to contact the physician. Test-Taking Strategy: Use the process of elimination. Noting the type of hospital admission will assist in eliminating option 4. To “persuade” a client to stay in the hospital is inappropriate. Option 2 should be eliminated simply based on the subjects of client rights and confidentiality. Review the various types of hospital admission and discharge processes if you had difficulty with this question.

33. The client is admitted to the mental health unit with a diagnosis of schizophrenia. A nursing diagnosis formulated for the client is thought processes, disturbed related to paranoia. In formulating nursing interventions with the members of the health care team, the nurse provides instructions to:

Increase socialization of the client with peers.

Avoid laughing or whispering in front of the client.

Begin to educate the client about social supports in the community.

Disturbed thought process related to paranoia is the client's problem, and the plan of care must address this problem. The client is experiencing paranoia and is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Therefore, laughing or whispering in front of the client would be counterproductive. Options 1, 3, and 4 ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client who is paranoid. Test-Taking Strategy: Use the process of elimination and knowledge regarding this disorder to answer the question. Noting that the client has paranoia will direct you to option 2. Review this disorder if you had difficulty with this question.

Explanation

Disturbed thought process related to paranoia is the client's problem, and the plan of care must address this problem. The client is experiencing paranoia and is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Therefore, laughing or whispering in front of the client would be counterproductive. Options 1, 3, and 4 ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client who is paranoid. Test-Taking Strategy: Use the process of elimination and knowledge regarding this disorder to answer the question. Noting that the client has paranoia will direct you to option 2. Review this disorder if you had difficulty with this question.

34. The client asks the nurse about milieu therapy. The nurse responds, knowing that the primary focus of milieu therapy can best be described as which of the following?

A form of behavior modification therapy

A cognitive approach to changing behavior

A living, learning, or working environment

A behavioral approach to changing behavior

Milieu therapy, or “therapeutic community,” has as its focus a living, learning, or working environment. Such therapy may be based on any number of therapeutic modalities from structured behavioral therapy to spontaneous, humanistically oriented approaches. Although milieu may include behavioral approaches, option 3 describes its primary focus.
Test-Taking Strategy: Use the process of elimination. Note that options 1, 2, and 4 are comparative or alike and that option 3 identifies a comprehensive description. Review milieu therapy if you had difficulty with this question.

Explanation

Milieu therapy, or “therapeutic community,” has as its focus a living, learning, or working environment. Such therapy may be based on any number of therapeutic modalities from structured behavioral therapy to spontaneous, humanistically oriented approaches. Although milieu may include behavioral approaches, option 3 describes its primary focus.
Test-Taking Strategy: Use the process of elimination. Note that options 1, 2, and 4 are comparative or alike and that option 3 identifies a comprehensive description. Review milieu therapy if you had difficulty with this question.

35. A nurse employed in a mental health unit of a hospital is the leader of a group psychotherapy session. The nurse's role in the termination stage of group development is to:

Encourage problem-solving.

Encourage accomplishment of the group's work.

Acknowledge the contributions of each group member.

Encourage members to become acquainted with one another.

In the termination stage, the group leader's task is to acknowledge the contributions of each member and the experience of the group as a whole. In this stage, the group members prepare for separation and assist each other to prepare for the future. Options 1 and 2 identify the tasks of the working stage. Option 4 identifies the orientation stage.
Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are comparative or alike. From the remaining options, note the relationship between the words termination stage in the question and option 3. Review the stages of group development if you had difficulty with this question.

Explanation

In the termination stage, the group leader's task is to acknowledge the contributions of each member and the experience of the group as a whole. In this stage, the group members prepare for separation and assist each other to prepare for the future. Options 1 and 2 identify the tasks of the working stage. Option 4 identifies the orientation stage.
Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are comparative or alike. From the remaining options, note the relationship between the words termination stage in the question and option 3. Review the stages of group development if you had difficulty with this question.

36. He client is unwilling to go out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound, except when accompanied outside by the spouse. Based on this data, the nurse determines that the client is experiencing:

Agoraphobia

Social phobia

Claustrophobia

Hypochondriasis

Agoraphobia is a fear of open spaces and the fear of being trapped in a situation from which there may not be an escape. Agoraphobia includes the possibility of experiencing a sense of helplessness or embarrassment if an attack occurs. Avoidance of such situations usually results in reduction of social and professional interactions. Social phobia focuses more on specific situations, such as the fear of speaking, performing, or eating in public. Claustrophobia is a fear of closed places. Clients with hypochondriacal symptoms focus their anxiety on physical complaints and are preoccupied with their health.
Test-Taking Strategy: Use the process of elimination. Focusing on the strategic words remains homebound will direct you to option 1. If you had difficulty with this question, review phobia types and associated client behaviors.

Explanation

Agoraphobia is a fear of open spaces and the fear of being trapped in a situation from which there may not be an escape. Agoraphobia includes the possibility of experiencing a sense of helplessness or embarrassment if an attack occurs. Avoidance of such situations usually results in reduction of social and professional interactions. Social phobia focuses more on specific situations, such as the fear of speaking, performing, or eating in public. Claustrophobia is a fear of closed places. Clients with hypochondriacal symptoms focus their anxiety on physical complaints and are preoccupied with their health.
Test-Taking Strategy: Use the process of elimination. Focusing on the strategic words remains homebound will direct you to option 1. If you had difficulty with this question, review phobia types and associated client behaviors.

37. The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group when the nurse hears the wife say:

“I no longer feel that I deserve the beatings my husband inflictson me.”

“My attendance at the meetings has helped me to see that I provoke my husband's violence.”

“I enjoy attending the meetings because they get me out of the house and away from my husband.”

“I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics.”

Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. Option 1 is the most healthy response because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. In option 2, the nonalcoholic partner should not feel responsible when the spouse loses control. Option 4 indicates that the wife remains codependent. Option 3 indicates that the group is viewed as an escape, not a place to work on issues. Test-Taking Strategy: Use the process of elimination. Note the strategic words benefiting from attending an Al-Anon group. This will direct you to option 1. Review the purpose of this group if you had difficulty with this question.

Explanation

Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. Option 1 is the most healthy response because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. In option 2, the nonalcoholic partner should not feel responsible when the spouse loses control. Option 4 indicates that the wife remains codependent. Option 3 indicates that the group is viewed as an escape, not a place to work on issues. Test-Taking Strategy: Use the process of elimination. Note the strategic words benefiting from attending an Al-Anon group. This will direct you to option 1. Review the purpose of this group if you had difficulty with this question.

38. A client with an eating disorder is planning to attend group meetings with Overeaters Anonymous, and the nurse describes this group to the client. The nurse determines that the client needs additional information if the client states which of the following about this self-help group?

“The leader is a nurse or psychiatrist.”

“The members provide support to each other.”

“People who have a similar problem are able to help others.”

“It is designed to serve people who have a common problem.”

The sponsor of a self-help group is an experienced member of the group. A nurse or psychiatrist may be asked by the group to serve as a resource but would not be the leader of the group. Options 2, 3, and 4 are characteristics of a self-help group. Test-Taking Strategy: Use the process of elimination and focus on the subject, self-help group. Note the strategic words needs
additional information in the question. Note that options 2, 3, and 4 are comparative or alike. This should direct you easily to option 1, the correct option. Review the characteristics of a self-help group if you had difficulty with this question.

Explanation

The sponsor of a self-help group is an experienced member of the group. A nurse or psychiatrist may be asked by the group to serve as a resource but would not be the leader of the group. Options 2, 3, and 4 are characteristics of a self-help group. Test-Taking Strategy: Use the process of elimination and focus on the subject, self-help group. Note the strategic words needs
additional information in the question. Note that options 2, 3, and 4 are comparative or alike. This should direct you easily to option 1, the correct option. Review the characteristics of a self-help group if you had difficulty with this question.

39. The nurse develops a nursing diagnosis of self-care deficit for an older client with dementia. Which of the following is an appropriate goal for this client?

The client will function at the highest level of independence possible.

The client will complete all activities of daily living independently within a 1-hour time frame.

The client will be admitted to a long-term care facility to have activities of daily living needs met.

The nursing staff will attend to all the client's activities of daily living needs during the hospital stay.

All clients, regardless of age, need to be encouraged to perform at the highest level of independence possible. Independence contributes to the client's sense of control and sense of well-being. Option 3 is incorrect because what the self-care deficit entails is not known. To assume that the client requires long-term care based on so little information would be erroneous. Options 2 and 4 are close-ended statements.
Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 4 first because of the close-ended word all. From the remaining options, select option 1 because it is the umbrella option. Review care of the client with dementia if you had difficulty with
this question.

Explanation

All clients, regardless of age, need to be encouraged to perform at the highest level of independence possible. Independence contributes to the client's sense of control and sense of well-being. Option 3 is incorrect because what the self-care deficit entails is not known. To assume that the client requires long-term care based on so little information would be erroneous. Options 2 and 4 are close-ended statements.
Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 4 first because of the close-ended word all. From the remaining options, select option 1 because it is the umbrella option. Review care of the client with dementia if you had difficulty with
this question.

40. The client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." The therapeutic response by the nurse is:

“Have you shared your feelings with your family?”

“I think we should talk more about your anger with your family.”

“You're feeling angry that your family continues to hope for you to be cured?”

“Well, it sounds like you're being pretty pessimistic. After all, years ago, people died of pneumonia.”

Restating is the therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review what was said. Option 3 uses the therapeutic technique of restating. In option 1, the nurse is attempting to assess the client's ability to discuss feelings openly with family members.
In option 2, the nurse attempts to use focusing, but the attempt to discuss central issues is premature. In option 4, the nurse makes a judgment and is nontherapeutic in the one-to-one relationship. Test-Taking Strategy: Use therapeutic communication techniques to answer the question. Option 3 is the only option that identifies the use of a therapeutic technique and focuses on the client's feelings. Review these techniques if you had difficulty with this question.

Explanation

Restating is the therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review what was said. Option 3 uses the therapeutic technique of restating. In option 1, the nurse is attempting to assess the client's ability to discuss feelings openly with family members.
In option 2, the nurse attempts to use focusing, but the attempt to discuss central issues is premature. In option 4, the nurse makes a judgment and is nontherapeutic in the one-to-one relationship. Test-Taking Strategy: Use therapeutic communication techniques to answer the question. Option 3 is the only option that identifies the use of a therapeutic technique and focuses on the client's feelings. Review these techniques if you had difficulty with this question.

41. During the termination phase of the nurse-client relationship, the clinic nurse observes that the client has made several sarcastic remarks and has an angry affect. The most appropriate interpretation of the behavior is that the client:

Needs to be admitted to the hospital.

Needs to be referred to the psychiatrist as soon as possible.

Requires further treatment and is not ready to be discharged.

Is displaying typical behaviors that can occur during termination.

In the termination phase of a relationship, it is normal for a client to demonstrate a number of regressive behaviors that can be disturbing to the nurse. Typical behaviors include return of symptoms, anger, withdrawal, and minimizing the relationship. The anger that the client is experiencing is a normal behavior during the termination phase and does not necessarily indicate the need for hospitalization or treatment.
Test-Taking Strategy: Note the strategic words termination phase. This alone may assist in directing you to option 4. Additionally,
note that options 1, 2, and 3 are comparable. These options address the need for further supervised treatment. If you are unfamiliar with the client behaviors associated with the termination phase, review this content.

Explanation

In the termination phase of a relationship, it is normal for a client to demonstrate a number of regressive behaviors that can be disturbing to the nurse. Typical behaviors include return of symptoms, anger, withdrawal, and minimizing the relationship. The anger that the client is experiencing is a normal behavior during the termination phase and does not necessarily indicate the need for hospitalization or treatment.
Test-Taking Strategy: Note the strategic words termination phase. This alone may assist in directing you to option 4. Additionally,
note that options 1, 2, and 3 are comparable. These options address the need for further supervised treatment. If you are unfamiliar with the client behaviors associated with the termination phase, review this content.

42. All treatment team members are seen as equally important in helping clients meet their treatment goals. This type of therapy approach is:

Milieu therapy

Interpersonal therapy

Behavior modification

Rational emotive therapy

All treatment team members are viewed as significant and valuable to the client's successful treatment outcomes in milieu therapy. Behavior modification is based on rewards and punishment. Rational emotive therapy deals with the correction of distorted
thinking. Interpersonal therapy on the other hand is based on a one-to-one or group therapy approach in which the therapist-client relationship is often used as a way for the client to examine other relationships in his or her life.
Test-Taking Strategy: Focus on the subject. Note the relationship between the words helping clients to meet their treatment goals and option 1. Review the types of therapy noted in the options if you had difficulty with this question.

Explanation

All treatment team members are viewed as significant and valuable to the client's successful treatment outcomes in milieu therapy. Behavior modification is based on rewards and punishment. Rational emotive therapy deals with the correction of distorted
thinking. Interpersonal therapy on the other hand is based on a one-to-one or group therapy approach in which the therapist-client relationship is often used as a way for the client to examine other relationships in his or her life.
Test-Taking Strategy: Focus on the subject. Note the relationship between the words helping clients to meet their treatment goals and option 1. Review the types of therapy noted in the options if you had difficulty with this question.

43. The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is appropriate?

Interrupt the client and weigh her immediately.

Interrupt the client and offer to take her for a walk.

Allow the client to complete her exercise program.

Tell the client that she is not allowed to exercise rigorously.

Clients with anorexia nervosa frequently are preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise and place limits on rigorous activities. Options 1, 3, and 4 are inappropriate nursing actions.
Test-Taking Strategy: Use the process of elimination and focus on the client's diagnosis. Also, focus on the need for the nurse to set firm limits with clients who have this disorder. If you had difficulty with this question, review interventions for the client with anorexia nervosa.

Explanation

Clients with anorexia nervosa frequently are preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise and place limits on rigorous activities. Options 1, 3, and 4 are inappropriate nursing actions.
Test-Taking Strategy: Use the process of elimination and focus on the client's diagnosis. Also, focus on the need for the nurse to set firm limits with clients who have this disorder. If you had difficulty with this question, review interventions for the client with anorexia nervosa.

44. A client begins to experience extrapyramidal side effects from an antipsychotic medication. The nurse anticipates that the physician will prescribe which of the following to treat this condition?

Haloperidol (Haldol)

Benztropine (Cogentin)

Prochlorperazine (Compazine)

Chlorpromazine (Thorazine)

Benztropine (Cogentin) is an anticholinergic medication used to treat drug-induced extrapyramidal reactions, except tardive dyskinesia. Options 1, 3, and 4 are antipsychotic medications. Antipsychotic medications can cause extrapyramidal reactions Test-Taking Strategy: Focus on the medications in the options. Recalling the classifications of each will direct you to option 2. Remember that benztropine (Cogentin) is an anticholinergic medication. Review the side effects and extrapyramidal reactions of antipsychotic medications if you had difficulty with this question.

Explanation

Benztropine (Cogentin) is an anticholinergic medication used to treat drug-induced extrapyramidal reactions, except tardive dyskinesia. Options 1, 3, and 4 are antipsychotic medications. Antipsychotic medications can cause extrapyramidal reactions Test-Taking Strategy: Focus on the medications in the options. Recalling the classifications of each will direct you to option 2. Remember that benztropine (Cogentin) is an anticholinergic medication. Review the side effects and extrapyramidal reactions of antipsychotic medications if you had difficulty with this question.

45. Laboratory work is prescribed for a client who has been experiencing delusions. When the nurse approaches the client to obtain a specimen of the client's blood, the client begins to shout "You're all vampires. Let me out of here!" The appropriate nursing response is which of the following?

“What makes you think that I am a vampire?”

“I'll leave and come back later for your blood.”

“I am not going to hurt you; I am going to help you.”

“It must be frightening to think that others want to hurt you.”

Option 4 helps the client focus on the emotion underlying the delusion but does not argue with it. Option 1 places the client in a position that requires a response. Option 2 avoids the client. Option 3 is an attempt to convince the client to believe another thought. This response may cause the client to hold the delusion more strongly. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques to answer the question. Option 4 is the only option that recognizes the client's needs and focuses on the client's feelings. Review therapeutic communication techniques if you had difficulty with this question.

Explanation

Option 4 helps the client focus on the emotion underlying the delusion but does not argue with it. Option 1 places the client in a position that requires a response. Option 2 avoids the client. Option 3 is an attempt to convince the client to believe another thought. This response may cause the client to hold the delusion more strongly. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques to answer the question. Option 4 is the only option that recognizes the client's needs and focuses on the client's feelings. Review therapeutic communication techniques if you had difficulty with this question.

46. A client is admitted to a medical nursing unit with a diagnosis of acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that when a family of three was killed. The nurse suspects that the client may be experiencing a:

Psychosis

Repression

Conversion disorder

Dissociative disorder

A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. A conversion disorder is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, thus interfering with the person's ability to deal with life's demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness.
Test-Taking Strategy: Use the process of elimination. The key to the correct option lies in the fact that the client presents no organic reason to account for the blindness—hence, a conversion disorder. If you had difficulty with this question, review defense mechanisms and the concepts associated with a conversion disorder.

Explanation

A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. A conversion disorder is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, thus interfering with the person's ability to deal with life's demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness.
Test-Taking Strategy: Use the process of elimination. The key to the correct option lies in the fact that the client presents no organic reason to account for the blindness—hence, a conversion disorder. If you had difficulty with this question, review defense mechanisms and the concepts associated with a conversion disorder.

47. A client who is delusional says to the nurse, "The federal guards were sent to kill me." The nurse's best response is:

“I don't believe this is true.”

“The guards are not out to kill you.”

“What makes you think the guards were sent to hurt you?”

“I don't know anything about the guards. Do you feel afraid that people are trying to hurt you?”

For the nurse to empathize with the client's experience is most therapeutic. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even
more. Encouraging discussion regarding the delusion is
inappropriate.
Test-Taking Strategy: Use therapeutic communication techniques. Eliminate options 1 and 2 because they are comparative or alike and are statements that disagree with the client. Option 3 encourages discussion regarding the delusion. Review communication techniques with the client experiencing delusions if you had
difficulty with this question.

Explanation

For the nurse to empathize with the client's experience is most therapeutic. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even
more. Encouraging discussion regarding the delusion is
inappropriate.
Test-Taking Strategy: Use therapeutic communication techniques. Eliminate options 1 and 2 because they are comparative or alike and are statements that disagree with the client. Option 3 encourages discussion regarding the delusion. Review communication techniques with the client experiencing delusions if you had
difficulty with this question.

48. The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, the nurse's immediate priority of care is to:

Provide safety for the client and other clients on the unit.

Provide the clients on the unit with a sense of comfort and safety.

Assist the staff in caring for the client in a controlled environment.

Offer the client a less stimulated area to calm down and gain control.

Safety of the client and other clients is the priority. Option 1 is the only option that addresses the client and other
clients' safety needs. Option 2 addresses other clients' needs. Option 3 is not client-centered. Option 4 addresses the client's needs. Test-Taking Strategy: Note the strategic words immediate priority and use Maslow's hierarchy of needs theory to prioritize. Note the words agitated, aggressive, and belligerent. Safety is the strategic subject. Option 1 is the umbrella option and addresses the safety of all. Review nursing interventions to provide safety to clients if you had difficulty with this question.

Explanation

Safety of the client and other clients is the priority. Option 1 is the only option that addresses the client and other
clients' safety needs. Option 2 addresses other clients' needs. Option 3 is not client-centered. Option 4 addresses the client's needs. Test-Taking Strategy: Note the strategic words immediate priority and use Maslow's hierarchy of needs theory to prioritize. Note the words agitated, aggressive, and belligerent. Safety is the strategic subject. Option 1 is the umbrella option and addresses the safety of all. Review nursing interventions to provide safety to clients if you had difficulty with this question.

49. The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal. Which of the following would alert the nurse to the potential for withdrawal delirium?

Hypotension, ataxia, hunger

Stupor, agitation, muscular rigidity

Hypotension, coarse hand tremors, agitation

Hypertension, changes in level of consciousness, hallucinations

Some of the symptoms associated with withdrawal delirium typically are anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions.
Test-Taking Strategy: Use the process of elimination. Review each option carefully to ensure that all the symptoms in the option are correct. Eliminate options 1 and 3 first, knowing that hypertension rather than hypotension occurs. From the remaining options, recalling that the client who is stuporous is not likely to exhibit withdrawal delirium will direct you to option 4. Review these symptoms if you had difficulty with this question.

Explanation

Some of the symptoms associated with withdrawal delirium typically are anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions.
Test-Taking Strategy: Use the process of elimination. Review each option carefully to ensure that all the symptoms in the option are correct. Eliminate options 1 and 3 first, knowing that hypertension rather than hypotension occurs. From the remaining options, recalling that the client who is stuporous is not likely to exhibit withdrawal delirium will direct you to option 4. Review these symptoms if you had difficulty with this question.

50. The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. The symptom presented by the client that requires the nurse's immediate intervention is the client's:

Outlandish behaviors and inappropriate dress

Nonstop physical activity and poor nutritional intake

Grandiose delusions of being a royal descendent of King Arthur

Constant, incessant talking that includes sexual innuendoes and teasing the staff

Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. Mania is a period when the mood is predominantly elevated, expansive, or irritable. All options reflect a client's possible symptomatology. Option 2, however, clearly presents a problem
that compromises physiological integrity and needs to be addressed immediately.
Test-Taking Strategy: Note the strategic word immediate and use Maslow's Hierarchy of Needs theory to assist you in answering the question. Option 2 is the only option that reflects a physiological need. Review care of the client with mania if you had difficulty
with this question.

Explanation

Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. Mania is a period when the mood is predominantly elevated, expansive, or irritable. All options reflect a client's possible symptomatology. Option 2, however, clearly presents a problem
that compromises physiological integrity and needs to be addressed immediately.
Test-Taking Strategy: Note the strategic word immediate and use Maslow's Hierarchy of Needs theory to assist you in answering the question. Option 2 is the only option that reflects a physiological need. Review care of the client with mania if you had difficulty
with this question.

51. The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa, and a nursing student will be observing the nurse. The nurse asks the student about the expected assessment findings and determines that the student needs to research the disorder further if the student states that which of the following is a characteristic finding?

Dental decay

Loss of tooth enamel

Electrolyte imbalances

Body weight well below ideal range

Clients with bulimia nervosa initially may not appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, the client demonstrates dental decay and loss of tooth enamel if the client has been inducing vomiting. Electrolyte imbalances are present.
Test-Taking Strategy: Focus on the subject, bulimia nervosa, and note the strategic words need to research. Eliminate options 1 and 2 because they are comparative or alike. From the remaining options, recall that in anorexia nervosa the body weight is normally below 85% of ideal body weight. Option 4 is a characteristic sign of anorexia nervosa, not bulimia nervosa. Review the characteristics of these disorders if you had difficulty with this question.

Explanation

Clients with bulimia nervosa initially may not appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, the client demonstrates dental decay and loss of tooth enamel if the client has been inducing vomiting. Electrolyte imbalances are present.
Test-Taking Strategy: Focus on the subject, bulimia nervosa, and note the strategic words need to research. Eliminate options 1 and 2 because they are comparative or alike. From the remaining options, recall that in anorexia nervosa the body weight is normally below 85% of ideal body weight. Option 4 is a characteristic sign of anorexia nervosa, not bulimia nervosa. Review the characteristics of these disorders if you had difficulty with this question.

52. A woman comes into the emergency room in a severe state of anxiety following a car accident. The appropriate nursing intervention is to:

Remain with the client.

Put the client in a quiet room.

Teach the client deep breathing.

Encourage the client to talk about their feelings and concerns.

If a client with severe anxiety is left alone, the client may feel abandoned and become overwhelmed. Placing the client in a quiet room is also important, but the nurse must stay with the client. Teaching the client deep breathing or relaxation is not possible until the anxiety decreases. Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased.
Test-Taking Strategy: Use the process of elimination. Note the strategic words severe state. Eliminate options 3 and 4 first, knowing that these actions are not possible when the client is in a severe state of anxiety. From the remaining options, the appropriate action is to remain with the client. Review care of the client with severe anxiety if you had difficulty with this question.

Explanation

If a client with severe anxiety is left alone, the client may feel abandoned and become overwhelmed. Placing the client in a quiet room is also important, but the nurse must stay with the client. Teaching the client deep breathing or relaxation is not possible until the anxiety decreases. Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased.
Test-Taking Strategy: Use the process of elimination. Note the strategic words severe state. Eliminate options 3 and 4 first, knowing that these actions are not possible when the client is in a severe state of anxiety. From the remaining options, the appropriate action is to remain with the client. Review care of the client with severe anxiety if you had difficulty with this question.

53. The nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by:

Engaging in immoral acts

Always reinforcing self-approval

Observing rigid rules and regulations

Having the need always to make the right decision

Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help the clients manage their anxiety.
Test-Taking Strategy: Use the process of elimination and focus on the subject, managing anxiety. Eliminate options 2 and 4 because of the close-ended word always. Option 1 is not characteristic of the client with anorexia. Review the characteristics associated with this disorder if you had difficulty with this question.

Explanation

Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help the clients manage their anxiety.
Test-Taking Strategy: Use the process of elimination and focus on the subject, managing anxiety. Eliminate options 2 and 4 because of the close-ended word always. Option 1 is not characteristic of the client with anorexia. Review the characteristics associated with this disorder if you had difficulty with this question.

54. The nurse is caring for a client who is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. On review of the record, the nurse notes that the admission was an involuntary hospitalization. Based on this information, the nurse determines:

That the physician will provide the informed consent

That an informed consent does not need to be obtained

That an informed consent should be obtained from the family

That an informed consent needs to be obtained from the client

Clients who are admitted involuntarily do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceeding. The informed consent needs to be obtained from the client.
Test-Taking Strategy: Knowledge regarding the hospital admission processes and client's rights is necessary to answer this question. If you had difficulty with this question, focus on the subject of client rights to direct you to option 4. Review client rights if you had difficulty with this question.

Explanation

Clients who are admitted involuntarily do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceeding. The informed consent needs to be obtained from the client.
Test-Taking Strategy: Knowledge regarding the hospital admission processes and client's rights is necessary to answer this question. If you had difficulty with this question, focus on the subject of client rights to direct you to option 4. Review client rights if you had difficulty with this question.

55. A male client with delirium becomes disoriented and confused in his room at night. The best initial nursing intervention is to:

Move the client next to the nurse's station.

Use an indirect light source and turn off the television.

Keep the television and a soft light on during the night.

Play soft music during the night, and maintain a well-lit room.

Provision of a consistent daily routine and a low stimulating environment is important when the client is disorientated. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses' station is not the initial action.
Test-Taking Strategy: Use the process of elimination and note the strategic word initial in the question. Eliminate options 3 and 4 first because they are comparative or alike. Focusing on the strategic word will direct you easily to option 2. Review measures related to the client who is disoriented and confused if you had difficulty with this question.

Explanation

Provision of a consistent daily routine and a low stimulating environment is important when the client is disorientated. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses' station is not the initial action.
Test-Taking Strategy: Use the process of elimination and note the strategic word initial in the question. Eliminate options 3 and 4 first because they are comparative or alike. Focusing on the strategic word will direct you easily to option 2. Review measures related to the client who is disoriented and confused if you had difficulty with this question.

56. The manic client announces to everyone in the dayroom that a stripper is coming to perform this evening. When the nurse firmly states that this will not happen, the manic client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, the nurse determines that the appropriate action would be to:

Orient the client to time, person, and place.

Tell the client that the behavior is not appropriate.

Escort the manic client to her room, with assistance.

Tell the client that smoking privileges are revoked for 24 hours.

The client is at risk for injury to self and others and therefore should be escorted out of the dayroom. Antipsychotic medications are useful to manage the manic client. Hyperactive and agitated behavior usually responds to haloperidol (Haldol). Option 4 may increase the agitation that already exists in this client. Orientation will not halt the behavior. Telling the client that the behavior is not appropriate already has been attempted by the nurse. Test-Taking Strategy: Use the process of elimination and Maslow's Hierarchy of Needs theory to answer the question. Look for the option that promotes safety of the client, other clients, and staff. If you had difficulty with this question, review the appropriate interventions when dealing with a manic client.

Explanation

The client is at risk for injury to self and others and therefore should be escorted out of the dayroom. Antipsychotic medications are useful to manage the manic client. Hyperactive and agitated behavior usually responds to haloperidol (Haldol). Option 4 may increase the agitation that already exists in this client. Orientation will not halt the behavior. Telling the client that the behavior is not appropriate already has been attempted by the nurse. Test-Taking Strategy: Use the process of elimination and Maslow's Hierarchy of Needs theory to answer the question. Look for the option that promotes safety of the client, other clients, and staff. If you had difficulty with this question, review the appropriate interventions when dealing with a manic client.

57. A client admitted to the mental health unit is experiencing disturbed thought processes and believes that the food is being poisoned. Which communication technique does the nurse plan to use to encourage the client to eat?

Using open-ended questions and silence

Focusing on self-disclosure regarding food preferences

Identifying the reasons that the client may not want to eat

Offering opinions about the necessity of adequate nutrition

Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Options 3 and 4 are not helpful to the client because they do not encourage the client to express feelings. The nurse should not offer opinions and should encourage the client to identify the reasons for the behavior. Option
2 is not a client-centered intervention.
Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they do not support client expression of feelings. Eliminate option 2 next because it is not a client-centered response. Focusing on the client's feelings will direct you to option 1. Review therapeutic communication techniques if you had difficulty with this question.

Explanation

Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Options 3 and 4 are not helpful to the client because they do not encourage the client to express feelings. The nurse should not offer opinions and should encourage the client to identify the reasons for the behavior. Option
2 is not a client-centered intervention.
Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they do not support client expression of feelings. Eliminate option 2 next because it is not a client-centered response. Focusing on the client's feelings will direct you to option 1. Review therapeutic communication techniques if you had difficulty with this question.

58. The nurse is working with a client who has sought counseling after trying to rescue a neighbor involved in a house fire. In spite of the client's efforts, the neighbor died. Which action does the nurse engage in with the client during the working phase of the nurse-client relationship?

Exploring the client's ability to function

Exploring the client's potential for self-harm

Inquiring about the client's perception or appraisal of the neighbor's death

Inquiring about and examining the client's feelings that may block adaptive coping

The client must first deal with feelings and negative responses before the client can work through the meaning of the crisis. Option 4 pertains directly to the client's feelings. Options 1 and 2 do not directly address the client's feelings. Option 3 is more of an assessment question. Test-Taking Strategy: Focus on the subject of the question, the working phase of the nurse-client relationship. Think about the interventions that occur in this phase. Using the process of elimination, focus on this subject and on the option that focuses on the feelings of the client. This will direct you to option 4. Review the phases of the nurse-client relationship if you had difficulty with this question.

Explanation

The client must first deal with feelings and negative responses before the client can work through the meaning of the crisis. Option 4 pertains directly to the client's feelings. Options 1 and 2 do not directly address the client's feelings. Option 3 is more of an assessment question. Test-Taking Strategy: Focus on the subject of the question, the working phase of the nurse-client relationship. Think about the interventions that occur in this phase. Using the process of elimination, focus on this subject and on the option that focuses on the feelings of the client. This will direct you to option 4. Review the phases of the nurse-client relationship if you had difficulty with this question.

59. The client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed room. A newly admitted client will be assigned to this client's room. Which of the following clients would be an appropriate choice as this client's roommate?

A client with pneumonia

A client receiving diagnostic tests

A client who thrives on managing others

A client who could benefit from the client's assistance at Mealtime

The client undergoing diagnostic tests is an acceptable roommate. The client with anorexia nervosa is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which the client can focus on the nutritional needs of others or being managed by others because this may contribute to sublimation and suppression of personal hunger.
Test-Taking Strategy: Use the process of elimination and note the strategic words, in a state of starvation. Recalling the characteristics associated with anorexia nervosa will direct you to option 2. Review care of the client with anorexia nervosa if you have difficulty with this question.

Explanation

The client undergoing diagnostic tests is an acceptable roommate. The client with anorexia nervosa is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which the client can focus on the nutritional needs of others or being managed by others because this may contribute to sublimation and suppression of personal hunger.
Test-Taking Strategy: Use the process of elimination and note the strategic words, in a state of starvation. Recalling the characteristics associated with anorexia nervosa will direct you to option 2. Review care of the client with anorexia nervosa if you have difficulty with this question.

60. Select the appropriate interventions for caring for the client in alcohol withdrawal. Select all that apply.

Monitor vital signs.

Maintain an NPO status.

Provide a safe environment

Address hallucinations therapeutically.

Provide stimulation in the environment

Provide reality orientation as appropriate.

When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming himself or herself or others. The nurse would provide a low stimulating environment to maintain the client in as calm a state as possible. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake need to be maintained.
Test-Taking Strategy: Use therapeutic communication techniques to assist in selecting the correct interventions. Also, recalling the characteristics associated with alcohol withdrawal will assist in answering correctly.
Review these interventions if you had difficulty with this question.

Explanation

When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming himself or herself or others. The nurse would provide a low stimulating environment to maintain the client in as calm a state as possible. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake need to be maintained.
Test-Taking Strategy: Use therapeutic communication techniques to assist in selecting the correct interventions. Also, recalling the characteristics associated with alcohol withdrawal will assist in answering correctly.
Review these interventions if you had difficulty with this question.

Submit

61. A client is admitted to the hospital with a diagnosis of major depression, severe, single episode. The nurse assesses the client and identifies a nursing diagnosis of nutrition: less than body requirements, imbalanced related to poor nutritional intake. The appropriate nursing intervention related to this diagnosis is:

Weigh the client three times per week before breakfast.

Explain to the client the importance of a good nutritional intake.

Schedule brief nursing interactions with the client during several meals in which small portions are offered.

Report the nutritional concern to the psychiatrist and obtain a nutritional consultation as soon as possible.

Change in appetite is one of the major symptoms of depression. Other symptoms include a depressed mood, increased fatigue, feelings of worthlessness, diminished ability to think, or indecisiveness and psychomotor agitation or retardation. Option 2 is incorrect because the client is experiencing poor concentration; thus, even if the client does understand the rationale, the client still may not be able to complete tasks. Weighing the client does not address how to increase nutritional intake. Reporting to the psychiatrist and the nutritionist is to some degree correct but does not present a method to increase food intake.
Test-Taking Strategy: Use the process of elimination, focusing on the subject, poor nutritional status. Option 3 is the only option that addresses the imbalanced nutrition concretely and designs a method in which the client feasibly will increase the nutritional intake.
Review care of the client with depression if you had difficulty with this question.

Explanation

Change in appetite is one of the major symptoms of depression. Other symptoms include a depressed mood, increased fatigue, feelings of worthlessness, diminished ability to think, or indecisiveness and psychomotor agitation or retardation. Option 2 is incorrect because the client is experiencing poor concentration; thus, even if the client does understand the rationale, the client still may not be able to complete tasks. Weighing the client does not address how to increase nutritional intake. Reporting to the psychiatrist and the nutritionist is to some degree correct but does not present a method to increase food intake.
Test-Taking Strategy: Use the process of elimination, focusing on the subject, poor nutritional status. Option 3 is the only option that addresses the imbalanced nutrition concretely and designs a method in which the client feasibly will increase the nutritional intake.
Review care of the client with depression if you had difficulty with this question.

62. A hospitalized client is started on phenelzine sulfate (Nardil) for the treatment of depression. The nurse instructs the client to avoid consuming which foods while taking this medication? Select all that apply.

Figs

Yogurt

Crackers

Aged cheese

Tossed salad

Oatmeal cookies

Phenelzine sulfate (Nardil) is a monoamine oxidase inhibitor. The client should avoid taking in foods that are high in tyramine. Use of these foods could trigger a potentially fatal hypertensive crisis. Foods to avoid include yogurt, aged cheeses, smoked or processed meats, red wines, and fruits such as avocados, raisins, or figs.
Test-Taking Strategy: Recall that phenelzine sulfate is a monoamine oxidase inhibitor and that foods high in tyramine needed to be avoided. Next, from the food items listed in the question, identify the food that contains tyramine. Review the food items to avoid with monoamine oxidase inhibitors if you had difficulty with this question

Explanation

Phenelzine sulfate (Nardil) is a monoamine oxidase inhibitor. The client should avoid taking in foods that are high in tyramine. Use of these foods could trigger a potentially fatal hypertensive crisis. Foods to avoid include yogurt, aged cheeses, smoked or processed meats, red wines, and fruits such as avocados, raisins, or figs.
Test-Taking Strategy: Recall that phenelzine sulfate is a monoamine oxidase inhibitor and that foods high in tyramine needed to be avoided. Next, from the food items listed in the question, identify the food that contains tyramine. Review the food items to avoid with monoamine oxidase inhibitors if you had difficulty with this question

Submit

63. Unresolved feelings related to loss most likely may be recognized during which phase of the therapeutic nurse-client relationship?

Working

Trusting

Orientation

Termination

In the termination phase, the relationship comes to a close. Ending treatment sometimes may be traumatic for clients who have come to value the relationship and the help. Because loss is an issue, any unresolved feelings related to loss may resurface during this phase. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Note the strategic words unresolved, loss, and recognized in the question. Considering the phases of the therapeutic nurse-client relationship will direct you to option 4. Review these phases and the nursing implications if you had difficulty with this question.

Explanation

In the termination phase, the relationship comes to a close. Ending treatment sometimes may be traumatic for clients who have come to value the relationship and the help. Because loss is an issue, any unresolved feelings related to loss may resurface during this phase. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Note the strategic words unresolved, loss, and recognized in the question. Considering the phases of the therapeutic nurse-client relationship will direct you to option 4. Review these phases and the nursing implications if you had difficulty with this question.

64. The depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." The best nursing response would be to:

Tell the client that this is not true, that we all have a purpose inlife.

Identify recent behaviors or accomplishments that demonstrate the client's skills.

Reassure the client that you know how the client is feeling and that things will get better.

Remain with the client and sit in silence; this will encourage the client to verbalize feelings.

Feelings of low self-esteem and worthlessness are common symptoms of the depressed client. An effective plan of care to enhance the client's personal self-esteem is to provide experiences for the client that are challenging but that will not be met with failure. Reminders of the client's past accomplishments or personal successes are ways to interrupt the client's negative self-talk and distorted cognitive view of self. Silence may be interpreted as agreement. Options 1 and 3 give advice and devalue the client's feelings.
Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques. Focus on the client's diagnosis. You can eliminate options 1 and 3 easily. From the remaining options, focusing on the client's diagnosis will direct you to option 2. Review care of the client with depression if you had difficulty with this question.

Explanation

Feelings of low self-esteem and worthlessness are common symptoms of the depressed client. An effective plan of care to enhance the client's personal self-esteem is to provide experiences for the client that are challenging but that will not be met with failure. Reminders of the client's past accomplishments or personal successes are ways to interrupt the client's negative self-talk and distorted cognitive view of self. Silence may be interpreted as agreement. Options 1 and 3 give advice and devalue the client's feelings.
Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques. Focus on the client's diagnosis. You can eliminate options 1 and 3 easily. From the remaining options, focusing on the client's diagnosis will direct you to option 2. Review care of the client with depression if you had difficulty with this question.

65. A nurse is preparing to care for a dying client, and several family members are at the client's bedside. Select the therapeutic techniques that the nurse will use when communicating with the family. Select all that apply.

Discourage reminiscing.

Make the decisions for the family.

Encourage expression of feelings, concerns, and fears.

Explain everything that is happening to all family members.

Extend touch and hold the client's or family member's hand if appropriate.

Be honest and truthful and let the client and family know that you will not abandon them.

The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for
informed choices and assist with the decision-making process if
asked. The nurse should encourage expression of feelings, concerns, and fears, as well as reminiscing. The nurse needs to be honest and truthful and let the client and family know that they will not be abandoned. Extend touch and hold the client's or family member's hand, if appropriate.
Test-Taking Strategy: Recalling therapeutic communication techniques and client and family rights will assist you in answering
this question. Review these techniques and care of the dying client if you had difficulty with this question.

Explanation

The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for
informed choices and assist with the decision-making process if
asked. The nurse should encourage expression of feelings, concerns, and fears, as well as reminiscing. The nurse needs to be honest and truthful and let the client and family know that they will not be abandoned. Extend touch and hold the client's or family member's hand, if appropriate.
Test-Taking Strategy: Recalling therapeutic communication techniques and client and family rights will assist you in answering
this question. Review these techniques and care of the dying client if you had difficulty with this question.

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66. Select the characteristics of the termination stage of group development. Select all that apply.

The group evaluates the experience.

The real work of the group is accomplished.

Group interaction involves superficial conversation.

Group members become acquainted with each other.

Some structuring of group norms, roles, and responsibilities take place.

The group explores members' feelings about the group and the impending separation.

The stages of group development include the initial stage, the working stage, and the termination stage. During the initial stage, the group members become acquainted with each other and some structuring of group norms, roles, and responsibilities take place. During the initial stage, group interaction involves superficial conversation During the working stage, the real work of the group is accomplished. During the termination stage. the group evaluates the experience and explores members' feelings about the group and the impending separation.
Test-Taking Strategy: Focus on the subject, the termination stage. Reading each item presented and recalling the stages of group development will assist in answering this question. Review these stages if you had difficulty with this question.

Explanation

The stages of group development include the initial stage, the working stage, and the termination stage. During the initial stage, the group members become acquainted with each other and some structuring of group norms, roles, and responsibilities take place. During the initial stage, group interaction involves superficial conversation During the working stage, the real work of the group is accomplished. During the termination stage. the group evaluates the experience and explores members' feelings about the group and the impending separation.
Test-Taking Strategy: Focus on the subject, the termination stage. Reading each item presented and recalling the stages of group development will assist in answering this question. Review these stages if you had difficulty with this question.

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