1.
When caring for clients who have mental illness, the nurse’s priority interventions are focused on:
Correct Answer
B. Client safety
Explanation
When caring for clients who have mental illness, the nurse's priority interventions should be focused on ensuring client safety. This is because individuals with mental illness may be at an increased risk of harm to themselves or others due to their condition. By prioritizing client safety, the nurse can help prevent any potential accidents, self-harm, or harm to others. This may involve implementing safety measures, closely monitoring the client's behavior, and intervening promptly in case of any potential risks or emergencies.
2.
The nurse is teaching a client about a complicated care regimen to follow upon discharge. The client appears distracted and cannot recall basic information reviewed yesterday. When the nurse asks the client to describe feelings about leaving the hospital, the client states, “There’s just too much to learn. I know I’m going to get home and mess something up.” The nurse recognizes that the client may be experiencing what level of anxiety?
Correct Answer
B. Moderate
Explanation
The client's statement about feeling overwhelmed and fearing making mistakes suggests that they may be experiencing moderate anxiety. This level of anxiety is characterized by difficulty concentrating, restlessness, and a sense of being overwhelmed. It is not as severe as panic, where the individual may experience extreme fear and physical symptoms such as rapid heartbeat and shortness of breath. Mild anxiety typically involves minimal interference with daily functioning, while severe anxiety can significantly impair the individual's ability to function.
3.
What change, if any, should the nurse expect in the dietary patterns of a client who is clinically depressed?
Correct Answer
A. Either overeating or eating little to nothing
Explanation
The nurse should expect a change in the dietary patterns of a client who is clinically depressed, which could manifest as either overeating or eating little to nothing. Depression can affect appetite and lead to changes in eating habits. Some individuals may turn to food as a coping mechanism and engage in excessive eating, while others may lose their appetite and have a decreased interest in food. Therefore, it is common for individuals with depression to experience either overeating or eating very little.
4.
When a nurse is teaching a client for whom Parnate, a monoamine oxidase inhibitor, has been prescribed, which of these instructions is essential?
Correct Answer
C. Do not take any medications unless they are prescribed by a health care provider.
Explanation
A potentially fatal hypertensive crisis can occur when taking this medication in combination with foods and other medications. Do not take any medications unless they are prescribed by a health care provider.
5.
What are the MOST common types of hallucinations?
Correct Answer
B. Auditory and visual
Explanation
The most common types of hallucinations are auditory and visual. Auditory hallucinations involve hearing sounds or voices that are not actually present, while visual hallucinations involve seeing things that are not there. These two types of hallucinations are often reported by individuals with conditions such as schizophrenia or psychosis. Other types of hallucinations, such as tactile or olfactory, are less common.
6.
Which type of hallucination is the MOST serious because it often results in the client causing harm to him- or herself or others?
Correct Answer
B. Command
Explanation
Command hallucinations are the most serious type of hallucination because they involve the person hearing voices that instruct them to harm themselves or others. These hallucinations can be extremely distressing and dangerous as they can lead to the person acting on the commands they hear. It is important to address and treat command hallucinations promptly to ensure the safety and well-being of the individual experiencing them and those around them.
7.
Most hospital readmissions for the client who has schizophrenia are the result of which of these factors?
Correct Answer
B. Noncompliance with the prescribed medication regimen
Explanation
The client with schizophrenia is very difficult to understand and treat because the symptoms can be based on a belief system that has become distorted so that they hold firmly to false ideas or delusions. This makes compliance with the prescribed medication regimen difficult.
8.
Which of these statements about attention-deficit hyperactivity disorder (ADHD) is TRUE?
Correct Answer
C. It increases client sensitivity to the environment and surroundings
Explanation
ADHD is a neurodevelopmental disorder that is characterized by symptoms such as inattention, hyperactivity, and impulsivity. One of the true statements about ADHD is that it increases client sensitivity to the environment and surroundings. Individuals with ADHD often have difficulty filtering out distractions and may be easily overwhelmed by sensory stimuli. This heightened sensitivity can make it challenging for them to focus and concentrate on tasks.
9.
A client who is experiencing complications of anorexia nervosa has a nursing diagnosis of Fluid volume deficit related to inadequate intake of liquids, self-induced vomiting, laxative, and diuretic use. What is an appropriate nursing goal for this diagnosis?
Correct Answer
A. The client’s intake and output will be approximately equal by the 4th hospital day
Explanation
During extreme cases, clients may be admitted for forced feeding, including the placement of a feeding tube or TPN, IV rehydration, and electrolyte replacement. The treatment goal should be that intake and output should advance until it will be approximately equal.
10.
When teaching a client about substance abuse, the nurse would BEST define a substance as:
Correct Answer
D. A drug, legal or illegal, that may cause pHysical or mental impairment
Explanation
A substance is defined as a drug, legal or illegal, that may cause physical or mental impairment. This definition encompasses all types of drugs, whether they are obtained on the street, readily available, or homemade. The key characteristic of a substance is its potential to cause physical or mental impairment, regardless of its legality or source.
11.
Which population group is unaffected by substance-abuse disorders?
Correct Answer
D. None
Explanation
Substance abuse disorders can affect individuals from any population group, regardless of age, gender, or profession. Therefore, none of the population groups listed in the options are unaffected by substance abuse disorders.
12.
Which of these terms describes the reversible effect on the central nervous system that occurs soon after the use of a substance?
Correct Answer
B. Intoxication
Explanation
Intoxication is the correct answer because it refers to the reversible effect on the central nervous system that occurs soon after the use of a substance. Intoxication is characterized by changes in perception, mood, cognition, behavior, and motor control. It is a temporary state that occurs when a substance is ingested or administered and can lead to impairment in judgment, coordination, and overall functioning.
13.
Which of these terms describes the recurrent use of a substance where abstinence does not cause withdrawal symptoms?
Correct Answer
A. Abuse
Explanation
Abuse refers to the recurrent use of a substance without experiencing withdrawal symptoms upon cessation. This means that individuals who abuse a substance can stop using it without experiencing physical or psychological symptoms commonly associated with withdrawal.
14.
Over a 12-month period, a client has been arrested twice for driving while intoxicated. The client is able to perform activities of daily living (ADLs) without the use of alcohol and restricts drinking to weekend social situations. This client meets the criteria for:
Correct Answer
C. Substance abuse
Explanation
Based on the given information, the client meets the criteria for substance abuse. This is because they have been arrested twice for driving while intoxicated, indicating a pattern of harmful use of alcohol. Although they are able to perform daily activities without alcohol and restrict their drinking to weekends, the fact that they have been arrested for drunk driving suggests that their alcohol use is causing problems in their life. This meets the criteria for substance abuse, which is characterized by recurrent use of a substance despite negative consequences.
15.
Which of these statements about the 19th Amendment to the U.S. Constitution is TRUE?
Correct Answer
A. It made the manufacture and sale of alcohol illegal.
Explanation
In 1919 Congress passed the 19th Ammendement to the U.S. Constitution declaring the making and selling of alcohol illegal. Prohibition lasted until 1933.
16.
According to the Comprehensive Drug Abuse Prevention and Control Act of 1970, a substance with high abuse and dependence potential, accepted medical use, obtainable only with a health care provider’s prescription that may not be refilled would be classified as which schedule of controlled substances?
Correct Answer
B. II (C-II)
Explanation
A controlled substance obtainable only with a health care provider's prescription that may not be refilled would be classified as Schedule II (C-II).
17.
Primary prevention of substance abuse focuses mainly on which of these groups?
Correct Answer
A. School age childen
Explanation
Family relationships play a big factor. Families in which positive parent-child relationships exist generally experience less substance abuse, whereas lack of closeness or involvement between parents and children may lead to substance abuse.
18.
When a person tests positive for drugs, what does this indicate?
Correct Answer
D. The person has been exposed to the substance.
Explanation
Tests may be done with either blood or urine specimens. A positive test only indicates exposure to the substance.
19.
The student nurse is aware that alcohol is classified as:
Correct Answer
C. A central nervous system (CNS) depressant
Explanation
Low doses of alcohol suppress areas of the brain that are inhibitory, causing diminshed self-control and impaired judgment. Alcohol is a central nervous system(CNS)depressant.
20.
When a person makes up information to fill in memory gaps as a result of abusing or depending on alcohol, what term describes this process?
Correct Answer
A. Confabulation
Explanation
Psychosocial aspects of alcohol abuse include memory blackouts, secretive drinking, rationalizaion of behavior, impaired thinking and moral deterioration. Confabulation, making up information to fill in memory gaps as a result of abusing or depending on alcohol, is often used to rationalize memory blackouts.
21.
Which of these conditions is NOT directly associated with chronic alcohol abuse?
Correct Answer
D. Pancreatic cancer
Explanation
Chronic alcohol abuse causes fatty liver, alcoholic hepatitis, and cirrhosis. Liver cells will not function once scar tissue has formed. Esophageal varices are also associated with cirrhosis and can be life threatening. Alcohol damages the stomach and esophagus by irritating the mucosa and causing inflammation and ulceration. Pancreatitis can also occur.
22.
The teratogenic effects of alcohol may cause which of these conditions?
Correct Answer
B. Fetal alcohol syndrome
Explanation
Thiamine deficiency caused by alcoholism leads to Wernicke’s encephalopathy and brain deterioration. Fetal alcohol syndrome is caused by the teratogenic effect on the fetus when a pregnant woman drinks alcohol.
23.
The most advanced stage of alcohol withdrawal, which develops 2 to 3 days after alcohol drinking has stopped and includes symptoms such as disorientation and inability to recognize familiar objects or persons, is called:
Correct Answer
B. Delirium tremens
Explanation
Alcohol withdrawal occurs 6-12 hours after drinking stops and may last up to 8 days. Delirium tremens is stage 3, the most advanced stage of alcohol withdrawal, which develops 2-3 days after drinking has stopped and includes symptoms such as disorientation and inability to recognize familar objects or persons.
24.
During detoxification, an alcoholic client becomes hypoglycemic. Which of these actions should the nurse take FIRST?
Correct Answer
C. Give the client thiamine prior to dextrose administration.
Explanation
Thiamine deficiency caused by alcoholism leads to Wernicke’s encephalopathy and brain deterioration. Correcting the deficiency aids in glucose metabolism.
25.
Which of these drugs when mixed with alcohol is known as the “date rape drug”?
Correct Answer
C. Rohypnol
Explanation
Rohypnol is known as the "date rape drug" when mixed with alcohol. It is a powerful sedative that can cause drowsiness, memory loss, and even unconsciousness. This drug is often used by individuals with malicious intent to incapacitate someone and facilitate sexual assault. Mixing Rohypnol with alcohol can intensify its effects, making it easier for perpetrators to take advantage of their victims. It is important to be aware of the dangers of this drug and always be cautious when accepting drinks from others.
26.
Which of these drugs is classified as a central nervous system stimulant?
Correct Answer
B. Cocaine
Explanation
Barbiturates, benzodiazepines, and alcohol all depress areas of the central nervous system (CNS). However, if given to a client in pain, excitment rather than sedation may occur. Side effects include drowsiness and residual effects on motor skills. In older adults, barbiturates cause excitment, irritability, or delirium, An overdose depresses respirations and causes cyanosis and possibly death. Cocaine is a central nervous system stimulant and acts by enhancing the CNS effects of the body.
27.
Recent changes in behavior for a woman living in a LTC facility such as poor appetite, difficulty sleeping, and decreased interactions with other residents may suggest which of the following conditions?
Correct Answer
D. Depression
Explanation
The recent changes in behavior such as poor appetite, difficulty sleeping, and decreased interactions with other residents are common symptoms of depression. Depression can cause a loss of interest in activities, changes in appetite and sleep patterns, and withdrawal from social interactions. Therefore, these changes in behavior may suggest that the woman is experiencing depression.
28.
An adolescent has been using lysergic acid diethylamide (LSD). The nurse is aware that this drug is classified as:
Correct Answer
B. Hallucinogens
Explanation
Lysergic acid diethylamide(LSD) affects both the peripheral and central nervous system. Common effects include hypertension, sweating, loss of appetite, dilated pupils, and dry mouth. Time and distance are distorted. The client will experience hallucinations and delusions and will hear colors and see sounds. LSD creates a state of euphoria or depression.
29.
A learned pattern of behavior and feelings in which a person always tries to meet the needs of others, demand love from others, and manipulate and control the lives of others is known as:
Correct Answer
D. Codependency
Explanation
Codependency was first recognized by those working with families of alcoholics. It is a learned pattern of behavior and feelings in which a person always tries to meet the needs of others, demand love from others, and manipulated and control the lives of others. Codependent persons lived based on what others think of them.
30.
An angry client shouts "Everyone here tells me what to do. I can't stand it! I want to speak with the hospital administrator!" The nurse should reply:
Correct Answer
C. "You seem very upset about something."
Explanation
The correct answer is "You seem very upset about something." This response acknowledges the client's emotions and shows empathy towards their frustration. It validates their feelings and opens up the opportunity for further discussion or assistance.
31.
A 55-year old male client admitted for drug detoxification and rehabilitation blames his family for his drug use. He states he could easily quit if he didn't have to deal with a wife and 2 teenage daughters. The client is:
Correct Answer
C. Denying his problem
Explanation
The client is denying his problem because he is blaming his family for his drug use and stating that he could quit if he didn't have to deal with them. This shows that he is not taking responsibility for his own actions and is not acknowledging that his drug use is his own problem.
32.
Nursing interventions for the angry client who exhibits manipulative behavior include (Select all that apply)
Correct Answer(s)
B. Communicate expected behavior to the client.
C. Assist the client to set limits on personal behavior
D. Be clear about the consequences of exceeding set limits
E. Follow-through with the consequences of behaviors which exceed set limits
Explanation
The correct answer choices focus on addressing the manipulative behavior of the angry client. By communicating the expected behavior to the client, the nurse sets clear boundaries and expectations. Assisting the client to set limits on personal behavior empowers them to take responsibility for their actions. Being clear about the consequences of exceeding set limits helps the client understand the potential outcomes of their behavior. Following through with the consequences reinforces the importance of adhering to the set limits and promotes accountability. These interventions aim to address and manage the manipulative behavior of the angry client.
33.
Place the following clients in order of MOST in need of the nurse's immediate attention to the lowest priority of care.
a.
A psychotic client, agitated and verbalizing anger
c.
A psychotic client sitting alone, rocking and repeated verbalizing "Help me"
b.
A client unable to avoid ritual hand washing for > 1 hour
d.
A client who is smiling but is talking about "the solution to all my problems."(1) ___________, (2) _____________, (3) ____________, (4) ____________
Correct Answer(s)
D, A, C, B
D, C, A, B
Explanation
The client who is smiling but talking about "the solution to all my problems" is the least in need of immediate attention as there are no immediate signs of agitation or distress. The psychotic client who is agitated and verbalizing anger is the most in need of immediate attention as their behavior suggests potential harm to themselves or others. The psychotic client sitting alone, rocking, and repeatedly verbalizing "Help me" is the next priority as they may be experiencing distress and require immediate intervention. The client unable to avoid ritual hand washing for > 1 hour is the lowest priority as their behavior, although concerning, does not pose immediate harm or distress.
34.
A nursing student is developing a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which incorrect intervention in the plan?
Correct Answer
C. Observe for excessive exercise
Explanation
Excessive exercise is characteristic of anorexia nervosa, not bulimia nervosa. Frequent vomitting, in addition to laxative and diuretic abuse, may lead to dehydration and electrolyte imbalance. Monitoring for dehydration and electrolyte imbalance are important nursing actions.
35.
A nurse is caring for a client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate?
Correct Answer
B. Interrupt the client and offer to take her for a walk
Explanation
Clients with anorexia nervosa are frequently preoccupied with vigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate execise as well as place limits on vigorous activities.