Psychiatric Nursing Exam By Budek (50 Items)

1. Client with a history of schizophrenia has been admitted for suicidal ideation. The client states "God is telling me to kill myself right now." The nurse's best response is:

I understand that God’s voice is real to you, But I don’t hear anything. I will stay with you.

The voice is part of your illness, it will stop if you take medication

The voice is all in your imagination, think of something else and itll go away

Don’t think of anything right now, just go and relax.

a. I understand that God’s voice is real to you, But I don’t hear anything. I will stay with you. : The nurse should first ACKNOWLEDGE that the voice is real to the patient and then, PRESENT REALITY by telling the patient that you do not hear anything. The third part of the nursing intervention in hallucination is LESSENING THE STIMULI by either staying with the patient or removing the patient from a highly stimulating place.
Telling the client that the voice is part of his illness is not therapeutic. People with schizophrenia do not think that they are ILL. Letter C and D disregards the client’s concern and therefore, not therapeutic.

Explanation

a. I understand that God’s voice is real to you, But I don’t hear anything. I will stay with you. : The nurse should first ACKNOWLEDGE that the voice is real to the patient and then, PRESENT REALITY by telling the patient that you do not hear anything. The third part of the nursing intervention in hallucination is LESSENING THE STIMULI by either staying with the patient or removing the patient from a highly stimulating place.
Telling the client that the voice is part of his illness is not therapeutic. People with schizophrenia do not think that they are ILL. Letter C and D disregards the client’s concern and therefore, not therapeutic.

2. The nurse should know that the normal therapeutic level of lithium is :

.6 to 1.2 meq/L

6 to 12 meq/L

.6 to .12 cc/ml

.6 to .12 cc3/L

a. .6 to .12 meq/L : According to brunner and suddarths MS nursing, The normal therapeutic level of lithium is .6 to 1.2 meq/L. Some books will say .5 to 1.5 meq/L.

Explanation

a. .6 to .12 meq/L : According to brunner and suddarths MS nursing, The normal therapeutic level of lithium is .6 to 1.2 meq/L. Some books will say .5 to 1.5 meq/L.

3. The most effective treatment modality for persons of anti social PD is

Hypnotherapy

Gestalt therapy

Behavior therapy

Crisis intervention

c. behavior therapy : The problem of the patient is his behavior. A is done for patient who has insomnia or severe anxiety. B is a therapy that promotes growth by providing a contact, either a person or an environment that will facilitate the growth of an individual. It is a humanistic psychotherapeutic model approach. D is done on clients who are in crisis like trauma, post traumatic disorders, raped or accidents.

Explanation

c. behavior therapy : The problem of the patient is his behavior. A is done for patient who has insomnia or severe anxiety. B is a therapy that promotes growth by providing a contact, either a person or an environment that will facilitate the growth of an individual. It is a humanistic psychotherapeutic model approach. D is done on clients who are in crisis like trauma, post traumatic disorders, raped or accidents.

4. A client who was wandering aimlessly around the streets acting inappropriately and appeared disheveled and unkempt was admitted to a psychiatric unit and is experiencing auditory and visual hallucinations. The nurse would develop a plan of care based on:

Borderline personality disorder

Anxiety disorder

Schizophrenia

Depression

c. schizophrenia : When disorders of perception and thoughts came in, The only feasible diagnosis a doctor can make is among the choices is schizophrenia. A,B and D can occur in normal individuals without altering their perceptions. Schizophrenia is characterized by disorders of thoughts, hallucination, delusion, illusion and disorganization.

Explanation

c. schizophrenia : When disorders of perception and thoughts came in, The only feasible diagnosis a doctor can make is among the choices is schizophrenia. A,B and D can occur in normal individuals without altering their perceptions. Schizophrenia is characterized by disorders of thoughts, hallucination, delusion, illusion and disorganization.

5. The client has been taking clomipramine (Anafranil) for his obsessive-compulsive disorder. He tells the nurse, "I'm not really better, and I've been taking the medication faithfully for the past 3 days just like it says on this prescription bottle." Which of the following actions would the nurse do first?

Tell the client to stop taking the medication and to call the physician.

Encourage the client to double the dose of his medication.

Ask the client if he has resumed smoking cigarettes.

a. Tell the client to continue taking the medication as prescribed because it takes 5 to 10 weeks for a full therapeutic effect. : Anafranil is an anti depressant; effects are noticeable within 1 to 2 weeks.

Explanation

a. Tell the client to continue taking the medication as prescribed because it takes 5 to 10 weeks for a full therapeutic effect. : Anafranil is an anti depressant; effects are noticeable within 1 to 2 weeks.

6. The nurse would teach the client taking tranylcypromine sulfate (Parnate) to avoid which food because of its high tyramine content?

Nuts.

Aged cheeses.

Grain cereals.

Reconstituted milk.

b. Aged cheeses. : This is high in tyramine, and therefore, removed from patient’s diet to prevent hypertensive crisis.

Explanation

b. Aged cheeses. : This is high in tyramine, and therefore, removed from patient’s diet to prevent hypertensive crisis.

7. As a counselor, the nurse performs which of the ff: task?

Encourage client to express feelings and concerns

Helps client to learn a dance or song to enable her to participate in activities

Help the client prepare in group activities

Assist the client in setting limits on her behavior

a. encourage client to express feelings and concerns : A counselor is much more of a listener than a speaker. She encourages the client to express feelings and concerns as to formulate necessary response and facilitate a channel to express anger, disappointments and frustrations.

Explanation

a. encourage client to express feelings and concerns : A counselor is much more of a listener than a speaker. She encourages the client to express feelings and concerns as to formulate necessary response and facilitate a channel to express anger, disappointments and frustrations.

8. A Diabetic patient was amputated following an unexpected necrosis on the right leg, he sustained and undergone BKA. He then underwent therapy on how to use his new prosthetic leg. This is a type of what level of prevention?

Primary

Secondary

Tertiary

Nota

c. tertiary : Tertiary prevention involves rehabilitation. Client is now being assisted to perform ADLs at his optimum functioning. Remember that all kinds of rehabilitatory and palliative management is included in tertiary prevention.

Explanation

c. tertiary : Tertiary prevention involves rehabilitation. Client is now being assisted to perform ADLs at his optimum functioning. Remember that all kinds of rehabilitatory and palliative management is included in tertiary prevention.

9. A 16 year old child is hospitalized, according to Erik Erikson, what is an appropriate intervention?

Tell the friends to visit the child

Encourage patient to help child learn lessons missed

Call the priest to intervene

Tell the child’s girlfriend to visit the child.

a. tell the friends to visit the child : The child is 16 years old, In the stage of IDENTITY VS. ROLE CONFUSION. The most significant persons in this group are the PEERS. B refers to children in the school age while C refers to the young adulthood stage of INTIMACY VS. ISOLATION. The child is not dying and the situation did not even talk about the child’s belief therefore, calling the priest is unnecessary.

Explanation

a. tell the friends to visit the child : The child is 16 years old, In the stage of IDENTITY VS. ROLE CONFUSION. The most significant persons in this group are the PEERS. B refers to children in the school age while C refers to the young adulthood stage of INTIMACY VS. ISOLATION. The child is not dying and the situation did not even talk about the child’s belief therefore, calling the priest is unnecessary.

10. When caring for a client receiving haloperidol (Haldol), the nurse would assess for which of the following?

Hypertensive episodes.

Extrapyramidal symptoms.

Hypersalivation.

Oversedation.

b. Extrapyramidal symptoms : Haldol is a neuroleptic, Specific to these neuroleptics are the EPS. The client will likely be hypotensive than hypertensive because neuroleptics causes postural hypotension, The client will complain of dry mouth due to its anticholinergic properties. Dizziness and drowsiness are side effects of neuroleptics but not oversedation.

Explanation

b. Extrapyramidal symptoms : Haldol is a neuroleptic, Specific to these neuroleptics are the EPS. The client will likely be hypotensive than hypertensive because neuroleptics causes postural hypotension, The client will complain of dry mouth due to its anticholinergic properties. Dizziness and drowsiness are side effects of neuroleptics but not oversedation.

11. SITUATION : Angelo, an 18 year old out of school youth was caught shoplifting in a department store. He has history of being quarrelsome and involving physical fight with his friends. He has been out of jail for the past two years

Initially, The nurse identifies which of the ff: Nursing diagnosis:

Self centered disturbance

Impaired social interaction

Sensory perceptual alteration

Altered thought process

b. impaired social interaction : There is no such nursing diagnosis as A , looking at C and D, they are much more compatible to schizophrenia which is not a characteristic of an ANTI SOCIAL P.D which is shown in the situation. Remember that Personality Disorder is FAR from Psychoses. When client exhibits altered thought process or sensory alteration, It is not anymore a personality disorder but rather, a sign and symptom of psychoses.

Explanation

b. impaired social interaction : There is no such nursing diagnosis as A , looking at C and D, they are much more compatible to schizophrenia which is not a characteristic of an ANTI SOCIAL P.D which is shown in the situation. Remember that Personality Disorder is FAR from Psychoses. When client exhibits altered thought process or sensory alteration, It is not anymore a personality disorder but rather, a sign and symptom of psychoses.

12. After 10 days of lithium therapy, the client's lithium level is 1.0 mEq/L. The nurse knows that this value indicates which of the following?

A laboratory error.

An anticipated therapeutic blood level of the drug.

An atypical client response to the drug.

A toxic level.

b. An anticipated therapeutic blood level of the drug.

Explanation

b. An anticipated therapeutic blood level of the drug.

13. A client is admitted to the hospital. Twelve hours later the nurse observes hand tremors, hyperexicitability, tachycardia, diaphoresis and hypertension. The nurse suspects alcohol withdrawal. The nurse should ask the client:

At what time was your last drink taken?

Why didn’t you tell us you’re a drinker?

Do you drink beer or hard liquor?

How long have you been drinking?

a. at what time was your last drink taken? : This question will give the nurse idea WHEN will the withdrawal occur. Withdrawal occurs 5 to 10 hours after the last intake of alcohol. This is a crucial and mortality is very high during this period. Client will undergo delirium tremens, seizures and DEATH if not recognize earlier by the nurse. B is very judgmental, C is non specific, whether it is a beer or a wine It is still alcohol and has the same effects. D is a valuable question to determine the chronic effects of alcohol ingestion but asking letter A can broaden the line between life and death.

Explanation

a. at what time was your last drink taken? : This question will give the nurse idea WHEN will the withdrawal occur. Withdrawal occurs 5 to 10 hours after the last intake of alcohol. This is a crucial and mortality is very high during this period. Client will undergo delirium tremens, seizures and DEATH if not recognize earlier by the nurse. B is very judgmental, C is non specific, whether it is a beer or a wine It is still alcohol and has the same effects. D is a valuable question to determine the chronic effects of alcohol ingestion but asking letter A can broaden the line between life and death.

14. A client has been taking lithium carbonate (Lithane) for hyperactivity, as prescribed by his physician. While the client is taking this drug, the nurse should ensure that he has an adequate intake of:

Sodium.

Iron.

Iodine.

Calcium.

a. Sodium : The levels of lithium in the body are dependent on sodium. The higher the sodium, the lower the levels of lithium. Clients should have an adequate intake of sodium to prevent sudden increase in the levels of lithium leading to toxicity and death.

Explanation

a. Sodium : The levels of lithium in the body are dependent on sodium. The higher the sodium, the lower the levels of lithium. Clients should have an adequate intake of sodium to prevent sudden increase in the levels of lithium leading to toxicity and death.

15. A decision is made to not hospitalize a client with obsessive-compulsive disorder. Of the following abilities the client has demonstrated, the one that probably most influenced the decision not to hospitalize him is his ability to:

Hold a job.

Relate to his peers.

Perform activities of daily living.

Behave in an outwardly normal

c. Perform activities of daily living : If a client can do ADLs , there is no reason for the client to be hospitalized.

Explanation

c. Perform activities of daily living : If a client can do ADLs , there is no reason for the client to be hospitalized.

16. A client was hospitalized with major depression with suicidal ideation for 1 week. He is taking venlafaxine (Effexor), 75 mg three times a day, and is planning to return to work. The nurse asks the client if he is experiencing thoughts of self-harm. The client responds, "I hardly think about it anymore and wouldn't do anything to hurt myself." The nurse judges:

The client to be decompensating and in need of being readmitted to the hospital.

The client to need an adjustment or increase in his dose of antidepressant.

The depression to be improving and the suicidal ideation to be lessening.

The presence of suicidal ideation to warrant a telephone call to the client's physician

c. The depression to be improving and the suicidal ideation to be lessening. : too obvious, no need to rationalize.

Explanation

c. The depression to be improving and the suicidal ideation to be lessening. : too obvious, no need to rationalize.

17. A client comes to the outpatient mental health clinic 2 days after being discharged from the hospital. The client was given a 1-week supply of clozapine (Clozaril). The nurse reviews information about clozapine with the client. Which client statement indicates an accurate understanding of the nurse's teaching about this medication?

"I need to call my doctor in 2 weeks for a checkup."

"I need to keep my appointment here at the hospital this week for a blood test."

"I can drink alcohol with this medication."

"I can take over-the-counter sleeping medication if I have trouble sleeping."

b."I need to keep my appointment here at the hospital this week for a blood test." : Regular blood check up is required for patients taking clozaril. As frequent as every 2 weeks. Clozapine can cause bone marrow depression; therefore, frequent blood counts are necessary.

Explanation

b."I need to keep my appointment here at the hospital this week for a blood test." : Regular blood check up is required for patients taking clozaril. As frequent as every 2 weeks. Clozapine can cause bone marrow depression; therefore, frequent blood counts are necessary.

18. After the nurse has taught the client who is being discharged on lithium (Eskalith) about the drug, which of the following client statements would indicate that the teaching has been successful?

"I need to restrict eating any food that contain salt."

"If I forget a dose, I can double the dose the next time I take it."

"I'll call my doctor right away for any vomiting, severe hand tremors, or muscle weakness."

"I should increase my fluid”

c. "I'll call my doctor right away for any vomiting, severe hand tremors, or muscle weakness." : This is a sign of light lithium toxicity. Increasing fluid intake will cause dilutional decrease of lithium level. Restriction of sodium will cause dilutional increase in lithium level.

Explanation

c. "I'll call my doctor right away for any vomiting, severe hand tremors, or muscle weakness." : This is a sign of light lithium toxicity. Increasing fluid intake will cause dilutional decrease of lithium level. Restriction of sodium will cause dilutional increase in lithium level.

19. After 3 days of taking haloperidol, the client shows an inability to sit still, is restless and fidgety, and paces around the unit. Of the following extrapyramidal adverse reactions, the client is showing signs of:

Dystonia.

Akathisia.

Parkinsonism.

Tardive dyskinesia.

b. Akathisia : The client shows sign of motor restlessness, which is specific for Akathisia.

Explanation

b. Akathisia : The client shows sign of motor restlessness, which is specific for Akathisia.

20. The client with depression has been hospitalized for 3 days on the psychiatric unit. This is the second hospitalization during the past year. The physician orders a different drug, tranylcypromine sulfate (Parnate), when the client does not respond positively to a tricyclic antidepressant. Which of the following reactions should the client be cautioned about if her diet includes foods containing tryaminetyramine?

Heart block.

Grand mal seizure.

Respiratory arrest.

Hypertensive crisis.

d. Hypertensive crisis.

Explanation

d. Hypertensive crisis.

21. The patient is complaining of vomiting, diarrhea and restlessness after taking lithane. The nurse’s initial intervention is:

Recognize that this is a sign of toxicity and withhold the next medication.

Notify the physician.

Check V/S to validate patient’s concerns.

Recognize that this is a normal side effects of lithium and still continue the drug.

a. Recognize that this is a sign of toxicity and withhold the next medication. : The nurse should recognize that this is an early s/s of lithium toxicity. Taking the clients vital signs will not confirm diarrhea, vomiting or restlessness. Notifying the physician is unnecessary at this point and the physician will likely to withhold the medication.

Explanation

a. Recognize that this is a sign of toxicity and withhold the next medication. : The nurse should recognize that this is an early s/s of lithium toxicity. Taking the clients vital signs will not confirm diarrhea, vomiting or restlessness. Notifying the physician is unnecessary at this point and the physician will likely to withhold the medication.

22. Freud stresses out that the EGO

Distinguishes between things in the mind and things in the reality.

Moral arm of the personality that strives for perfection than pleasure.

Reservoir of instincts and drives

Control the physical needs instincts.

a. Distinguishes between things in the mind and things in the reality. : The ego is responsible for distinguishing what is REAL and what is NOT. It is the one that balances the ID and super ego. B and D is a characteristic of the SUPER EGO which is the CONTROLLER of instincts and drives and serve as our CONSCIENCE or the MORAL ARM. The ID is our DRIVES and INSTINCTS that is mediated by the EGO and controlled by the SUPER EGO.

Explanation

a. Distinguishes between things in the mind and things in the reality. : The ego is responsible for distinguishing what is REAL and what is NOT. It is the one that balances the ID and super ego. B and D is a characteristic of the SUPER EGO which is the CONTROLLER of instincts and drives and serve as our CONSCIENCE or the MORAL ARM. The ID is our DRIVES and INSTINCTS that is mediated by the EGO and controlled by the SUPER EGO.

23. Which of the ff: is not a characteristic of PD?

Disregard rights of others

Loss of cognitive functioning

Fails to conform to social norms

Not capable of experiencing guild or remorse for their behavior

b. loss of cognitive functioning : As I said, symptoms of PD will never show alteration in cognitive functioning. They are much more of SOCIAL Disturbances rather than PSYCHOLOGICAL.

Explanation

b. loss of cognitive functioning : As I said, symptoms of PD will never show alteration in cognitive functioning. They are much more of SOCIAL Disturbances rather than PSYCHOLOGICAL.

24. Which of the following drugs needs a WBC level checked regularly?

Lithane

Clozaril

Tofranil

Diazepam

b. Clozaril : Clozapine is a dreaded atypical antipsychotic because it causes severe bone marrow depression, agranulocytosis, infection and sore throat. WBC count is important to assess if the clients immune function is severely impaired. The first presenting sign of agranulocytosis is SORE THROAT.

Explanation

b. Clozaril : Clozapine is a dreaded atypical antipsychotic because it causes severe bone marrow depression, agranulocytosis, infection and sore throat. WBC count is important to assess if the clients immune function is severely impaired. The first presenting sign of agranulocytosis is SORE THROAT.

25. Which of the following clinical manifestations would alert the nurse to lithium toxicity?

A. Increasingly agitated behaviour.

B. Markedly increased food intake.

C. Sudden increase in blood pressure.

D. Anorexia with nausea and vomiting.

d. Anorexia with nausea and vomiting.

Explanation

d. Anorexia with nausea and vomiting.

26. A client with paranoid schizophrenia has persecutory delusions and auditory hallucinations and is extremely agitated. He has been given a PRN dose of Thorazine IM. Which of the following would indicate to the nurse that the medication is having the desired effect?

Complains of dry mouth

State he feels restless in his body

Stops pacing and sits with the nurse

Exhibits increase activity and speech

c. Stops pacing and sits with the nurse: Thorazine is a neuroleptic. Desired effect evolves on controlling the client’s psychoses. Letter A is the side effect of the drug, which is not desired. B and D indicate that the drug is not effective in controlling the client’s agitation, restlessness and disorders of perception.

Explanation

c. Stops pacing and sits with the nurse: Thorazine is a neuroleptic. Desired effect evolves on controlling the client’s psychoses. Letter A is the side effect of the drug, which is not desired. B and D indicate that the drug is not effective in controlling the client’s agitation, restlessness and disorders of perception.

27. 60 year old post CVA patient is taking TPA for his disease; the nurse understands that this is an example of what level of prevention?

Primary

Secondary

Tertiary

Nota

C. Tertiary : The client already had stroke, TPA stands for TRANSPLASMINOGEN ACTIVATOR which are thrombolytics, dissolving clots formed in the vessels of the brain. We are just preventing COMPLICATIONS here.

Explanation

C. Tertiary : The client already had stroke, TPA stands for TRANSPLASMINOGEN ACTIVATOR which are thrombolytics, dissolving clots formed in the vessels of the brain. We are just preventing COMPLICATIONS here.

28. The client has been taking the monoamine oxidase inhibitor (MAOI) phenelzine (Nardil), 10 mg bid. The physician orders a selective serotonin reuptake inhibitor (SSRI), paroxetine (Paxil), 20 mg given every morning. The nurse:

Gives the medication as ordered.

Questions the physician about the order.

Questions the dosage ordered.

Asks the physician to order benztropine (Cogentin) for the side effects.

b. Questions the physician about the order : 2 anti depressants cannot be given at the same time unless the other one is tapered while the other one is given gradually.

Explanation

b. Questions the physician about the order : 2 anti depressants cannot be given at the same time unless the other one is tapered while the other one is given gradually.

29. The nurse shows a patient advocate role when:

Defend the patients right

Refer patient for other services she needs

Work with significant others

Intercedes in behalf of the patient.

a. defend the patients right : An advocate role is shown when the nurse defends the rights of the client. Interceding in behalf of the patient should not be done by a nurse. Counter transference can develop in that case and we should avoid that. Only the family and the health attorney of the patient can intercede or speak for the patient.

Explanation

a. defend the patients right : An advocate role is shown when the nurse defends the rights of the client. Interceding in behalf of the patient should not be done by a nurse. Counter transference can develop in that case and we should avoid that. Only the family and the health attorney of the patient can intercede or speak for the patient.

30. A client is admitted to the inpatient psychiatric unit. He is unshaven, has body odor, and has spots on his shirt and pants. He moves slowly, gazes at the floor, and has a flat affect. The nurse's highest priority in assessing the client on admission would be to ask him:

How he sleeps at night.

If he is thinking about hurting himself.

About recent stresses.

How he feels about himself.

b. If he is thinking about hurting himself : The client shows typical sign and symptoms of DEPRESSION. Moving slowly, gazes on the floor, blank stares and showing flat affect. The highest priority among depressed client is assessing any suicide plans or ideation for the nurse to establish a no suicide contract early on or, in any case client do not participate in a no suicide contract, a 24 hour continuous monitoring is established.

Explanation

b. If he is thinking about hurting himself : The client shows typical sign and symptoms of DEPRESSION. Moving slowly, gazes on the floor, blank stares and showing flat affect. The highest priority among depressed client is assessing any suicide plans or ideation for the nurse to establish a no suicide contract early on or, in any case client do not participate in a no suicide contract, a 24 hour continuous monitoring is established.

31. A female client undergoes yearly mammography. This is a type of what level of prevention?

Primary

Secondary

Tertiary

Nota

b. secondary : The client is never sick of anything but we are detecting the POSSIBILITY by giving yearly mammography. Remember that all kinds of tests, case findings and treatment belong to the secondary level of prevention.

Explanation

b. secondary : The client is never sick of anything but we are detecting the POSSIBILITY by giving yearly mammography. Remember that all kinds of tests, case findings and treatment belong to the secondary level of prevention.

32. Which of the following health status assessments must be completed before the client starts taking imipramine (Tofranil)?

Electrocardiogram (ECG).

Urine sample for protein.

Thyroid scan.

Creatinine clearance test.

a. Electrocardiogram (ECG). : Aside from tonometry or IOP measurement, Client should undergo regular ECG schedule. Most TCAs cause tachycardias and ECG changes, an ECG should be done before the client takes the medication.

Explanation

a. Electrocardiogram (ECG). : Aside from tonometry or IOP measurement, Client should undergo regular ECG schedule. Most TCAs cause tachycardias and ECG changes, an ECG should be done before the client takes the medication.

33. As a care provider, The nurse should do first:

Provide direct nursing care.

Participate with the team in performing nursing intervention.

Therapeutic use of self.

Early recognition of the client’s needs.

d. Early recognition of the client’s needs. : We are talking about what the nurse should do first. ASSESSMENT involves early recognition of clients needs. A,B,C are all involve in the intervention phase of the nursing process.

Explanation

d. Early recognition of the client’s needs. : We are talking about what the nurse should do first. ASSESSMENT involves early recognition of clients needs. A,B,C are all involve in the intervention phase of the nursing process.

34. Which of the following is the most appropriate during the orientation phase?

Patients perception on the reason of her hospitalization

Identification of more effective ways of coping

Exploration of inadequate coping skills

Establishment of regular meeting of schedules

d. establishment of regular meeting of schedules : Orientation phase is synonymous with CONTRACT ESTABLISHMENT. Here, the nurse will establish regular meeting of schedule, agreements and giving the client information that there is a TERMINATION. Letter A and B assesses the client’s coping skills, which is in the working phase and so is letter B. In working phase, The nurse assesses the coping skills of the client and formulate plans and intervention to correct deficiencies. Although assessment is also made in the orientation phase, COPING SKILLS are assessed in the working phase.

Explanation

d. establishment of regular meeting of schedules : Orientation phase is synonymous with CONTRACT ESTABLISHMENT. Here, the nurse will establish regular meeting of schedule, agreements and giving the client information that there is a TERMINATION. Letter A and B assesses the client’s coping skills, which is in the working phase and so is letter B. In working phase, The nurse assesses the coping skills of the client and formulate plans and intervention to correct deficiencies. Although assessment is also made in the orientation phase, COPING SKILLS are assessed in the working phase.

35. As a manager, the nurse should:

Initiates nursing action with co workers.

Plans nursing care with the patient.

Speaks in behalf of the patient.

Works together with the team.

d. Works together with the team. : As a nurse manager, you should be able to work with the team. A,B,C are not specific of a nurse manager. They can be done by an ordinary R.N.

Explanation

d. Works together with the team. : As a nurse manager, you should be able to work with the team. A,B,C are not specific of a nurse manager. They can be done by an ordinary R.N.

36. NMS is characterized by:

Hypertension, hyperthermia, flushed and dry skin.

Hypotension, hypothermia, flushed and dry skin.

Hypertension, hyperthermia, diaphoresis

Hypertension, hypothermia, diaphoresis

c. Hypertension, hyperthermia, diaphoresis. : Neuroleptic malignant syndrome is a side effect of neuroleptics. This is characterized by fever, increase in blood pressure and warm, diaphoretic skin.

Explanation

c. Hypertension, hyperthermia, diaphoresis. : Neuroleptic malignant syndrome is a side effect of neuroleptics. This is characterized by fever, increase in blood pressure and warm, diaphoretic skin.

37. In assessing a client's suicide potential, which statement by the client would give the nurse the HIGHEST cause for concern?

My thoughts of hurting myself are scary to me

I’d like to go to sleep and not wake up

I’ve thought about taking pills and alcohol till I pass out

I’d like to be free from all these worries

c. I’ve thought about taking pills and alcohol till I pass out: This is the only statement of the client that contains a specific and technical plan. B,D are all indicative of suicidal ideation but it contains no specific plans to carry out the objective. Letter A admits the client thinks of hurting himself, but not doing it because it scares him; therefore, it is not indicative of suicidal ideation.

Explanation

c. I’ve thought about taking pills and alcohol till I pass out: This is the only statement of the client that contains a specific and technical plan. B,D are all indicative of suicidal ideation but it contains no specific plans to carry out the objective. Letter A admits the client thinks of hurting himself, but not doing it because it scares him; therefore, it is not indicative of suicidal ideation.

38. The type of anxiety that leads to personality disorganization is:

Mild

Moderate

Severe

Panic

d. panic : Panic is the only level of anxiety that leads to personality disorganization.

Explanation

d. panic : Panic is the only level of anxiety that leads to personality disorganization.

39. The client is taking risperidone (Risperdal) to treat the positive and negative symptoms of schizophrenia. Which of the following negative symptoms will improve?.

Abnormal thought form.

Hallucinations and delusions.

Bizarre behaviour.

Asocial behaviour and anergia.

d. Asocial behavior and anergia : A,B and C are all positive symptoms of schizophrenia. Negative symptoms include anhedonia, anergia, associative looseness and Asocial behavior.

Explanation

d. Asocial behavior and anergia : A,B and C are all positive symptoms of schizophrenia. Negative symptoms include anhedonia, anergia, associative looseness and Asocial behavior.

40. The nurse judges correctly that a client is experiencing an adverse effect from amitriptyline hydrochloride (Elavil) when the client demonstrates:

An elevated blood glucose level.

Insomnia.

Hypertension.

Urinary retention.

d. Urinary retention : Elavil is an TC antidepressant. It should not cause insomnia. Hypertension are specific of MAOI anti depressants when tyramine is ingested. Due to the anticholinergic s/e of TCAs, Urinary retention is an adverse effect.

Explanation

d. Urinary retention : Elavil is an TC antidepressant. It should not cause insomnia. Hypertension are specific of MAOI anti depressants when tyramine is ingested. Due to the anticholinergic s/e of TCAs, Urinary retention is an adverse effect.

41. Which of the following is not an example of alteration of perception?

Ideas of reference

Flight of ideas

Illusion

Hallucination

b. flight of ideas : Flight of ideas is a condition in which patient talks continuously and then switching to unrelated topic. An example is “ Ang ganda ng bulaklak na ito no budek? Rose ito hindi ba? Kilala mo ba si jack yung boyfriend ni rose? Grabe yung barko no ang laki laki tapos lumubog lang. Dapat sana nag seaman ako eh, gusto kasi ng nanay ko. “. Loose association is somewhat similar but the switch in topic is more obvious and completely unrelated. Example “ Ang cute nung rabbit, paano si paul kasi tanga eh, papapatay ko yan kay albert. Ang ganda nung bag na binigay ni jenny, tanga nga lang yung aswang dun sa kanto. Pero bakit ka ba andito? Wala akong pagkain, Penge ako kotse aakyat ako everest.”

A,C,D are all alteration in perception. A refers to a person thinking that everyone is talking about him. C and D are all sensory alterations. The difference is that, in hallucination, there is no need for a stimuli. In illusion, a stimuli [ A phone cord ] is mistakenly identified by the client as something else [ Snake ]

Explanation

b. flight of ideas : Flight of ideas is a condition in which patient talks continuously and then switching to unrelated topic. An example is “ Ang ganda ng bulaklak na ito no budek? Rose ito hindi ba? Kilala mo ba si jack yung boyfriend ni rose? Grabe yung barko no ang laki laki tapos lumubog lang. Dapat sana nag seaman ako eh, gusto kasi ng nanay ko. “. Loose association is somewhat similar but the switch in topic is more obvious and completely unrelated. Example “ Ang cute nung rabbit, paano si paul kasi tanga eh, papapatay ko yan kay albert. Ang ganda nung bag na binigay ni jenny, tanga nga lang yung aswang dun sa kanto. Pero bakit ka ba andito? Wala akong pagkain, Penge ako kotse aakyat ako everest.”

A,C,D are all alteration in perception. A refers to a person thinking that everyone is talking about him. C and D are all sensory alterations. The difference is that, in hallucination, there is no need for a stimuli. In illusion, a stimuli [ A phone cord ] is mistakenly identified by the client as something else [ Snake ]

42. A client is brought to the hospital’s emergency room by a friend, who states, "I guess he had some bad junk (heroin) today." In assessing the client, the nurse would likely find which of the following symptoms?

Increased heart rate, dilated pupils, and fever.

Tremulousness, impaired coordination, increased blood pressure, and ruddy complexion.

Decreased respirations, constricted pupils, and pallor.

Eye irritation, tinnitus, and irritation of nasal and oral mucosa.

c. Decreased respirations, constricted pupils, and pallor. : Heroin is a narcotic. Together with morphine, meperidine, codeine and opiods, they are DEPRESSANTS and will cause decrease respiration, constricted pupils and pallor due to vasoconstriction.

Explanation

c. Decreased respirations, constricted pupils, and pallor. : Heroin is a narcotic. Together with morphine, meperidine, codeine and opiods, they are DEPRESSANTS and will cause decrease respiration, constricted pupils and pallor due to vasoconstriction.

43. Preparing the client for the termination phase begins:

Pre orientation

Orientation

Working

Termination

c. working : Telling the client that there is a TERMINATION PHASE should be in the ORIENTATION PHASE, however, in preparing the client for the TERMINATION, it should be done in the working phase. The nurse will start to lessen the number of meetings to prevent development of transference or counter transference.

Explanation

c. working : Telling the client that there is a TERMINATION PHASE should be in the ORIENTATION PHASE, however, in preparing the client for the TERMINATION, it should be done in the working phase. The nurse will start to lessen the number of meetings to prevent development of transference or counter transference.

44. During the nurse patient interaction, the nurse assesses the ff: to determine the patients coping strategy:

How are you feeling right now?

Do you have anyone to take you home?

What do you think will help you right now?

How does your problem affect your life?

d. How does your problem affect your life? : This is the only question that determines the effects of the problem on the client and the ways she is dealing with it. Letter A can only be answered by FINE and close further communication. B is unrelated to coping strategies. Letter C, asking the client what do you think can help you right now is INAPPROPRIATE for the nurse to ask. The client is in the hospital because she needs help. If she knows something that can help her with her problem she shouldn’t be there.

Explanation

d. How does your problem affect your life? : This is the only question that determines the effects of the problem on the client and the ways she is dealing with it. Letter A can only be answered by FINE and close further communication. B is unrelated to coping strategies. Letter C, asking the client what do you think can help you right now is INAPPROPRIATE for the nurse to ask. The client is in the hospital because she needs help. If she knows something that can help her with her problem she shouldn’t be there.

45. A client is taking fluoxetine hydrochloride (Prozac) for treatment of depression. The client asks the nurse when the maximum therapeutic response occurs. The nurse's best response is that the maximum therapeutic response for fluoxetine hydrochloride may occur in the:

10-14 days

First week

Third week

Fourth week

c. Third week : A and B are similar, therefore , removed them first. Recognizing that most antidepressants exert their effects within 2-3 weeks will lead you to letter C.

Explanation

c. Third week : A and B are similar, therefore , removed them first. Recognizing that most antidepressants exert their effects within 2-3 weeks will lead you to letter C.

46. The client is taking TOFRANIL. The nurse should closely monitor the patient for:

Hypertension

Hypothermia

Increase Intra Ocular Pressure

Increase Intra Cranial Pressure

c. Increase Intra Ocular Pressure : Tofranil is a neuroleptic. It is well known that this is the antipsychotic that increases the IOP and contraindicated in patients with glaucoma. Hypertension is not specific with TOFRANIL. All neuroleptics can cause NMS or the neuroleptic malignant syndrome.

Explanation

c. Increase Intra Ocular Pressure : Tofranil is a neuroleptic. It is well known that this is the antipsychotic that increases the IOP and contraindicated in patients with glaucoma. Hypertension is not specific with TOFRANIL. All neuroleptics can cause NMS or the neuroleptic malignant syndrome.

47. The client is taking sertraline (Zoloft), 50 mg q AM. The nurse includes which of the following in the teaching plan about Zoloft?

Zoloft causes erectile dysfunction in men.

Zoloft causes postural hypotension

Zoloft increases appetite and weight gain

It may take 3-4 weeks before client will start feeling better.

a. Zoloft causes erectile dysfunction in men: Zoloft causes erectile dysfunction and decrease libido. Letter B and C are specific of TCAs. Zoloft will exert its effects as early as 1 week.

Explanation

a. Zoloft causes erectile dysfunction in men: Zoloft causes erectile dysfunction and decrease libido. Letter B and C are specific of TCAs. Zoloft will exert its effects as early as 1 week.

48. A helping relationship is a process characterized by:

Recovery promoting

Mutual interaction

Growth facilitating

Health enhancing

c. growth facilitating : In psychiatric nursing, The epitome of all nursing goal should focus on facilitating GROWTH of the client.

Explanation

c. growth facilitating : In psychiatric nursing, The epitome of all nursing goal should focus on facilitating GROWTH of the client.

49. Which of the following client statements about clozapine (Clozaril) indicate that the client needs additional teaching?

"I need to have my blood checked once every several months while I’m taking this drug."

"I need to sit on the side of the bed for a while when I wake up in the morning."

"The sleepiness I feel will decrease as my body adjusts to clozapine."

"I need to call my doctor whenever I notice that I have a fever or sore throat."

d. "I need to call my doctor whenever I notice that I have a fever or sore throat." : Clozapine causes AGRANULOCYTOSIS and bone marrow depression. Early s/s includes fever and sore throat. The medication is to be withheld this time or the patient might develop severe infection leading to death.

Explanation

d. "I need to call my doctor whenever I notice that I have a fever or sore throat." : Clozapine causes AGRANULOCYTOSIS and bone marrow depression. Early s/s includes fever and sore throat. The medication is to be withheld this time or the patient might develop severe infection leading to death.

50. A nurse is caring for a client with Parkinson's disease who has been taking carbidopa/levodopa (Sinemet) for a year. Which of the following adverse reactions will the nurse monitor the client for?

Dykinesia

Glaucoma

Hypotension

Respiratory depression

c. hypotension : Hypotension, dizziness and lethargy are side effects of anti parkinson drugs like levodopa and carbidopa.

Explanation

c. hypotension : Hypotension, dizziness and lethargy are side effects of anti parkinson drugs like levodopa and carbidopa.