1. Mental health is defined as:
A. The ability to distinguish what is real from what is not.
B. A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work productively.
C. Is the promotion of mental health, prevention of mental disorders, nursing care of patients during illness and rehabilitation
D. Absence of mental illness
Answer: (B) A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work productively.
Mental health is a state of emotional and psychosocial well being. A mentally healthy individual is self aware and self directive, has the ability to solve problems, can cope with crisis without assistance beyond the support of family and friends fulfill the capacity to love and work and sets goals and realistic limits. A. This describes the ego function reality testing. C. This is the definition of Mental Health and Psychiatric Nursing. D. Mental health is not just the absence of mental illness.
2. Which of the following describes the role of a technician?
A. Administers medications to a schizophrenic patient.
B. The nurse feeds and bathes a catatonic client
C. Coordinates diverse aspects of care rendered to the patient
D. Disseminates information about alcohol and its effects.
Answer: (A) Administers medications to a schizophrenic patient.
Administration of medications and treatments, assessment, documentation are the activities of the nurse as a technician. B. Activities as a parent surrogate. C. Refers to the ward manager role. D. Role as a teacher.
3. Liza says, “Give me 10 minutes to recall the name of our college professor who failed many students in our anatomy class.” She is operating on her:
A. Subconscious
B. Conscious
C. Unconscious
D. Ego
Answer: (A) Subconscious
Subconscious refers to the materials that are partly remembered partly forgotten but these can be recalled spontaneously and voluntarily. B. This functions when one is awake. One is aware of his thoughts, feelings actions and what is going on in the environment. C. The largest potion of the mind that contains the memories of one’s past particularly the unpleasant. It is difficult to recall the unconscious content. D. The conscious self that deals and tests reality.
4. The superego is that part of the psyche that:
A. Uses defensive function for protection.
B. Is impulsive and without morals.
C. Determines the circumstances before making decisions.
D. The censoring portion of the mind.
Answer: (D) The censoring portion of the mind.
The critical censoring portion of one’s personality; the conscience. A. This refers to the ego function that protects itself from anything that threatens it.. B. The Id is composed of the untamed, primitive drives and impulses. C. This refers to the ego that acts as the moderator of the struggle between the id and the superego.
5. Primary level of prevention is exemplified by:
A. Helping the client resume self care.
B. Ensuring the safety of a suicidal client in the institution.
C. Teaching the client stress management techniques
D. Case finding and surveillance in the community
Answer: (C) Teaching the client stress management techniques
Primary level of prevention refers to the promotion of mental health and prevention of mental illness. This can be achieved by rendering health teachings such as modifying ones responses to stress. A. This is tertiary level of prevention that deals with rehabilitation. B and D. Secondary level of prevention which involves reduction of actual illness through early detection and treatment of illness.
6. Situation: In a home visit done by the nurse, she suspects that the wife and her child are victims of abuse.
Which of the following is the most appropriate for the nurse to ask?
A. “Are you being threatened or hurt by your partner?
B. “Are you frightened of you partner”
C. “Is something bothering you?”
D. “What happens when you and your partner argue?”
Answer: (A) “Are you being threatened or hurt by your partner?
The nurse validates her observation by asking simple, direct question. This also shows empathy. B, C, and D are indirect questions which may not lead to the discussion of abuse.
7. The wife admits that she is a victim of abuse and opens up about her persistent distaste for sex. This sexual disorder is:
A. Sexual desire disorder
B. Sexual arousal Disorder
C. Orgasm Disorder
D. Sexual Pain Disorder
Answer: (A) Sexual desire disorder
Has little or no sexual desire or has distaste for sex. B. Failure to maintain the physiologic requirements for sexual intercourse. C. Persistent and recurrent inability to achieve an orgasm. D. Also called dyspareunia. Individuals with this disorder suffer genital pain before, during and after sexual intercourse.
8. What would be the best approach for a wife who is still living with her abusive husband?
A. “Here’s the number of a crisis center that you can call for help .”
B. “Its best to leave your husband.”
C. “Did you discuss this with your family?”
D. “ Why do you allow yourself to be treated this way”
Answer: (A) “Here’s the number of a crisis center that you can call for help .”
Protection is a priority concern in abuse. Help the victim to develop a plan to ensure safety. B. Do not give advice to leave the abuser. Making decisions for the victim further erodes her esteem. However discuss options available. C. The victim tends to isolate from friends and family. D. This is judgmental. Avoid in anyway implying that she is at fault.
9. Which comment about a 3 year old child if made by the parent may indicate child abuse?
A. “Once my child is toilet trained, I can still expect her to have some"
B. “When I tell my child to do something once, I don’t expect to have to tell"
C. “My child is expected to try to do things such as, dress and feed.”
D. “My 3 year old loves to say NO.”
Answer: (B) “When I tell my child to do something once, I don’t expect to have to tell"
Abusive parents tend to have unrealistic expectations on the child. A,B and C are realistic expectations on a 3 year old.
10. The primary nursing intervention for a victim of child abuse is:
A. Assess the scope of the problem
B. Analyze the family dynamics
C. Ensure the safety of the victim
D. Teach the victim coping skills
Answer: (C) Ensure the safety of the victim
The priority consideration is the safety of the victim. Attend to the physical injuries to ensure the physiologic safety and integrity of the child. Reporting suspected case of abuse may deter recurrence of abuse. A,B and D may be addressed later.
11. Situation: 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
Answer: (D) Somatoform Pain Disorder
This is characterized by severe and prolonged pain that causes significant distress. A. This is a chronic syndrome of somatic symptoms that cannot be explained medically and is associated with psychosocial distress. B. This is an unrealistic preoccupation with a fear of having a serious illness. C. Characterized by alteration or loss in sensory or motor function resulting from a psychological conflict.
12. Freud explains anxiety as:
A. Strives to gratify the needs for satisfaction and security
B. Conflict between id and superego
C. A hypothalamic-pituitary-adrenal reaction to stress
D. A conditioned response to stressors
Answer: (B) Conflict between id and superego
Freud explains anxiety as due to opposing action drives between the id and the superego. A. Sullivan identified 2 types of needs, satisfaction and security. Failure to gratify these needs may result in anxiety. C. Biomedical perspective of anxiety. D. Explanation of anxiety using the behavioral model.
13. The following are appropriate nursing diagnosis for the client EXCEPT:
A. Ineffective individual coping
B. Alteration in comfort, pain
C. Altered role performance
D. Impaired social interaction
Answer: (D) Impaired social interaction
The client may not have difficulty in social exchange. The cues do not support this diagnosis. A. The client maladaptively uses body symptoms to manage anxiety. B. The client will have discomfort due to pain. C. The client may fail to meet environmental expectations due to pain.
14. The following statements describe somatoform disorders:
A. Physical symptoms are explained by organic causes
B. It is a voluntary expression of psychological conflicts
C. Expression of conflicts through bodily symptoms
D. Management entails a specific medical treatment
Answer: (C) Expression of conflicts through bodily symptoms
Bodily symptoms are used to handle conflicts. A. Manifestations do not have an organic basis. B. This occurs unconsciously. D. Medical treatment is not used because the disorder does not have a structural or organic basis.
15. What would be the best response to the client’s repeated complaints of pain:
A. “I know the feeling is real tests revealed negative results.”
B. . “I think you’re exaggerating things a little bit.”
C. “Try to forget this feeling and have activities to take it off your mind”
D. “So tell me more about the pain”
Answer: (A) “I know the feeling is real tests revealed negative results.”
Shows empathy and offers information. B. This is a demeaning statement. C. This belittles the client’s feelings. D. Giving undue attention to the physical symptom reinforces the complaint.
16. Situation: A nurse may encounter children with mental disorders. Her knowledge of these various disorders is vital.
When planning school interventions for a child with a diagnosis of attention deficit hyperactivity disorder, a guide to remember is to:
A. provide as much structure as possible for the child
B. ignore the child’s overactivity.
C. encourage the child to engage in any play activity to dissipate energy
D. remove the child from the classroom when disruptive behavior occurs
Answer: (A) provide as much structure as possible for the child
Decrease stimuli for behavior control thru an environment that is free of distractions, a calm non –confrontational approach and setting limit to time allotted for activities. B. The child will not benefit from a lenient approach. C. Dissipate energy through safe activities. D. This indicates that the classroom environment lacks structure.
17. The child with conduct disorder will likely demonstrate:
A. Easy distractibility to external stimuli.
B. Ritualistic behaviors
C. Preference for inanimate objects.
D. Serious violations of age related norms.
Answer: (D) Serious violations of age related norms.
This is a disruptive disorder among children characterized by more serious violations of social standards such as aggression, vandalism, stealing, lying and truancy. A. This is characteristic of attention deficit disorder. B and C. These are noted among children with autistic disorder.
18. Ritalin is the drug of choice for chidren with ADHD. The side effects of the following may be noted:
A. increased attention span and concentration
B. increase in appetite
C. sleepiness and lethargy
D. bradycardia and diarrhea
Answer: (A) increased attention span and concentration
The medication has a paradoxic effect that decrease hyperactivity and impulsivity among children with ADHD. B, C, D. Side effects of Ritalin include anorexia, insomnia, diarrhea and irritability.
19. School phobia is usually treated by:
A. Returning the child to the school immediately with family support.
B. Calmly explaining why attendance in school is necessary
C. Allowing the child to enter the school before the other children
D. Allowing the parent to accompany the child in the classroom
Answer: (A) Returning the child to the school immediately with family support.
Exposure to the feared situation can help in overcoming anxiety. A. This will not help in relieving the anxiety due separation from a significant other. C. and C. Anxiety in school phobia is not due to being in school but due to separation from parents/caregivers so these interventions are not applicable. D. This will not help the child overcome the fear
20. A 10 year old child has very limited vocabulary and interaction skills. She has an I.Q. of 45. She is diagnosed to have Mental retardation of this classification:
A. Profound
B. Mild
C. Moderate
D. Severe
Answer: (C) Moderate
The child with moderate mental retardation has an I.Q. of 35-50 Profound Mental retardation has an I.Q. of below 20; Mild mental retardation 50-70 and Severe mental retardation has an I.Q. of 20-35.
21. The nurse teaches the parents of a mentally retarded child regarding her care. The following guidelines may be taught except:
A. overprotection of the child
B. patience, routine and repetition
C. assisting the parents set realistic goals
D. giving reasonable compliments
Answer: (A) overprotection of the child
The child with mental retardation should not be overprotected but need protection from injury and the teasing of other children. B,C, and D Children with mental retardation have learning difficulty. They should be taught with patience and repetition, start from simple to complex, use visuals and compliment them for motivation. Realistic expectations should be set and optimize their capability.
22. The parents express apprehensions on their ability to care for their maladaptive child. The nurse identifies what nursing diagnosis:
A. hopelessness
B. altered parenting role
C. altered family process
D. ineffective coping
Answer: (B) altered parenting role
Altered parenting role refers to the inability to create an environment that promotes optimum growth and development of the child. This is reflected in the parent’s inability to care for the child. A. This refers to lack of choices or inability to mobilize one’s resources. C. Refers to change in family relationship and function. D. Ineffective coping is the inability to form valid appraisal of the stressor or inability to use available resources
23. A 5 year old boy is diagnosed to have autistic disorder.
Which of the following manifestations may be noted in a client with autistic disorder?
A. argumentativeness, disobedience, angry outburst
B. intolerance to change, disturbed relatedness, stereotypes
C. distractibility, impulsiveness and overactivity
D. aggression, truancy, stealing, lying
Answer: (B) intolerance to change, disturbed relatedness, stereotypes
These are manifestations of autistic disorder. A. These manifestations are noted in Oppositional Defiant Disorder, a disruptive disorder among children. C. These are manifestations of Attention Deficit Disorder D. These are the manifestations of Conduct Disorder
24. The therapeutic approach in the care of an autistic child include the following EXCEPT:
A. Engage in diversionary activities when acting -out
B. Provide an atmosphere of acceptance
C. Provide safety measures
D. Rearrange the environment to activate the child
Answer: (D) Rearrange the environment to activate the child
The child with autistic disorder does not want change. Maintaining a consistent environment is therapeutic. A. Angry outburst can be rechannelled through safe activities. B. Acceptance enhances a trusting relationship. C. Ensure safety from self-destructive behaviors like head banging and hair pulling.
25. According to Piaget a 5 year old is in what stage of development:
A. Sensory motor stage
B. Concrete operations
C. Pre-operational
D. Formal operation
Answer: (C) Pre-operational
Pre-operational stage (2-7 years) is the stage when the use of language, the use of symbols and the concept of time occur. A. Sensory-motor stage (0-2 years) is the stage when the child uses the senses in learning about the self and the environment through exploration. B. Concrete operations (7-12 years) when inductive reasoning develops. D. Formal operations (2 till adulthood) is when abstract thinking and deductive reasoning develop.
26. Situation : The nurse assigned in the detoxification unit attends to various patients with substance-related disorders.
A 45 years old male revealed that he experienced a marked increase in his intake of alcohol to achieve the desired effect This indicates:
A. withdrawal
B. tolerance
C. intoxication
D. psychological dependence
Answer: (B) tolerance
tolerance refers to the increase in the amount of the substance to achieve the same effects. A. Withdrawal refers to the physical signs and symptoms that occur when the addictive substance is reduced or withheld. B. Intoxication refers to the behavioral changes that occur upon recent ingestion of a substance. D. Psychological dependence refers to the intake of the substance to prevent the onset of withdrawal symptoms.
27. The client admitted for alcohol detoxification develops increased tremors, irritability, hypertension and fever. The nurse should be alert for impending:
A. delirium tremens
B. Korsakoff’s syndrome
C. esophageal varices
D. Wernicke’s syndrome
Answer: (A) delirium tremens
Delirium Tremens is the most extreme central nervous system irritability due to withdrawal from alcohol B. This refers to an amnestic syndrome associated with chronic alcoholism due to a deficiency in Vit. B C. This is a complication of liver cirrhosis which may be secondary to alcoholism . D. This is a complication of alcoholism characterized by irregularities of eye movements and lack of coordination.
28. The care for the client places priority to which of the following:
A. Monitoring his vital signs every hour
B. Providing a quiet, dim room
C. Encouraging adequate fluids and nutritious foods
D. Administering Librium as ordered
Answer: (A) Monitoring his vital signs every hour
Pulse and blood pressure are usually elevated during withdrawal, Elevation may indicate impending delirium tremens B. Client needs quiet, well lighted, consistent and secure environment. Excessive stimulation can aggravate anxiety and cause illusions and hallucinations. C. Adequate nutrition with sulpplement of Vit. B should be ensured. D. Sedatives are used to relieve anxiety.
29. Another client is brought to the emergency room by friends who state that he took something an hour ago. He is actively hallucinating, agitated, with irritated nasal septum.
A. Heroin
B. cocaine
C. LSD
D. marijuana
Answer: (B) cocaine
The manifestations indicate intoxication with cocaine, a CNS stimulant. A. Intoxication with heroine is manifested by euphoria then impairment in judgment, attention and the presence of papillary constriction. C. Intoxication with hallucinogen like LSD is manifested by grandiosity, hallucinations, synesthesia and increase in vital signs D. Intoxication with Marijuana, a cannabinoid is manifested by sensation of slowed time, conjunctival redness, social withdrawal, impaired judgment and hallucinations.
30. A client is admitted with needle tracts on his arm, stuporous and with pin point pupil will likely be managed with:
A. Naltrexone (Revia)
B. Narcan (Naloxone)
C. Disulfiram (Antabuse)
D. Methadone (Dolophine)
Answer: (B) Narcan (Naloxone)
Narcan is a narcotic antagonist used to manage the CNS depression due to overdose with heroin. A. This is an opiate receptor blocker used to relieve the craving for heroine C. Disulfiram is used as a deterrent in the use of alcohol. D. Methadone is used as a substitute in the withdrawal from heroine
31. Situation: An old woman was brought for evaluation due to the hospital for evaluation due to increasing forgetfulness and limitations in daily function.
The daughter revealed that the client used her toothbrush to comb her hair. She is manifesting:
A. apraxia
B. aphasia
C. agnosia
D. amnesia
Answer: (C) agnosia
This is the inability to recognize objects. A. Apraxia is the inability to execute motor activities despite intact comprehension. B. Aphasia is the loss of ability to use or understand words. D. Amnesia is loss of memory.
32. She tearfully tells the nurse “I can’t take it when she accuses me of stealing her things.” Which response by the nurse will be most therapeutic?
A. ”Don’t take it personally. Your mother does not mean it.”
B. “Have you tried discussing this with your mother?”
C. “This must be difficult for you and your mother.”
D. “Next time ask your mother where her things were last seen.”
Answer: (C) “This must be difficult for you and your mother.”
This reflecting the feeling of the daughter that shows empathy. A and D. Giving advise does not encourage verbalization. B. This response does not encourage verbalization of feelings.
33. The primary nursing intervention in working with a client with moderate stage dementia is ensuring that the client:
A. receives adequate nutrition and hydration
B. will reminisce to decrease isolation
C. remains in a safe and secure environment
D. independently performs self care
Answer: (C) remains in a safe and secure environment
Safety is a priority consideration as the client’s cognitive ability deteriorates.. A is appropriate interventions because the client’s cognitive impairment can affect the client’s ability to attend to his nutritional needs, but it is not the priority B. Patient is allowed to reminisce but it is not the priority. D. The client in the moderate stage of Alzheimer’s disease will have difficulty in performing activities independently
34. She says to the nurse who offers her breakfast, “Oh no, I will wait for my husband. We will eat together” The therapeutic response by the nurse is:
A. “Your husband is dead. Let me serve you your breakfast.”
B. “I’ve told you several times that he is dead. It’s time to eat.”
C. “You’re going to have to wait a long time.”
D. “What made you say that your husband is alive?
Answer: (A) “Your husband is dead. Let me serve you your breakfast.”
The client should be reoriented to reality and be focused on the here and now.. B. This is not a helpful approach because of the short term memory of the client. C. This indicates a pompous response. D. The cognitive limitation of the client makes the client incapable of giving explanation.
35. Dementia unlike delirium is characterized by:
A. slurred speech
B. insidious onset
C. clouding of consciousness
D. sensory perceptual change
Answer: (B) insidious onset
Dementia has a gradual onset and progressive deterioration. It causes pronounced memory and cognitive disturbances. A,C and D are all characteristics of delirium.
36. Situation: A 17 year old gymnast is admitted to the hospital due to weight loss and dehydration secondary to starvation.
Which of the following nursing diagnoses will be given priority for the client?
A. altered self-image
B. fluid volume deficit
C. altered nutrition less than body requirements
D. altered family process
Answer: (B) fluid volume deficit
Fluid volume deficit is the priority over altered nutrition (A) since the situation indicates that the client is dehydrated. A and D are psychosocial needs of a client with anorexia nervosa but they are not the priority.
37. What is the best intervention to teach the client when she feels the need to starve?
A. Allow her to starve to relieve her anxiety
B. Do a short term exercise until the urge passes
C. Approach the nurse and talk out her feelings
D. Call her mother on the phone and tell her how she feels
Answer: (C) Approach the nurse and talk out her feelings
The client with anorexia nervosa uses starvation as a way of managing anxiety. Talking out feelings with the nurse is an adaptive coping. A. Starvation should not be encouraged. Physical safety is a priority. Without adequate nutrition, a life threatening situation exists. B. The client with anorexia nervosa is preoccupied with losing weight due to disturbed body image. Limits should be set on attempts to lose more weight. D. The client may have a domineering mother which causes the client to feel ambivalent. The client will not discuss her feelings with her mother.
38. The client with anorexia nervosa is improving if:
A. She eats meals in the dining room.
B. Weight gain
C. She attends ward activities.
D. She has a more realistic self concept.
Answer: (B) Weight gain
Weight gain is the best indication of the client’s improvement. The goal is for the client to gain 1-2 pounds per week. (A)The client may purge after eating. (C) Attending an activity does not indicate improvement in nutritional state. (D) Body image is a factor in anorexia nervosa but it is not an indicator for improvement.
39. The characteristic manifestation that will differentiate bulimia nervosa from anorexia nervosa is that bulimic individuals
A. have episodic binge eating and purging
B. have repeated attempts to stabilize their weight
C. have peculiar food handling patterns
D. have threatened self-esteem
Answer: (A) have episodic binge eating and purging
Bulimia is characterized by binge eating which is characterized by taking in a large amount of food over a short period of time. B and C are characteristics of a client with anorexia nervosa D. Low esteem is noted in both eating disorders
40. A nursing diagnosis for bulimia nervosa is powerlessness related to feeling not in control of eating habits. The goal for this problem is:
A. Patient will learn problem solving skills
B. Patient will have decreased symptoms of anxiety.
C. Patient will perform self care activities daily.
D. Patient will verbalize how to set limits on others.
Answer: (A) Patient will learn problem solving skills
if the client learns problem solving skills she will gain a sense of control over her life. (B) Anxiety is caused by powerlessness. (C) Performing self care activities will not decrease ones powerlessness (D) Setting limits to control imposed by others is a necessary skill but problem solving skill is the priority.
41. In the management of bulimic patients, the following nursing interventions will promote a therapeutic relationship EXCEPT:
A. Establish an atmosphere of trust
B. Discuss their eating behavior.
C. Help patients identify feelings associated with binge-purge behavior
D. Teach patient about bulimia nervosa
Answer: (B) Discuss their eating behavior.
The client is often ashamed of her eating behavior. Discussion should focus on feelings. A,C and D promote a therapeutic relationship
42. Situation: A 35 year old male has intense fear of riding an elevator. He claims “ As if I will die inside.” This has affected his studies
The client is suffering from:
A. agoraphobia
B. social phobia
C. Claustrophobia
D. xenophobia
Answer: (C) Claustrophobia
Claustrophobia is fear of closed space. A. Agoraphobia is fear of open space or being a situation where escape is difficult. B. Social phobia is fear of performing in the presence of others in a way that will be humiliating or embarrassing. D. Xenophobia is fear of strangers.
43. Initial intervention for the client should be to:
A. Encourage to verbalize his fears as much as he wants.
B. Assist him to find meaning to his feelings in relation to his past.
C. Establish trust through a consistent approach.
D. Accept her fears without criticizing.
Answer: (D) Accept her fears without criticizing.
The client cannot control her fears although the client knows its silly and can joke about it. A. Allow expression of the client’s fears but he should focus on other productive activities as well. B and C. These are not the initial interventions.
44. The nurse develops a countertransference reaction. This is evidenced by:
A. Revealing personal information to the client
B. Focusing on the feelings of the client.
C. Confronting the client about discrepancies in verbal or non-verbal behavior
D. The client feels angry towards the nurse who resembles his mother.
Answer: (A) Revealing personal information to the client
A. Countertransference is an emotional reaction of the nurse on the client based on her unconscious needs and conflicts. B and C. These are therapeutic approaches. D. This is transference reaction where a client has an emotional reaction towards the nurse based on her past.
45. Which is the desired outcome in conducting desensitization:
A. The client verbalize his fears about the situation
B. The client will voluntarily attend group therapy in the social hall.
C. The client will socialize with others willingly
D. The client will be able to overcome his disabling fear.
Answer: (D) The client will be able to overcome his disabling fear.
The client will overcome his disabling fear by gradual exposure to the feared object. A,B and C are not the desired outcome of desensitization.
46. Which of the following should be included in the health teachings among clients receiving Valium:
A. Avoid taking CNS depressant like alcohol.
B. There are no restrictions in activities.
C. Limit fluid intake.
D. Any beverage like coffee may be taken
Answer: (A) Avoid taking CNS depressant like alcohol.
Valium is a CNS depressant. Taking it with other CNS depressants like alcohol; potentiates its effect. B. The client should be taught to avoid activities that require alertness. C. Valium causes dry mouth so the client must increase her fluid intake. D. Stimulants must not be taken by the client because it can decrease the effect of Valium.
47. Situation: A 20 year old college student is admitted to the medical ward because of sudden onset of paralysis of both legs. Extensive examination revealed no physical basis for the complaint.
The nurse plans intervention based on which correct statement about conversion disorder?
A. The symptoms are conscious effort to control anxiety
B. The client will experience high level of anxiety in response to the paralysis.
C. The conversion symptom has symbolic meaning to the client
D. A confrontational approach will be beneficial for the client.
Answer: (C) The conversion symptom has symbolic meaning to the client
the client uses body symptoms to relieve anxiety. A. The condition occurs unconsciously. B. The client is not distressed by the lost or altered body function. D. The client should not be confronted by the underlying cause of his condition because this can aggravate the client’s anxiety.
48. Nina reveals that the boyfriend has been pressuring her to engage in premarital sex. The most therapeutic response by the nurse is:
A. “I can refer you to a spiritual counselor if you like.”
B. “You shouldn’t allow anyone to pressure you into sex.”
C. “It sounds like this problem is related to your paralysis.”
D. “How do you feel about being pressured into sex by your boyfriend?”
Answer: (D) “How do you feel about being pressured into sex by your boyfriend?”
Focusing on expression of feelings is therapeutic. The central force of the client’s condition is anxiety. A. This is not therapeutic because the nurse passes the responsibility to the counselor. B. Giving advice is not therapeutic. C. This is not therapeutic because it confronts the underlying cause.
49. Malingering is different from somatoform disorder because the former:
A. Has evidence of an organic basis.
B. It is a deliberate effort to handle upsetting events
C. Gratification from the environment are obtained.
D. Stress is expressed through physical symptoms.
Answer: (B) It is a deliberate effort to handle upsetting events
Malingering is a conscious simulation of an illness while somatoform disorder occurs unconscious. A. Both disorders do not have an organic or structural basis. C. Both have primary gains. D. This is a characteristic of somatoform disorder.
50. Unlike psychophysiologic disorder Linda may be best managed with:
A. medical regimen
B. milieu therapy
C. stress management techniques
D. psychotherapy
Answer: (C) stress management techniques
Stree management techniques is the best management of somatoform disorder because the disorder is related to stress and it does not have a medical basis. A. This disorder is not supported by organic pathology so no medical regimen is required. B and D. Milieu therapy and psychotherapy may be used a therapeutic modalities but these are not the best.
51. Which is the best indicator of success in the long term management of the client?
A. His symptoms are replaced by indifference to his feelings
B. He participates in diversionary activities.
C. He learns to verbalize his feelings and concerns
D. He states that his behavior is irrational.
Answer: (C) He learns to verbalize his feelings and concerns
C. The client is encouraged to talk about his feelings and concerns instead of using body symptoms to manage his stressors. A. The client is encouraged to acknowledge feelings rather than being indifferent to her feelings. B. Participation in activities diverts the client’s attention away from his bodily concerns but this is not the best indicator of success. D. Help the client recognize that his physical symptoms occur because of or are exacerbated by specific stressor, not as irrational.
52. Situation: A young woman is brought to the emergency room appearing depressed. The nurse learned that her child died a year ago due to an accident.
The initial nursing diagnosis is dysfunctional grieving. The statement of the woman that supports this diagnosis is:
A. “I feel envious of mothers who have toddlers”
B. “I haven’t been able to open the door and go into my baby’s room “
C. “I watch other toddlers and think about their play activities and I cry.”
D. “I often find myself thinking of how I could have prevented the death.
Answer: (B) “I haven’t been able to open the door and go into my baby’s room “
This indicates denial. This defense is adaptive as an initial reaction to loss but an extended, unsuccessful use of denial is dysfunctional. A. This indicates acknowledgement of the loss. Expressing feelings openly is acceptable. C. This indicates the stage of depression in the grieving process. D. Remembering both positive and negative aspects of the deceased love one signals successful mourning.
53. The client said “I can’t even take care of my baby. I’m good for nothing.” Which is the appropriate nursing diagnosis?
A. Ineffective individual coping related to loss.
B. Impaired verbal communication related to inadequate social skills.
C. Low esteem related to failure in role performance
D. Impaired social interaction related to repressed anger.
Answer: (C) Low esteem related to failure in role performance
This indicates the client’s negative self evaluation. A sense of worthlessness may accompany depression. A,B and D are not relevant. The cues do not indicate inability to use coping resources, decreased ability to transmit/process symbols, nor insufficient quality of social exchange
54. The following medications will likely be prescribed for the client EXCEPT:
A. Prozac
B. Tofranil
C. Parnate
D. Zyprexa
Answer: (D) Zyprexa
This is an antipsychotic. A. This is a SSRI antidepressant. B. This antidepressant belongs to the Tricyclic group. C. This is a MAOI antidepressant.
55. Which is the highest priority in the post ECT care?
A. Observe for confusion
B. Monitor respiratory status
C. Reorient to time, place and person
D. Document the client’s response to the treatment
Answer: (B) Monitor respiratory status
A side effect of ECT which is life threatening is respiratory arrest. A and C. Confusion and disorientation are side effects of ECT but these are not the highest priority.
56. Situation: A 27 year old writer is admitted for the second time accompanied by his wife. He is demanding, arrogant talked fast and hyperactive.
Initially the nurse should plan this for a manic client:
A. set realistic limits to the client’s behavior
B. repeat verbal instructions as often as needed
C. allow the client to get out feelings to relieve tension
D. assign a staff to be with the client at all times to help maintain control
Answer: (A) set realistic limits to the client’s behavior
The manic client is hyperactive and may engage in injurious activities. A quiet environment and consistent and firm limits should be set to ensure safety. B. Clear, concise directions are given because of the distractibility of the client but this is not the priority. C. The manic client tend to externalize hostile feelings, however only non-destructive methods of expression should be allowed D. Nurses set limit as needed. Assigning a staff to be with the client at all times is not realistic.
57. An activity appropriate for the client is:
A. table tennis
B. painting
C. chess
D. cleaning
Answer: (D) cleaning
The client’s excess energy can be rechanelled through physical activities that are not competitive like cleaning. This is also a way to dissipate tension. A. Tennis is a competitive activity which can stimulate the client.
58. The client is arrogant and manipulative. In ensuring a therapeutic milieu, the nurse does one of the following:
A. Agree on a consistent approach among the staff assigned to the client.
B. Suggest that the client take a leading role in the social activities
C. Provide the client with extra time for one on one sessions
D. Allow the client to negotiate the plan of care
Answer: (A) Agree on a consistent approach among the staff assigned to the client.
A consistent firm approach is appropriate. This is a therapeutic way of to handle attempts of exploiting the weakness in others or create conflicts among the staff. Bargaining should not be allowed. B. This is not therapeutic because the client tends to control and dominate others. C. Limits are set for interaction time. D. Allowing the client to negotiate may reinforce manipulative behavior.
59. The nurse exemplifies awareness of the rights of a client whose anger is escalating by:
A. Taking a directive role in verbalizing feelings
B. Using an authoritarian, confrontational approach
C. Putting the client in a seclusion room
D. Applying mechanical restraints
Answer: (A) Taking a directive role in verbalizing feelings
The client has the right to be free from unnecessary restraints. Verbalization of feelings or “talking down” in a non-threatening environment is helpful to relieve the client’s anger. B. This is a threatening approach. C and D. Seclusion and application restraints are done only when less restrictive measures have failed to contain the client’s anger.
60. A client on Lithium has diarrhea and vomiting. What should the nurse do first:
A. Recognize this as a drug interaction
B. Give the client Cogentin
C. Reassure the client that these are common side effects of lithium therapy
D. Hold the next dose and obtain an order for a stat serum lithium level
Answer: (D) Hold the next dose and obtain an order for a stat serum lithium level
Diarrhea and vomiting are manifestations of Lithium toxicity. The next dose of lithium should be withheld and test is done to validate the observation. A. The manifestations are not due to drug interaction. B. Cogentin is used to manage the extra pyramidal symptom side effects of antipsychotics. C. The common side effects of Lithium are fine hand tremors, nausea, polyuria and polydipsia.
61. Situation: A widow age 28, whose husband died one year ago due to AIDS, has just been told that she has AIDS.
Pamela says to the nurse, “Why me? How could God do this to me?” This reaction is one of:
A. Depression
B. Denial
C. anger
D. bargaining
Answer: (C) anger
Anger is experienced as reality sets in. This may either be directed to God, the deceased or displaced on others. A. Depression is a painful stage where the individual mourns for what was lost. B. Denial is the first stage of the grieving process evidenced by the statement “No, it can’t be true.” The individual does not acknowledge that the loss has occurred to protect self from the psychological pain of the loss. D. In bargaining the individual holds out hope for additional alternatives to forestall the loss, evidenced by the statement “If only…”
62. The nurse’s therapeutic response is:
A. “I will refer you to a clergy who can help you understand what is happening to you.”
B. “ It isn’t fair that an innocent like you will suffer from AIDS.”
C. “That is a negative attitude.”
D. ”It must really be frustrating for you. How can I best help you?”
Answer: (D) ”It must really be frustrating for you. How can I best help you?”
This response reflects the pain due to loss. A helping relationship can be forged by showing empathy and concern. A. This is not therapeutic since it passes the buck or responsibility to the clergy. B. This response is not therapeutic because it gives the client the impression that she is right which prevents the client from reconsidering her thoughts. C. This statement passes judgment on the client.
63. One morning the nurse sees the client in a depressed mood. The nurse asks her “What are you thinking about?” This communication technique is:
A. focusing
B. validating
C. reflecting
D. giving broad opening
Answer: (D) giving broad opening
Broad opening technique allows the client to take the initiative in introducing the topic. A,B and C are all therapeutic techniques but these are not exemplified by the nurse’s statement.
64. The client says to the nurse ” Pray for me” and entrusts her wedding ring to the nurse. The nurse knows that this may signal which of the following:
A. anxiety
B. suicidal ideation
C. Major depression
D. Hopelessness
Answer: (B) suicidal ideation
The client’s statement is a verbal cue of suicidal ideation not anxiety. While suicide is common among clients with major depression, this occurs when their depression starts to lift. Hopelessness indicates no alternatives available and may lead to suicide, the statement and non verbal cue of the client indicate suicide.
65. Which of the following interventions should be prioritized in the care of the suicidal client?
A. Remove all potentially harmful items from the client’s room.
B. Allow the client to express feelings of hopelessness.
C. Note the client’s capabilities to increase self esteem.
D. Set a “no suicide” contract with the client.
Answer: (A) Remove all potentially harmful items from the client’s room.
Accessibility of the means of suicide increases the lethality. Allowing patient to express feelings and setting a no suicide contract are interventions for suicidal client but blocking the means of suicide is priority. Increasing self esteem is an intervention for depressed clients bur not specifically for suicide.
66. Situation: A 14 year old male was admitted to a medical ward due to bronchial asthma after learning that his mother was leaving soon for U.K. to work as nurse.
The client has which of the following developmental focus:
A. Establishing relationship with the opposite sex and career planning.
B. Parental and societal responsibilities.
C. Establishing ones sense of competence in school.
D. Developing initial commitments and collaboration in work
Answer: (A) Establishing relationship with the opposite sex and career planning.
The client belongs to the adolescent stage. The adolescent establishes his sense of identity by making decisions regarding familial, occupational and social roles. The adolescent emancipates himself from the family and decides what career to pursue, what set of friends to have and what value system to uphold. B. This refers to the middle adulthood stage concerned with transmitting his values to the next generation to ensure his immortality through the perpetuation of his culture. C. This reflects school age which is concerned with the pursuit of knowledge and skills to deal with the environment both in the present and in the future. D. The stage of young adulthood is concerned with development of intimate relationship with the opposite sex, establishment of a safe and congenial family environment and building of one’s lifework.
67. The personality type of Ryan is:
A. conforming
B. dependent
C. perfectionist
D. masochistic
Answer: (B) dependent
A client with dependent personality is predisposed to develop asthma. A. The conforming non-assertive client is predisposed to develop hypertension because of the tendency to repress rage. C. The perfectionist and compulsive tend to develop migraine. D. The masochistic, self sacrificing type are prone to develop rheumatoid arthritis.
68. The nurse ensures a therapeutic environment for the client. Which of the following best describes a therapeutic milieu?
A. A therapy that rewards adaptive behavior
B. A cognitive approach to change behavior
C. A living, learning or working environment.
D. A permissive and congenial environment
Answer: (C) A living, learning or working environment.
A therapeutic milieu refers to a broad conceptual approach in which all aspects of the environment are channeled to provide a therapeutic environment for the client. The six environmental elements include structure, safety, norms, limit setting, balance and unit modification. A. Behavioral approach in psychiatric care is based on the premise that behavior can be learned or unlearned through the use of reward and punishment. B. Cognitive approach to change behavior is done by correcting distorted perceptions and irrational beliefs to correct maladaptive behaviors. D. This is not congruent with therapeutic milieu.
69. Included as priority of care for the client will be:
A. Encourage verbalization of concerns instead of demonstrating them through the body
B. Divert attention to ward activities
C. Place in semi-fowlers position and render O2 inhalation as ordered
D. Help her recognize that her physical condition has an emotional component
Answer: (C) Place in semi-fowlers position and render O2 inhalation as ordered
Since psychopysiologic disorder has organic basis, priority intervention is directed towards disease-specific management. Failure to address the medical condition of the client may be a life threat. A and B. The client has physical symptom that is adversely affected by psychological factors. Verbalization of feelings in a non threatening environment and involvement in relaxing activities are adaptive way of dealing with stressors. However, these are not the priority. D. Helping the client connect the physical symptoms with the emotional problems can be done when the client is ready.
70. The client is concerned about his coming discharge, manifested by being unusually sad. Which is the most therapeutic approach by the nurse?
A. “You are much better than when you were admitted so there’s no reason to worry.”
B. “What would you like to do now that you’re about to go home?”
C. “You seem to have concerns about going home.”
D. “Aren’t you glad that you’re going home soon?”
Answer: (C) “You seem to have concerns about going home.”
. This statement reflects how the client feels. Showing empathy can encourage the client to talk which is important as an alternative more adaptive way of coping with stressors.. A. Giving false reassurance is not therapeutic. B. While this technique explores plans after discharge, it does not focus on expression of feelings. D. This close ended question does not encourage verbalization of feelings.
71. Situation: The nurse may encounter clients with concerns on sexuality.
The most basic factor in the intervention with clients in the area of sexuality is:
A. Knowledge about sexuality.
B. Experience in dealing with clients with sexual problems
C. Comfort with one’s sexuality
D. Ability to communicate effectively
Answer: (C) Comfort with one’s sexuality
The nurse must be accepting, empathetic and non-judgmental to patients who disclose concerns regarding sexuality. This can happen only when the nurse has reconciled and accepted her feelings and beliefs related to sexuality. A,B and D are important considerations but these are not the priority.
72. Which of the following statements is true for gender identity disorder?
A. It is the sexual pleasure derived from inanimate objects.
B. It is the pleasure derived from being humiliated and made to suffer
C. It is the pleasure of shocking the victim with exposure of the genitalia
D. It is the desire to live or involve in reactions of the opposite sex
Answer: (D) It is the desire to live or involve in reactions of the opposite sex
Gender identity disorder is a strong and persistent desire to be the other sex. A. This is fetishism. B. This refers to masochism. C. This describes exhibitionism.
73. The sexual response cycle in which the sexual interest continues to build:
A. Sexual Desire
B. Sexual arousal
C. Orgasm
D. Resolution
Answer: (B) Sexual arousal
Sexual arousal or excitement refers to attaining and maintaining the physiologic requirements for sexual intercourse. A. Sexual Desire refers to the ability, interest or willingness for sexual stimulation. C. Orgasm refers to the peak of the sexual response where the female has vaginal contractions for the female and ejaculatory contractions for the male. D. Resolution is the final phase of the sexual response in which the organs and the body systems gradually return to the unaroused state.
74. The inability to maintain the physiologic requirements in sexual intercourse is:
A. Sexual Desire Disorder
B. Sexual Arousal Disorder
C. Orgasm Disorder
D. Sexual Pain disorder
Answer: (B) Sexual Arousal Disorder
This describes sexual arousal disorder. A. Sexual Desire Disorder refers to the persistent and recurrent lack of desire or willingness for sexual intercourse. C. Orgasm Disorder is the inability to complete the sexual response cycle because of the inability to achieve an orgasm. D. Sexual Pain Disorder is characterized by genital pain before, during or after sexual intercourse.
75. The nurse asks a client to roll up his sleeves so she can take his blood pressure. The client replies “If you want I can go naked for you.” The most therapeutic response by the nurse is:
A. “You’re attractive but I’m not interested.”
B. “You wouldn’t be the first that I will see naked.”
C. “I will report you to the guard if you don’t control yourself.”
D. “I only need access to your arm. Putting up your sleeve is fine.”
Answer: (D) “I only need access to your arm. Putting up your sleeve is fine.”
The nurse needs to deal with the client with sexually connotative behavior in a casual, matter of fact way. A and B. These responses are not therapeutic because they are challenging and rejecting. C. Threatening the client is not therapeutic.
76. Situation: Knowledge and skills in the care of violent clients is vital in the psychiatric unit. A nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway and making aggressive remarks.
Which of the following statements is most appropriate to make to this patient?
A. What is causing you to become agitated?
B. You need to stop that behavior now.
C. You will need to be restrained if you do not change your behavior.
D. You will need to be placed in seclusion.
Answer: (A) What is causing you to become agitated?
In a non-violent aggressive behavior, help the client identify the stressor or the true object of hostility. This helps reveal unresolved issues so that they may be confronted. B. Pacing is a tension relieving measure for an agitated client. C. This is a threatening statement that can heighten the client’s tension. D. Seclusion is used when less restrictive measures have failed.
77. The nurse closely observes the client who has been displaying aggressive behavior. The nurse observes that the client’s anger is escalating. Which approach is least helpful for the client at this time?
A. Acknowledge the client’s behavior
B. Maintain a safe distance from the client
C. Assist the client to an area that is quiet
D. Initiate confinement measures
Answer: (D) Initiate confinement measures
The proper procedure for dealing with harmful behavior is to first try to calm patient verbally. . When verbal and psychopharmacologic interventions are not adequate to handle the aggressiveness, seclusion or restraints may be applicable. A, B and C are appropriate approaches during the escalation phase of aggression.
78. The charge nurse of a psychiatric unit is planning the client assignment for the day. The most appropriate staff to be assigned to a client with a potential for violence is which of the following:
A. A timid nurse
B. A mature experienced nurse
C. an inexperienced nurse
D. a soft spoken nurse
Answer: (B) A mature experienced nurse
The unstable, aggressive client should be assigned to the most experienced nurse. A, C and D. A shy, inexperienced, soft spoken nurse may feel intimidated by the angry patient.
79. The nurse exemplifies awareness of the rights of a client whose anger is escalating by:
A. Taking a directive role in verbalizing feelings
B. Using an authoritarian, confrontational approach
C. Putting the client in a seclusion room
D. Applying mechanical restraints
Answer: (A) Taking a directive role in verbalizing feelings
Taking a directive role in the client’s verbalization of feelings can deescalate the client’s anger. B. A confrontational approach can be threatening and adds to the client’s tension. C and D. Use of restraints and isolation may be required if less restrictive interventions are unsuccessful.
80. The client jumps up and throws a chair out of the window. He was restrained after his behavior can no longer be controlled by the staff. Which of these documentations indicates the safeguarding of the patient’s rights?
A. There was a doctor’s order for restraints/seclusion
B. The patient’s rights were explained to him.
C. The staff observed confidentiality
D. The staff carried out less restrictive measures but were unsuccessful.
Answer: (D) The staff carried out less restrictive measures but were unsuccessful.
This documentation indicates that the client has been placed on restraints after the least restrictive measures failed in containing the client’s violent behavior.
81. Situation: Clients with personality disorders have difficulties in their social and occupational functions.
Clients with personality disorder will most likely:
A. recover with therapeutic intervention
B. respond to antianxiety medication
C. manifest enduring patterns of inflexible behaviors
D. Seek treatment willingly from some personally distressing symptoms
Answer: (C) manifest enduring patterns of inflexible behaviors
Personality disorders are characterized by inflexible traits and characteristics that are lifelong. A and D. This disorder is manifested by life-long patterns of behavior. The client with this disorder will not likely present himself for treatment unless something has gone wrong in his life so he may not recover from therapeutic intervention. B. Medications are generally not recommended for personality disorders.
82. A client tends to be insensitive to others, engages in abusive behaviors and does not have a sense of remorse. Which personality disorder is he likely to have?
A. Narcissistic
B. Paranoid
C. Histrionic
D. Antisocial
Answer: (D) Antisocial
These are the characteristics of an individual with antisocial personality. A. Narcissistic personality disorder is characterized by grandiosity and a need for constant admiration from others. B. Individuals with paranoid personality demonstrate a pattern of distrust and suspiciousness and interprets others motives as threatening. C. Individuals with histrionic have excessive emotionality, and attention-seeking behaviors.
83. The client joins a support group and frequently preaches against abuse, is demonstrating the use of:
A. denial
B. reaction formation
C. rationalization
D. projection
Answer: (B) reaction formation
Reaction formation is the adoption of behavior or feelings that are exactly opposite of one’s true emotions. A. Denial is refusal to accept a painful reality. C. Rationalization is attempting to justify one’s behavior by presenting reasons that sounds logical. D. Projection is attributing of one’s behaviors and feelings to another person.
84. A teenage girl is diagnosed to have borderline personality disorder. Which manifestations support the diagnosis?
A. Lack of self esteem, strong dependency needs and impulsive behavior
B. social withdrawal, inadequacy, sensitivity to rejection and criticism
C. Suspicious, hypervigilance and coldness
D. Preoccupation with perfectionism, orderliness and need for control
Answer: (A) Lack of self esteem, strong dependency needs and impulsive behavior
These are the characteristics of client with borderline personality. B. This describes the avoidant personality. C. These are the characteristics of a client with paranoid personality D. This describes the obsessive compulsive personality
85. The plan of care for clients with borderline personality should include:
A. Limit setting and flexibility in schedule
B. Giving medications to prevent acting out
C. Restricting her from other clients
D. Ensuring she adheres to certain restrictions
Answer: (D) Ensuring she adheres to certain restrictions
The client is manipulative. The client must be informed about the policies, expectations, rules and regulation upon admission. A. Limits should be firmly and consistently implemented. Flexibility and bargaining are not therapeutic in dealing with a manipulative client. B. There is no specific medication prescribed for this condition. C. This is not part of the care plan. Interaction with other clients are allowed but the client should be observed and given limits in her attempt to manipulate and dominate others.
86. Situation: A 42 year old male client, is admitted in the ward because of bizarre behaviors. He is given a diagnosis of schizophrenia paranoid type.
The client should have achieved the developmental task of:
A. Trust vs. mistrust
B. Industry vs. inferiority
C. Generativity vs. stagnation
D. Ego integrity vs. despair
Answer: (D) Ego integrity vs. despair
The client belongs to the middle adulthood stage (30 to 65 yrs.) The developmental task generativity is characterized by concern and care for others. It is a productive and creative stage. (A) Infancy stage (0 – 18 mos.) is concerned with gratification of oral needs (B) School Age child (6 – 12 yrs.) is characterized by acquisition of school competencies and social skills (C) Late adulthood ( 60 and above) Concerned with reflection on the past and his contributions to others and face the future.
87. Clients who are suspicious primarily use projection for which purpose:
A. deny reality
B. to deal with feelings and thoughts that are not acceptable
C. to show resentment towards others
D. manipulate others
Answer: (B) to deal with feelings and thoughts that are not acceptable
Projection is a defense mechanism where one attributes ones feelings and inadequacies to others to reduce anxiety. A. This is not true in all instances of projection C and D. This focuses on the self rather than others
88. The client says “ the NBI is out to get me.” The nurse’s best response is:
A. “The NBI is not out to catch you.”
B. “I don’t believe that.”
C. “I don’t know anything about that. You are afraid of being harmed.”
D. “ What made you think of that.”
Answer: (C) “I don’t know anything about that. You are afraid of being harmed.”
This presents reality and acknowledges the clients feeling A and B. are not therapeutic responses because these disagree with the client’s false belief and makes the client feel challenged D. unnecessary exploration of the false
89. The client on Haldol has pill rolling tremors and muscle rigidity. He is likely manifesting:
A. tardive dyskinesia
B. Pseudoparkinsonism
C. akinesia
D. dystonia
Answer: (B) Pseudoparkinsonism
Pseudoparkinsonism is a side effect of antipsychotic drugs characterized by mask-like facies, pill rolling tremors, muscle rigidity A. Tardive dyskinesia is manifested by lip smacking, wormlike movement of the tongue C. Akinesia is characterized by feeling of weakness and muscle fatigue D. Dystonia is manifested by torticollis and rolling back of the eyes
90. The client is very hostile toward one of the staff for no apparent reason. The client is manifesting:
A. Splitting
B. Transference
C. Countertransference
D. Resistance
Answer: (B) Transference
Transference is a positive or negative feeling associated with a significant person in the client’s past that are unconsciously assigned to another A. Splitting is a defense mechanism commonly seen in a client with personality disorder in which the world is perceived as all good or all bad C. Counterttransference is a phenomenon where the nurse shifts feelings assigned to someone in her past to the patient D. Resistance is the client’s refusal to submit himself to the care of the nurse
91. Situation: An 18 year old female was sexually attacked while on her way home from work. She is brought to the hospital by her mother.
Rape is an example of which type of crisis:
A. Situational
B. Adventitious
C. Developmental
D. Internal
Answer: (B) Adventitious
Adventitious crisis is a crisis involving a traumatic event. It is not part of everyday life. A. Situational crisis is from an external source that upset ones psychological equilibrium C and D. Are the same. They are transitional or developmental periods in life
92. During the initial care of rape victims the following are to be considered EXCEPT:
A. Assure privacy.
B. Touch the client to show acceptance and empathy
C. Accompany the client in the examination room.
D. Maintain a non-judgmental approach.
Answer: (B) Touch the client to show acceptance and empathy
The client finds touch intrusive and therefore should be avoided. A. Privacy is one of the rights of a victim of rape. C.The client is anxious. Accompanying the client in a quiet room ensures safety and offers emotional support. D. Guilt feeling is common among rape victims. They should not be blamed.
93. The nurse acts as a patient advocate when she does one of the following:
A. She encourages the client to express her feeling regarding her experience.
B. She assesses the client for injuries.
C. She postpones the physical assessment until the client is calm
D. Explains to the client that her reactions are normal
Answer: (C) She postpones the physical assessment until the client is calm
The nurse acts as a patient advocate as she protects the client from psychological harm A. The nurse acts a a counselor B. The nurse acts as a technician D. This exemplifies the role of a teacher
94. Crisis intervention carried out to the client has this primary goal:
A. Assist the client to express her feelings
B. Help her identify her resources
C. Support her adaptive coping skills
D. Help her return to her pre-rape level of function
Answer: (D) Help her return to her pre-rape level of function
The goal of crisis intervention to help the client return to her level of function prior to the crisis. A,B and C are interventions or strategies to attain the goal
95. Five months after the incident the client complains of difficulty to concentrate, poor appetite, inability to sleep and guilt. She is likely suffering from:
A. Adjustment disorder
B. Somatoform Disorder
C. Generalized Anxiety Disorder
D. Post traumatic disorder
Answer: (D) Post traumatic disorder
Post traumatic stress disorder is characterized by flashback, irritability, difficulty falling asleep and concentrating following an extremely traumatic event. This lasts for more that one month A. Adjustment disorder is the maladaptive reaction to stressful events characterized by anxiety, depression and work or social impairments. This occurs within 3 months after the event B. Somatoform disorders are anxiety related disorders characterized by presence of physical symptoms without demonstrable organic basis C. Generalized anxiety disorder is characterized by chronic, excessive anxiety for at least 6 months
96. Situation: A 29 year old client newly diagnosed with breast cancer is pacing, with rapid speech headache and inability to focus with what the doctor was saying.
The nurse assesses the level of anxiety as:
A. Mild
B. Moderate
C. Severe
D. Panic
Answer: (C) Severe
The client’s manifestations indicate severe anxiety. A Mild anxiety is manifested by slight muscle tension, slight fidgeting, alertness, ability to concentrate and capable of problem solving. B. Moderate muscle tension, increased vital signs, periodic slow pacing, increased rate of speech and difficulty in concentrating are noted in moderate anxiety. D. Panic level of anxiety is characterized immobilization, incoherence, feeling of being overwhelmed and disorganization
97. Anxiety is caused by:
A. an objective threat
B. a subjectively perceived threat
C. hostility turned to the self
D. masked depression
Answer: (B) a subjectively perceived threat
Anxiety is caused by a subjectively perceived threat A. Fear is caused by an objective threat C. A depressed client internalizes hostility D. Mania is due to masked depression
98. It would be most helpful for the nurse to deal with a client with severe anxiety by:
A. Give specific instructions using speak in concise statements.
B. Ask the client to identify the cause of her anxiety.
C. Explain in detail the plan of care developed
D. Urge the client to focus on what the nurse is saying
Answer: (A) Give specific instructions using speak in concise statements.
The client has narrowed perceptual field. Lengthy explanations cannot be followed by the client. B. The client will not be able to identify the cause of anxiety C and D. The client has difficulty concentrating and will not be able to focus.
99. Which of the following medications will likely be ordered for the client?”
A. Prozac
B. Valium
C. Risperdal
D. Lithium
Answer: (B) Valium
Antianxiety A. Antidepressant C. Antipsychotic D. Antimanic
100. Which of the following is included in the health teachings among clients receiving Valium?:
A. Avoid foods rich in tyramine.
B. Take the medication after meals.
C. It is safe to stop it anytime after long term use.
D. Double up the dose if the client forgets her medication.
Answer: (B) Take the medication after meals.
Antianxiety medications cause G.I. upset so it should be taken after meals. A. This is specific for antidepressant MAOI. Taking tyramine rich food can cause hypertensive crisis. C. Valium causes dependency. In which case, the medication should be gradually withdrawn to prevent the occurrence of convulsion. D The dose of Valium should not be doubled if the previous dose was not taken. It can intensify the CNS depressant effects.
