Test 2

Question 1

A client is brought to the emergency department stating, “I’m scared because the Federal Bureau of Investigation is now tapping my home phone, and I can hear them talking between my two telephones during the night.” The client’s eyes dart around the room while the nurse is trying to interview the client, and the client is tapping the client’s fingers on the table. Which action should the nurse prioritize?

A. Reassure the client that the client is in a safe place where the client will be helped.
B. Speak with the client about calling members of the client’s family to come in.
C. Give the haloperidol IM to reduce the client’s paranoia.Give the haloperidol IM to reduce the client’s paranoia.
D. Assess the client’s family for dysfunctional dynamics

Answer 1

A. Reassure the client that the client is in a safe place where the client will be helped.Reassure the client that the client is in a safe place where the client will be helped.

Question 2

A nurse is caring for a client diagnosed with schizophreniform disorder. The nurse demonstrates understanding of this disorder when identifying that the client is at risk for developing what?

A. Substance use disorder
B. Major depression
C. Schizophrenia
D. Personality disorder

Answer 2

C. Schizophrenia

Question 3

What interventions does the nurse use to promote therapeutic communication with the client diagnosed with obsessive-compulsive disorder (OCD)?

A. Ask the client to avoid discussing ritualistic behaviors with friends.
B. Explain to the client that anxiety is irrational.
C. Explore the thoughts and feelings that trouble the client.
D. Inform the client that these thoughts cannot be controlled

Answer 3

C. Explore the thoughts and feelings that trouble the client.

Question 4

A client with schizophrenia is receiving antipsychotic therapy. The nurse understands that which is a medical emergency should it develop in the client?

A. Neuroleptic malignant syndrome
B. Akathisia
C. Parkinsonism
D. Tardive dyskinesia

Answer 4

A. Neuroleptic malignant syndrome

Question 5

Which statement made by a client raises the greatest concern that the client may be experiencing intimate partner violence?

A. I don’t know what else I can do to keep my partner from getting angry at me.”
B. “My partner doesn’t like it when I go out with my friends.”
C. “My partner was so much nicer when we started dating.”
D. “My partner’s parent physically abused the spouse for years.”

Answer 5

A. I don’t know what else I can do to keep my partner from getting angry at me.”

Question 6

The nurse is educating a client that is experiencing mild anxiety. Which statement made by the client indicates that the education is effective?

A. “There are no physical symptoms with anxiety.”
B. “I need to eliminate all of the stress in my life.”
C. “I need to take medication for my anxiety every day.”
D. “Some degree of anxiety is beneficial for learning.”

Answer 6

D. “Some degree of anxiety is beneficial for learning.”

Question 7

A client is diagnosed with a delusional disorder. While providing care to the client, the nurse assesses the client’s delusions. Which would be least appropriate for the nurse to do?

A. Try to change the client’s delusional belief
B. Determine the impact of the delusion on the client’s safety
C. Evaluate the significance to the client
D. Avoid dwelling on the delusion

Answer 7

A. Try to change the client’s delusional belief

Question 8

A client brought to the outpatient department by a family member is diagnosed with obsessive-compulsive disorder (OCD). What characteristic of OCD does the nurse expect to find during the assessment of the client?

A. Increase in the amount of time spent with the family.
B. Reduced body and mind coordination.
C. Decrease in the level of intelligence.
D. Rituals that interfere with occupational function.

Answer 8

D. Rituals that interfere with occupational function.

Question 9

The nurse is assessing a client with anxiety. Which behavior might indicate that the client has moderate anxiety?

A. The client has impaired cognitive skills.
B. The client is focused in an activity.
C. The client is unable to communicate verbally.
D. The client is nervous and agitated.

Answer 9

D. The client is nervous and agitated.

Question 10

What does the nurse find on assessment of the thought processes of a client with obsessive-compulsive disorder (OCD)?

A. The client’s intellectual functioning is deteriorating.
B. The client has gradual memory loss.
C. The obsessions become intense as the client tries to stop the behavior.
D. Obsessions occur when the client is not engaged in an activity.

Answer 10

C. The obsessions become intense as the client tries to stop the behavior.

Question 11

A nurse is planning a presentation to a group of nursing students on the topic of anxiety disorders. Which statement would the nurse include when describing panic disorder?

A. “Typically, individuals experience this disorder after the age of 30 years.”
B. “Persons rarely have an underlying comorbid condition of depression.”
C. “People with panic attacks often have fewer attacks if they also have agoraphobia.”
D. “Individuals may believe that they are having a heart attack when a panic attack occurs.”

Answer 11

D. “Individuals may believe that they are having a heart attack when a panic attack occurs.”

Question 12

A client has been prescribed clozapine for schizoaffective disorder (SCA) with depression. The nurse should explain to the client that one advantage of clozapine is that it can provide what?

A. Reduction of hospitalizations and risk for suicide
B. Cost savings
C. Combination with lithium for greater effect
D. Weight loss

Answer 12

A. Reduction of hospitalizations and risk for suicide

Question 13

A client is late for work every day because the client spends about 20 minutes checking and rechecking the lights and water taps before leaving home. What kind of behavior does the nurse understand is exhibited by the client?

A. The client is particular about resource management.
B. The client is exhibiting attention-seeking behavior.
C. The client is trying to reduce anxiety by repeating specific tasks.
D. The client is intentionally reporting late to work.

Answer 13

C. The client is trying to reduce anxiety by repeating specific tasks.

Question 14

A client is watching the news and tells the nurse that the newscaster is sending a message to the client. What term is used to identify this symptom?

A. Delusion
B. Hallucination
C. Idea of reference
D. Flight of idea

Answer 14

C. Idea of reference

Question 15

Assessment of violence potential is an important part of nursing care on the inpatient unit. Which is an indicator that the client with schizophrenia may be at high risk for violence while in the hospital?

A. The client is suspicious of the nursing staff.
B. The client has never used substances or alcohol.
C. The client reports feeling that everyone on the unit is “out to get me.”
D. The client assaulted an officer prior to admission.

Answer 15

D. The client assaulted an officer prior to admission.

Question 16

The community health nurse meets with the family members of an older adult client that will be living with them, since the client is no longer able to live alone. Which will the nurse include in the plan of care as a preventive measure against older adult abuse?

A. Reassure the primary caregiver that they are in the best position to provide care to the client.
B. Provide the primary caregiver with resources to meet the client’s needs.
C. Assist in the transfer of legal authority for care to the primary caregiver.
D. Teach the primary caregiver skills to meet all of the client’s needs.

Answer 16

B. Provide the primary caregiver with resources to meet the client’s needs.

Question 17

One of the primary goals in caring for the client with schizophrenia is to establish clear, consistent, open communication. Which nursing intervention would be most effective in accomplishing this goal?

A. Arrange for the client to go home as soon as possible on a day pass.
B. Supervise all of the client’s activities of daily living.
C. Assist the client to do at least one physical activity each day.
D. Present reality in clear, simple language, and demonstrate patience.

Answer 17

D. Present reality in clear, simple language, and demonstrate patience.

Question 18

A client with a persecutory delusion has been explaining to the nurse the specifics of the conspiracy against the client. The client pauses and says, “I get the feeling that you don’t actually believe that what I’m telling you is true.” How should the nurse respond?

A. “What makes you think that I don’t believe you?”
B. “What you’re telling me is difficult for me to believe. This may be real for you, but not me.”
C. “What’s important to me is that it’s real for you.”
D. “The conspiracy that you’re explaining to me is actually a delusion.”

Answer 18

B. “What you’re telling me is difficult for me to believe. This may be real for you, but not me.”

Question 19

A client has been taking haloperidol for 5 years when the client is admitted to the inpatient unit for relapse of symptoms of schizophrenia. Upon assessment, the client demonstrates akathisia, dystonia, a stiff gait, and rigid posture. The nurse correctly identifies these symptoms are indicative of what?

A. Progressed schizophrenia
B. Extrapyramidal side effects
C. Psychosis
D. Tardive dyskinesia

Answer 19

B. Extrapyramidal side effects

Question 20

A nursing student is preparing to care for a client diagnosed with schizophrenia. When interacting with the client, the student notices that the client is highly suspicious and guarded, stating, “They’re out to get me.” The student identifies this as what?

A. Autistic thinking
B. Stilted language
C. Pressured speech
D. Paranoia

Answer 20

D. Paranoia

Question 21

A client states, “I will just die if I don’t get this job.” The nurse then asks the client, “What will be the worst that will happen if you don’t get the job?” Which outcome does the nurse attempt to achieve?

A. Clarify the client’s meaning
B. Assess whether the client has health problems compounded by stress
C. Assist the client to make alternative plans for the future
D. Help the client appraise their situation more realistically

Answer 21

D. Help the client appraise their situation more realistically

Question 22

During the admission assessment of a 27-year-old client who has been diagnosed with an anxiety disorder, the nurse observes that the client is becoming increasingly restless and agitated. How should the nurse respond to this development?

A. Provide education regarding the level of anxiety that the client may be experiencing.
B. Explain to the client that the client’s current feelings of anxiety have the potential to foster better coping skills in the future.
C. Increase the speed of the assessment in order to ensure that it is completed sooner and inform the client that the nurse is doing so.
D. Inform the client that the assessment can be postponed if the client is finding it overwhelming.

Answer 22

D. Inform the client that the assessment can be postponed if the client is finding it overwhelming.

Question 23

An emergency department nurse is caring for client who was involved in a house fire and who is crying hysterically and stating, “I can’t believe this has happened!”. The client has a third-degree burn on their left arm. What is the nurse’s priority intervention for the client?

A. Assess the extent of the burns.
B. Maintain a calm presence.
C. Assess the client’s support system.
D. Assess the client’s mental status.

Answer 23

A. Assess the extent of the burns.

Question 24

An adult client being admitted to the psychiatric-mental health unit is experiencing severe anxiety. What is the nurse’s priority action for the client?

A. Encourage the client to problem solve.
B. Leave the client alone.
C. Teach relaxation techniques.
D. Decrease the client’s anxiety level.

Answer 24

D. Decrease the client’s anxiety level.

Question 25

A nurse is caring for a client who is being treated in the emergency department for a panic attack. Which nursing intervention would be most appropriate? A. The nurse tells the client that they must leave to go report the client's symptoms to the psychiatrist on duty. B. The nurse demonstrates empathy for the client by trying to mimic the client's state of anxiety. C. The nurse tells the client that this is an acute exacerbation with a positive prognosis and low morbidity. D. The nurse stays with the client, emphasizing safety and that the nurse will remain with the client.

Answer 25

D. The nurse stays with the client, emphasizing safety and that the nurse will remain with the client.

Question 26

After an angry outburst, the client is tearful and remorseful. Which statement by the nurse would be most supportive? A. "You should not have let your anger build up like it did." B. "I will not allow you to get that angry again." C. "What could you have done when you first started to feel angry?" D. "You still need to work on your problem-solving skills."

Answer 26

C. "What could you have done when you first started to feel angry?"

Question 27

Which client behavior does the nurse recognize as being an initial part of the trigger phase of the aggression cycle? A. Client loudly verbalizes guilt and remorse. B. Client is overreacting to minor stimuli. C. Client paces with fists clenched. D. Client throws a chair across the room.

Answer 27

B. Client is overreacting to minor stimuli.

Question 28

A client being seen in the clinic was having visual hallucinations 8 weeks ago during a crisis. The client’s history includes depression and anxiety. Which assessment is most important for the nurse to conduct? A. Assess the client’s activities of daily living. B. Assess for the presence of hallucinations. C. Assess the client’s mood. D. Assess the client’s appearance.

Answer 28

B. Assess for the presence of hallucinations.

Question 29

How does the nurse help to decrease anxiety and build confidence in a client with obsessive-compulsive disorder? A. Help the client find alternative methods to deal with anxiety. B. Provide the client with a quiet and dimly lit room. C. Provide opportunities to perform tasks usually avoided by the client. D. Permit minimal interactions with other clients during the therapy.

Answer 29

A. Help the client find alternative methods to deal with anxiety.

Question 30

During an interview, a rape victim says, "I don’t think of anything else but the incident. I think I have had enough problems in life and there is no purpose for my life, either. Now all I need is to go back to the Lord Almighty.” The nurse advises the client to be admitted in the psychiatric facility. What would be the reason for the nurse to ask the client to be admitted? A. The client may have negative feelings about the self. B. The client may be extremely depressed. C. The client may be unable to cope with the stress. D. The client may have suicidal ideation.

Answer 30

D. The client may have suicidal ideation.

Question 31

A client with schizophrenia is reluctant to take prescribed oral medication. Which is the most therapeutic response by the nurse to this refusal? A. "If you refuse these pills, you'll have to get an injection." B. "You know you have to take this medicine for your own good." C. "I can see that you're uncomfortable now, so we can wait until tomorrow." D. "What is it about the medicine that you don't like?"

Answer 31

D. "What is it about the medicine that you don't like?"

Question 32

A client who has a major depressive episode tells a nurse that, for the past 2 weeks, the client has been hearing voices and at times thinks that they are being followed. History reveals that the client had these alternating symptoms before. The client also has experienced time with neither of these symptoms and has been able to function adequately. The nurse interprets these findings as suggesting which condition? A. Undifferentiated schizophrenia B. Schizoaffective disorder C. Brief psychotic disorder D. Paranoid schizophrenia

Answer 32

B. Schizoaffective disorder

Question 33

The nurse is preparing to interview a female client who is a victim of intimate partner violence (IPV). Which action would the nurse take to establish rapport with the client? A. Express personal feelings about the situation. B. Focus on current injuries. C. Start with the least sensitive area. D. Question explanations about the event.

Answer 33

C. Start with the least sensitive area.

Question 34

A hospitalized client diagnosed with schizophrenia is receiving antipsychotic medications. While assessing the client, a nurse identifies signs and symptoms of a dystonic reaction. Which agent would the nurse expect to administer? A. Propranolol B. Aripiprazole C. Risperidone D. Diphenhydramine

Answer 34

D. Diphenhydramine

Question 35

The family members of a military veteran are distraught that the client has withdrawn from them emotionally after returning home from a tour of duty. What is the nurse's most appropriate action? A. Educate the family about the usual emotional responses to returning home from military service B. Organize a family meeting where family members can tell the client how they feel C. Educate the family about the relationship between hyperarousal and emotional distance D. Assess the client for signs and symptoms associated with post-traumatic stress disorder

Answer 35

D. Assess the client for signs and symptoms associated with post-traumatic stress disorder

Question 36

The nurse provides education to a group regarding the physiologic response to acute stress. Which participant statement indicates a need for additional teaching? A. “My blood glucose will likely increase to provide additional energy.” B. “My heart rate and respiratory rate will likely be increased.” C. "My blood pressure will likely decrease.” D. “I will be less likely to bleed if I experience a cut.”

Answer 36

C. "My blood pressure will likely decrease.”

Question 37

A frightened young female calls the emergency department and tearfully tells the nurse, “I've been raped! Please help me!” Before telling the client what to do, the nurse would need to know if A. If the client had bathed, douched, or changed clothes B. If the client was injured, was in a safe place, and had transportation available C. If the client has insurance, if they could get to the hospital by themself, and if pregnancy is a possibility D. If the client knew their assailant, knew their own location, and had notified the police

Answer 37

B. If the client was injured, was in a safe place, and had transportation available

Question 38

The nurse is assessing a 6-year-old child suspected of being emotionally abused. Which assessment finding should the nurse further investigate related to potential emotional abuse? A. The nurse assesses inconsistent development and mild language delays. B. The child lives with a single parent who is often busy but ensures the child's basic needs are met. C. Despite attending day care regularly, the child appears withdrawn but engages when prompted. D. During the exam, the child appears anxious and avoids interaction with adults.

Answer 38

D. During the exam, the child appears anxious and avoids interaction with adults.

Question 39

A nursing instructor teaching about sexual assault identifies a need for further instruction when one of the students makes which statement? A. "Fondling can be a type of sexual assault." B. "Sexual assault occurs about once every 2 minutes in the United States." C. "It is not considered rape if it occurs with same-sex couples." D. "Sexual assault involves nonconsenting sexual activity."

Answer 39

C. "It is not considered rape if it occurs with same-sex couples."

Question 40

In which phase of the aggression cycle is the client removed from restraint or seclusion as soon as they meet the behavioral criteria? A. Postcrisis B. Escalation C. Crisis D. Triggering

Answer 40

A. Postcrisis

Question 41

The nursing student learning about intimate partner violence correctly identifies its prevalence in same-sex couples as what? A. Twice as often as in heterosexual couples B. Same frequency as in heterosexual couples C. Half as frequent as in heterosexual couples D. Three times more frequent as in heterosexual couples

Answer 41

B. Same frequency as in heterosexual couples.

Question 42

When assessing a client's potential for aggression and violence, which would the nurse identify as the most important predictor? A. family dysfunction B. legal problems C. gender D. limited coping skills

Answer 42

D. limited coping skills

Question 43

A client with schizophrenia is prescribed clozapine. The nurse would monitor the client closely for specific signs of: A. weight loss. B. nausea. C. infection. D. hypotension.

Answer 43

C. infection.

Question 44

A client with schizophrenia is attending a follow-up appointment at the community mental health clinic. The client reports to the nurse, "I stopped taking the antipsychotic medication because I can't get an erection with my partner anymore." Which response by the nurse will enhance the client's well-being? A. "It is important for you to take an antipsychotic medication, but perhaps a different type will be less likely to affect your sexual functioning. I would like to call your health care provider about this." B. "You should avoid having sex with your partner anyway. Do you really want them to get pregnant?" C. "It sounds like that is a problem for you. Don't you still find them to be sexy enough?" D. "Sexual dysfunction is a temporary side effect and should get better once your body is used to the medication."

Answer 44

A. "It is important for you to take an antipsychotic medication, but perhaps a different type will be less likely to affect your sexual functioning. I would like to call your health care provider about this."

Question 45

The client has been diagnosed with schizophrenia. Which element(s) indicate to the nurse the presence of avolition? Select all that apply. A. lack of ambition B. unkept appearance C. incapable of decisions D. paranoid delusions E. persistent anergia

Answer 45

A. lack of ambition B. unkept appearance C. incapable of decisions E. persistent anergia

Question 46

All except which are considered clinical symptoms of anxiety? A. Motor excitement B. Extreme restlessness C. Tearfulness and sadness D. Palpitations

Answer 46

C. Tearfulness and sadness

Question 47

Which has not been proposed as a potential mechanism for the etiology of thought disorders? A. Hemispheric brain dysfunction B. Dysregulation of neurotransmitter systems C. Genetic predispositions D. Neglect in childhood

Answer 47

D. Neglect in childhood

Question 48

A client experiences panic attacks when confronted with riding in elevators. The nurse is teaching the client ways to relax while incrementally exposing the client to getting on an elevator. Which technique will the nurse employ to assist the client with overcoming the phobia? A. Flooding B. Combination therapy C. Systematic desensitization D. Cognitive restructuring

Answer 48

C. Systematic desensitization

Question 49

The inpatient psychiatric nurse removes the restraints from a client who had an aggressive episode earlier and is currently calm and rational. The client asks if they can attend the group. Which response demonstrates insight into the postcrisis phase of anger and aggression? A. Recommend the client wait another day before interacting with their peers. B. Tell them they can attend but have a staff member stand next to them. C. Encourage the client to attend with the expectation that they will remain nonaggressive. D. Remind the client that if they are aggressive, they will be asked to leave.

Answer 49

C. Encourage the client to attend with the expectation that they will remain nonaggressive.

Question 50

A client begins to exhibit hallucinations and delusions along with disorganized speech after forgetting to take antipsychotic medication. The nurse suspects that the client is at which point in the clinical course of the disorder?

Answer 50

Relapse