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NUNRSING PRACTICE V

Situation: Many patients with problems in perception and coordination require critical care management. Nurses are better
prepared to manage the acute and chronic needs of these patients if they understand the course of the disease, as well
as the medical and surgical tools available for these disorders. Nurse Luis, a Neurologic nurse is assigned in a newly set-
up special unit.

1. An adult has a medical diagnosis of increased intracranial pressure and is being cared for in the neurology unit.
The nursing care plan includes elevating the head of the bed and positioning the client’s head in proper alignment.
What is the reason for these actions?
A. make it easier for the client to breathe C. promotes venous drainage
B. prevents a Valsalva maneuver D. Reduces pain

2. Which of the following reduces cerebral edema by constricting cerebral veins?

A. Dexamethasone (Decadron) C. Mannitol (Osmitrol)
B. Mechanical Hyperventilation D. Ventriculostomy

3. Utilizing the Glasgow Coma Scale, which score would be indicative of coma?
A. 0 B. 2 C. 6 D. 10

4. When Nurse Luis tested the unconscious client for noxious stimuli, the client responded with decorticate rigidity or
posturing. What is the best description for this action?
A. flexion of the upper and lower extremities into a fetal-like position
B. rigid extension of the upper and lower extremities and plantar flexion
C. complete flaccidity of both upper and lower extremities and hypertension of the neck
D. flexion of the upper extremities, extension of the lower extremities, and plantar flexion

5. A client with a closed head injury is confused, drowsy, and has unequal pupils. Which of the following nursing
diagnoses is most important at this time?
A. altered level of cognitive function C. altered cerebral tissue perfusion
B. high risk for injury D. sensory perceptual alteration

6. Based on this assessment, what condition does the nurse suspect?

A. meningitis C. brain tumor
B. brain abscess D. epilepsy

7. When comparing a cerebrovascular accident (CVA) to a transient ischemic attack (TIA), what is unique about the
TIA?
A. it has permanent long-term focal deficits
B. it is intermittent with spontaneous resolution of the neurologic deficit
C. it is intermittent with permanent motor and sensory deficits
D. it has permanent long-term neurologic deficits

8. A 36-year-old female reports double vision, visual loss, muscular weakness, numbness of the hands, fatigue,
tremors, and incontinence. Based on this report, what would Nurse Barnie suspect?
A. Parkinson’s disease C. Amyotrophic sclerosis (ALS)
B. Myasthenia Gravis (MG) D. Multiple sclerosis (MS)

9. Nurse Barnie has explained the use of neostigmine methylsulfate (Prostigmin) to a client with Myasthenia Gravis.
Which comment by the client indicates the need for further instruction?
A. “I need to take the medication regularly, even when I feel strong.”
B. “I should take the medication once daily at bedtime.”
C. “If I take too much medication, I can become weak and have breathing problems.”
D. “I may have difficulty swallowing my saliva if I take too much medication.”
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10. A Novice Nurse observes a companion of the client who is transferring a client with hemiplegia from a sitting
position in the bed to the wheelchair. Which action by the Novice Nurse requires correction?
A. grasping the client’s arms to pull the client to a standing position
B. reminding the client to lean forward before rising
C. moving the client toward the unaffected side
D. bracing the affected knee and foot to assist the client to stand

11. Nurse Rio is assessing a client with a head injury. The client has clear drainage from the nose and ears. How can
Nurse Rio determine if the drainage is cerebrospinal fluid (CSF)?
A. measure the pH of the fluid C. test for glucose
B. measure the specific gravity of the fluid D. test for chloride

12. Nurse Rio is also evaluating the ability of a client with trigeminal neuralgia to implement the treatment that has
been suggested. Which of the following behaviors by the client will be most effective in controlling manifestations?
A. exercise the facial muscles at least twice daily
B. put the affected arm through full range of motion daily
C. avoid extremes in temperature of food and drink
D. use proper body mechanics in sitting and bending

13. A client with Bell’s palsy asks Nurse Rio why artificial tears were ordered by the Physician. Select the best reply by
the Nurse Rio.
A. “When your affected eye fails to make tears, the eye can become irritated and ulcerated.”
B. “Because your eye remains closed, foreign matter can be trapped beneath the lid.”
C. “Artificial tears will remove the purulent drainage from your eye, which speeds healing.”
D. “Because you cannot blink the affected eye, it can become dry and irritated.”

14. Nurse Rio received a client from another medical station with Guillain-Barré syndrome (GBS ). Which of the
following strategies is of most importance in the plan of care?
A. range of motion exercises three to four times per day
B. frequent measurement of vital capacity
C. use of artificial tears
D. starting the enteral feeding

15. Nurse Rio has presented information about Amyotrophic Lateral Sclerosis (ALS) to a newly diagnosed client. Which
question by the client indicates that he understands the nature of the disease?
A. “How can I avoid infecting my family with the virus?”
B. “How can I execute a living will?”
C. “How can I prevent an exacerbation of the disease?”
D. “How many people achieve remission with chemotherapy?”

Situation : Nurse Gabby recalls the lecture of a Consultant on retinal detachment that refers to the separation of the retinal
pigment epithelium (RPE ) . A surgical management is usually recommended on this kind of vision disorder.
Item no. 157 pg. 233
16. A client is admitted with a detached retina of the left eye. Nurse Gabby patches both eyes. What is the rationale for
patching both eyes?
A. to prevent eye infections C. to prevent photophobia
B. to decrease eye movement D. to prevent nystagmus

17. An adult male is receiving cryotherapy for repair of a detached retina. When taking a history from him, which
symptom should the Nurse Rio expect him to have?
A. diplopia C. sudden blindness
B. severe eye pain D. bright flashes of light

18. Another client of Nurse Gabby reports gradual, painless blurring of vision. On assessment, the nurse notes a
cloudy opaque lens. What condition does the nurse suspect?
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A. glaucoma C. retinal detachment

B. cataracts D. diabetic retinopathy

19. Which of the following is the best way for Nurse Rio to assist a blind client in ambulation?
A. allow client to take nurse’s arm with the nurse walking slightly ahead of the client
B. allow the client to walk beside the nurse with the nurse’s hand on the client’s back
C. allow client to walk down the hall with his or her hand along the wall
D. push the client in a wheelchair
20. Nurse Rio has been planning for home care with the family of a client who will undergo extracapsular lens
extraction with an intraocular lens implant. Because the client and family speak very little English, Nurse Rio takes
extra care to evaluate their understanding. Which behavior by the client and/or family shows progress in
understanding post-op home care instructions?

A. using a chart showing various sleeping positions, the client points to a person lying on the affected side
B. the family demonstrates that the eye should be cleaned with a washcloth, soap and water
C. the client demonstrates medication instillation by carefully dropping the solution of the cornea
D. the family shows the nurse the sunglasses they have purchased for the client to wear post-op

21. An adult client has a Stapedectomy. Which of the following is most important for Nurse Yolly to include in the post-
op care plan?
A. checking the gag reflex
B. encouraging independence
C. instructing the client not to blow the nose
D. positioning the client on the operative side

22. The nurse is teaching a post-op stapedectomy client. What should be included in the teaching?
A. work can be resumed the next day
B. gently sneeze or cough with the mouth closed
C. avoid airline flight for 6 months
D. resume exercise in 1 week

23. Which of the following is the best way for Nurse Yolly to communicate with the hearing impaired client?
A. talk directly into the impaired ear
B. speak directly and clearly facing the person
C. shout into the good ear
D. write out all communication

24. A client reports very loud, overpowering ringing in the ears, fluctuating hearing loss on the right side with severe
vertigo accompanied by nausea and vomiting. What condition does Nurse Yolly suspect?
A. Ménière’s disease C. Otosclerosis
B. Acoustic neuroma D. Cholesteatoma

25. What is the priority nursing diagnosis for a client with very loud overpowering ringing in his ears, fluctuating hearing
loss on the right side with severe vertigo accompanied by nausea and vomiting and a feeling of fullness in the right
ear?
A. knowledge deficit related to the disease process
B. anxiety
C. impaired physical mobility
D. pain

Situation : Amputation is done to relieve symptoms , improve function and improve patient’s quality of life. Nurse Ampy is
attending to post-amputated clients.

26. Pedro, a 46 year old male adult client had an above-the-knee amputation of the left leg 2 days ago. The nurse
should include which of the following in the care plan?
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A. resting in a prone or supine position with the stump extended several times a day
B. using a rolled towel or small pillow to elevate the stump at all times
C. applying warm soaks to the stump to reduce phantom limb pain
D. avoiding turning to the left side until the stump has healed completely

27. Another adult male client had a below-the-knee amputation of the right foot 2 days ago. He is complaining of pain
in his right foot. What is the best response by the Nurse Ampy?
A. explain to him that this is a common sensation after amputation
B. remind him that the foot was amputated and therefore cannot have pain
C. apply an ice pack to the stump
D. show him the stump so he will realize his right foot is gone
.
28. Nurse Ampy is providing a preventive health care seminar related to ways to decrease the effects of osteoporosis.
Which of the following risk factors should Nurse Ampy discuss that both apply to men and women?
A. Anorexia
B. Diet low in calcium and vitamin D
C. History of maternal hip fracture
D. Low body weight and low body mass index

29. The diagnosis of Fibromyalgia is based on the patient’s report of:

A. long-term arthritis history
B. treatment for depression
C. familial tendency of the condition
D. subjective symptoms

30. While assessing a patient with a musculoskeletal injury, Nurse Ampy asks if the patient uses any assistive devices.
This question would be considered as being a part of which of the following areas of the patient’s history?
A. Chief complaint C. Demographic data
B. Social D. Biographical data

Situation : Nurses should encourage the clients in the ward to perform range of motion exercises (ROME) even they are in
the hospital. This is to promote function, mobility and strength.

31. The nurse asks a patient to raise the arms above the head with the palms facing each other. The body area that
the nurse is currently assessing would be the:
A. Elbow C. Wrist
B. Shoulders D. Hand

32. The nurse is planning a health promotion program for sports injuries. Which of the following would be the most
important for the nurse to emphasize in this program?
A. How to use new equipment C. Why sports need to be supervised
B. Prevention of injuries D. How injuries are related to the time of day

33. A patient with a fracture is able to have his cast removed. The nurse realizes this patient is in which phase of the
fractured bone healing process?
A. Fibroblast framework C. Bone calcification
B. Callus formation D. Ossification

34. A victim of a motor vehicle crash has an open fracture of the left femur. Which of the following is a priority of care
for this patient?
A. Provide pain relief
B. Prevent damage to surrounding tissue
C. Decrease the potential for contamination
D. Cast the affected bone immediately
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35. The patient who had a right above-the-knee amputation tells the nurse “I keep wanting to scratch my right foot.”
Which of the following should the nurse respond to this patient?
A. It’s a side effect of your pain medication.
B. You are experiencing something called phantom sensations.
C. Your leg was amputated and it isn’t there anymore.
D. I can get a psychiatrist for you to talk with.

Situation : Nurse Ashley, an Orthopaedic Nurse for 5 years is promoted as a Head nurse in her Unit. She has a 4 team of
staff nurses to attend to a 30 bed census.

36. One of the staff nurses strongly suspects the occurrence of compartment syndrome in a patient wearing a long-leg
cast. In preparation for the health care provider to come and perform the necessary treatment; the nurse would
gather what supplies or equipment?
A. Ace bandages to wrap around the bivalved cast
B. Extra pillows to elevate the casted leg above the heart
C. Syringe, needle and topical anesthetic to aspirate the hematoma
D. A percussion hammer to physically assess reflexes for damage

37. The nurse is teaching a client with a broken left ankle how to go up stairs when using crutches. Which statement by
the nurse is correct?
A. “Place both crutches on the next step, stand on the right foot and place the left foot on the step next to the
crutches.”
B. “Place the left crutch and right foot on the next step and push off with both arms then lift the left foot up to the
step.”
C. “Place the right foot on the next step, then move the crutches and the left foot onto the step.”
D. “Place the right crutch and left foot on the next step; move the right crutch up onto the step, then swing the
right foot up.”

38. A woman who has had rheumatoid arthritis for several years is admitted to the hospital. Upon physical examination
of the client, what should the nurse expect to find?
A. asymmetric joint involvement C. obesity
B. Heberden’s nodes D. small joint involvement

39. In assessing the client with osteomyelitis, the nurse would expect to find which of the following?
A. pale, cool, tender skin at site
B. decrease white blood cell count
C. positive wound cultures
D. decreased erythrocyte sedimentation rate

40. A nurse is reviewing home care with a patient following a hip replacement procedure. Which of the following
instructions would be included?
A. Slightly bend the operative leg when getting up from the chair or bed.
B. Exercise the affected extremity by turning the leg inward 5-10 times.
C. Progressively increase the amount of bending at the wrist daily.
D. Use an elevated toilet seat in the main bathroom at home.

Situation: A newly admitted client diagnosed with posttraumatic stress disorder is exhibiting recurrent flashbacks,
nightmares, sleep deprivation, and isolation from others.

41. Which Nursing Diagnosis takes priority?

A. Posttrauma syndrome R/T a distressing event AEB flashbacks and nightmares.
B. Social isolation R/T anxiety AEB isolating because of fear of flashbacks.
C. Ineffective coping R/T flashbacks AEB alcohol abuse and dependence.
D. Risk factor injury R/T exhaustion because of sustained levels of anxiety.
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42. A newly admitted client is diagnosed with post-traumatic stress disorder. Which behavioral symptom would the
nurse expect to assess?
A. Recurrent, distressing flashbacks
B. Intense fear, helplessness, and horror
C. Diminished participation in significant activities
D. Detachment or estrangement from others

43. A hospitalized client diagnosed with post-traumatic stress disorder has a nursing diagnosis of ineffective coping
R/T history of rape AEB abusing alcohol. Which is the expected short-term outcome for this client problem?
A. The client will recognize triggers that precipitate alcohol abuse by day 2.
B. The client will attend follow-up weekly therapy sessions after discharge.
C. The client will refrain from self-blame regarding the rape by day 2.
D. The client will be free from injury to self throughout the shift.

44. A client on an in-patient psychiatric unit is experiencing a flashback. Which intervention takes priority?
A. Maintain and reassure the client of his or her safety and security.
B. Encourage the client to express feelings.
C. Decrease extraneous external stimuli.
D. Use a nonjudgemental and matter-of-fact approach.

45. The nurse teaches an anxious client diagnosed with post-traumatic stress disorder a breathing technique. Which
action by the client would indicate that the teaching was successful?
A. The client eliminates anxiety by using the breathing technique.
B. The client performs activities of daily living independently by discharge.
C. The client recognizes signs and symptoms of escalating anxiety.
D. The client maintains a 3/10 anxiety level without medications.

Situation : A Psychiatric Nurse admitted several clients with Dementia and Amnestic disorders. One of the clients Mrs.
Nonato 61 years old newly diagnosed with Alzheimer’s disease was admitted 72 hours ago. The client states, “Last
night I went on a wonderful dinner cruise.”

46. Which type of communication is this client expressing, and what is the underlying reason for its use?
A. The client is using confabulation to achieve secondary gains.
B. The client is using confabulation to protect the ego.
C. The client is using perseveration to divert attention.
D. The client is using perseveration to maintain self-esteem.

47. Ms. Evelyn, a 47 year old high school teacher is newly diagnosed with vascular dementia. She isolates herself
because of consistently poor role performance and increasing loss of independent functioning. Which nursing
diagnosis reflects this client’s problem?
A. Disturbed thought process R/T decreased cerebral circulation as evidence by (AEB) disorientation.
B. Risk for injury R/T poor role performance AEB decreased functioning.
C. Disturbed body image R/T loss of independent functioning AEB tearful, sad affect.
D. Low self-esteem R/T loss of independent functioning AEB social isolation.

48. A client diagnosed with dementia has a nursing diagnosis of Risk for injury R/T extreme psychomotor agitation.
Which would be an appropriate short-term outcome related to this problem?
A. The client will remain free from injury during this shift.
B. The client will ask the nurse for assistance when becoming confused.
C. The client will verbalize staff appreciation by day 3.
D. The client will demonstrate ability to perform activities of daily living on discharge.

49. Another client diagnosed with primary dementia has a nursing diagnosis of altered thought process R/T
disorientation and confusion. Which nursing intervention should be implemented first?
A. Use tranquilizing medications and soft restrains
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B. Continually orient client to reality and surroundings

C. Assess client’s level of disorientation and confusion
D. Remove potentially harmful objects from the client’s room

50. On discharge, a client diagnosed with dementia is prescribed donepezil hydrochloride (Aricept). Which would the
nurse include in a teaching plan for the client’s family?
A. “Donepezil is a sedative/hypnotic used for short-term treatment of insomnia.”
B. “Donepezil is an Alzheimer’s treatment used for mild-to-moderate dementia.”
C. “Donepezi is an antipsychotic used for clients diagnosed with dementia.”
D. “Donepezil is an antianxiety agent used for clients diagnosed with dementia.”

Situation : Personality disorders are grouped in clusters according to their behavioural characteristics. Nurse
Monique is attending to clients with various personality disorders.

51. In which cluster are the disorders correctly matched with their behavioral characteristics?
A. Cluster C: antisocial, borderline, histrionic, narcissistic disorders; anxious or fearful characteristic behaviors.
B. Cluster A: avoidant, dependent, obsessive-compulsive disorders; odd or eccentric characteristic behaviors.
C. Cluster A: antisocial, borderline, histrionic, narcissistic disorders; dramatic, emotional, or erratic characteristics
behaviors.
D. Cluster C: avoidant, dependent, obsessive-compulsive disorders; anxious or fearful characteristic behaviors.
52. A client diagnosed with schizoid personality disorder chooses solitary activities, lacks close friends, and appears
indifferent to criticism. Which nursing diagnosis would be appropriate for this client’s problem?
A. Anxiety R/T poor self-esteem as evidence by (AEB ) lack of close friends
B. Ineffective coping R/T inability to communicate AEB indifferent to criticism.
C. Altered sensory perception R/T threat to self-concept AEB magical thinking.
D. Social isolation R/T discomfort with human interaction AEB avoiding others.

53. A client diagnosed with an obsessive-compulsive personality disorder has a nursing diagnosis of Anxiety R/T
interference with hand washing AEB “I’ll go crazy if you don’t let me do what I need to do.” Which short-term
outcome is appropriate for this client?
A. The client will refrain from hand washing during a 3-hour period after admission to unit.
B. The client will wash hands only at appropriate intervals; that is, bathroom and meals.
C. The client will refrain from hand washing throughout the night.
D. The client will verbalize signs and symptoms of escalating anxiety within 72 hours of admission.

54. Leila, a nurse for 12 years, who worked in Saudi Arabia is diagnosed with paranoid personality disorder, needs
information regarding medications. Which nursing intervention would assist this client in understanding prescribed
medications?
A. Ask the client to join the medication education group
B. Provide one-on-one teaching in the client’s room.
C. During rounds, have the physician ask if the client has any questions.
D. Let the client read the medication information handout.

55. Another client diagnosed with obsessive-compulsive personality disorder is admitted to a psychiatric unit in a highly
agitated state. The Physician prescribes a benzodiazepine. Which medication is classified as a benzodiazepine?
A. Clonazepam (Klonopin) C. Clozapine (Clozaril)
B. Lithium carbonate (Lithium) D. Olanzapine (Zyprexa)

Situation : A frightened client diagnosed with dissociative fugue tells the nurse, “I don’t know where I am or how I
got here. What is wrong with me?”

56. Which nursing response reflects a neurobiological perspective?

A. “You appear to have repressed distressing feelings from your conscious awareness.”
B. “Sometimes these symptoms are found in individuals with temporal lobe epilepsy or severe migraine
headaches.”
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C. “When individuals have experienced some sort of trauma, the primary self needs to escape from reality.”
D. “It has been found that these symptoms are seen more often when first-degree relatives have similar
symptoms.”

57. Which statement supports a psychodynamic theory in the etiology of dissociative disorders?
A. Dysfunction in the hippocampus affects memory
B. Dissociative reactions may be precipitated by excessive cortical arousal
C. Coping capacity is overwhelmed by a set of traumatic experiences
D. Repression is used as a way to protect the client from emotional pain

58. A client diagnosed with depersonalization disorder has a short-term outcome that states, “The client will verbalize
an alternate way of dealing with stress by day 4.” Which nursing diagnosis reflects the problem that this outcome
addresses?
A. Disturbed sensory perception R/T severe psychological stress
B. Ineffective coping R/T overwhelming anxiety.
C. Self-esteem disturbance R/T dissociative events
D. Anxiety R/T repressed traumatic events

59. A newly admitted client is diagnosed with dissociative identity disorder. Which nursing intervention is a priority?
A. Establish an atmosphere of safety and security
B. Identify relationships among subpersonalities and work with each equally
C. Teach new coping skills to replace dissociative behaviors
D. Process events associated with the origins of the disorder
60. The nursing student is learning about depersonalization disorder. Which student statement indicates that learning
has occurred?
A. “Depersonalization disorder has an alteration in the perception of the external environment.”
B “The symptoms of depersonalization are rate, and few adults experience transient episodes.”
C. “Depersonalization disorder is characterized by temporary change in the quality of self-awareness.”
D. “The alterations in perceptions are experienced as relaxing and are rarely accompanied by other symptoms.”

Situation : Nurse Wendy is gathering significant data necessary for an effective nursing care plan. While performing an
initial interview, the nurse learns that the client drinks to avoid early morning shakes.

61. The nurse recognizes this behavior as characteristic of which assessment?

A. Substance abuse C. Substance intoxication
B. Substance dependence D. Delirium tremens

62. Which is the priority diagnosis for a client experiencing alcohol withdrawal?
A. Ineffective health maintenance C. Risk for injury
B. Ineffective coping D. Dysfunctional family processes: alcoholism

63. A client who is exhibiting signs and symptoms of alcohol withdrawal is admitted to the substance abuse unit for
detox. One of the nursing diagnoses for this client is ineffective health maintenance. Which is a long-term outcome
for this diagnosis?
A. The client will agree to attend nutritional counseling sessions.
B. The client’s medical tests will show a reduced incidence of medical complications related to substance abuse
within 6 months.
C. The client will identify three effects of alcohol on the body by day 2 of hospitalization.
D. The client will remain free from injury while withdrawing from alcohol.

64. A client diagnosed with alcoholism is admitted to substance abuse unit complaining of decreased exercise
tolerance, lower extremity edema, arrhythmias, and dyspnea. Which nursing intervention would be appropriate for
this client?
A. Providing thiamine-rich foods
B. Administering digoxin (Lanoxin) and furosemide (Lasix)
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C. Reorienting the client to person, place, and time.

D. Encouraging high-sodium foods.

65. The nurse has given a client information on alcoholism recovery. Which client statement indicates that learning has
occurred?
A. “Once I have detoxed, my recovery is complete.”
B. “I understand that the goal of recovery is to decrease my drinking.”
C “I realize that recovery is a lifelong process that comes about in steps.”
D. “Al-Anon can assist me in my recovery process.”

Situation : The nurse is assessing a client diagnosed with schizophrenia. The client states, “We wanted to take the
bus, but the airport took all the traffic.”

66. Which charting entry accurately documents this symptom?

A. “The client is experiencing associative looseness.”
B. “The client is attempting to communicate by the use of word salad.”
C. “The client is experiencing delusional thinking.”
D. “The client is experiencing an illusion involving planes.”

67. Although symptoms of schizophrenia occur at various times in the life span, what client would be at the highest risk
for the diagnosis?
A. a 10-year-old girl C. a 50-year-old woman
B. a 20-year-old man D. a 65-year-old man

68. What is required for effective treatment of schizophrenia?

A. Concentration on pharmacotherapy alone to alter imbalances in neurotransmitter.
B. Multidisciplinary, comprehensive efforts, which include pharmacotherapy and psychosocial care.
C. Emphasis on social and living skills training to help the client fit into society.
D. Group and family therapy to increase socialization skills.

69. A client diagnosed with paranoid schizophrenia tells the nurse about three previous suicide attempts. Which
nursing diagnosis would take priority and reflect this client’s problem?
A. disturbed thought processes C. violence: directed toward others
B. risk for suicide D. risk for altered sensory perception

70. A nursing instructor is teaching about the etiology of schizophrenia. What statement by the nursing student
indicates an understanding of the content presented?
A. “Schizophrenia is a disorder of the brain that can be cured with the correct treatment.”
B. “A person inherits schizophrenia from a parent.”
C. “Problems in the structure of the brain cause schizophrenia.”
D. “There are lots of potential causes for this disease, and this continues to be a controversial topic.”

Situation : Mr. Tonio a 49 year old , a jolly person works at the Commercial bank for 13 years had been informed
for some changs in is work load. Three months after he was observed of unbecoming behaviour. He was
diagnosed with Bipolar I disorder and experiencing a Manic episode is newly admitted to the in-patient psychiatric
unit.

71. Which nursing diagnosis is a priority at this time?

A. Risk for violence: other-directed R/T poor impulse control
B. Altered though process R/T hallucinations
C. Social isolation R/T manic excitement
D. Low self-esteem R/T guilt about promiscuity

72. In the mental hospital Mr. Tonio is yelling at another peer in the milieu. Which nursing intervention takes priority?
A. calmly redirect and remove the client from the milieu
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B. administer prescribed PRN intramuscular injection for agitation

C. notify the client to lower voice
D. obtain an order for seclusion to help decrease external stimuli

73. Another client diagnosed with bipolar II disorder has a nursing diagnosis of impaired social interactions R/T
egocentrism. Which short-term outcome is an appropriate expectation for this client problem?
A. the client will have an appropriate one-on-one interaction with a peer by day 4
B. the client will exchange personal information with peers at lunchtime
C. the client will verbalize the desire to interact with peers by day 2
D. the client will initiate an appropriate social relationship with a peer

74. An adult client 52 years old , diagnosed with major depressive disorder is being considered for electroconvulsive
therapy (ECT). Which client teaching should the nurse prioritize?
A. empathize with the client about fears regarding ECT.
B. monitor for any cardiac alterations to avoid possible negative outcomes
C. discuss the client and family expected short-term memory loss
D. inform the client that injury related to induced seizure commonly occurs

75. A nursing instructor is teaching about the cause of mood disorders. Which statement by a nursing student best
indicates an understanding of the etiology of mood disorders?
A. “When clients experience loss, they learn that it is inevitable and become hopeless and helpless.”
B. “There are alterations in the neurochemicals, such as serotonin, which cause the client’s symptoms.”
C. “Evidence continues to support multiple causations related to an individual’s susceptibility to mood symptoms.”
D “There is a genetic component affecting the development of mood disorder.”

Situation : Paulo 9 years old is diagnosed with an autistic disorder makes no eye contact; is unresponsive to staff
members and continuously twists, spins, and head bangs.

76. Which nursing diagnosis would take priority?

A. personal identity disorder R/T poor ego differentiation
B. impaired verbal communication R/T withdrawal into self
C. risk for injury R/T head banging
D. impaired social interaction R/T delay in accomplishing developmental tasks

77. Paulo diagnosed with an autistic disorder withdraws into self and, when spoken to, makes appropriate nonverbal
expressions. The nursing diagnosis Impaired verbal communication is documented. Which intervention would
address this problem?

A. assist the child to recognize separateness during self-care activities

B. use a face-to-face and eye-to-eye approach when communicating
C. provide the child with a familiar toy or blanket to increase feelings of security
D. offer self to the child during times of increasing anxiety

78. The nurse decided to have a nursing diagnosis of impaired social interaction for Paulo. He is currently making eye
contact and allowing physical touch. Which of the following statements addresses the evaluation of this child’s
behavior?
A. The nurse is unable to evaluate the child’s ability to interact socially based on the observed behaviors
B. The child is experiencing improved social interactions as evidenced by making eye contact and allowing
physical touch
C. The nurse is unable to evaluate this child’s ability to interact socially because the child has not experienced
these behaviors for an external period
D. The child’s making eye contact and allowing physical touch are indication of improved personal identity, not
improved social interaction

79. Which is a description of the etiology of autism from a genetic perspective?

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A. parents who have one child diagnosed with autism are at higher risk for having other children with the disorder
B. Amygdala abnormality in the anterior portion of the temporal lobe is associated with the diagnosis of autism
C. decreased levels of serotonin have been found in individuals diagnosed with autism
D. congenital rubella is implicated in the predisposition to autistic disorders

80. Which is a predisposing factor in the diagnosis of autism?

A. having a sibling diagnosed with mental retardation
B. congenital rubella
C. dysfunctional family systems
D. inadequate ego development

Situation : Therapeutic communication is the purposeful use of dialog to bring about the client’s insight , control of system
and healing . Nurses need a thorough understanding of communication theory and how to build a positive nurse- client
relationship.

81. A client admitted for alcohol detoxification states, “I don’t think my drinking has anything to do with why I am here in
the hospital. I think I have problems with depression.” Which statement by the nurse is the most therapeutic
response?
A. “I think you really need to look at the amount you are drinking and consider the effect on your family.”
B. “That’s wrong. I disagree with that. Your admission is because of your alcohol abuse and not for any other
reason.”
C “I’m sure you don’t mean that. You have realized that alcohol is the root of you problems.”
D. “I find it hard to believe that alcohol is not a problem because you have recently lost your job and your driver’s
license.”

82. Which is an example of the nontherapeutic technique of “giving reassurance?”

A. “That’s good. I’m glad that you….” C. “Don’t worry, everything will work out.”
B. “Hang in there, every dog has his day.” D. “I think you should…”

83. A client on an in-patient psychiatric unit has pressured speech and flight of ideas and is extremely irritable. During
an intake assessment, which is most appropriate nursing response?
A. “I think you need to know more about your medications.”
B. “What have you been thinking about lately?”
C. “I think we should talk more about what brought you into the hospital.”
D. “Yes, I see. And go on please.”

84. A nurse is communicating with a client, an in-patient psychiatric unit. The client moves closer and invades the
nurse’s personal space, making the nurse uncomfortable. Which is an appropriate nursing intervention?
A. the nurse ignores this behavior because it shows the client is progressing
B. the nurse expresses a sense of discomfort and limits behaviors
C. the nurse understands that clients require various amounts of personal space and accepts the behavior
D. the nurse confronts and informs the client that the client will be secluded if this behavior continues

85. A health-care team in a Mental hospital, a client, and several members of the client’s family are meeting together to
discuss the client’s imminent discharge. During this time, the client does not speak and makes eye contact only
with family members. From a cultural perspective, which nursing assessment accurately describes the client’s
behavior?
A. the client has a lack of understanding of the disease process
B. the client is experiencing denial related to the client’s condition
C the client is experiencing paranoid thoughts toward authority figures
D. the client has respect for members of health-care team

Situation : Understanding Psychiatric medications requires a basic knowledge on the concepts of administration to treat
Psychosis and other mood disorders.
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86. A client diagnosed with generalized anxiety disorder is placed on clonazepam (Klonopin) and buspirone (BuSpar).
Which client statement indicates teaching has been effective?

A. the client verbalizes that the clonazepam (Klonopin) is to be used for long-term therapy in conjunction with
buspirone (BuSpar)
B the client verbalizes that buspirone (BuSpar) can cause sedation and should be taken at night
C. the client verbalizes that clonazepam (Klonopin) is to be used short-term until the buspirone (BuSpar) takes full
effect
D. the client verbalizes that tolerance can result with long-term use of buspirone (BuSpar)

87. For the past year, a client has received haloperidol (Haldol). The nurse administering the client’s next notes a
twitch on the right side of the client’s face and tongue movements. Which nursing intervention takes priority?
A. administer haloperidol (Haldol) along with benztropine (Cogentin) 1 mg IM PRN per order
B. assess for the other signs of hyperglycemia resulting from the use of haloperidol (Haldol)
C check the client’s temperature, and assess mental status
D. Hold the haloperidol (Haldol), and call the physician

88. A client diagnosed with major depressive disorder and experiencing suicidal ideation is showing signs of anxiety.
Alprazolam (Xanax) is prescribed. Which assessment should be prioritized?
A. monitor for signs and symptoms of physical and psychological withdrawal
B. teach the client about side effects of the medication, and how to handle these side effects
C. assess for nausea, and give the medication with food if nausea occurs
D. ask the client to rate his or her mood scale, and monitor for suicidal ideations

89. A client is newly prescribed lithium carbonate (lithium). Which teaching point by the nurse takes priority?
A. “Make sure your salt intake is consistent.”
B. “Limit your fluid intake to 2000 mL/day
C. “Monitor your caloric intake because of potential weight gin.”
D. “Get yourself in a daily routine to assist in avoiding relapse”

90. A client taking a Barbiturate such a s pentobarbital (Nembutal ) should be taught to :

A. decrease the drug gradually rather than stop it abruptly

B. decrease the dose if drowsiness occurs
C. drink alcohol only in moderation
D. avoid driving a car while taking the drug

Situation : Everyday, Psychiatric Nurses confront a variety of ethical and legal issues that arise in the course of providing
special care to these clients.

91. A nurse is pulled from a medical/surgical floor to the Psychiatric unit. Which client would the nurse manager assign
to this nurse?
A. a chronically depressed client C. a client experiencing paranoid thinking
B. an actively psychotic client D. a client diagnosed with cluster B traits

92. On which client would a nurse on an in-patient psychiatric unit appropriately use four points restraints?
A. a client who is hostile and threatening the staff and other clients
B. a client who is intrusive and demanding and requires added attention
C. a client who is noncompliant with medications and treatments
D. a client who splits staff and manipulates other clients

93. A client has been fired from work because of downsizing. Although clearly upset, when explaining the situation to a
friend, the client states, “Imagine what I can do with this extra time.” Which defense mechanism is this client using?
A. denial C. rationalization
B. intellectualization D. suppression
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94. Which of the following questions needs to be answered before resorting to restraining a client?
A. Is the client obviously out of control?
B. Does the client distinguish between right and wrong?
C. can the client distinguish between right and wrong?
D. How long can the client maintain this behavior before hurting self or others?

95. When a nurse is working with a suicidal or self-destructive person, which of the following guideline would be the
most appropriate?
A. Nurses have the responsibility to promote and maintain life, but we cannot force clients to do so. As an
alternative, we encourage them to examine and understand how they arrived at suicide or self-destruction
B. Every individual has a right to decide whether to commit suicide or not. This is imperative at all times
C. Nurses need to be aware that the legal implications of not preventing suicide are paramount
D. It is mandatory that every nurse promotes the notion of preventing death and promoting life

Situation : A famous Nurse Psychiatrist was invited as a guest lecturer in a Psychiatric hospital as their continuing
education program .

96. The Nurse Lecturer emphasized that Psychiatric nursing education has been characterized by the significant theorists.
Which of the following is an exception?
A. Florence Nightingale , the first Nurse researcher , who focused on nursing education
B. Linda Richards, the first American Psychiatric Nurse
C. Hildegard Peplau, the first Nursing Psychiatrist
D. Nursing mental diseases , the first Nursing Psychiatric book

97. When creating a therapeutic milieu, the lecturer consider the 6 environmental elements namely , safety, structure ,
norms, limit-setting , balance and :
A. Pharmacotherapy C. Environmental modification
B. Use f self D. Empathy

98. Psychotherapeutic management of clients emphasizes three intervention tools necessary in the management of
Mental Illness , which are combination of :
A. Self, drugs, milieu management C. Self , drugs, behaviour therapy
B. Self , behaviour therapy, milieu management D. self , support groups , drugs.

99. Which of the following frameworks of Psychiatric intervention holds that social processes are involved in the
development and resolution of behavioural disturbances ?
A. Behaviorist model C. Socio-interpersonal model
B. Psychobiologic model D. Psychoanalytic model

100. In dealing with mentally disturbed clients the lecturer asks which statement of the nurses represent clarifying as a
therapeutic technique :
A. I’m not sure , I understand what you meant when you said “life is not easy “
B. Let’s look more closely at your sleep problems
C. If I were you, I would try herbal remedies
D. Tell me about your family