PSYCIATRIC NURSING WORKBOOK D. Monitoring vital signs before, during, and after the 11.

re, during, and after the 11. A client diagnosed with major depressive disorder has the
procedure nursing diagnosis of Disturbed sleep pattern.When developing a
1. A client reports becoming involved with legislation that plan of care for this client, the following actions are appropriate
promotes gun safety after the death of a child by accidental 6. What situation must occur prior to initiating treatment with except for one. Choose the exception. *
shooting. Which defense mechanism is the client exhibiting?  lithium carbonate to a patient with acute mania? * A. Reinforce reality thinking.
A. Identification A. Administration of benzodiazepine has been terminated. B. Determine sleep patterns prior to hospitalization.
B. Denial B. Room seclusion has proven ineffective in controlling the C. Discourage sleeping during the day.
C. Sublimation client’s behavior. D. Record and limit caffeinated drinks.
D. Intellectualization C. The client has been fasting for 12 hours. E. Encourage measures that aid in relaxation.
D. The client’s history and physical results, including
2. A client who had a suicidal attempt is being discharged laboratory results, are reviewed. 12. A nurse is assessing a client with dysthymia who reports
from the hospital. Which question asked by the nurse symptoms of depressed mood. Which of the following is an
assesses the learned prevention and future coping strategies 7. A nurse is teaching a client about prescription antidepressant essential feature of dysthymia? *
of the client? medications and the appropriate expectations when taking these. A. Chronically depressed mood for most of the day for at least
A. “Do you have the phone number of the suicide prevention Which statement by the nurse is correct? * 2 years
center?” A. “Your symptoms will subside about 72 hours after starting B. Recurrent thoughts of death
B. “What skills can you utilize if you experience problems the antidepressant medication.” C. Diminished ability to think or concentrate
again?” B. “Some common side effects of SSRIs are dry mouth, blurred D. Significant weight loss
C. “How did you try to kill yourself?” vision, and urinary retention.”
D. “Why did you think life wasn’t worth living?” C. “It is important to continue taking antidepressant medication 13. A nurse is developing a care plan for a client diagnosed with
even after you feel better.” bipolar disorder and includes the nursing diagnosis: Risk for
3. To which nursing diagnosis should nurse give the highest D. “The most potent antidepressant is fluoxetine.” imbalanced nutrition. This demonstrates that the nurse
priority when caring for a client with major depressive understands that clients diagnosed with bipolar disorder: *
disorder? 8. A nurse is reviewing diet restrictions with a client taking a A. have a greater risk for obesity.
A. Disturbed sleep patterns monoamine oxidase inhibitor (MAOI). Which of the following B. are compulsive eaters.
B. Risk for self-directed behavior will occur if the client does not adhere to the dietary C. often suffer from poor nutrition.
C. Powerlessness restriction? * D. take medications that can cause weight losss
D. Potential for spiritual distress A. Severe hypotension
B. Agranulocytosis 14. A client diagnosed with mania tells a nurse, “I think you’re
4. Which care setting is the most appropriate for a client who C. Explosive occipital headache very pretty. Maybe we could go to my room.” What would be
recently attempted suicide and continues to report suicidal D. Akathisia the most therapeutic response by the nurse? *
ideation?  A. “That’s not appropriate and I’m offended.”
A. A nursing home 9. Which intervention would establish a therapeutic relationship B. “I don’t have that kind of relationship with clients.”
B. An outpatient clinic with a client diagnosed with major depressive disorder? * C. “It’s time for occupational therapy.”
C. An inpatient mental health unit A. Invite the client to attend an exercise class. D. “Let’s walk down to the seclusion room.”
D. A community mental health center B. Ask the client to join others to watch a 2-hour movie.
C. Sit with the client in silence. 15. Which action should a nurse perform when caring for a
5. A new nurse is establishing a plan of care for a client D. Ask the client how his or her day should be scheduled. client experiencing agitation related to acute mania? *
scheduled for electroconvulsive therapy (ECT).Which action by A. Leave the client alone
the new nurse requires intervention from the nurse supervisor? * 10. A pregnant client diagnosed with depression asks the nurse B. Maintain a low level of stimuli in the client’s environment
A. Administering succinylcholine after the procedure to what other treatment options are available, besides taking C. Apply restraints to prevent the client from harming self or
decrease recovery time antidepressant medications. Which type of therapy should a others
B. Educating the client that experiencing confusion, tiredness, nurse recommend as an alternate treatment for depression? * D. Involve the client in group activities to provide structure
headache, muscle pain, or back pain after the procedure is A. Cognitive behavioral therapy
normal B. Client-centered therapy 16. A female client who is in a manic state emerges from her
C. Administering a short-acting barbiturate prior to the C. Gestalt therapy room topless while making sexual remarks and lewd gestures
procedure D. Therapeutic touch therapy
toward the staff and her peers. Which intervention should the B. Tell the client that the behavior is inappropriate. SOMATOFORM DISORDERS, SEXUALITY, EATING
nurse initiate first? * C. Escort the client to their room, with the assistance of other DISORDERS
A. Confront the client on the inappropriateness of her behavior staff.
and offer her a time out. D. Tell the client that their telephone privileges are revoked for 1. Which of the following interventions would help stop a
B. Ask the other clients to ignore her behavior; eventually she 24 hours. client’s binge eating due to her bulimia nervosa *
will return to her own room. A. Focus on dysfunctional family and peer relationships and
C. Approach the client in the hallway and insist that she go to 21. A manic client is placed in a seclusion room after an teach positive self-talk.
her own room immediately. outburst of violent behavior and physical assault on another B. Address the defense mechanism of projection and talk about
D. Quietly approach the client, escort her to her room, and client. Which intervention should the nurse include in her plan underlying conflicts.
offer help to get dressed. of care before seclusion? * C. Provide anger management counseling and later involve the
A. Remain silent because verbal interaction would be too client’s family in the treatment.
17. Which nursing action should the nurse plan when caring for stimulating. D. Discuss the binge-purge cycle and identify where the cycle
a client admitted and diagnosed with acute mania? * B. Tell the client that she will be allowed to come out when she could be interrupted.
A. Sustain conversations to improve the client’s concentration. can behave.
B. Teach the client and family about available community C. Inform the client that she is being secluded to help her 2. A client who confesses to binge eating was assessed by the
resources. regain her self-control. nurse. Which assessment should the nurse elicit from the
C. Help the family understand that anger directed at them is D. Ask the client if she understands why the seclusion is client? *
likely to escalate unless they confront the client’s behavior. necessary. A. Extreme restlessness
D. Provide finger foods that the client can carry while moving B. Adolescent turmoil
around the unit. 22. During a group therapy session, a client diagnosed with C. Disorganized behavior
mania consistently disrupts the group’s interactions. Which D. Emotional hunger
18. A nurse observes presence coarse hand tremors in a patient intervention should the nurse implement first? *
with acute mania. Upon reviewing the patient’s laboratory A. Setting limits on the client’s behavior 3. When admitting a patient with bulimia nervosa, the nurse
results, it shows that the client’s serum lithium level is 1.8 B. Asking the client to leave the group session should be expects the client to have a history of? *
mEq/L. Which action should be taken by the nurse? * C. Asking another nurse to escort the client out of the group A. Is accepting of body size
A. Advise the client to limit fluids. session B. Overeats for the enjoyment of eating food
B. Acknowledge that the side effects are unpleasant. D. Telling the client that they will not be able to attend any C. Overeats in response to losing control of diet
C. Continue to administer lithium as ordered. future group sessions D. Binge eats, then purges
D. Withhold the medication and notify the physician.
23. The nurse determines that which menu choice would be best 4. The nurse is taking care of a female client who was admitted
19. A nurse appropriately address a manic behavior by doing for a bipolar client in a manic state? * for anorexia nervosa. When attending to her needs, she
the following, except? * A. Beef stew, fruit salad, tea suddenly engages in rigorous push-ups. What should the nurse
A. Follow through about the consequences of behavior in a B. Cheeseburger, banana, milk do? *
nonpunitive manner. C. Macaroni and cheese, apple, milk A. Interrupt the client and offer to take the client for a walk.
B. Communicate expected behaviors to the client. D. Scrambled eggs, orange juice, coffee with cream and sugar B. Interrupt the client and weigh the client immediately.
C. Ensure that the client knows that they are not in charge of C. Allow the client to complete the exercise program.
the nursing unit. 24. A client is taking lithium carbonate for the treatment of D. Tell the client that she is not allowed to exercise rigorously.
D. Assist the client in identifying ways of setting limits on bipolar disorder. Which assessment question should the nurse
ask the client to determine signs of early lithium toxicity?  5. Which of these illicit drugs are commonly taken by client’s
personal behaviors.
A. “Have you noted excessive urination?” who have bulimia nervosa? *
20. A manic client begins to make sexual advance towards B. “Do you have frequent headaches?” A. Sedatives
visitors in the dayroom. When the nurse firmly states that this is C. “Have you been experiencing any nausea, vomiting, or B. Cannabis
inappropriate and will not be allowed, the client becomes diarrhea?” C. Amphetamines
verbally abusive and threatens physical violence to the nurse. D. “Have you been experiencing leg aches over the past few D. Hallucinogens
Based on the analysis of this situation, which intervention days?”
6. The nurse is planning an eating disorder protocol for
should the nurse implement? *
hospitalized clients experiencing bulimia and anorexia. Which
A. Place the client in seclusion for 30 minutes.
should be included in the protocol? Select all that apply. i .
Clients are not allowed to discuss food or eating in groups or 10. The nurse is developing a teaching plan about anorexia B. Being able to attend college in another state without binging
informal conversation with peers. ii. Clients must rest within nervosa and its signs and symptoms which would be taught to or purging
view of a staff member and not go to the bathroom for one-half high school health class. Which of the following would the C. Eating meals at home without binging or purging.
hour to an hour after eating. iii. Clients are not told their weight nurse include as the primary group of people who are affected D. Managing stresses in life without binging or purging.
and cannot see their weight while being weighed. iv. lients must by this condition? *
eat within view of a staff member. v. Clients cannot participate A. Women, onset typically after 30 years. 15. While coaching a youth basketball team, the nurse notices
in any groups after admission until they gain 1 lb. * B. Women, age at onset between 12 and 20 years. that one of the students have been binging and purging on
A. I, III, V C. Men, onset during the college years. multiple occasions. The nurse calls the mother of the child to
B. I, II, IV D. Men, onset after 20 years. discuss the situation. How would the nurse initiate the
C. II, III, IV conversation? 
D. I, IV V 11. A family approaches the nurse complaining of their A. “Let me get right to the point. Your daughter is very sick
daughter. With further investigation, the client exhibits signs and needs to see a mental health therapist right away.”
7. An adolescent exhibiting signs of anorexia nervosa refuses to and symptoms of anorexia nervosa. Which of the following B. “Thank you for letting your daughter play on the team. She's
comply with her daily weigh in saying that she had just drank a subjective data is a typical response for a client with this a very good player and is also pleasant and easy to coach.”
glass of water, which in turn would have greatly increased her ailment? * C. “I have some very bad news for you. Your daughter has a
weight. What would be the best response to give the client? * A. “She's been a model child. We've never had any problems serious problem that is diagnosed as an eating disorder.”
A. “You are here to gain weight so that will work in your with her.” D. “I am a nurse. I have seen your daughter doing things that
favor.” B. “We have five children, all normal kids with some problems are considered to be part of an eating disorder.”
B. “You must weigh in every day at this time. Please step on at times.”
the scale.” C. “We've given her everything, and look how she repays us!” 16. A client who was newly diagnosed with bulimia tells the
C. “Don't drink or eat for 2 hours and then I'll weigh you.” D. “She's had behavior problems for the past year both at home nurse who was leading a group discussion that the only reason
D. “If you don't get on the scale, I will be forced to call your and at school.” she was attending the class was her husband. She elaborates that
doctor.” her husband said that he would get angry with her if she did not
12. A 20 year old male client and his roommate go the get help. What is the best response of the nurse? *
8. While doing rounds, the nurse notices that a client with emergency department complaining of an upset stomach. The A. “You sound angry with your husband. Is that correct?”
anorexia nervosa has been taking diet pills instead of complying client reveals that he attends college and works at a fast food B. “You will find that you like coming to group. These people
with her diet regimen. What should the nurse do first? * joint each evening. a further look into the client’s diet reveals are a lot of fun.”
A. Talk with the client about how weight loss and emaciation that his menu consist mainly of carbonated drinks and junk C. “Tell me more about why you are here and how you feel
worry the health care providers. food. His roommate then adds that the client would always about that.”
B. Explain to the client how diet pills can jeopardize health. complain of uneasiness on his stomach and would always go to D. “Tell me something about what has caused you to be
C. Listen to the client about fears of losing control of eating the bathroom. The nurse should refer the client to:  bulimic.”
while being treated. A. A weight loss program
D. Inquire about worries of the client's family concerning the B. An overeating support group 17. A client with bulimia explains to the nurse that she only
client's physical and emotional health C. A mental health clinic binge when she fights with her best friend and purges in fear of
D. The client’s family doctor gaining weight. The nurse should next: *
9. When teaching a group of adolescents about anorexia A. Enroll client in a coping skills group.
nervosa, the nurse should describe this disorder as being 13. A nurse is working with a client with bulimia. Which of the B. Schedule daily family therapy sessions.
characterized by which of the following? * following goals should be excluded in the care plan? * C. Work with the client to limit her purging.
A. Extreme concern about dieting, calorie counting, and an A. The client will maintain normal weight. D. Have client take lorazepam (Ativan) 1 mg as needed
unrealistic body image. B. The client will comply with medication therapy. whenever she feels the urge to binge.
B. Intense fear of becoming obese, emaciation, and a disturbed C. The client will achieve a positive self-concept.
body image. D. The client will acknowledge the disorder. 18. While interviewing a client with an eating disorder, the
C. Excessive fear of becoming obese, near-normal weight, and E. The client will never have the desire to purge again. client exclaims “I hate how my body looks!” Which of the
a self-critical body image. following statements by the nurse is most therapeutic? *
D. Obsession with the weight of others, chronic dieting, and an 14. Considering a client with bulimia, what is an appropriate A. “Don't worry, you'll soon be back in shape.”
altered body image. long-term client goal for this client? * B. “I don't think you look bad at all.”
A. Being able to eat out without binging or purging. C. “Tell me more about your feelings.”
D. “Everyone who has the same problem feels like you do.” 24. When assessing a client, he verbalizes that he feels nurse that she underwent sex-reassignment surgery. What is the
“estranged and separated from himself.” This is typically best response of the nurse? *
19. A community health nurse working with a group of fourth- associated with which illness?  A. “Tell me about your sexual preference. Are you attracted to
grade girls is planning a primary prevention strategy to teach men or women?”
the girls how to avoid developing eating disorders during their A. Intoxication B. “I understand your reluctance to tell the physician, but it
teen years. The nurse should focus on which of the following? * B. Anti-motivational syndrome may have an impact on your treatment.”
A. Limiting the girls' access to media images of very thin C. Depersonalization C. “Your sex change and your hormones have nothing to do
models and celebrities. D. Existentialism with your heart attack.”
B. Telling the girls' parents to monitor their daughter's weight D. “Based on client confidentiality, I won’t tell the physician if
and media access. 25. A client is complaining of amnesia. The nurse later on you wish.”
C. Working with the school nurse to closely monitor the girls' discovers the client to have dissociative disorder.What could
weight during middle school. have triggered the client’s amnesia? * 30. Which of the following responses would be best when a
D. Helping the girls accept and appreciate their bodies and feel A. Conscious sedation client with problems on his sexual arousal asks if attending
good about themselves. B. Short-acting sedation educational sessions on sexual disorders bring about change to
C. Severe psychosocial stress his condition? *
20. Which of the following nursing interventions is appropriate D. Syndrome of inappropriate antidiuretic hormone (SIADH) A. “If you have a substance abuse problem, the class won’t be
for a client who has anorexia nervosa? * helpful.”
A. Instruct the client to get plenty of exercise. 26. A client who has dissociative amnesia has just experienced B. “I’m not sure if the class is appropriate for you; please ask
B. Encourage the client to go for a walk to get some exercise. her divorce recently. What interventions would the nurse your doctor what he thinks.”
C. Tell the client to lie down for 2 hours after eating. include in her plan of care? * C. “I’ll be talking about how certain medications can enhance
D. Prevent the client from using the bathroom for 90 minutes A. Tell the client that everything will be all right. sexual functioning.”
after eating. B. Encourage the client to verbalize feelings of distress. D. “I think that everyone can benefit from an educational class
C. Discourage the client from verbalizing feelings because they on sexual functioning.”
21. A nurse who is assigned din the mental health ward is taking will be too traumatic.
care of several patients who have eating disorders. Based on the D. Force the client to confront her memories about the divorce 31. A male adolescent client is brought into the psychiatric
physical appearance, which parameters differentiates bulimic in a direct, confrontational manner. crisis room by his mother. The mother reports that the client
patients from anorectic patients? * prefers to wear woman’s clothing and asks if there is anything
A. By looking for Mallory-Weiss tears 27. A client verbalizes that he is experiencing a notable that could help alleviate said peculiarities. The best response
B. By their teeth decrease in sexual desire. The nurse notes this to be hypoactive would be? *
C. By body size and weight sexual desire. What is its classification? A. “Your son will be evaluated shortly.”
D. The clients are indistinguishable upon physical examination A. Sexual desire disorder B. “I see you’re upset. Would you like to talk?”
B. Sexual pain disorder C. “You’re being judgmental. There’s nothing wrong with a
22. What treatment best suits a bulimic client? * C. Sexual arousal disorder boy wearing female clothing.”
A. Antidepressants D. Orgasmic disorder D. “I will explain to your son that his behavior isn’t
B. Cognitive-behavioral therapy
appropriate.”
C. Total parenteral nutrition (TPN) and antidepressants 28. A nurse is caring for a client who is said to have episodes of
D. Antidepressants and cognitive behavioral therapy voyeurism as noted by his neighbors.Which term most 32. A nurse who is caring for a client notes symptoms such as
appropriately describes such behavior? * gait disturbances, paralysis, pseudoseizures, and tremors. These
23. A nurse is caring for a client who has a depersonalization A. Depersonalization disorder symptoms may be manifestations of what psychiatric
disorder. Which of the following would be the most favorable B. Gender identity disorder disorder? *
outcomes would the nurse want to obtain? * C. Dissociative fugue A. Conversion disorder
A. Focusing on past accomplishments, rather than the current D. Paraphilia B. Pain disorder
condition
C. Adjustment disorder
B. Increasing confidence and active participation in planning 29. A female client who is about to undergo thrombolytic D. Delirium
and implementation of the treatment therapy was asked by her physician about her last menstrual
C. Emphasizing strengths, rather than the pathologic condition period. The client then becomes flushed and asks the physician 33. A client diagnosed with pain disorder is talking with the
D. Eliciting empathetic responses from the client if she could talk to her nurse in private. The client then tells the nurse about bowling when he suddenly reverts to talking about
the pain in his arm. Which of the following should the nurse do 37. Which of these statements made by the client would indicate B. “He won’t get worse if he continues to take his medication.”
next? * that he is progressing positively to his treatment for somatoform C. “We will need to keep him at home so we can monitor his
A. Ask the client if he needs more pain medication. disorder? * illness closely.”
B. Get up and leave the client. A. “My stomach pain will go away once I get properly D. “We will need to watch for signs of depression.”
C. Allow the client to talk about his pain. diagnosed.”
D. Redirect the interaction back to bowling. B. “My headache feels better when I time my medication 5. The nurse is planning care for a hallucinating and delusional
dose.” client who has been rescued from a suicide attempt. Which
34. The unlicensed assistive personnel (UAP) verbalizes that the C. “I understand my pain will feel worse when I'm worried intervention should the nurse incorporate into the nursing care
client with somatoform disorder is sick and decided that he about my divorce.” plan? *
can’t come for lunch. The nurse should direct the UAP to do D. “I need to find a doctor who understands what my pain is A. Initiate one-to-one suicide precautions immediately.
which of the following? * like.” B. Ask the client to report suicidal thoughts immediately
A. Tell the client he'll need to wait until supper to eat if he C. Begin suicide precautions with 30-minute checks.
misses lunch. SCHIZOPHRENIA/PSYCHOSIS D. Check the client’s location every 15 minutes.
B. Take the client a lunch tray and let him eat in his room.
C. Inform the client that he has 10 minutes to get to the dining 1. A nurse includes the nursing diagnosis of Disturbed thought 6. A client experiencing paranoid delusions tells a nurse that
room for lunch. processes secondary to paranoia in the care plan for a newly “The foreigner who lives next to me wants to kill me.” Which
D. Invite the client to lunch and accompany him to the dining admitted client diagnosed with schizophrenia. Which approach nursing response is most therapeutic to assist the client
room. is most appropriate for this client? * experiencing paranoid delusions? *
A. Have the client sign a written release of information form. A. “What makes you think your neighbor wants to kill you?”
35. At 9 am, a client with an Axis I diagnosis of pain disorder B. Begin to identify social supports in the community. B. “That’s not true. I’m sure your neighbor is a nice person.”
orders that the nurse call the primary health care provider for C. Avoid laughing or whispering in front of the client. C. “Do you feel afraid that people are trying to hurt you?”
more pain medication because she's still in pain after the 8 am D. Encourage the client to interact with others on the unit. D. “You believe that your foreign neighbor really wants to kill
analgesic. Which of the following should the nurse do next? * you?”
A. Tell the client that the primary health care provider will be 2. A nurse is assessing a client with a history of aggressive
in later to talk to her about it. behavior toward others. Which client behavior requires 7. A nurse is evaluating a client who threatens suicide. The
B. Inform the client that the nurse cannot give her additional immediate nursing intervention? * nurse’s primary responsibility to the client is to provide a safe,
medication at this time. A. Refusing to attend a mandatory group session on the unit therapeutic environment. Which nursing intervention is most
C. Call the primary health care provider as the client requests. B. Petitioning the staff to extend recreation time by 30 minutes effective in establishing a safe environment for the client? *
D. Suggest the client lie down while she is waiting for her next C. Stating, “The guy over there needs to sit down and shut up.” A. Assign a staff member to stay with the client and provide
dose. D. Crying while talking on the telephone with family constant observation.
B. Place the client in a seclusion room designed to minimize
36. A nurse who was taking care of a client with conversion 3. A nurse observes a client who has a history of aggressive stimulation.
disorder with presenting symptoms of a paralyzed arm reports, I behavior toward others swearing and kicking the furniture in the C. Keep the client involved in structured activities with other
would tell the client that the reason her arm is paralyzed is dayroom. Based on the client’s behavior, what should be the clients as directed by the staff.
because she neglected the care her infant needed to the extent nurse’s immediate priority of care? * D. Remove all potential items that could assist the client in
that the said infant was hospitalized for severe dehydration.” A. Eliminate the source of agitation. committing suicide.
What is the best response by the senior nurse? * B. De-escalate the client’s agitation.
A. “Pushing insight will increase the client's anxiety and the C. Assess the client’s agitation level. 8. A nurse observes a client with a history of violent command
need for physical symptoms.” D. Provide for a safe, therapeutic milieu. hallucinations mumbling erratically while making threatening
B. “Pushing awareness will be helpful and further the client's gestures directed toward a particular staff member. Which
4. A nurse is reviewing with the client’s father the discharge nursing intervention is most appropriate when working with a
recovery.”
plan of a client recently diagnosed with paranoid schizophrenia. client with violent command hallucinations? *
C. “Ignore the client's behaviors and treat her with respect.”
Which of the father’s statements indicates to the nurse that he A. Observe the client for signs of escalating agitation.
D. “We'll meet with the client and confront her with her
understands the diagnoses and prognosis of paranoid B. Place the client in seclusion to help de-escalate anger.
behavior.”
schizophrenia? * C. Inform the client of pending restraint if behavior does not
A. “There is a good chance that this will be his only subside.
hospitalization.” D. Ask the client to explain the cause of anger.
9. A nurse is evaluating a client experiencing paranoid addition to being free of physical injury during phases of 17. A nurse engages an older adult client by describing the
delusions. The client states, “Two men wearing gray shirts keep hyperactivity, which short-term goal is appropriate for this weather as “raining cats and dogs.” The client looks bewildered
coming into the dayroom and watching me.” Which of the client? * and shows concern for the “animals.” The nurse determines that
nurse’s responses is most therapeutic when communicating to a A. The client will show decreased activity within 24 hours of the client is exhibiting concrete thinking. Which response by the
client with paranoid delusions? * onset of hyperactivity. nurse is most therapeutic? *
A. “Ignore them, and let’s select a movie to watch after B. The client will sleep at least 6 hours per night. A. Assure the client that the animals are not being hurt in any
dinner.” C. The client will engage in at least one client-to client way.
B. “What makes you think they are interested in you?” interaction daily. B. Alert the staff to the client’s inability to understand abstract
C. “Those are maintenance personnel discussing the room D. The client will consume adequate food and fluid per day. concepts.
remodeling.” C. Explain to the client that it is a way of saying it is raining
D. “I don’t believe you have anything to worry about.” 14. The mother of a client newly diagnosed with paranoid heavily.
schizophrenia visits her son for the first time 2 days after the D. Document the client’s response to the conversation as
10. A nurse is assessing the mood and cognitive state of mind of client was admitted to the psychiatric unit. Bewildered, she concrete thinking.
a client diagnosed with schizophrenia.Which signs and approaches a nurse and states, “He is still talking about how the
symptoms is the nurse most likely to observe? SELECT ALL government is controlling his thoughts.” What is the most 18. A nurse is assessing a client recently admitted into a
THAT APPLY.iI. Involuntary muscle movementII. Compulsive accurate nursing appraisal of the mother’s statement? * psychiatric unit for observation. Which client behavior is
behaviorIII. Poor appetiteIV. Disrupted sleepV. Poor A. The mother’s expectations of her son are realistic. indicative of impaired cognition? *
concentrationVI. Incongruous affect * B. The mother’s concern is reasonable. A. Asking repeatedly, “How did I get here?”
A. III, IV, V, VI C. The mother should request a medication adjustment. B. Spending hours staring out the window
B. I, III, V, VI D. The mother requires further education regarding the client’s C. Discussing “the voices” with another client
C. I, II, III, IV, VI diagnosis D. Mumbling
D. I, II, III, IV, V, VI
15. A client who was recently prescribed with haloperidol 19. A nurse is discussing discharge plans with a homeless client
11. A client is admitted to the inpatient mental health unit. complains of severe muscle pain. Upon assessment, the nurse diagnosed with paranoid schizophrenia.What is the primary
When asked her name, she responds, “I am Elizabeth, the noted the following: HR 104 beats per minute, BP 175/52 mm factor that will affect the formulation of the discharge plan for
Queen of England.” What should the nurse recognize this client Hg, and temperature 38.4°C. Based on the assessment findings, this client?
statement as indicating? * what is the most appropriate nursing action? * A. The nurse’s ability to work effectively with the homeless
A. Auditory hallucination A. Assure the client that the symptoms are unrelated to the new client
B. Visual illusion medication. B. The existence of community resources such as homeless
C. Grandiose delusion B. Gather information concerning the client’s possible shelters
D. Loose association exposure to a bacterial infection. C. The formulation of a support system for the homeless client
C. Question the client concerning known cardiovascular health D. The homeless client’s ability to comply with the discharge
12. A client, who is experiencing both positive and negative status. plan
symptoms of schizophrenia, is prescribed an atypical D. Immediately notify the client’s health-care provider of the
antipsychotic, risperidone. The client asks the nurse to explain assessment findings and complaints. 20. A nurse is developing a plan of care for a client prescribed
the common side effects of this medication. Which side effects the traditional antipsychotic drug haloperidol for the treatment
should the nurse state to the client? SELECT ALL THAT 16. A nurse is evaluating a client diagnosed with paranoid of schizophrenia. Which medication should the nurse expect to
APPLY.I. DizzinessII. DystoniaIII.DrowsinessIV. weight schizophrenia who reports hearing a voice that says, “Do not administer if extrapyramidal side effects develop? *
gainV. ConstipationVI. Hypotension * remove your hat because they will be able to read your mind.” A. Benztropine
A. I, III, IV, Vi Which response by the nurse is the most therapeutic? * B. Olanzapine
B. II, IV, V, VI A. “It must be very frightening to believe that someone can C. Escitalopram oxalate
C. I, II, III, IV, VI read your mind.” D. Chlorpromazine
D. I, II, III, IV, V, VI B. “I do not believe that anyone can read another’s mind.”
C. “Who are ‘they’?” 21. A client who is taking an antipsychotic is preparing for
13. A client admitted to a behavioral medicine unit with a D. “Why would someone want to read your mind?” discharge. To facilitate health promotion for this client, what
diagnosis of catatonic schizophrenia is constantly rearranging instruction should the nurse provide? *
furniture and appears to be responding to internal stimuli. In
A. Recognize the signs and symptoms of a relapse of D. “One of the things that was agreed upon was that anyone 7. While assessing a 14-year-old child, the nurse notes bruises
depression. who did not use appropriate behavior would be asked to leave and cigarette burns on the child’s chest and rope burns on the
B. Have therapeutic blood levels drawn because the medication the dining room. Please leave now.” buttocks. The child states, “I’m afraid to go home because my
has a narrow therapeutic range. stepfather will be angry with me for telling on him!” The nurse
C. Avoid prolonged exposure to the sun. 3. A client with a diagnosis of major depression says to the should make which therapeutic response to the child? *
D. Adhere to a strict tyramine-restricted diet. nurse, “I should have died. I’ve always been a failure.” The A. “You must know that your presence in the house will only
nurse should make which therapeutic response to the client? * tease your stepfather more.”
22. The nurse notes that a client with schizophrenia and A. “I see a lot of positive things in you.” B. “You can’t go back there with that man. How do you think
receiving an antipsychotic medication is moving her mouth, B. “You’ve been feeling like a failure for some time now?” your mother will react?”
protruding her tongue, and grimacing as she watches television. C. “You still have a great deal to live for.” C. “I am sorry that this has happened to you, but you will be
The nurse determines that the client is experiencing which D. “Feeling like a failure is part of your illness.” safe here until plans can be made.”
medication complication? (955) * D. “Let’s keep this between you, me, and the health care
A. Parkinsonism 4. A health care provider prescribes a follow-up home care visit
provider until we formulate further plans to assist you.”
B. Tardive dyskinesia for an older adult client with emphysema.When the home care
C. Hypertensive crisis nurse arrives, the client is smoking. Which statement by the 8. The nurse is caring for a 12-year-old client who has been
D. Neuroleptic malignant syndrome nurse would be therapeutic? * physically and sexually abused by her father. The father angrily
approaches the nurse and says, “I’m taking my daughter home.
DEFENSE MECHANISMS AND THERAPEUTIC She’s told me what you people are up to, and we’re out of
COMMUNICATION A. “I’m glad I caught you smoking! Now that your secret is here!” Which therapeutic response should the nurse make? *
out, let’s decide what you are going to do.” A. “Your daughter will remain here until the doctor discharges
1. The spouse of a dying client says to the nurse, “I don’t think I B. “Well, I can see you never got to the stop smoking clinic!” her. I’ll call hospital security and the police if you attempt to
can come anymore and watch her die.It’s chewing me up too C. “I notice that you are smoking. Did you explore the stop take her.”
much!” Which therapeutic response should the nurse make to smoking program at the senior citizens center?” B. “You seem very upset. Let’s talk at the nurse’s station. I
the spouse? * D. “I wonder if you realize that you are slowly killing yourself. know you’re very concerned and that you want to help your
A. “Focus on your wife’s pain rather than yours. I know it’s Why prolong the agony? You can just jump off the bridge!” daughter. It will be best if you agree to let your daughter stay
hard, but this isn’t about what’s happening to you, you know.”
5. A client says to the nurse, “I can’t get any help with my care! here for now.”
B. “I know it’s hard for you, but she would know if you’re not
I call and call, but the nurses never answer my light. Last night C. “Try to listen to me, please. If you are insistent and do take
there, and you would feel so very guilty all of the rest of your
one of them told me she had other clients besides me! I’m very your daughter from this unit, the police will most certainly
days.”
sick, but the nurses don’t care!” Which statement from the nurse order you to bring her back again.”
C. “It’s hard to watch someone you love die. You’ve been here
is therapeutic? * D. “Your daughter is ill and needs to be here. I know you want
with your wife every day. Are you taking any time for
A. “You poor thing! I’m so sorry this happened to you. That to help her to recover and that you will work to help everyone
yourself?”
nurse should be fired immediately.” straighten out the circumstances that caused this.”.
D. “I think you’re making the right decision. Your wife knows
you love her. You don’t have to come every day. I’ll take care B. “I think you are being very impatient. The nurses come as 9. A female victim of a sexual assault is being seen in the crisis
of her.” quickly as they can.” center for a third visit. She states that although the rape
C. “It’s hard to be in bed and to have to ask for help. You feel occurred nearly 2 months ago, she still feels “as though the rape
2. An older adult client at the retirement center spits her food that the nurses do not seem to care?” just happened yesterday.” How should the nurse respond? *
out and throws it on the floor. She yells, “This turkey is dry and D. “I can hear your anger. That nurse had no right to speak to A. “What can you do to alleviate some of your fears about
cold! I can’t stand the food here!” How should the nurse you that way. I will report her.” being assaulted again?”
respond to the client? *
6. The nurse is caring for a dying client who says, “Will you be B. “Tell me more about those aspects of the rape that cause you
A. “Let me get you another serving that is more to your liking.
the executor of my will?” How should the nurse best respond to to feel like the rape just occurred.”
Would you like to see the chef and select your own serving?”
this client? * C. “In reality, the rape did not just occur. It has been over 2
B. “I think you had better return to your apartment now. I’ll
A. “I must decline your offer because I am your nurse.” months now.”
make arrangements for a new meal to be served to you there.”
B. “I will carry out your will according to your wishes.” D. “In time, our goal will be to help you move on from these
C. “Now look what you’ve done! You’re ruining this meal for
C. “It is an honor to be named the executor of your will.” strong feelings about your rape.”
the whole community. Aren’t you ashamed of yourself?”
D. “Tell me more so that I can understand your thinking.”
10. The nurse is caring for a client who says, “I don’t want to B. “While there may be spiders on the wall, they are not going interprets these behaviors as indicative of the client's use of
talk with you because you’re only the nurse.I’ll wait for my to hurt you.” which of the following defense mechanisms? 
doctor.” What should the nurse say in response to the client? * C. “You are having a hallucination; I’m sure there are no
A. “I understand. So should I call your health care provider?” spiders in this room.” A. Denial
B. “I’m angry with the way you dismissed me.” D. “Would you like me to kill the spiders for you?” B. Displacement
C. “So then, you would prefer to speak with your health care C. Rationalization
provider?” 15. A mother comes to the pediatric clinic because her D. Reaction formation
D. “Your health care provider directs me in your nursing care.” previously continent 6-yearold son has resumed bedwetting.
The nurse assesses the home environment and discovers there is
11. The client angrily tells the nurse that the health care a new baby at home. Which explanation by the nurse describes
provider (HCP) purposefully provided incorrect information. for the mother the defense mechanism the son is using? *
Which response to the client would hinder therapeutic A. Identification
communication? * B. Rationalization
A. “I’m not sure what information you are referring to.” C. Regression
B. “Can you describe the information that you are referring D. Repression
to?”
C. “I’m certain that the HCP would not lie to you.” 16. A client reports becoming involved with legislation that
D. “Do you think it would be helpful to talk to your doctor promotes gun safety after the death of a child by accidental
about this?” shooting. Which defense mechanism is the client exhibiting? *
A. Sublimation
12. A charge nurse is supervising a nursing student who is B. Denial
providing care to a client with end-stage heart failure. The client C. Intellectualization
is withdrawn and reluctant to talk, and she shows little interest D. Identification
in participating in hygienic care or activities. Which statement,
if made by the student to the client, indicates that the student 17. Anna’s dog Lucky got away from her while they were
requires teaching regarding the use of therapeutic taking a walk. He ran into the street and was hit by a car. Anna
communication techniques? * cannot remember any of these circumstances of his death. This
A. “What are your feelings right now?” is an example of what defense mechanism? *
B. “Why don’t you feel like getting up for your bath?” A. Suppression
C. “These dreams you mentioned, what are they like?” B. Denial
D. “Many clients with end-stage heart failure fear death.” C. Rationalization
D. Repression
13. The nurse is caring for a client diagnosed with depression
who appears anxious and withdrawn. Which statement is 18. Lucky sometimes refused to obey Anna and, indeed, did not
appropriate for the nurse to make when initially initiating come back to her when she called to him on the day he was
conversation? * killed. But Anna continues to insist, “he was the very best dog.
A. “Can you tell me how you are feeling today?” He always minded me. He always did everything I told him to
B. “You are wearing your new shoes.” do.” This represents the defense mechanism of? *
C. “It appears that talking makes you anxious.” A. compensation.
D. “Do you feel like talking today?” B. reaction formation.
C. undoing.
14. The nurse is caring for a client diagnosed with delirium who D. sublimation.
states, “Look at the spiders on the wall.” How should the nurse
respond? * 19. The client sees no connection between her liver disorder and
A. “I know that you are frightened, but I do not see any spiders her alcohol intake. She believes that she drinks very little and
on the wall.” that her family is making something out of nothing. The nurse