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Set A/B
1/13. When planning the discharge of a client with chronic anxiety, the nurse directs the goal at promoting a safe
environment at home. The appropriate maintenance goal should focus on which of the following?
a. Ignoring feelings of anxiety
c. Continued contact with a crisis counselor
b. Identifying anxiety-producing situations.
d. Eliminating all anxiety from daily situations
Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid 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
2/21. A woman comes into the emergency in a severe state of anxiety following a car accident. The appropriate
nursing intervention is to:
a. Remain with client.
c. Teach the client deep breathing.
b. Put a client in a quiet room.
d. 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 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 decrease.
3/16. The 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:
a. Agoraphobia
b. Social phobia
c. Claustrophobia
d. Hypochondriasis
Agoraphobia is the 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 the reduction of social and professional interactions. Social
phobia focuses more on specific situations, such as fear of speaking, performing or eating in public. Claustrophobia is
a fear of closed places. Clients who have hypochondriacal symptoms focus their anxiety on physical complaints and
preoccupied with their health.
4/14. 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 his client cannot see. The nurse later learns that the client became blind
after witnessing a hit-and-run car accident, when a family of three was killed. The nurse suspects that the client may
be experiencing a:
a. Psychosis
b. Repression
c. Conversion disorder
d. 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 is thought to be an expression of a physiological need or conflict. In this
situation, the client witnessed an accident that was so physiologically painful that the client became blind. A
dissociative disorder is a disturbance or alteration in the normally integrative functions of which identity, memory or
consciousness. Psychosis is a state of which a persons capacity to recognize reality, communicate, and relate to
others is impaired, thus, interfering with the persons ability to deal with lifes demands. Repression is coping
mechanism in which unacceptable feelings are kept out of awareness.
5/22. A client reports experiencing nightmares and constant worry about the weather since typhoon Ondoy destroyed
the clients house. The nurse assesses that this client is experiencing:
a. Hallucinations
b. Panic attacks
c. flashbacks
d. delusions
A client who repeatedly experiences nightmares and constantly worries about the weather since a typhoon destroyed
his house is experiencing flashbacks. Clients who have flashbacks have recurrent intrusive recollections of the
traumatic event. Clients with delusions, hallucinations, and panic attacks would reexperience the traumatic event.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 428-429
6/17. A 30 year old male employee frequently complains of low back pain that leads to frequent absences from work.
Consultation and tests reveal negative results. The client has which somatoform disorder?
a. Somatization Disorder
b. Hypochondriaisis
c. Conversion Disorder
d. Somatoform Pain Disorder
This is characterized by severe and prolonged pain that causes significant distress. Option A: This is a chronic
syndrome of somatic symptoms that cannot be explained medically and is associated with psychosocial distress.
Option B: This is an unrealistic preoccupation with a fear of having a serious illness. Option C: Characterized by
alteration or loss in sensory or motor function resulting from a psychological conflict.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 497
7/15. The nurse is assessing a parent who abused her child. Which of the following risk factors would the nurse
suspect to find in this case?

a. Flexible role functioning between parents

c. Single parent home situation
b. History of parent having been abused as child
d. Presence of parental mental illness
One of the most important risk factors is history of childhood abuse in the parent who abuses. Family violence follows
a multigenerational pattern. Parents who are flexible in their roles are characteristic of healthy functioning, not abuse.
Single parent households and a history of mental illness are not established risk factors for child abuse by a parent.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 865-866
8/19. Incidents of a child molestation that come out years later when the victims is an adult are best explained the
ego defense mechanism of:
a. Repression
b. Regression
c. Rationalization
d. Reaction formation
Repression is a coping mechanism in which unacceptable feelings are kept out of conscious awareness; later under
stress or anxiety, thoughts or feelings surface and come into ones conscious awareness
Reference: Videbeck. Psychiatric Mental Health Nursing. 3rd edition. Page 51-52
9/12. A nurse working in the emergency department is conducting an interview with a victim of spousal abuse. Which
step should the nurse take first?
a. Contact appropriate legal service
b. Ensure privacy for interviewing the victim away from the abuser
c. Establish rapport with the victim and abuser
d. Call security guard
Privacy away from the abuser is important. This allows the victim to discuss the problem freely, without fear of
reprisal from the abuser. Option A: It is not the responsibility of the nurse to call the legal service, it is up to the
woman to make that decision. However if injury is inflicted the nurse is obligated to report the abuse. Option C:
Although the nurse would want to establish rapport with the victim, her initial concern would not be to establish
rapport with the abuser. The situation does not describe the abuser as currently violent, requesting a security is
inappropriate at this time.
Reference. Ann Isaacs. Psychiatric Nursing. Page 175

10/23. The depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as Im
such a failure. I cant do anything right. The best nursing response would be to:
a. Tell the client that this is not true, that we all have a purpose in life.
b. Identify recent behaviors or accomplishments that demonstrate the clients skill.
c. Reassure the client that you know how the client is feeling and that things will get better.
d. Remain with the client and sit in silence; this will encourage the client to verbalize feelings.
Feeling of low self-esteem and worthlessness are common symptoms of the depressed client. An effective plan of care
to enhance the clients personal self-esteem is to provide experiences for the client that are challenging but that will
not be met with failure. Reminders of clients past accomplishments or personal successes are ways to interrupt the
clients negative self-talk, and distorted cognitive view of self. Silence may be interpreted as agreement. Options A
and C give advice and devalue the clients feelings.
11/18. 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 clients:
a. Self-care deficit.
b. Imbalanced nutrition.
c. Deficient knowledge.
d. Disturbed thought processes.
Major depressions, recurrent, with psychotic features, alert the nurse that in addition to the criteria that designate the
diagnosis of major depression, one also must deal with clients psychosis. Psychosis is defined as a state in which a
persons mental capacity to recognize reality and communicate and relate to others is impaired, thus, referring with
the persons 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 diagnosis may be appropriate
because the client is experiencing psychosis, option D is the correct option.
12/24. The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. The symptom
presented by the client that requires the nurses immediate intervention is the clients:
a. Outlandish behaviors and inappropriate dress
b. Nonstop physical therapy and nutritional intake
c. Grandiose delusions of being a royal descendent of King Arthur
d. Constant, incessant talking that includes sexual innuendos 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 trend of thought. Mania is a period when the mood is
predominantly elevated, expansive, or irritable. All options reflect a clients symptomatology. Option 2, however,
clearly presents a problem that compromises physiological integrity and needs to be addressed immediately.
13/20. A client who has been raped tells the nurse that the rape was her fault because she walked down an alley on
her way to school. Which response by the nurse would be best in this situation?
a. Accept the clients statement that this was risk-taking behavior
b. Ask the client what other behaviors may have been risky
c. Emphasize that the rapist, not the client is responsible
d. Suggest that the client discuss this issue later
The clients feeling of self-blame is a common response to rape-trauma crisis. However, this is not realistic perception
of the event, and the nurse should point out reality (telling the victim that the rapist is responsible). The responses in

options A and B would only serve to reinforce the clients misperception that her own behavior caused the rape and,
therefore, are incorrect. The response in option D is incorrect because it avoids addressing the clients distress and is
unsupportive to the situation.
Reference: Norman Keltner. Psychiatric Nursing. 5th edition. Page 612-613
14/25. 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:
a. Increase socialization of the client with peers.
b. Avoid laughing or whispering in front of the client.
c. Begin to educate the client about social supports in the community.
d. Have the client sign a release of information to appropriate parties so that adequate date can be obtained for
assessment purposes.
Disturbed thought process related to paranoia is the clients 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 A, C and D ask the client to trust on a multitude of levels. These options are actions that
are too intrusive of levels. These options are actions that are too intrusive for a client who is paranoid.
15/11. A client is admitted to a psychiatric unit with a diagnosis of undifferentiated schizophrenia. Which of the
following defense mechanism is probably used?
a. Projection
b. Rationalization
c. Regression
d. Repression
Answer: C
Regression, a return to earlier behavior to reduce anxiety, is the basic defense mechanism in schizophrenia.
Repression is the basic defense mechanism in the neuroses. Rationalization is a defense mechanism used to justify
ones action. Projection is a defense mechanism in which one blames others and attempts to justify actions; its used
primarily by people with paranoid schizophrenia and delusional disorder.
16/6. A client with a diagnosis of schizophrenia, paranoid type, is admitted to an acute-care psychiatric hospital unit.
In anticipation of the clients needs, what nursing diagnosis would be given the highest priority?
a. Altered thought processes
c. Social isolation
b. Impaired verbal communication
d. Risk for violence directed at self or at others
Answer: D
Safety is always the highest priority when caring for a client with a diagnosis of schizophrenia, paranoid type. Clients
with diagnosis are potentially violent and can quickly become aggressive as a result of their psychosis. The other
options (A,B and C) of diagnoses are appropriate for the clients care plan but are not given the highest priority.
17/1. A clients disruptive behavior on the ward has been increasingly annoying to the other patients. One approach
by the nurse might be to
a. Tell her she is annoying others and confine her to her room
b. Ignore her behavior, realizing it is consistent with her illness
c. Set limits on her behavior and be consistent in approach
d. Make a rigid structured plan that she will have to follow
Answer: C
Set limits on her behavior and be consistent in approach this is important to avoid rejection of the other patients
with subsequent lowering of self esteem.
18/5. A clients illness can best be understood as the egos attempt to compensate for an assault against it and fear of
the punitive superego. What underlying condition would be the source of the mania?
a. Delusions of grandeur
b. Depression
c. Fear of loss
d. Malformed superego
Answer: B
Depression is a result of the assault on the ego and the mania covers the depression.
19/9. During a manic state, a client paced around the dayroom for 3 days. He talked to the furniture, proclaimed he
was a king, and refused to partake in unit activities. Which of the following nursing diagnoses has priority?
a. Hypertension related to hyperactivity
c. Altered nutrition related to hyperactivity
b. Risk for violence related to manic state
d. Ineffective individual coping related to manic state
Answer: C
During a manic state, clients are at risk for malnutrition due to not taking in enough calories for the energy theyre
expending. This client isnt showing violent behavior. Individual coping issues arent the primary concern at this time.
Hypertension isnt an approved nursing diagnosis.
20/2. Which word best describes the type of schizophrenia identified by marked negativism, rigidity, excitement,
stupor or posturing?
a. Catatonic
b. Disorganized
c. Undifferentiated
d. Paranoid
Answer: A
Catatonic schizophrenia is a state of psychologically induced immobilization, which is, at times, interrupted by
episodes of extreme agitation, such as negativism, rigidity, excitement, stupor, or posturing. Undifferentiated
schizophrenia occurs when no single clinical presentation dominates (paranoid, disorganized, or catatonic).
Disorganized schizophrenia is characterized by disorganized speech, disorganized behavior, and inappropriate affect.
The dominant theme in paranoid schizophrenia is one of delusions and hallucinations.
21/7. The neuroleptic malignant syndrome was under control, which of the following statement if made by the client
would indicate an understanding of the resumption of antipsychotic medications?
a. After three days I will resume my medication
c. I can restart my medication after 2 to 3 weeks
b. Immediately after the resolution of NMS
d. I can resume anytime I feel like taking the medications

Antipsychotics should not be reinstituted for at least 2 weeks after complete resolution of NMS.
Reference:Norman Keltner. Psychiatric Nursing. 5th edition. Page 221
22/3. The nurse is caring for a client with schizophrenia. Which of the following outcomes is the least desirable?
a. The client spends more time by himself.
b. The client doesn't engage in delusional thinking.
c. The client doesn't harm himself or others.
d. The client demonstrates the ability to meet his own self-care needs.
The client with schizophrenia is commonly socially isolated and withdrawn; therefore, having the client spend more
time by himself wouldn't be a desirable outcome. Rather, a desirable outcome would specify that the client spend
more time with other clients and staff on the unit. Delusions are false personal beliefs. Reducing or eliminating
delusional thinking using talking therapy and antipsychotic medications would be a desirable outcome. Protecting the
client and others from harm is a desirable client outcome achieved by close observation, removing any dangerous
objects, and administering medications. Because the client with schizophrenia may have difficulty meeting his or her
own self-care needs, fostering the ability to perform self-care independently is a desirable client outcome.
Reference: Ann Isaacs. Mental health and Psychiatric Nursing.4th edition. Page 131
23/10. A client diagnosed with schizophrenia is displaying flat affect, slowed thinking and a lack of motivation. The
nurse interprets these as which of the following?
a. Delusions
b. Positive symptoms
c. hallucinations
d. negative symptoms
Negative symptoms such as flattened affect, slowed thinking and lack of motivation are observed and in many ways
are more debilitating Unlike positive clinical manifestations, negative symptoms are behaviors fundamentally different
from behaviors exhibited by many people. They are more common and severe in schizophrenia. They are particularly
obvious when contrasted to how the client was before the onset of the disorder. Delusions and hallucinations are
positive symptoms because they must be self reported by the client.
Reference:Norman Keltner. Psychiatric Nursing. 5th edition. Page 342-343
24/8. Mike tells nurse Gener that the Actress in the teleserye is sending a secret message to him. Nurse Gener
suspects that Mike is experiencing:
a. A delusion
b. Flight of ideas
c. Delusions of reference
d. A hallucination
25/4. According to the hypothesis in Biochemical theory of schizophrenia, treatment is directed towards correcting the
chemical imbalance. Which neurotransmitter would the nurse identify as being the target for antipsychotic
a. Dopamine
b. Serotonin
c. Acetylcholine
d. Norepinephrine