Nurse Tony should first discuss terminating the nurse-client relationship with a client during the:

a. Termination phase when discharge plans are being made.

b. Working phase when the client shows some progress.
c. Orientation phase when a contract is established.
d. Working phase when the client brings it up.
2. Malou is diagnosed with maor depression spends maority of the day lying in bed with the sheet pulled
o!er his head. Which of the following approaches by the nurse would be the most therapeutic"
a. #uestion the client until he responds
b. $nitiate contact with the client fre%uently
c. &it outside the clients room
d. Wait for the client to begin the con!ersation
'. (oe who is !ery depressed e)hibits psychomotor retardation* a flat affect and apathy. The nurse in
charge obser!es (oe to be in need of grooming and hygiene. Which of the following nursing actions
would be most appropriate"
a. Waiting until the client+s family can participate in the client+s care
b. ,sking the client if he is ready to take shower
c. -)plaining the importance of hygiene to the client
d. &tating to the client that it+s time for him to take a shower
.. When teaching Mario with a typical depression about foods to a!oid while taking phenel/ine0Nardil1*
which of the following would the nurse in charge include"
a. 2oasted chicken
b. 3resh fish
c. &alami
d. 4amburger
5. When assessing a female client who is recei!ing tricyclic antidepressant therapy* which of the
following would alert the nurse to the possibility that the client is e)periencing anticholinergic
effects"
a. 6rine retention and blurred !ision
b. 2espiratory depression and con!ulsion
c. 7elirium and &edation
d. Tremors and cardiac arrhythmias
8. 3or a male client with dysthymic disorder* which of the following approaches would the nurse e)pect
to implement"
a. -9T
b. :sychotherapeutic approach
c. :sychoanalysis
d. ,ntidepressant therapy
;. 7anny who is diagnosed with bipolar disorder and acute mania* states the nurse* <Where is my
daughter" $ lo!e =ouis. 2ain* rain go away. 7ogs eat dirt.> The nurse interprets these statements as
indicating which of the following"
a. -cholalia
b. Neologism
c. 9lang associations
d. 3light of ideas
?. Terry with mania is skipping up and down the hallway practically running into other clients. Which of
the following acti!ities would the nurse in charge e)pect to include in Terry+s plan of care"
a. Watching T@
b. 9leaning dayroom tables
c. =eading group acti!ity
d. 2eading a book
A. When assessing a male client for suicidal risk* which of the following methods of suicide would the
nurse identify as most lethal"
a. Wrist cutting
b. 4ead banging
c. 6se of gun
d. ,spirin o!erdose
BC. (un has been hospitali/ed for maor depression and suicidal ideation. Which of the following
statements indicates to the nurse that the client is impro!ing"
a. <$+m of no use to anyone anymore.>
b. <$ know my kids don+t need me anymore since they+re grown.>
c. <$ couldn+t kill myself because $ don+t want to go to hell.>
d. <$ don+t think about killing myself as much as $ used to.>
BB. Which of the following acti!ities would Nurse Trish recommend to the client who becomes !ery
an)ious when thoughts of suicide occur"
a. 6sing e)ercise bicycle
b. Meditating
c. Watching T@
d. 2eading comics
B2. When de!eloping the plan of care for a client recei!ing haloperidol* which of the following
medications would nurse Monet anticipate administering if the client de!eloped e)tra pyramidal side
effects"
a. Olan/apine 0Dypre)a1
b. :aro)etine 0:a)il1
c. Een/tropine mesylate 09ogentin1
d. =ora/epam 0,ti!an1
B'. (on a suspicious client states that <$ know you nurses are spraying my food with poison as you take it
out of the cart.> Which of the following would be the best response of the nurse"
a. Fi!ing the client canned supplements until the delusion subsides
b. ,sking what kind of poison the client suspects is being used
c. &er!ing foods that come in sealed packages
d. ,llowing the client to be the first to open the cart and get a tray
B.. , client is suffering from catatonic beha!iors. Which of the following would the nurse use to
determine that the medication administered :2N ha!e been most effecti!e"
a. The client responds to !erbal directions to eat
b. The client initiates simple acti!ities without direction
c. The client walks with the nurse to her room
d. The client is able to mo!e all e)tremities occasionally
B5. Nurse 4a/el in!ites new client+s parents to attend the psycho educational program for families of the
chronically mentally ill. The program would be most likely to help the family with which of the
following issues"
a. 7e!eloping a support network with other families
b. 3eeling more guilty about the client+s illness
c. 2ecogni/ing the client+s weakness
d. Managing their financial concern and problems
B8. When planning care for 7ory with schi/otypal personality disorder* which of the following would
help the client become in!ol!ed with others"
a. ,ttending an acti!ity with the nurse
b. =eading a sing a long in the afternoon
c. :articipating solely in group acti!ities
d. Eeing in!ol!ed with primarily one to one acti!ities
B;. Which statement about an indi!idual with a personality disorder is true"
a. :sychotic beha!ior is common during acute episodes
b. :rognosis for reco!ery is good with therapeutic inter!ention
c. The indi!idual typically remains in the mainstream of society* although he has problems in
social and occupational roles
d. The indi!idual usually seeks treatment willingly for symptoms that are personally distressful.
B?. Nurse (ohn is talking with a client who has been diagnosed with antisocial personality about how to
sociali/e during acti!ities without being seducti!e. Nurse (ohn would focus the discussion on which
of the following areas"
a. 7iscussing his relationship with his mother
b. ,sking him to e)plain reasons for his seducti!e beha!ior
c. &uggesting to apologi/e to others for his beha!ior
d. -)plaining the negati!e reactions of others toward his beha!ior
BA. Tina with a histrionic personality disorder is melodramatic and responds to others and situations in an
e)aggerated manner. Nurse Trish would recommend which of the following acti!ities for Tina"
a. Eaking class
b. 2ole playing
c. &crap book making
d. Music group
2C. (oy has entered the chemical dependency unit for treatment of alcohol dependency. Which of the
following client+s possession will the nurse most likely place in a locked area"
a. Toothpaste
b. &hampoo
c. ,ntiseptic wash
d. Moisturi/er
2B. Which of the following assessment would pro!ide the best information about the client+s physiologic
response and the effecti!eness of the medication prescribed specifically for alcohol withdrawal"
a. &leeping pattern
b. Mental alertness
c. Nutritional status
d. @ital signs
22. ,fter administering nalo)one 0Narcan1* an opioid antagonist* Nurse 2onald should monitor the female
client carefully for which of the following"
a. 2espiratory depression
b. -pilepsy
c. Gidney failure
d. 9erebral edema
2'. Which of the following would nurse 2onald use as the best measure to determine a client+s progress in
rehabilitation"
a. The way he gets along with his parents
b. The number of drug-free days he has
c. The kinds of friends he makes
d. The amount of responsibility his ob entails
2.. , female client is brought by ambulance to the hospital emergency room after taking an o!erdose of
barbiturates is comatose. Nurse Trish would be especially alert for which of the following"
a. -pilepsy
b. Myocardial $nfarction
c. 2enal failure
d. 2espiratory failure
25. (oey who has a chronic user of cocaine reports that he feels like he has cockroaches crawling under
his skin. 4is arms are red because of scratching. The nurse in charge interprets these findings as
possibly indicating which of the following"
a. 7elusion
b. 3ormication
c. 3lash back
d. 9onfusion
28. (ose is diagnosed with amphetamine psychosis and was admitted in the emergency room. Nurse
2onald would most likely prepare to administer which of the following medication"
a. =ibrium
b. @alium
c. ,ti!an
d. 4aldol
2;. Which of the following li%uids would nurse =eng administer to a female client who is into)icated with
phencyclidine 0:9:1 to hasten e)cretion of the chemical"
a. &hake
b. Tea
c. 9ranberry (uice
d. Frape uice
2?. When de!eloping a plan of care for a female client with acute stress disorder who lost her sister in a
car accident. Which of the following would the nurse e)pect to initiate"
a. 3acilitating progressi!e re!iew of the accident and its conse%uences
b. :ostponing discussion of the accident until the client brings it up
c. Telling the client to a!oid details of the accident
d. 4elping the client to e!aluate her sister+s beha!ior
2A. The nursing assistant tells nurse 2onald that the client is not in the dining room for lunch. Nurse
2onald would direct the nursing assistant to do which of the following"
a. Tell the client he+ll need to wait until supper to eat if he misses lunch
b. $n!ite the client to lunch and accompany him to the dining room
c. $nform the client that he has BC minutes to get to the dining room for lunch
d. Take the client a lunch tray and let the client eat in his room
'C. The initial nursing inter!ention for the significant-others during shock phase of a grief reaction should
be focused on:
a. :resenting full reality of the loss of the indi!iduals
b. 7irecting the indi!idual+s acti!ities at this time
c. &taying with the indi!iduals in!ol!ed
d. Mobili/ing the indi!idual+s support system
'B. (oy+s stream of consciousness is occupied e)clusi!ely with thoughts of her father+s death. Nurse
2onald should plan to help (oy through this stage of grie!ing* which is known as:
a. &hock and disbelief
b. 7e!eloping awareness
c. 2esol!ing the loss
d. 2estitution
'2. When taking a health history from a female client who has a moderate le!el of cogniti!e impairment
due to dementia* the nurse would e)pect to note the presence of:
a. ,ccentuated premorbid traits
b. -nhance intelligence
c. $ncreased inhibitions
d. 4yper !igilance
''. What is the priority care for a client with a dementia resulting from ,$7&"
a. :lanning for remoti!ational therapy
b. ,rranging for long term custodial care
c. :ro!iding basic intellectual stimulation
d. ,ssessing pain fre%uently
'.. (erome who has eating disorder often e)hibits similar symptoms. Nurse =hey would e)pect an
adolescent client with anore)ia to e)hibit:
a. ,ffecti!e instability
b. 7ishered* unkempt physical appearance
c. 7epersonali/ation and dereali/ation
d. 2epetiti!e motor mechanisms
'5. The primary nursing diagnosis for a female client with a medical diagnosis of maor depression would
be:
a. &ituational low self-esteem related to altered role
b. :owerlessness related to the loss of ideali/ed self
c. &piritual distress related to depression
d. $mpaired !erbal communication related to depression
'8. When de!eloping an initial nursing care plan for a male client with a Eipolar $ disorder 0manic
episode1 nurse 2on should plan to"
a. $solate his gym time
b. -ncourage his acti!e participation in unit programs
c. :ro!ide foods* fluids and rest
d. -ncourage his participation in programs
';. Frace is e)hibiting withdrawn patterns of beha!ior. Nurse (ohnny is aware that this type of beha!ior
e!entually produces feeling of:
a. 2epression
b. =oneliness
c. ,nger
d. :aranoia
'?. One morning a female client on the inpatient psychiatric ser!ice complains to nurse 4a/el that she has
been waiting for o!er an hour for someone to accompany her to acti!ities. Nurse 4a/el replies to the
client <We+re doing the best we can. There are a lot of other people on the unit who needs attention
too.> This statement shows that the nurse+s use of:
a. 7efensi!e beha!ior
b. 2eality reinforcement
c. =imit-setting beha!ior
d. $mpulse control
'A. , nursing diagnosis for a male client with a diagnosed multiple personality disorder is chronic low
self-esteem probably related to childhood abuse. The most appropriate short term client outcome
would be:
a. @erbali/ing the need for an)iety medications
b. 2ecogni/ing each e)isting personality
c. -ngaging in obect-oriented acti!ities
d. -liminating defense mechanisms and phobia
.C. , 25 year old male is admitted to a mental health facility because of inappropriate beha!ior. The client
has been hearing !oices* responding to imaginary companions and withdrawing to his room for
se!eral days at a time. Nurse Monette understands that the withdrawal is a defense against the client+s
fear of:
a. :hobia
b. :owerlessness
c. :unishment
d. 2eection
.B. When asking the parents about the onset of problems in young client with the diagnosis of
schi/ophrenia* Nurse =inda would e)pect that they would relate the client+s difficulties began in:
a. -arly childhood
b. =ate childhood
c. ,dolescence
d. :uberty
.2. (ose who has been hospitali/ed with schi/ophrenia tells Nurse 2on* <My heart has stopped and my
!eins ha!e turned to glassH> Nurse 2on is aware that this is an e)ample of:
a. &omatic delusions
b. 7epersonali/ation
c. 4ypochondriasis
d. -cholalia
.'. $n recogni/ing common beha!iors e)hibited by male client who has a diagnosis of schi/ophrenia*
nurse (osie can anticipate:
a. &lumped posture* pessimistic out look and flight of ideas
b. Frandiosity* arrogance and distractibility
c. Withdrawal* regressed beha!ior and lack of social skills
d. 7isorientation* forgetfulness and an)iety
... One morning* nurse 7iane finds a disturbed client curled up in the fetal position in the corner of the
dayroom. The most accurate initial e!aluation of the beha!ior would be that the client is:
a. :hysically ill and e)periencing abdominal discomfort
b. Tired and probably did not sleep well last night
c. ,ttempting to hide from the nurse
d. 3eeling more an)ious today
.5. Nurse Eea notices a female client sitting alone in the corner smiling and talking to herself. 2eali/ing
that the client is hallucinating. Nurse Eea should:
a. $n!ite the client to help decorate the dayroom
b. =ea!e the client alone until he stops talking
c. ,sk the client why he is smiling and talking
d. Tell the client it is not good for him to talk to himself
.8. When being admitted to a mental health facility* a young female adult tells Nurse Mylene that the
!oices she hears frighten her. Nurse Mylene understands that the client tends to hallucinate more
!i!idly:
a. While watching T@
b. 7uring meal time
c. 7uring group acti!ities
d. ,fter going to bed
.;. Nurse (ohn recogni/es that paranoid delusions usually are related to the defense mechanism of:
a. :roection
b. $dentification
c. 2epression
d. 2egression
.?. When planning care for a male client using paranoid ideation* nurse (asmin should reali/e the
importance of:
a. Fi!ing the client difficult tasks to pro!ide stimulation
b. :ro!iding the client with acti!ities in which success can be achie!ed
c. 2emo!ing stress so that the client can rela)
d. Not placing any demands on the client
.A. Nurse Ferry is aware that the defense mechanism commonly used by clients who are alcoholics is:
a. 7isplacement
b. 7enial
c. :roection
d. 9ompensation
5C. Within a few hours of alcohol withdrawal* nurse (ohn should assess the male client for the presence
of:
a. 7isorientation* paranoia* tachycardia
b. Tremors* fe!er* profuse diaphoresis
c. $rritability* heightened alertness* erky mo!ements
d. Iawning* an)iety* con!ulsions
,N&W-2&
1. C. When the nurse and client agree to work together* a contract should be established* the length
of the relationship should be discussed in terms of its ultimate termination.
2. B. The nurse should initiate brief* fre%uent contacts throughout the day to let the client know that
he is important to the nurse. This will positi!ely affect the client+s self-esteem.
3. D. The client with depression is preoccupied* has decreased energy* and is unable to make
decisions. The nurse presents the situation* <$t+s time for a shower>* and assists the client with
personal hygiene to preser!e his dignity and self-esteem.
4. C. 3oods high in tyramine* those that are fermented* pickled* aged* or smoked must be a!oided
because when they are ingested in combination with M,O$s a hypertensi!e crisis will occur.
5. A. ,nticholinergic effects* which result from blockage of the parasympathetic 0craniosacral1
ner!ous system including urine retention* blurred !ision* dry mouth J constipation.
6. B. 7ysthymia is a less se!ere* chronic depression diagnosed when a client has had a depressed
mood for more days than not o!er a period of at least 2 years. 9lient with dysthymic disorder
benefit from psychotherapeutic approaches that assist the client in re!ersing the negati!e self
image* negati!e feelings about the future.
7. D. 3light of ideas is speech pattern of rapid transition from topic to topic* often without finishing
one idea. $t is common in mania.
8. B. The client with mania is !ery acti!e J needs to ha!e this energy channeled in a constructi!e
task such as cleaning or tidying the room.
9. C. , crucial factor is determining the lethality of a method is the amount of time that occurs
between initiating the method J the deli!ery of the lethal impact of the method.
10.D. The statement <$ don+t think about killing myself as much as $ used to.> $ndicates a lessening
of suicidal ideation and impro!ement in the client+s condition.
11.A. 6sing e)ercise bicycle is appropriate for the client who becomes !ery an)ious when thoughts
of suicidal occur.
12.C. The drug of choice for a client e)periencing e)tra pyramidal side effects from haloperidol
04aldol1 is ben/tropine mesylate 0cogentin1 because of its anti cholinergic properties.
13.D. ,llowing the client to be the first to open the cart J take a tray presents the client with the
reality that the nurses are not touching the food J tray* thereby dispelling the delusion.
14.B. ,lthough all the actions indicate impro!ement* the ability to initiate simple acti!ities without
directions indicates the most impro!ement in the catatonic beha!iors.
15.A. :sychoeducational groups for families de!elop a support network. They pro!ide education
about the biochemical etiology of psychiatric disease to reduce* not increase family guilt.
16.C. ,ttending acti!ity with the nurse assists the client to become in!ol!ed with others slowly. The
client with schi/otypal personality disorder needs support* kindness J gentle suggestion to
impro!e social skills J interpersonal relationship.
17.C. ,n indi!idual with personality disorder usually is not hospitali/ed unless a coe)isting ,)is $
psychiatric disorder is present. Fenerally* these indi!iduals make marginal adustments and
remain in society* although they typically e)perience relationship and occupational problems
related to their infle)ible beha!iors. :ersonality disorders are chronic lifelong patterns of
beha!iorK acute episodes do not occur. :sychotic beha!ior is usually not common* although it can
occur in either schi/otypal personality disorder or borderline personality disorder. Eecause these
disorders are enduring and e!asi!e and the indi!idual is infle)ible* prognosis for reco!ery is
unfa!orable. Fenerally* the indi!idual does not seek treatment because he does not percei!e
problems with his own beha!ior. 7istress can occur based on other people+s reaction to the
indi!idual+s beha!ior.
18.D. The nurse would e)plain the negati!e reactions of others towards the client+s beha!iors to
make the clients aware of the impact of his seducti!e beha!iors on others.
19.B. The nurse would use role-playing to teach the client appropriate responses to others and in
!arious situations. This client dramati/es e!ents* drawn attention to self* and is unaware of and
does not deal with feelings. The nurse works to help the client clarify true feelings J learn to
e)press them appropriately.
20.C. ,ntiseptic mouthwash often contains alcohol J should be kept in locked area* unless labeling
clearly indicates that the product does not contain alcohol.
21.D. Monitoring of !ital signs pro!ides the best information about the client+s o!erall physiologic
status during alcohol withdrawal J the physiologic response to the medication used.
22.A. ,fter administering nalo)one 0Narcan1 the nurse should monitor the client+s respiratory status
carefully* because the drug is short acting J respiratory depression may recur after its effects
wear off.
23.B. The best measure to determine a client+s progress in rehabilitation is the number of drug- free
days he has. The longer the client is free of drugs* the better the prognosis is.
24.D. Earbiturates are 9N& depressantsK the nurse would be especially alert for the possibility of
respiratory failure. 2espiratory failure is the most likely cause of death from barbiturate o!er
dose.
25.B. The feeling of bugs crawling under the skin is termed as formication* and is associated with
cocaine use.
26.D. The nurse would prepare to administer an antipsychotic medication such as 4aldol to a client
e)periencing amphetamine psychosis to decrease agitation J psychotic symptoms* including
delusions* hallucinations J cogniti!e impairment.
27.C. ,n acid en!ironment aids in the e)cretion of :9:. The nurse will definitely gi!e the client with
:9: into)ication cranberry uice to acidify the urine to a ph of 5.5 J accelerate e)cretion.
28.A. The nurse would facilitate progressi!e re!iew of the accident and its conse%uence to help the
client integrate feelings J memories and to begin the grie!ing process.
29.B. The nurse instructs the nursing assistant to in!ite the client to lunch J accompany him to the
dinning room to decrease manipulation* secondary gain* dependency and reinforcement of
negati!e beha!ior while maintaining the client+s worth.
30.C. This pro!ides support until the indi!iduals coping mechanisms and personal support systems
can be immobili/ed.
31.C. 2esol!ing a loss is a slow* painful* continuous process until a mental image of the dead person*
almost de!oid of negati!e or undesirable features emerges.
32.A. , moderate le!el of cogniti!e impairment due to dementia is characteri/ed by increasing
dependence on en!ironment J social structure and by increasing psychologic rigidity with
accentuated pre!ious traits J beha!iors.
33.C. This action maintains for as long as possible* the clients intellectual functions by pro!iding an
opportunity to use them.
34.A. $ndi!iduals with anore)ia often display irritability* hospitality* and a depressed mood.
35.D. 7epressed clients demonstrate decreased communication because of lack of psychic or
physical energy.
36.C. The client in a manic episode of the illness often neglects basic needs* these needs are a
priority to ensure ade%uate nutrition* fluid* and rest.
37.B. The withdrawn pattern of beha!ior presents the indi!idual from reaching out to others for
sharing the isolation produces feeling of loneliness.
38.A. The nurse+s response is not therapeutic because it does not recogni/e the client+s needs but
tries to make the client feel guilty for being demanding.
39.B. The client must recogni/e the e)istence of the sub personalities so that interpretation can
occur.
40.D. ,n aloof* detached* withdrawn posture is a means of protecting the self by withdrawing and
maintaining a safe* emotional distance.
41.C. The usual age of onset of schi/ophrenia is adolescence or early childhood.
42.A. &omatic delusion is a fi)ed false belief about one+s body.
43.C. These are the classic beha!iors e)hibited by clients with a diagnosis of schi/ophrenia.
44.D. The fetal position represents regressed beha!ior. 2egression is a way of responding to
o!erwhelming an)iety.
45.B. This pro!ides a stimulus that competes with and reduces hallucination.
46.D. ,uditory hallucinations are most troublesome when en!ironmental stimuli are diminished and
there are few competing distractions.
47.A. :roection is a mechanism in which inner thoughts and feelings are proected onto the
en!ironment* seeming to come from outside the self rather than from within.
48.B. This will help the client de!elop self-esteem and reduce the use of paranoid ideation.
49.B. 7enial is a method of resol!ing conflict or escaping unpleasant realities by ignoring their
e)istence.
50.C. ,lcohol is a central ner!ous system depressant. These symptoms are the body+s neurologic
adaptation to the withdrawal of alcohol.