Exams

Question 1

The nurse states, “I notice you become very anxious when we talk about your drug use.” Which of the following therapeutic communication is being used?

Answer 1

Making observations

Question 2

A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints?

Answer 2

self-destructive behavior despite alternative interventions

Question 3

A client tells the nurse, “I experience stress on a regular basis. Why do I feel this way?” Which is the nurse’s most appropriate response?

Answer 3

“Your reactions to past experiences influence your current feelings.”

Question 4

Which is the first step the nurse should take when using therapeutic communication?

Answer 4

to clarify personal attitudes values and beliefs

Question 5

An aging client with chronic schizophrenia takes an antipsychotic and propranolol, a beta-adrenergic blocking agent, for hypertension. Given the combined side effects of these drugs, which client teaching should the nurse provide?

Answer 5

rise slowly when you change position from lying to sitting or sitting to standing

Ortho hypo

Question 6

1. The nurse states, “I notice you become very anxious when we talk about your drug use.” Which of the following therapeutic communication is being used?

Answer 6

making observations

Question 7

A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints?

Answer 7

self-destructive behavior despite alternative

interventions

Question 8

A client tells the nurse, “I experience stress on a regular basis. Why do I feel this way?” Which is the nurse’s most appropriate response?

Answer 8

“Your reactions to past experiences influence your current feelings.”

Question 9

The patient is telling the nurse that she is going to divorce her cheating husband. The nurse states, “ I don’t blame you, you deserve better than that”. This is an example of which type of communication?

Answer 9

giving advice

Question 10

A nurse is reviewing the medical record of a client who has schizophrenia and is receiving olanzapine. Which of the following findings should the nurse identify as an adverse effect of olanzapine?

Answer 10

Weight gain of 3lb in 2 weeks

Question 11

A client tells the nurse, “I have nothing left to enjoy in life. My children are grown and married.” The nurse replies, “I’m sure you are looking forward to having
Grandchildren.”
Which communication technique is the nurse using?

Answer 11

using denial

Question 12

A client with schizophrenia has recently begun a new medication, clozapine (Clozaril). About which potentially fatal side effect will the nurse teach the client?

Answer 12

Agranulocytosis

Question 13

A psychiatric nurse working on an inpatient unit receives a call asking if an individual has been a client in the facility. Which nursing response reflects appropriate legal
and ethical obligations?

Answer 13

The nurse refuses to give any information to the caller, citing rules of confidentiality.

Question 14

Your patient is depressed. She has a sudden change of mood and becomes more interactive and bright. She begins talking about giving some of her possessions to friends and family. What should the nurse’s response be?

Answer 14

ask the patient if she has any thoughts about suicide

Question 15

The client understands dietary restrictions when taking MAOIs when the client makes which of the following statements?

Answer 15

“I should avoid foods that are high in the amino acid tyramine such as aged cheese, meats, and chocolate because this drug causes the level of tyramine to go up to dangerous levels.”

Question 16

Which information suggests caution is necessary in prescribing a benzodiazepine to an anxious client?

Answer 16

the client has a hx of alcohol dependence

**sedation

Question 17

A nurse is providing education on anxiety and stress management. Which of the following should be identified as the most important initial step in learning how to manage anxiety?

Answer 17

awareness of factors creating stress

Question 18

According to a mental health diagnosis, in which axis would borderline personality disorder be located?

Answer 18

Axis II

Question 19

Which client statement alerts the nurse that the client may be responding maladaptively to stress?

Answer 19

avoiding contact w others help me cope

Question 20

A client began taking lithium for the treatment of bipolar disorder approximately 1 month ago and asks why he has gained 12 pounds since then. Which is the most appropriate nursing response?

Answer 20

“Weight gain is a common, but troubling side effect. Let’s talk about some strategies for safely improving your nutrition and exercise habits.”

Question 21

When the nurse asks that patient to describe their problem, what is the nurse actually assessing?

Answer 21

perception of the problem

Question 22

A nurse concludes that a restless, agitated client is manifesting a fight-or-flight response. The nurse understands the client’s response is associated with which neurotransmitter?

Answer 22

norepi

Question 23

Which statement reflects the therapeutic communication technique the nurse should use when communicating with a client who is experiencing auditory hallucinations?

Answer 23

I understand that the voice seem real to you, but i do not hear any voices

Question 24

A client diagnosed with major depressive disorder asks, “What part of my brain controls my emotions?” Which nursing response is best?

Answer 24

The limbic system

Question 25

A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse’s station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?

Answer 25

you must be very upset about something

Question 26

In which axis would you find that a patient has no support system?

Answer 26

Axis IV

Question 27

When a patient is physically being moved by the mental health professionals, this is considered to be which type of restraint?

Answer 27

Physical restraint

Question 28

When used in combination with anxiolytic medication, alcohol leads to ____ effects and caffeine leads to ____ effects.

Answer 28

increase; decrease

Question 29

A client was admitted with a single episode of major depression that was moderate. During her stay, she was started on Prozac (fluoxetine) at 40 mg PO qd. The nurse’s discharge teaching should include all of the following except:

Answer 29

u can discontinue prozac (ssri) when u feel better

answer: avoid tyramine foods: beer, beans, processed meats, and red wine

Question 30

When caring for a Schizophrenic who is receiving Risperdal (risperidone), the nurse is aware that this medication is likely to have which possible long-term effect on the client?

Answer 30

A potential for gynecomastia

** Rise a pair

Question 31

An instructor is teaching nursing students about neurotransmitters. Which term best explains the process by which neurotransmitters released into the synaptic cleft return to the presynaptic neuron?

Answer 31

Reuptake

Question 32

While reviewing laboratory results of a newly admitted client, the nurse discovers that the client’s thyroid stimulating hormone (TSH) levels are elevated. The nurse anticipates the client will exhibit which symptoms?

Answer 32

depression & fatigue

Question 33

What is the most important nursing intervention when restraining an aggressive client?

Answer 33

Check correct application if the restraints

Question 34

. A patient asks the nurse why he has to attend therapy and not just take his prescribed antidepressant medication for his depression. Which is the most therapeutic response?

Answer 34

Stating, “Medications help your brain function better, but the therapy helps you achieve lasting behavior change.”

Question 35

A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean clothes, and with combed and styled hair. Which of the following responses by the nurse is therapeutic?

Answer 35

“I see you have some grooming today”

Question 36

A nurse is reviewing the medical histories of four clients. Which of the following clients may develop extrapyramidal symptoms (EPS) from medication therapy?

Answer 36

A client who has schizophrenia and is taking

antipsychotic medication

Question 37

A school nurse is assessing a female high-school student who is overly concerned about her appearance. The client’s mother states, “That’s not something to be stressed about!” Which response by the nurse is best?

Answer 37

Stress can be psychological. A threat to self-esteem may result in high stress levels.”

Question 38

A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the first priority?

Answer 38

Assign a staff member stay with the client at all times

Question 39

A nurse is caring for a client who has schizophrenia and generalized anxiety disorder. The client has a prescription for alprazolam 0.25 mg PO every 8 hr PRN anxiety. For which of the following client statements should the nurse consider administering alprazolam?

Answer 39

The client states “my heart is pounding out of my chest”

**anxiety

Question 40

When is the short-term use of restraints permitted?

Answer 40

Only when the client is imminently aggressive and dangerous to themselves or others.

Question 41

Which part of the nervous system should the nurse identify as playing a major role during stressful situations?

Answer 41

Sympathetic nervous system

**StreSS

Question 42

The patient has a lithium level of 1.2 mEq/L. Which intervention is appropriate?

Answer 42

No intervention is necessary at this time

normal is: 0.6-1.2

Question 43

A physician prescribes an additional medication for a client taking an antipsychotic agent. The medication is to be administered “prn for EPS.” Which is the most appropriate nursing assessment to determine when to give this medication?

Answer 43

When the client exhibits tremors and a shuffling gait

Question 44

A client with depression and substance abuse has an interrupted sleep pattern. She demands that her psychiatrist prescribe her a sedative. Which teaching should the nurse provide about the rationale for the use of
nonpharmacological interventions instead?

Answer 44

“Sedative-hypnotics are potentially addictive and gradually lose their effectiveness as one builds up tolerance to them.”

Question 45

As part of discharge teaching, which guideline regarding lithium therapy will the nurse plan to include?

Answer 45

1. Avoid excessive use of beverages containing caffeine.
2. Maintain a consistent sodium intake.
3. Consume at least 2,500 to 3,000 mL of fluid per day. 4. All of the above

Question 46

Which medication is most likely to be prescribed for the extrapyramidal side effects of antipsychotic
medications?

Answer 46

Benztropine (Cogentin)

Question 47

The nurse’s patient states “it has been so long since I have seen my family”. How can the nurse use the therapeutic communication technique of RESTATING?

Answer 47

“you say you haven’t seen your family in a while”

Question 48

Education for the client who is taking MAOI’s should include which of the following?

Answer 48

tyramine-restricted diet, prohibitive concurrent use of over the counter medications without physician notification.

Question 49

A nurse administers 100 percent oxygen to a client during and after electroconvulsive therapy treatment (ECT). What is the rationale for this procedure?

Answer 49

To prevent anoxia due to medication-induced paralysis of respiratory muscles

Question 50

A client with depression asks, “why are they checking my thyroid function when I clearly have depression, and I’m not overweight?” Which of these is an accurate response?

Answer 50

Thyroid hormone replacement is a first-line treatment for most clients with depression.

• An underactive thyroid gland can manifest as depression.

Question 51

What signs and symptoms must patients with Major

Depressive Disorder have to report in order to be given that diagnosis?

Answer 51

Sleep disturbances, lack of interest in activities,
appetite changes, psychomotor retardation

SIGECAPS

Question 52

What is a true statement regarding suicide contracts?

Answer 52

“There’s no demonstrated benefit of no-suicide

contracts, though they’re not believed to be harmful.”

Question 53

When planning care for a depressed client, which correctly written outcome should be a nurse’s first priority?

Answer 53

The client will remain safe during hospital stay

Question 54

What is a true statement regarding ECT therapy?

Answer 54

It effectively treats severe depression

Question 55

What statement is true regarding SSRI medications designed to treat symptoms of depression?

Answer 55

They have an increase risk for suicidal thoughts

Question 56

In order to be diagnosed with major depressive disorder, what time frame criteria has to be met?

Answer 56

2 weeks “2 blue weeks”

Question 57

A client diagnosed with Schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should the nurse expect a physician to order to address this type of symptom?

Answer 57

Risperidone (Risperdal)

Question 58

A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania?

Answer 58

The client responds to questions with disorganized speech

DIGFAST

Question 59

.Which medication should the nurse anticipate for a client who has a history of a complicated withdrawal of benzodiazepine?

Answer 59

Chlordiazepoxide (Librium) and phenytoin

Dilantin

Question 60

A nurse evaluates a client’s patient-controlled analgesia (PCA) pump and notices 100 attempts within 30 minutes period. Which Is the best rationale for assessing this client for substance addiction?

Answer 60

Clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require INCREASED doses to achieve effective pain control.

Question 61

A client with a history of heavy alcohol use us brought to an emergency department (ED) by family members who states that the client has had nothing to drink in the last 48 hours. When the nurse reports to the ED physician, which client symptoms should be the nurse’s first priority

Answer 61

bp 180/100

Question 62

A client is diagnosed with schizophrenia spectrum disorder is prescribed clozapine. Which client symptoms related to the side effect of this medication should prompt a nurse to intervene immediately?

Answer 62

Sore throat, fever, and malaise

** agranulocytosis-> risk of infection

Question 63

Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnoses with schizophrenia spectrum disorder?

Answer 63

Being reliable, honest, and consistent during

interactions

Question 64

When planning care for a depressed client, which correctly written outcome should be a nurse’s first priority?

Answer 64

The client will remain safe during hospital stay

Question 65

A family member is seeking advice about an older parent who seems to worry unnecessarily about everything. The family member states, “should I seek psychiatric help for my mother”. Which is an appropriate nursing response?

Answer 65

“Anxiety is considered abnormal when it is out of proportion to the stimulus causing it and when it impairs functioning.”

Question 66

Without authorization, a nurse administers an extra dose of narcotic tranquilizer to an agitated client. The nurse’s coworker observes this action but does nothing for fear of retaliation. What is the ethical interpretation of the coworker’s lack of involvement?

Answer 66

Taking no action is still considered an unethical action by the coworker.

Question 67

Which client statement indicates a knowledge deficit related to a substance use disorder?

Answer 67

“Marijuana is like smoking cigarettes. Everyone

does it. It’s essentially harmless.”

Question 68

A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse, “I should have died because I am totally worthless”. Which of the following responses should the nurse make?

Answer 68

“You’ve been feeling that your life has no meaning.”

Question 69

Which information suggests caution is necessary in prescribing a benzodiazepine to an anxious client?

Answer 69

The client has a history of alcohol dependence.

Question 70

A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD), which of the following actions should the nurse take first?

Answer 70

Identify precipitating factors for ritualistic behaviors.

Question 71

A highly agitated client paces the unit and sates, “ I could buy and sell this place” the client’s mood fluctuates from fits to laughter to outburst of anger. Which is the most accurate documentation of the client’s behavior?

Answer 71

“Agitated and pacing. Exhibiting grandiosity. Mood labile.”

Question 72

What is the rationale for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive episode?

Answer 72

Depression can generate somatic symptoms that can

mask actual physical disorders.

Question 73

A nurse is caring for a client who is schizophrenia and tells the nurse, “they lie about me all the time and they are trying to poison my food” which of the following statements should the nurse make?

Answer 73

“You seem to be having very frightening thoughts.”

Question 74

A client is diagnosed with schizophrenia spectrum disorder. A physician orders haloperidol (Haldol) 50mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10mg HS. Which client behavior would warrant the nurse to administer benztropine?

Answer 74

Restlessness and muscle rigidity

Question 75

A client diagnosed with bipolar 1 disorder is exhibiting severe maniac behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client’s spouse asks the nurse how Zyprexa works. Which is the appropriate nursing response?

Answer 75

Zyprexa calms hyperactivity until the Eskalith takes effect.”

Question 76

A nurse is reviewing a medical record of a client who has schizophrenia and is receiving olanzapine, which if the following findings should the nurse identify as an adverse effect of olanzapine?

Answer 76

Weight gain of 3 lbs in 2 weeks

Question 77

A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address?

Answer 77

command hallucinations

Question 78

What is a true statement regarding ECT therapy?

Answer 78

Patient’s report decreased short-term memory as a side effect of the tx.

Question 79

The client states “I get into trouble because I respond violently without thinking. That usually gets me in a mess” which nursing reply is most therapeutic?

Answer 79

“Let’s explore methods to help you stop and think before taking action.”

Question 80

Which statement should the nurse identify as correct regarding a client’s right to refuse treatment?

Answer 80

Professionals can overridetreatment refusal if the client is actively suicidal or homicidal

Question 81

A school nurse is talking with a 13-year-old female at her annual health screening visit. Which of the following comments made by the adolescent should be the nurse’s priority to address?

Answer 81

“None of the kids at this school like me, and I don’t like them either.”

Question 82

A nurse is admitting a client who has been diagnosed with PTSD. Which of the following symptoms might the nurse expect to access? Select all that applies

Answer 82

1.Feelings of guilt that precipitate social isolation 2.Aggressive behavior that affects job
performance
3.Relationship problems
4.High levels of anxiety

Question 83

A patient treated for symptoms of PTSD following a shotting incident at a local elementary school reports, “I feel like there’s no reason to go on living when so many others died” which is the most appropriate response by the nurse now?

Answer 83

“Are you having thoughts of hurting or killing yourself?”

Question 84

A military veteran who recently returned for active duty in the Middle Eastern country and suffers for PTSD states he will not allow that laboratory technician who is Iranian to draw his blood. The patient states, “he will probably use a
contaminated needle on me” which of these is the most appropriate nursing response by the nurse?

Answer 84

“Let me see if I can arrange for a different technician to draw your blood.”

Question 85

A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for this client?

Answer 85

A private room in a quite location on the unit

Question 86

A client began taking lithium for treatment of bipolar disorder approximately 1 month ago and asks why he has gained 12 pounds since then. Which is the most appropriate nursing response?

Answer 86

“Weight gain is a common, but troubling side effect. Let’s talk about some strategies for safely improving your nutrition and exercise habits.

Question 87

A woman comes to an emergency department with a broken nose and multiple bruises after being beaten by her husband. “the beatings have been getting worse and I’m afraid next time he will kill me” which is the appropriate nursing response?

Answer 87

“Let’s talk about your options so that you don’t have to go home.”

Question 88

A client has been diagnosed with major depressive episode. After treatment with fluoxetine (Prozac), the client exhibits pressured speech and flight of ideas. Based on this symptom change, which physician action would the nurse anticipate?

Answer 88

Discontinue the fluoxetine and rethink the client’s diagnosis.

Question 89

A male nurse is assigned to care for a female client who was admitted to the hospital for treatment of injuries following a domestic abuse incident. The client tells the nurse manager she does not want a male nurse as her caregiver. Which of the following nursing responses should then nurse manager make?

Answer 89

I can review the assignments and arrange for a female nurse to care for you

Question 90

A nurse is planning care for a client diagnosed with bipolar disorder, manic episode. In which order should the nurse prioritize the client outcomes in the exhibit?

Answer 90

Choices: 1. Maintain nutritional status, 2. Interacts appropriately with peers, 3. Remain free from injury, 4. Sleeps 6 to 8 hours a night 
ANSWER:
3. remain free of injury 
1. maintain nutritional status 
4. sleep 6-8 hrs a night 
2. interacts appropriately with peers

Question 91

A nurse reports an incidence of suspected child abuse. One of the parents of the child becomes upsets and demands to know the reason for the nurse’s action. Which of the following responses by the nurse is appropriate?

Answer 91

“as a nurse, i’m required by law to report suspected child abuse.”

Question 92

A client diagnosed with schizophrenia spectrum disorder
tells a nurse about voices commanding him to kill the president. Which is the priority nursing diagnosis for this client?

Answer 92

Risk for violence: directed toward others

Question 93

A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements.

Answer 93

“In my dreams, all I can see are the wounded reaching out and trying to grab me.”

Question 94

A cab driver stuck in traffic becomes lightheaded, tremulous, diaphoretic and dyspneic because his boss told him that if he didn’t make it back on time to the station he would be fired. A workup in the emergency department reveals no pathology. Which medical diagnosis should the nurse suspect and what nursing diagnosis should be then nurse’s first priority?

Answer 94

Panic disorder and a nursing diagnoses of anxiety

Question 95

The client understands dietary restrictions when taking MAOIs when the client makes which of the following statements?

Answer 95

“I should avoid foods that are high in the amino acid tyramine such as aged cheese, meats, and chocolate because this drug causes the level of tyramine to go up to dangerous levels.”

Question 96

A nurse is caring for a client who has major depressive disorder and is scheduled for electroconvulsive therapy
(ECT). The client’s spouse asks the nurse about the possible side effects of ECT. Which of the following responses should the nurse make?

Answer 96

The main side effects are temporary and may include some mild confusion, a headache, and short term memory loss

Question 97

A nurse is caring for a client who has major depressive disorder and is scheduled for electroconvulsive therapy
(ECT). The client’s spouse asks the nurse about the possible side effects of ECT. Which of the following responses should the nurse make?

Answer 97

The main side effects are temporary and may include some mild confusion, a headache, and short term memory loss

Question 98

Which of the following medications could be used to decrease aggression by dampening excessive noradrenergic activity ?

Answer 98

Beta blockers (end in -lol)

Question 99

Sammy is diagnosed with a trauma disorder and is being treated at an inpatient psychiatric unit, what nursing short term goal is most appropriate for Sammy?

Answer 99

Sammy demonstrates three relaxation

techniques upon discharge.

Question 100

A kindergarten student is frequently violent towards other children. The school nurse notices bruises and burns on the child’s face and arms. Which are other symptoms should indicate to the nurse that the child may have been physically abused?

Answer 100

The child shrinks at the approach of adults.

Question 101

Sandy, a rape survivor, is being treated for PTSD, which of these statements are good indication sandy is beginning to recover from PTSD?

Answer 101

“This traumatic event immobilized me for awhile, but I have found imagery helpful in reducing my anxiety.”

Question 102

An adult client assaults another client and is placed in restraints. Which client statement alerts the nurse that a further assessment is necessary?

Answer 102

My fingers are tingly.”

Question 103

A nurse is caring for four clients. Which client does the

nurse identify is least prone to developing problems with anger or aggression?

Answer 103

An adolescent raised by Scandinavian immigrant parents

Question 104

The client states, “ I get into trouble because I respond violently without thinking that usually gets me into a mess.” Which nursing reply is most therapeutic

Answer 104

“Let’s explore methods to help you stop and think before taking action.”

Question 105

When planning care for a client diagnosed with BPD, which self-harm behavior should the nurse expect the client to exhibit?

Answer 105

The use of suicidal gestures to evoke a rescue response from others

Question 106

A client’s altered body image is evidenced by claims of “feeling fat” even though the clients emaciated. Which is the appropriate outcome criterion for this client’s problem?

Answer 106

The client will perceive an ideal body weight and shape as normal

Question 107

A client diagnosed with NCD due to Alzheimer’s disease
can no longer ambulate, does not recognize family members, and communicates with agitated behaviors and incoherent verbalization. The nurse recognizes that these symptoms indicate which stage of illness?

Answer 107

Late stage

Question 108

A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

Answer 108

Affective flattening

Question 109

A nurse in the emergency department is implementing a plan of care for an older adult who is experiencing delirium tremens. Which of the following actions should the nurse take first?

Answer 109

Raise the bed side rails (risk for falls)