Sie sind auf Seite 1von 43

Answers & Rationale

1. Which of the following classes of drugs is most widely used in the treatment of cardiomyopathy? Stem: Treatment of Cardiomyopathy Answer: (B) Beta-adrenergic Rationale: By decreasing the heart rate and contractility, beta-adrenergic blockers improve myocardial filling and cardiac output, which are primary goals in the treatment of cardiomyopathy. Distractor: () Rationale: Antihypertensives arent usually indicated because they would decrease cardiac output in clients who are often already hypotensive. Calcium channel blockers are sometimes used for the same reasons as beta-adrenergic blockers; however, they arent as effective as beta -adrenergic blockers and cause increase hypotension. Nitrates arent used because of their dilating effects, which would further compromise the myocardium. Source: 2. Which of the following types of cardiomyopathy can be associated with childbirth? Stem: Answer: (A) Dilated Rationale: Although the cause isnt entirely known, cardiac dilation and heart failure may develop during the last month of pregnancy of the first few months after birth. The condition may result from a preexisting cardiomyopathy not apparent prior to pregnancy. Distractor: () Rationale: Hypertrophic cardiomyopathy is an abnormal symmetry of the ventricles that has an unknown etiology but a strong familial tendency. Myocarditis isnt specifically associated with childbirth. Restrictive

cardiomyopathy indicates constrictive pericarditis; the underlying cause is usually myocardial. Source: 3. Which of the following groups of symptoms indicated a ruptured abdominal aneurysm? Stem: Answer: (B) Severe lower back pain, decreased BP, decreased RBC, increased WBC Rationale: Severe lower back pain indicates an aneurysm rupture, secondary to pressure being applied within the abdominal cavity. When rupture occurs, the pain is constant because it cant be alleviated until the aneurysm is repaired. Blood pressure decreases due to the loss of blood. After the aneurysm ruptures, the vasculature is interrupted and blood volume is lost, so blood pressure wouldnt increase. For the same reason, the RBC count is decreased not increase. The WBC count increases as cells migrate to the site of injury. Distractor: () Rationale: Source: 4. Which of the following treatments is the definitive one for a ruptured aneurysm? Stem: Answer: (D) Surgical intervention Rationale: When the vessel ruptures, surgery is the only intervention that can repair it. Distractor: () Rationale: Administration of antihypertensive medications and beta-adrenergic blockers can help control hypertension, reducing the risk of rupture. An aortogram is a diagnostic tool used to detect an aneurysm. Source: 5. What is the term used to describe an enlargement of the heart muscle?

Stem: Answer: (A) Cardiomegaly Rationale: Cardiomegaly denotes an enlarged heart muscle. Distractor: () Rationale: Cardiomyopathy is a heart muscle disease of unknown origin. Myocarditis refers to inflammation of heart muscle. Pericarditis is an inflammation of the pericardium, the sac surrounding the heart. Source: 6. Which of the following recurring conditions most commonly occurs in clients with cardiomyopathy? Stem: Answer: (A) Heart failure Rationale: Because the structure and function of the heart muscle is affected, heart failure most commonly occurs in clients with cardiomyopathy. Distractor: () Rationale: Myocardial infarction results from prolonged myocardial ischemia due to reduced blood flow through one of the coronary arteries. Pericardial effusion is most predominant in clients with pericarditis. Diabetes mellitus is unrelated to cardiomyopathy. Source: 7. Which of the following sounds is distinctly heard on auscultation over the abdominal region of an abdominal aortic aneurysm client? Stem: Answer: (A) Bruit Rationale: A bruit, a vascular sound resembling heart murmur, suggests partial arterial occlusion. Distractor: ()

Rationale: Crackles are indicative of fluid in the lungs. Dullness is heard over solid organs, such as the liver. Friction rubs indicate inflammation of the peritoneal surface. Source: 8. Which of the following cardiac conditions does a fourth heart sound (S4) indicate? Stem: Answer: (D) Failure of the ventricle to eject all the blood during systole Rationale: An S4 occurs as a result of increased resistance to ventricular filling after atrial contraction. This increased resistance is related to decrease compliance of the ventricle. Distractor: () Rationale: A dilated aorta doesnt cause an extra heart sound, though it does cause a murmur. Decreased myocardial contractility is heard as a third heart sound. An s4 isnt heard in a normally functioning heart. Source: 9. Which of the following classes of medications maximizes cardiac performance in clients with heat failure by increasing ventricular contractility? Stem: Answer: (D) Inotropic agents Rationale: Inotropic agents are administered to increase the force of the hearts contractions, thereby increasing ventricular contractility and ultimately increasing cardiac output. Distractor: () Rationale: Beta-adrenergic blockers and calcium channel blockers decrease the heart rate and ultimately decrease the workload of the heart. Diuretics are administered to decrease the overall vascular volume, also decreasing the workload of the heart. Source: 10. Which of the following arteries primarily feeds the anterior wall of the heart?

Stem: Answer: (C) Left anterior descending artery Rationale: The left anterior descending artery is the primary source of blood for the anterior wall of the heart. Distractor: () Rationale: The circumflex artery supplies the lateral wall, the internal mammary artery supplies the mammary, and the right coronary artery supplies the inferior wall of the heart. Sources: 11. Which of the following blood tests is most indicative of cardiac damage? Stem: Answer: (C) Troponin I Rationale: Troponin I levels rise rapidly and are detectable within 1 hour of myocardial injury. Troponin I levels arent detectable in people without cardiac injury. Distractor: () Rationale: Lactate dehydrogenase is present in almost all body tissues and not specific to heart muscle. LDH isoenzymes are useful in diagnosing cardiac injury. CBC is obtained to review blood counts, and a complete chemistry is obtained to review electrolytes. Because CK levels may rise with skeletal muscle injury, CK isoenzymes are required to detect cardiac injury. Source: 12. Medical treatment of coronary artery disease includes which of the following procedures? Stem: Answer: (C) Oral medication administration Rationale: Oral medication administration is a noninvasive, medical treatment for coronary artery disease.

Distractor: () Rationale: Cardiac catheterization isnt a treatment but a diagnostic tool. Coronary artery bypass surgery and percutaneous transluminal coronary angioplasty are invasive, surgical treatments. Source: 13. What position should the nurse place the head of the bed in to obtain the most accurate reading of jugular vein distention? Stem: Answer: (C) Raised 30 degrees Rationale: Jugular venous pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation with the head of the bed inclined between 15 and 30 degrees. Distractor: () Rationale: Inclined pressure cant be seen when the client is supine or when the head of the bed is raised 10 degrees because the point that marks the pressure level is above the jaw (therefore, not visible). In high Fowlers position, the veins would be barely discernible above the clavicle. Source: 14. In caring for clients with pain and discomfort, which task is most appropriate to delegate to the nursing assistant? Stem: Answer: (A) Assist the client with preparation of a sitz bath. Rationale: The nursing assistant is able to assist the client with hygiene issues and knows the principles of safety and comfort for this procedure. Distractor: () Rationale: Monitoring the client, teaching techniques, and evaluating outcomes are nursing responsibilities. 15. In caring for a young child with pain, which assessment tool is the most useful?

Stem: Answer: (C) Faces pain-rating scale Rationale: The Faces pain rating scale (depicting smiling, neutral, frowning, crying, etc.) is appropriate for young children who may have difficulty describing pain or understanding the correlation of pain to numerical or verbal descriptors. Distractor: () Rationale: The other tools require abstract reasoning abilities to make analogies and use of advanced vocabulary. Source:

16. The leader of the study knows that certain patients who are in a specialized research setting tend to respond psychologically to the conditions of the study. This is referred to as: Stem: Research Answer: (B) Hawthorne effect Rationale: Hawthorne effect is based on the study by Elton Mayo and company about the effect of an intervention done to improve the working conditions of the workers on their productivity. It resulted to an increased productivity but not due to the intervention but due to the psychological effects of being observed. They performed differently because they were under observation. Distractor: (A) Cause and Effect Rationale: Cause and Effect is the manipulation of one variable causing a change to occur in another variable. Source: http://answers.yahoo.com/question/index?qid=20091004231414AAxvKGD 17. Family members are encouraging your client to tough it out rather than run the risk of becoming addicted to narcotics. The client is stoically abiding by the familys wishes. Priority nursing interventions for this client should target which dimension of pain? Stem: Answer: (C) Sociocultural

Rationale: The family is part of the sociocultural dimension of pain. They are influencing the client should be included in the teaching sessions about the appropriate use of narcotics and about the adverse effects of pain on the healing process. Distractor: () Rationale: The other dimensions should be included to help the client/family understand overall treatment plan and pain mechanism.

18. As the charge nurse, you are reviewing the charts of clients who were assigned to a newly graduated RN. The RN has correctly charted dose and time of medication, but there is no documentation regarding non-pharmaceutical measures. What action should you take first? Stem: Answer: (D) Give praise for the correct dose and time and discuss the deficits in charting. Rationale: In supervising the new RN, good performance should be reinforced first and then areas of improvement can be addressed. Distractor: () Rationale: Asking the nurse about knowledge of pain management is also an option; however, it would be a more indirect and time-consuming approach. Making a note and watching do not help the nurse to correct the immediate problem. In-service might be considered if the problem persists. Source: 19. On admission to the emergency department the burned clients blood pressure is 90/60, with an apical pulse rate of 122. These findings are an expected result of what thermal injuryrelated response? Stem: Answer: (A) Fluid shift Rationale: The physiologic effect of histamine release in injured tissues is a loss of vascular volume to the interstitial space, with a resulting decrease in blood pressure. Distractor: ()

Rationale: Intense pain and carbon monoxide poisoning increase blood pressure. Hemorrhage is unusual in a burn injury. Source: 20. A client is being tapered off opioids and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal? Stem: Answer: (C) Diaphoresis Rationale: Diaphoresis is one of the early signs that occur between 6 and 12 hours. Distractor: () Rationale: Fever, nausea, and abdominal cramps are late signs that occur between 48 and 72 hours. Source: 21. A tearful parent brings a child to the ED for taking an unknown amount of childrens chewable vitamins at an unknown time. The child is currently alert and asymptomatic. What information should be immediately reported to the physician? Stem: Answer: (A) The ingested childrens chewable vitamins contain iron. Rationale: Iron is a toxic substance that can lead to massive hemorrhage, coma, shock, and hepatic failure. Deferoxame is an antidote that can be used for severe cases of iron poisoning. Distractor: () Rationale: Other information needs additional investigation, but will not change the immediate diagnostic testing or treatment plan. Source: 22. When an unexpected death occurs in the ED, which of the following tasks is most appropriate to delegate to the nursing assistant?

Stem: Answer: (C) Assist with postmortem care. Rationale: Postmortem care requires some turning, cleaning, lifting, etc., and the nursing assistant is able to assist with these duties. Distractor: () Rationale: The RN should take responsibility for the other tasks to help the family begin the grieving process. In cases of questionable death, belongings may be retained for evidence, so the chain of custody would have to be maintained. Source:

23. A 36-year-old patient with a history of seizures and medication compliance of phenytoin (Dilantin) and carbamazepine (Tegretol) is brought to the ED by the MS personnel for repetitive seizure activity that started 45 minutes prior to arrival. You anticipate that the physician will order which drug for status epilepticus? Stem: Answer: (B) IV lorazepam (Ativan) Rationale: IV Lorazepam (Ativan) is the drug of choice for status epilepticus. Distractor: () Rationale: Tegretol is used in the management of generalized tonic-clonic, absence or mixed type seizures, but it does not come in an IV form. PO (per os) medications are inappropriate for this emergency situation. Magnesium sulfate is given to control seizures in toxemia of pregnancy. Source: 24. Joey knows that he has to protect the rights of human research subjects. Which of the following actions of Joey ensures anonymity? Stem: Ensuring anonymity of human research subjects Answer: (A) Keep the identities of the subject a secret Rationale: Keeping the identities of the research subject secret will ensure anonymity because this will hinder providing link between the information given to whoever is its source.

Distractor: (D) Release findings only to the participants of the study Rationale: Releasing the findings only to the participants of the study does not ensure their anonymity rather it serves as a sign that they are one of the participants of the study.

25. The burned client newly arrived from an accident scene is prescribed to receive 4 mg of morphine sulfate by IV push. What is the most important reason to administer the opioid analgesic to this client by the intravenous route? Stem: Answer: (C) The danger of an overdose during fluid remobilization is reduced. Rationale: Although providing some pain relief has a high priority, and giving the drug by the IV route instead of IM, SC, or orally does increase the rate of effect, the most important reason is to prevent an overdose from accumulation of drug in the interstitial space during the fluid shift of the emergent phase. When edema is present, cumulative doses are rapidly absorbed when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. Distractor: () Rationale: Source: 26. The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking agent, during the emergent phase. When the clients family asks why this drug is being given, what is the nurses best response? Stem: Answer: (C) To decrease hydrochloric acid production in the stomach and prevent ulcers. Rationale: Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and decreased mucosal barrier. Cimetidine inhibits the production and release of hydrochloric acid. Distractor: () Rationale:

Source: 27. The physician has ordered cooling measures for a child with fever who is likely to be discharged when the temperature comes down. Which of the following would be appropriate to delegate to the nursing assistant? Stem: Answer: (A) Assist the child to remove outer clothing. Rationale: The nursing assistant can assist with the removal of the outer clothing, which allows the heat to dissipate from the childs skin. Distractor: () Rationale: Advising and explaining are teaching functions that are the responsibility of the RN. Tepid baths are not usually performed because of potential for rebound and shivering. Source: 28. What clinical manifestation indicates that an escharotomy is needed on a circumferential extremity burn? Stem: Answer: (C) Capillary refill is slow in the digits and the distal pulse is absent. Rationale: Circumferential eschar can act as a tourniquet when edema forms from the fluid shift, increasing tissue pressure and preventing blood flow to the distal extremities and increasing the risk for tissue necrosis. This problem is an emergency and, without intervention, can lead to loss of the distal limb. This problem can be reduced or corrected with an escharotomy. Distractor: () Rationale: 29. Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery? Stem: Answer: (B) Crystalloids

Rationale: Although not universally true, most fluid resuscitation for burn injuries starts with crystalloid solutions, such as normal saline and Ringers lactate. Distractor: () Rationale: The burn client rarely requires blood during the emergent phase unless the burn is complicated by another injury that involved hemorrhage. Colloids and plasma are not generally used during the fluid shift phase because these large particles pass through the leaky capillaries into the interstitial fluid, where they increase the osmotic pressure. Increased osmotic pressure in the interstitial fluid can worsen the capillary leak syndrome and make maintaining the circulating fluid volume even more difficult. Source: 30. Ten hours after the client with 50% burns is admitted, her blood glucose level is 90 mg/dL. What is the nurses best action? Stem: Answer: (B) Document the finding as the only action. Rationale: Neural and hormonal compensation to the stress of the burn injury in the emergent phase increases liver glucose production and release. An acute rise in the blood glucose level is an expected client response and is helpful in the generation of energy needed for the increased metabolism that accompanies this trauma. Distractor: () Rationale: Source: 31. During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent? Stem: Answer: (D) Increased serum creatinine level Rationale: Gentamicin does not stimulate pain in the wound. The small, pale pink bumps in the wound bed are areas of re-epithelialization and not an adverse reaction. Gentamicin is nephrotoxic and sufficient amounts can be absorbed

through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored. Distractor: () Rationale: Source: 9999 32. Nurse Angela is caring for a client who has been treated long term with antipsychotic medication. During the assessment, Nurse Angela checks the client for tardive dyskinesia. If tardive dyskinesia is present, Nurse Angela would most likely observe: Stem: Tardive dyskinesia Answer: (A) Abnormal movements and involuntary movements of the mouth, tongue, and face. Rationale: Tardive dyskinesia is a severe reaction associated with long term use of antipsychotic medication. The clinical manifestations include abnormal movements (dyskinesia) and involuntary movements of the mouth, tongue (fly catcher tongue), and face. Distractor: (D) Severe headache, flushing, tremors, and ataxia Rationale: Ataxia, flushing, tremors are not included in the signs of Tardive dyskinesia. Source: http://en.wikipedia.org/wiki/Tardive_dyskinesia 33. After seeking help at an outpatient mental health clinic, Ruby who was raped while walking her dog is diagnosed with post-traumatic stress disorder (PTSD). Three months later, Ruby returns to the clinic, complaining of fear, loss of control, and helpless feelings. Which nursing intervention is most appropriate for Ruby? Stem: Post-traumatic Stress Disorder Answer: (D) Exploring the meaning of the traumatic event with the client. Rationale: The client with PTSD needs encouragement to examine and understand the meaning of the traumatic event and consequent losses. Otherwise, symptoms may worsen and the client may become depressed or engage in self-destructive behavior such as substance abuse. Distractor: (A) Recommending a high-protein, low-fat diet.

Rationale: The client must explore the meaning of the event and wont heal without this, no matter how much time passes. Behavioral techniques, such as relaxation therapy, may help decrease the clients anxiety and induce sleep. The physician may prescribe anti-anxiety agents or antidepressants cautiously to avoid dependence; sleep medication is rarely appropriate. A special diet isnt indicated unless the client also has an eating disorder or a nutritional problem. Source: http://en.wikipedia.org/wiki/Posttraumatic_stress_disorder 34. Jessica with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication? Stem: Lithium Answer: (B) Sodium Rationale: Lithium is chemically similar to sodium. If sodium levels are reduced, such as from sweating or diuresis, lithium will be reabsorbed by the kidneys, increasing the risk of toxicity. Clients taking lithium shouldnt restrict their intake of sodium and should drink adequate amounts of fluid each day. The other electrolytes are important for normal body functions but sodium is most important to the absorption of lithium. Distractor: (D) Potassium Rationale: Potassium has an inverse relationship with Sodium Source: http://en.wikipedia.org/wiki/Lithium http://www.medscape.com/viewarticle/759042 35. Nurse Angela develops methods for data gathering. Which of the following criteria of a good instrument refers to the ability of the instrument to yield the same results upon its repeated administration? Stem: Criteria of a good data gathering instrument Answer: (D) Reliability Rationale: Reliability is consistency of the research instrument. It refers to the repeatability of the instrument in extracting the same responses upon its repeated administration. Distractor: (B) Specificity

Rationale: Specificity is the probability in a binary test, of a true negative being correctly identified. Source: http://en.wiktionary.org/wiki/specificity 36. A dying male client gradually moves toward resolution of feelings regarding impending death. Basing care on the theory of Kubler-Ross, Nurse Angela plans to use nonverbal interventions when assessment reveals that the client is in the: Stem: Stages of Grief Answer: (D) Acceptance stage Rationale: Communication and intervention during this stage mainly nonverbal, as when the client gestures to hold the nurses hand. Distractor: (B) Denial stage Rationale: The client is already moving towards a resolution of his feelings towards dying. Source: http://en.wikipedia.org/wiki/K%C3%BCbler-Ross_model 37. Nurse Angela develops a countertransference reaction. This is evidenced by: Stem: Countertransference reaction Answer: (A) Revealing personal information to the client Rationale: Countertransference is an emotional reaction of the nurse on the client based on her unconscious needs and conflicts. Distractor: (D) The client feels angry towards the nurse who resembles his mother. Rationale: B and C are therapeutic approaches. While option D is transference reaction where a client has an emotional reaction towards the nurse based on her past. Source: http://en.wikipedia.org/wiki/Countertransference 38. An 83 year-old male client is in extended care facility is anxious most of the time and frequently complains of a number of vague symptoms that interfere with his ability to eat. These symptoms indicate which of the following disorders? Stem: Eating disturbance are

Answer: (B) Hypochondriasis Rationale: Complains of vague physical symptoms that have no apparent medical causes are characteristic of clients with hypochondriasis. In many cases, the GI system is affected. Distractor: (C) Severe anxiety. Rationale: Conversion disorders are characterized by one or more neurologic symptoms. The clients symptoms dont suggest severe anxiety. A client experiencing sublimation channels maladaptive feelings or impulses into socially acceptable behavior Source: http://en.wikipedia.org/wiki/Hypochondriasis 39. Nurse Angela notices other clients on the unit avoiding a client diagnosed with antisocial personality disorder. When discussing appropriate behavior in group therapy, which of the following comments is expected about this client by his peers? Stem: Antisocial personality disorder Answer: (A) Lack of honesty Rationale: Clients with antisocial personality disorder tent to engage in acts of dishonesty, shown by lying. Distractor: (B) Belief in superstition Rationale: Clients with schizotypal personality disorder tend to be superstitious. Clients with histrionic personality disorders tend to overreact to frustrations and disappointments, have temper tantrums, and seek attention. Source: http://en.wikipedia.org/wiki/Antisocial_personality_disorder 40. The effectiveness of monoamine oxidase (MAO) inhibitor drug therapy in client with post-traumatic stress disorder can be demonstrated by which of the following client self reports? Stem: Post-traumatic Stress Disorder Answer: (A) Im sleeping better and dont have nightmares Rationale: MAO inhibitors are used to treat sleep problems, nightmares, and intrusive daytime thoughts in individual with posttraumatic stress disorder.

Distractor: (D) Ive lost my phobia for water. Rationale: MAO inhibitors arent used to help control flashbacks or phobias or to decrease the craving for alcohol. Source: http://en.wikipedia.org/wiki/Monoamine_oxidase_inhibitor 41. Nurse Angela is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to: Stem: Bulimia Answer: (C) Identify anxiety-causing situations Rationale: Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Distractor: (B) Control eating impulses Rationale: You cannot control the clients eating impulses unless you have identified the cause of the clients anxiety. Source: http://en.wikipedia.org/wiki/Bulimia_nervosa 42. The psychiatrist orders lithium carbonate 600 mg P.O. T.I.D. for a female client. Nurse Angela would be aware that the teaching about the side effects of this drug was understood when the client state, I will call my doctor immediately if I notice any: Stem: Side effects of Lithium Carbonate Answer: (B) Fine hand tremors or slurred speech Rationale: These are common side effects of lithium carbonate. Distractor: (A) Sensitivity to bright light or sun Rationale: Medications that causes sensitivity to heat or sun are anti-psychotic drugs such as Haldol. Source: http://en.wikipedia.org/wiki/Lithium http://www.mindlink.org/meds_sensitivity.html

43. Nurse Angela would expect that a client with vascular dementia would experience: Stem: Vascular dementia Answer: (D) Disturbance in recalling recent events related to cerebral hypoxia. Rationale: Cell damage seems to interfere with registering input stimuli, which affects the ability to register and recall recent events; vascular dementia is related to multiple vascular lesions of the cerebral cortex and subcortical structure. Distractor: (B). Loss of abstract thinking related to emotional state Rationale: Loss of thinking related to emotional state is not in connection with the question. Source: http://www.alz.org/dementia/vascular-dementia-symptoms.asp 44. Jessica is diagnosed with panic disorder with agoraphobia is talking with the nurse in-charge about the progress made in treatment. Which of the following statements indicates a positive client response? Stem: Agoraphobia Answer: (A) I went to the mall with my friends last Saturday Rationale: Clients with panic disorder tend to be socially withdrawn. Going to the mall is a sign of working on avoidance behaviors. Distractor: (C) Today I decided that I can stop taking my medication Rationale: Hyperventilating is a key symptom of panic disorder. Teaching breathing control is a major intervention for clients with panic disorder. The client taking medications for panic disorder; such as tricylic antidepressants and benzodiazepines must be weaned off these drugs. Most clients with panic disorder with agoraphobia dont have nutritional problems. Source: http://www.medicalnewstoday.com/articles/162169.php 45. Nurse Angela enters a clients room, the client says, Theyre crawling on my sheets! Get them off my bed! Which of the following assessment is the most accurate? Stem: Visual disturbance

Answer: (D) The client is experiencing visual hallucination Rationale: The presence of a sensory stimulus correlates with the definition of a hallucination, which is a false sensory perception. Distractor: (B) The client is experiencing dysarthria Rationale: Aphasia refers to a communication problem. Dysarthria is difficulty in speech production. Flight of ideas is rapid shifting from one topic to another. Source: http://www.healthline.com/health/hallucinations http://en.wikipedia.org/wiki/Dysarthria 46. Jessica is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the clients physical health, the nurse should plan to: Stem: Anorexia nervosa Answer: (C) Monitor vital signs, serum electrolyte levels, and acid-base balance. Rationale: An anorexic client who requires hospitalization is in poor physical condition from starvation and may die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalances. Therefore, monitoring the clients vital signs, serum electrolyte level, and acid base balance is crucial. Distractor: (D) Instruct the client to keep an accurate record of food and fluid intake. Rationale: Option A may worsen anxiety. Option B is incorrect because a weight obtained after breakfast is more accurate than one obtained after the evening meal. Option D would reward the client with attention for not eating and reinforce the control issues that are central to the underlying psychological problem; also, the client may record food and fluid intake inaccurately. Source: http://en.wikipedia.org/wiki/Anorexia_nervosa 47. Jessica is a psychiatric client is to be discharged with orders for haloperidol (haldol) therapy. When developing a teaching plan for discharge, the nurse should include cautioning the client against: Stem: Haloperidol therapy Answer: (B) Staying in the sun Rationale: Haldol causes on exposure to the sun. photosensitivity. Severe sunburn can occur

Distractor: (C) Ingesting wine and cheese Rationale: Option C is contraindicated for patients taking MAOIs. Source: http://en.wikipedia.org/wiki/Haloperidol 48. Which medications have been found to help reduce or eliminate panic attacks? Stem: Panic attack Answer: (A) Antidepressants Rationale: Tricyclic and monoamine oxidase (MAO) inhibitor antidepressants have been found to be effective in treating clients with panic attacks. Why these drugs help control panic attacks isnt clearly understood. Distractor: (C) Antipsychotics Rationale: Anticholinergic agents, which are smooth-muscle relaxants, relieve physical symptoms of anxiety but dont relieve the anxiety itself. Antipsychotic drugs are inappropriate because clients who experience panic attacks arent psychotic. Mood stabilizers arent indicated because panic attacks are rarely associated with mood changes. Source: http://en.wikipedia.org/wiki/Monoamine_oxidase_inhibitor http://en.wikipedia.org/wiki/Antipsychotic 49. Ensuring that there is an informed consent on the part of the patient before a surgery is done, illustrates the bioethical principle of: Stem: Bioethical Principle Answer: (B) Autonomy Rationale: Informed consent means that the patient fully understands about the surgery, including the risks involved and the alternative solutions. In giving consent it is done with full knowledge and is given freely. The action of allowing the patient to decide whether a surgery is to be done or not exemplifies the bioethical principle of autonomy. Distractor: (D) Non-maleficence Rationale: Non-maleficence mean do no harm. We must refrain from providing ineffective treatments or acting with malice toward patients.

Source: http://missinglink.ucsf.edu/lm/ethics/content%20pages/fast_fact_bene_nonmal.htm 50. The outcome that is unrelated to a crisis state is: Stem: Crisis state Answer: (D) A higher level of anxiety continuing for more than 3 months. Rationale: This is not an expected outcome of a crisis because by definition a crisis would be resolved in 6 weeks. Distractor: (A) Learning more constructive coping skills Rationale: Learning more constructive coping skills is an outcome most related to crisis state. 51. Jessica with chronic schizophrenia takes neuroleptic medication is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. These findings suggest which life-threatening reaction: Stem: Chronic Schizophrenia Answer: (C) Neuroleptic malignant syndrome. Rationale: The clients signs and symptoms suggest neuroleptic malignant syndrome, a life-threatening reaction to neuroleptic medication that requires immediate treatment. Distractor: (D) Akathisia Rationale: Tardive dyskinesia causes involuntary movements of the tongue, mouth, facial muscles, and arm and leg muscles. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Akathisia causes restlessness, anxiety, and jitteriness.

Source: http://en.wikipedia.org/wiki/Akathisia 52. Nurse Angela ensures a therapeutic environment for all the client. Which of the following best describes a therapeutic milieu? Stem: Therapeutic Milieu Answer: (C) A living, learning or working environment.

Rationale: A therapeutic milieu refers to a broad conceptual approach in which all aspects of the environment are channeled to provide a therapeutic environment for the client. The six environmental elements include structure, safety, norms; limit setting, balance and unit modification. Distractor: (D) A permissive and congenial environment Rationale: A. Behavioral approach in psychiatric care is based on the premise that behavior can be learned or unlearned through the use of reward and punishment. B. Cognitive approach to change behavior is done by correcting distorted perceptions and irrational beliefs to correct maladaptive behaviors. D. This is not congruent with therapeutic milieu. Source: http://en.wikipedia.org/wiki/Milieu_therapy 53. Jessica, an adolescent who is depressed and reported by his parents as having difficulty in school is brought to the community mental health center to be evaluated. Which of the following other health problems would the nurse suspect? Stem: Depression Answer: (B) Behavioral difficulties Rationale: Adolescents tend to demonstrate severe irritability and behavioral problems rather than simply a depressed mood. Distractor: (D) Labile mood Rationale: Anxiety disorder is more commonly associated with small children rather than with adolescents. Cognitive impairment is typically associated with delirium or dementia. Labile mood is more characteristic of a client with cognitive impairment or bipolar disorder. Source: http://en.wikipedia.org/wiki/Anxiety_disorder http://psychcentral.com/encyclopedia/2008/labile-mood/ 54. Nurse Angela knows that the non-antipsychotic medication used to treat some clients with schizoaffective disorder is: Stem: Non-antipsychotic medication for schizoaffective disorder Answer: (C) lithium carbonate (Lithane) Rationale: Lithium carbonate, an antimania drug, is used to treat clients with schizoaffective disorder, a psychotic disorder once classified under

schizophrenia that causes affective symptoms, including manic-like activity. Lithium helps control the affective component of this disorder Distractor: (B) Chlordiazepoxide (Librium) Rationale: Phenelzine is a monoamine oxidase inhibitor prescribed for clients who dont respond to other antidepressant drugs such as imipramine. Chlordiazepoxide, an antianxiety agent, generally is contraindicated in psychotic clients. Imipramine, primarily considered an antidepressant agent, is also used to treat clients with agoraphobia and that undergoing cocaine detoxification. Source: http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682078.html 55. Nurse Angela recognizes that the suicidal risk for depressed client is greatest: Stem: Suicidal risk for depressed client Answer: (A) As their depression begins to improve Rationale: At this point the client may have enough energy to plan and execute an attempt. Distractor: (D) As they lose interest in the environment Rationale: As the client loses interest in his/her environment, that means he doesnt yet have the energy and will to attempt to kill themselves. 56. Jessica, 17 years old was sexually attacked while on her way home from school. She is brought to the hospital by her mother. Rape is an example of which type of crisis: Stem: Rape Answer: (B) Adventitious Rationale: Adventitious crisis is a crisis involving a traumatic event. It is not part of everyday life. Distractor: (A) Situational Rationale: A. Situational crisis is from an external source that upset ones psychological equilibrium C and D. Are the same. They are transitional or developmental periods in life Source: http://medical-dictionary.thefreedictionary.com/adventitious+crisis http://www.uh.edu/crc/sit.html

57. Nurse Angela is aware that Ritalin is the drug of choice for a child with ADHD. The side effects of the following may be noted by the nurse: Stem: Sides effects of Ritalin Answer: (A) increased attention span and concentration Rationale: The medication has a paradoxic effect that decreases hyperactivity and impulsivity among children with ADHD. Distractor: (B) Increase in appetite Rationale: Side effects of Ritalin include anorexia, insomnia, diarrhea and irritability. Source: http://www.drugs.com/ritalin.html 58. Ms. Gonzales visits the physicians office to seek treatment for depression, feelings of hopelessness, poor appetite, insomnia, fatigue, low self-esteem, poor concentration, and difficulty making decisions. The client states that these symptoms began at least 2 years ago. Based on this report, the nurse Angela suspects: Stem: Long term depression Answer: (D) Dysthymic disorder. Rationale: Dysthymic disorder is marked by feelings of depression lasting at least 2 years, accompanied by at least two of the following symptoms: sleep disturbance, appetite disturbance, low energy or fatigue, low self-esteem, poor concentration, difficulty making decisions, and hopelessness. These symptoms may be relatively continuous or separated by intervening periods of normal mood that last a few days to a few weeks. Distractor: (B) Atypical affective disorder Rationale: Cyclothymic disorder is a chronic mood disturbance of at least 2 years duration marked by numerous periods of depression and hypomania. Atypical affective disorder is characterized by manic signs and symptoms and is opposite of the symptoms Ms. Gonzales reported. Major depression is a recurring, persistent sadness or loss of interest or pleasure in almost all activities, with signs and symptoms recurring for at least 2 weeks. Source: http://www.mentalhealth.com/dis/p20-md04.html http://www.mayoclinic.com/health/cyclothymia/DS00729

59. Nurse Angela is aware that most crisis situations should resolve in about: Stem: Crisis situation duration Answer: (B) 4 to 6 weeks Rationale: Crisis is self-limiting and lasts from 4 to 6 weeks. Distractor: (D) 6 to 12 months Rationale: A crisis lasting up to 6 to 12 months is equivalent to major depression 60. The nurse is aware that the side effect of electroconvulsive therapy that a client may experience: Stem: Side effects of Electroconvulsive Therapy Answer: (C) Confusion for a time after treatment Rationale: The electrical energy passing through the cerebral cortex during ECT results in a temporary state of confusion after treatment. Distractor: (D) Complete loss of memory for a time Rationale: The client who has undergone ECT will not suffer from a complete loss of memory for a time. 61. John is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but that he can control his use if he chooses. Which coping mechanism is he using? Stem: Defense mechanism Answer: (D) Denial Rationale: Denial is unconscious defense mechanism in which emotional conflict and anxiety is avoided by refusing to acknowledge feelings, desires, impulses, or external facts that are consciously intolerable. Distractor: (B) Logical thinking Rationale: Withdrawal is a common response to stress, characterized by apathy. Logical thinking is the ability to think rationally and make responsible decisions, which would lead the client admitting the problem and seeking help. Repression is suppressing past events from the consciousness because of guilty association. Source:

http://www.ask.com/question/what-is-logical-thinking http://en.wikipedia.org/wiki/Denial 62. The nurse is caring for a client diagnosed with antisocial personality disorder. The client has a history of fighting, cruelty to animals, and stealing. Which of the following traits would the nurse be most likely to uncover during assessment? Stem: Antisocial personality disorder Answer: (D) A low tolerance for frustration Rationale: Clients with an antisocial personality disorder exhibit a low tolerance for frustration, emotional immaturity, and a lack of impulse control. Distractor: (C) Demonstrates ability to maintain close, stable relationships Rationale: They commonly have a history of unemployment, miss work repeatedly, and quit work without other plans for employment. They dont feel guilt about their behavior and commonly perceive themselves as victims. They also display a lack of responsibility for the outcome of their actions. Because of a lack of trust in others, clients with antisocial personality disorder commonly have difficulty developing stable, close relationships. Source: http://psychcentral.com/disorders/antisocial-personality-disorder-symptoms/ 63. A 65 years old client is in the first stage of Alzheimers disease. Nurse Angela should plan to focus this clients care on: Stem: First stage of Alzheimers disease Answer: (B) Providing emotional support and individual counseling. Rationale: Clients in the first stage of Alzheimers disease are aware that something is happening to them and may become overwhelmed and frightened. Therefore, nursing care typically focuses on providing emotional support and individual counseling. Distractor: (A) Offering nourishing finger foods to help maintain the clients nutritional status Rationale: The other options are appropriate during the second stage of Alzheimers disease, when the client needs continuous monitoring to prevent minor illnesses from progressing into major problems and when maintaining adequate nutrition may become a challenge. During this stage, offering nourishing finger foods helps clients to feed themselves and maintain adequate nutrition.

Source: http://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp?gclid=CP6EzLnytLs CFcZV4god_w4A9A 64. Hermione, a 42-year-old client with a diagnosis of chronic undifferentiated schizophrenia lives in a rooming house that has a weekly nursing clinic. She scratches while she tells the nurse she feels creatures eating away at her skin. Which of the following interventions should be done first? Stem: Chronic Undifferentiated Schizophrenia Answer: (C) Assess for possible physical problems such as rash Rationale: Clients with schizophrenia generally have poor visceral recognition because they live so fully in their fantasy world. They need to have as in-depth assessment of physical complaints that may spill over into their delusional symptoms. Distractor: (A) Talk about her hallucinations and fears Rationale: Talking with the client wont provide as assessment of his itching, and itching isnt as adverse reaction of antipsychotic drugs, calling the physician to get the clients medication increased doesnt address his physical complaints. Source: http://www.helpguide.org/mental/schizophrenia_symptom.htm 65. When Nurse Angela is providing care to her patient, she must remember that her duty is bound to not do any action that will cause the patient harm. This is the meaning of the bioethical principle: Stem: Principle of Bioethics Answer: (A) Non-maleficence Rationale: Non-maleficence means do not cause harm or do any action that will cause any harm to the patient/client. To do good is referred as beneficence. Distractor: (D) Solidarity Rationale: Solidarity is unity that produces or is based on community of interests, objectives, and standards. Source: http://en.wikipedia.org/wiki/Solidarity

66. Ivy, who is on the psychiatric unit is copying and imitating the movements of her primary nurse. During recovery, she says, I thought the nurse was my mirror. I felt connected only when I saw my nurse. This behavior is known by which of the following terms? Stem: Imitation of movement Answer: (B) Echopraxia Rationale: Echopraxia is the copying of anothers behaviors and is the result of the loss of ego boundaries. Distractor: (D) Ritualism Rationale: Modeling is the conscious copying of someones behaviors. Egosyntonicity refers to behaviors that correspond with the individuals sense of self. Ritualism behaviors are repetitive and compulsive. Source: http://en.wikipedia.org/wiki/Echopraxia 67. Jessica, a college student who frequently visited the health center during the past year with multiple vague complaints of GI symptoms before course examinations. Although physical causes have been eliminated, the student continues to express her belief that she has a serious illness. These symptoms are typically of which of the following disorders? Stem: Complaints without physiological cause Answer: (C) Hypochondriasis Rationale: Hypochondriasis in this case is shown by the clients belief that she has a serious illness, although pathologic causes have been eliminated. The disturbance usually lasts at least 6 with identifiable life stressor such as, in this case, course examinations. Distractor: (B) Depersonalization Rationale: Conversion disorders are characterized by one or more neurologic symptoms. Depersonalization refers to persistent recurrent episodes of feeling detached from ones self or body. Somatoform disorders generally have a chronic course with few remissions. Source: http://www.thefreedictionary.com/defense+mechanism

68. Nurse Angela is monitoring a male client who has been placed in restraints because of violent behavior. Nurse determines that it will be safe to remove the restraints when: Stem: Restraints Answer: (C) No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints. Rationale: The best indicator that the behavior is controlled, if the client exhibits no signs of aggression after partial release of restraints. Distractor: (B) The client apologizes and tells the nurse that it will never happen again Rationale: Options A, B, and D do not ensure that the client has controlled the behavior. 69. Jessica is experiencing hallucinations tells the nurse, The voice s are telling me Im no good. The client asks if the nurse hears the voices. The most appropriate response by the nurse would be: Stem: Hallucination Answer: (B) No, I do not hear your voices, but I believe you can hear them. Rationale: The nurse, demonstrating knowledge and understanding, accepts the clients perceptions even though they are hallucinatory. Distractor: (A) It is the voice of your conscience, which only you can control. Rationale: Saying this as a response to the clients statement will not help her because the nurse it not presenting reality. 70. Freud stresses out that EGO is: Stem: Definition of Ego. Answer: (A) Distinguishes between things in the mind and things in the reality. Rationale: The ego is responsible for distinguishing what is real and what is not. It is the one that balances the Id and Superego. Distractor: (B) Moral arm of the personality that strives for perfection than pleasure Rationale: Options B and D are a characteristic of the super ego which is the controller of instincts and drives and serves as the conscience of moral arm. The Id is our drive and instinct that is mediated by the ego and controlled by the super ego.

Source: http://en.wikipedia.org/wiki/Id,_ego_and_super-ego 71. Nurse Angela is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan? Stem: Anorexia Nervosa Answer: (C) Set up a strict eating plan for the client. Rationale: Establishing a consistent eating plan and monitoring the clients weight are very important in this disorder. Distractor: (B) Provide privacy during meals Rationale: The family and friends should be included in the clients care. The client should be monitored during meals-not given privacy. Exercise must be limited and supervised. 72. Jessica is to be discharged on a regimen of lithium carbonate. In the teaching plan for discharge the nurse should include: Stem: Lithium Carbonate Answer: (D) Encouraging the client to have blood levels checked as ordered. Rationale: Blood levels must be checked monthly or bimonthly when the client is on maintenance therapy because there is only a small range between therapeutic and toxic levels. Distractor: (A) Advising the client to watch the diet carefully Rationale: The client ca maintain a normal diet with an average consumption of Sodium Source: http://www.rxlist.com/eskalith-drug/consumer-missed-dose.htm 73. Which information is most important for the nurse Angela to include in a teaching plan for a male schizophrenic client taking clozapine (Clozaril)? Stem: Male schizophrenic client taking clozapine Answer: (B) Report a sore throat or fever to the physician immediately. Rationale: A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clozapine. Distractor: (D) Stop the medication when symptoms have subside

Rationale: Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly, not monthly. If the WBC count drops below 3,000/l, the medication must be stopped. Hypotension may occur in clients taking this medication. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. The medication should be continued, even when symptoms have been controlled. If the medication must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician. Source: http://en.wikipedia.org/wiki/Clozapine 74. Jessica has a lithium level of 2.4 mEq/L. The nurse immediately would assess the client for which of the following signs or symptoms? Stem: Lithium level Answer: (C) Blurred vision Rationale: At lithium levels of 2 to 2.5 mEq/L the client will experienced blurred , muscle twitching, severe hypotension, and persistent nausea and vomiting Distractor: (D) Fecal incontinence Rationale: With levels between 1.5 and 2 mEq/L the client experiencing vomiting, diarrhea, muscle weakness, ataxia, dizziness, slurred speech, and confusion. At lithium levels of 2.5 to 3 mEq/L or higher, urinary and fecal incontinence occurs, as well as seizures, cardiac dysrythmias, peripheral vascular collapse, and death. 75. Tristan is on Lithium has suffered from diarrhea and vomiting. What should the nurse in-charge do first: Stem: Diarrhea and vomiting Answer: (D) Hold the next dose and obtain an order for a stat serum lithium level Rationale: Diarrhea and vomiting are manifestations of Lithium toxicity. The next dose of lithium should be withheld and test is done to validate the observation. Distractor: (A) Recognize this as a drug interaction Rationale: A. The manifestations are not due to drug interaction. B. Cogentin is used to manage the extra pyramidal symptom side effects of antipsychotics. C. The common side effects of Lithium are fine hand tremors, nausea, polyuria and polydipsia. Source:

http://www.nlm.nih.gov/medlineplus/ency/article/002667.htm 76. Jessica, with a diagnosis of generalized anxiety disorder wants to stop taking his lorazepam (Ativan). Which of the following important facts should nurse Angela discuss with the client about discontinuing the medication? Stem: Discontinuing Lorazepam (Ativan) Answer: (D) Stopping the drug can cause withdrawal symptoms Rationale: Stopping antianxiety drugs such as benzodiazepines can cause the patient to have withdrawal symptoms. Distractor: (B) Stopping the drug increases cognitive abilities Rationale: Stopping a benzodiazepine doesnt tend to cause depression, increase cognitive abilities, or decrease sleeping difficulties. Source: http://www.rxlist.com/ativan-drug.htm 77. Which of the following descriptions of a clients experience and behavior can be assessed as an illusion? Stem: Illusion Answer: (D) The client looks at the shadow on a wall and tells the nurse she sees frightening faces on the wall. Rationale: Minor memory problems are distinguished from dementia by their minor severity and their lack of significant interference with the clients social or occupational lifestyle. Distractor: (C) The client becomes anxious whenever the nurse leaves the bedside Rationale: Option C is a manifestation of paranoia. Source: http://en.wikipedia.org/wiki/Paranoid_personality_disorder 78. Jun approaches the nurse and tells that he hears a voice telling him that hes evil and deserves to die. Which of the following terms describes the clients perception? Stem: False perception Answer: (C) Hallucination

Rationale: Hallucinations are sensory experiences that are misrepresentations of reality or have no basis in reality. Distractor: (D) Idea of Reference Rationale: Delusions are beliefs not based in reality. Disorganized speech is characterized by jumping from one topic to the next or using unrelated words. An idea of reference is a belief that an unrelated situation holds special meaning for the client. Source: http://en.wikipedia.org/wiki/Ideas_of_reference_and_delusions_of_reference 79. Mike is admitted to a psychiatric unit with a diagnosis of undifferentiated schizophrenia. Which of the following defense mechanisms is probably used by mike? Stem: Defense Mechanism Answer: (C) Regression Rationale: Regression, a return to earlier behavior to reduce anxiety, is the basic defense mechanism in schizophrenia. Distractor: (B) Rationalization Rationale: Projection is a defense mechanism in which one blames others and attempts to justify actions; its used primarily by people with paranoid schizophrenia and delusional disorder. Rationalization is a defense mechanism used to justify ones action. Repression is the basic defense mechanism in the neuroses; its an involuntary exclusion of painful thoughts, feelings, or experiences from awareness. Source: http://en.wikipedia.org/wiki/Regression http://en.wikipedia.org/wiki/Rationalization_(making_excuses) 80. The nurse is aware that the following ways in vascular dementia different from Alzheimers disease is: Stem: Difference between Vascular Dementia and Alzheimers disease Answer: (A) Vascular dementia has more abrupt onset Rationale: Vascular dementia differs from Alzheimers disease in that it has a more abrupt onset and runs a highly variable course. Distractor: (D) The inability to perform motor activities occurs in vascular dementia

Rationale: Personally change is common in Alzheimers disease. The duration of delirium is usually brief. The inability to carry out motor activities is common in Alzheimers disease. Source: http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=161 81. Nurse Angela is aware that the following is classified as an Axis I disorder by the Diagnosis and Statistical Manual of Mental Disorders, Text Revision (DSM-IVTR) is: Stem: Axis I disorder Answer: (C) Major depression Rationale: The DSM-IV-TR classifies major depression as an Axis I disorder. Distractor: (B) Borderline personality disorder Rationale: Personality disorder as an Axis II; obesity and hypertension, Axis III. Source: http://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Manual_of_Mental_Disorders 82. Stem: Manic depression Answer: (D) Listening attentively with a neutral attitude and avoiding power struggles. Rationale: The nurse should listen to the clients requests, express willingness to seriously consider the request, and respond later. Distractor: (C) Allowing the client to exhibit hyperactive, demanding, manipulative behavior without limit Rationale: The nurse should encourage the client to take short daytime naps because he expends so much energy. The nurse shouldnt try to restrain the client when he feels the need to move around as long as his activity isnt harmful. High calorie finger foods should be offered to supplement the clients diet, if he cant remain seated long enough to eat a complete meal. The nurse shouldnt be forced to stay seated at the table to finish a meal. The nurse should set limits in a calm, clear, and self-confident tone of voice. 83. Richard is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations? Stem: Schizotypal Personality Disorder

Answer: (B) Paranoid thoughts Rationale: Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts. Distractor: (C) Emotional affect Rationale: Aggressive behavior is uncommon, although these clients may experience agitation with anxiety. Their behavior is emotionally cold with a flattened affect, regardless of the situation. These clients demonstrate a reduced capacity for close or dependent relationships. Source: http://en.wikipedia.org/wiki/Schizotypal_personality_disorder 84. When establishing an initial nurse-client relationship, Nurse Angela should explore with the client the: Stem: Nurse-client Relationship Answer: (A) Clients perception of the presenting problem. Rationale: The nurse can be most therapeutic by starting where the client is, because it is the clients concept of the problem that serves as the starting point of the relationship. Distractor: (B) Occurrence of fantasies the client may experience Rationale: Choices B, C, and D are established once the nurse was able to build rapport between her and the client. Source: http://en.wikipedia.org/wiki/Nurse%E2%80%93client_relationship 85. Nurse Angela is caring for a client who has been diagnosed with delirium. Which statement about delirium is true? Stem: Delirium Answer: (D) Its characterized by an acute onset and lasts hours to a number of days Rationale: Delirium has an acute onset and typically can last from several hours to several days Distractor: (C) Its characterized by a slowly evolving onset and lasts about 1 month Rationale: Delirium has an acute onset and typically can last from several hours to several days

Source: http://www.mayoclinic.com/health/delirium/DS01064/DSECTION=symptoms 86. Jessica with a history of polysubstance abuse is admitted to the facility. She complains of nausea and vomiting 24 hours after admission. The nurse assesses the client and notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through which of the following withdrawals? Stem: Type of Withdrawal Answer: (D) Opioid withdrawal Rationale: The symptoms listed are specific to opioid withdrawal. Distractor: (B) Cannabis withdrawal Rationale: Alcohol withdrawal would show elevated vital signs. There is no real withdrawal from cannabis. Symptoms of cocaine withdrawal include depression, anxiety, and agitation. Source: https://www.marijuana-anonymous.org/literature/pamphlets/detoxing-from-marijuana 87. Nurse Angela is aware that the following pharmacologic agents are sedative hypnotic medication is used to induce sleep for a client experiencing a sleep disorder is: Stem: Sedative hypnotic agent for a sleep disorder Answer: (A) Triazolam (Halcion) Rationale: Triazolam is one of a group of sedative hypnotic medication that can be used for a limited time because of the risk of dependence. Distractor: (D) Risperidone (Risperdal) Rationale: Paroxetine is a scrotonin-specific reutake inhibitor used for treatment of depression panic disorder, and obsessive-compulsive disorder. Fluoxetine is a scrotonin-specific reuptake inhibitor used for depressive disorders and obsessive-compulsive disorders. Risperidome is indicated for psychotic disorders. Source: http://www.nlm.nih.gov/medlineplus/druginfo/meds/a694015.html

88. During conversation of Nurse Angela with a client, he observes that the client shift from one topic to the next on a regular basis. Which of the following terms describes this disorder? Stem: Disorder Answer: (D) Loose association Rationale: Loose associations are conversations that constantly shift in topic. Distractor: (B) Concrete thinking Rationale: Concrete thinking implies highly definitive thought processes. Flight of ideas is characterized by conversation thats disorganized from the onset. Loose associations dont necessarily start in a cogently, then becomes loose. Source: http://medical-dictionary.thefreedictionary.com/concrete+thinking 89. The therapeutic approach in the care of Coco, an autistic child includes the following EXCEPT: Stem: Therapeutic approach in an autistic child Answer: (D) Rearrange the environment to activate the child Rationale: The child with autistic disorder does not want change. Maintaining a consistent environment is therapeutic. Distractor: (C) Provides safety measures Rationale: A. Angry outburst can be re-channeling through safe activities. B. Acceptance enhances a trusting relationship. C. Ensure safety from selfdestructive behaviors like head banging and hair pulling. 90. Jessica, a 9 year old child has very limited vocabulary and interaction skills. She has an I.Q. of 45. She is diagnosed to have Mental retardation of this classification: Stem: Mental retardation Answer: (C) Moderate Rationale: The child with moderate mental retardation has an I.Q. of 35- 50 Distractor: (D) Severe Rationale: Profound Mental retardation has an I.Q. of below 20; Mild mental retardation 50-70 and severe mental retardation has an I.Q. of 20-35.

Source: http://behavenet.com/node/21026 91. Angela with a diagnosis of depression is started on imipramine (Tofranil), 75 mg by mouth at bedtime. The nurse should tell the client that: Stem: Imipramine Answer: (D) This medication may initially cause tiredness, which should become less bothersome over time. Rationale: Sedation is a common early adverse effect of imipramine, a tricyclic antidepressant, and usually decreases as tolerance develops. Distractor: (C) The client should avoid eating such foods as aged cheeses. Yogurt, and chicken livers while taking medication Rationale: Dietary restrictions, such as avoiding aged cheeses, yogurt, and chicken livers, are necessary for a client taking a monoamine oxidase inhibitor, not a tricyclic antidepressant. Source: http://www.mayoclinic.com/health/maois/MH00072 92. Which nursing intervention would be most appropriate if a male client develop orthostatic hypotension while taking amitriptyline (Elavil)? Stem: Orthostatic Hypotension Answer: (B) Advising the client to sit up for 1 minute before getting out of bed. Rationale: To minimize the effects of amitriptyline-induced orthostatic hypotension, the nurse should advise the client to sit up for 1 minute before getting out of bed. Orthostatic hypotension commonly occurs with tricyclic antidepressant therapy. In these cases, the dosage may be reduced or the physician may prescribe nortriptyline, another tricyclic antidepressant. Distractor: (C) Instructing the client to double the dosage until the problem resolves. Rationale: Orthostatic is discontinued. hypotension disappears only when the drug

Source: http://www.medicinenet.com/orthostatic_hypotension/page2.htm 93. Nurse Angela recognizes that the most important factor necessary for the establishment of trust in a critical care area is:

Stem: Establishment of Trust Answer: (D) Presence Rationale: The constant presence of a nurse provides emotional support because the client knows that someone is attentive and available in case of an emergency. Distractor: (B) Respect Rationale: Respect can only be gained after the nurse has established trust with the client. 94. When assessing the premorbid personality characteristics of a client with a major depression, it would be unusual for the nurse to find that this client demonstrated: Stem: Characteristics of a major depression Answer: (C) Diverse interest Rationale: Before onset of depression, these clients usually have very narrow, limited interest. Distractor: (D) Over meticulousness Rationale: A client suffering from major depression does not have any interest on the surrounding environment. Source: http://www.mayoclinic.com/health/depression/DS00175/DSECTION=symptoms 95. Rose with paranoid schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse would be most appropriate? Stem: Paranoid Schizophrenia Answer: (C) Your cursing is interrupting the activity. Take time out in your room for 10 minutes. Rationale: The nurse should set limits on client behavior to ensure a comfortable for all clients. Distractor: (B) Youre just doing this to get back at me for making you come to therapy. Rationale: The nurse should accept hostile or quarrelsome client outbursts within limits without becoming personally offended, as in option A. Option B is incorrect because it implies that the clients actions reflect feelings toward the

staff instead of the clients own misery. Judgmental remarks, such as option D, may decrease the clients self-esteem. 96. After taking an overdose of phenobarbital (Barbita), Jessica is admitted to the emergency department. Dr. Aviles prescribes activated charcoal (Charcocaps) to be administered by mouth immediately. Before administering the dose, the nurse verifies the dosage ordered. What is the usual minimum dose of activated charcoal? Stem: Minimum dose of activated charcoal Answer: (C) 30 g mixed in 250 ml of water Rationale: The usual adult dosage of activated charcoal is 5 to 10 times the estimated weight of the drug or chemical ingested, or a minimum dose of 30 g, mixed in 250 ml of water. Distractor: (A) 5 g mixed in 250 ml of water Rationale: Doses less than this will be ineffective; doses greater than this can increase the risk of adverse reactions, although toxicity doesnt occur with activated charcoal, even at the maximum dose. Source: http://en.wikipedia.org/wiki/Activated_carbon 97. Lily, a newly admitted client was diagnosed with delirium and has history of hypertension and anxiety. She had been taking digoxin, furosemide (Lasix), and diazepam (Valium) for anxiety. This clients impairment may be related to which of the following conditions? Stem: Delirium Answer: (C) Drug intoxication Rationale: This client was taking several medications that have a propensity for delirium; digoxin (a digitalis glycoxide), furosemide (a thiazide diuretic), and diazepam (a benzodiazepine). Sufficient supporting data dont exist to suspect the other options as causes. Distractor: (B) Metabolic acidosis Rationale: Metabolic acidosis can manifest through confusion or lethargy but it does not cause delirium Source: http://www.nlm.nih.gov/medlineplus/ency/article/000335.htm

98. Klaus, an outpatient in psychiatric facility is diagnosed with dysthymic disorder. Which of the following statement about dysthymic disorder is true? Stem: Dysthymic Disorder Answer: (D) Its a mood disorder similar to major depression but of mild to moderate severity Rationale: Dysthymic disorder is a mood disorder similar to major depression but it remains mild to moderate in severity. Distractor: (C) Its a form of depression that occurs in the fall and winter Rationale: Cyclothymic disorder is a mood disorder characterized by a mood range from moderate depression to hypomania. Bipolar I disorder is characterized by a single manic episode with no past major depressive episodes. Seasonal affective disorder is a form of depression occurring in the fall and winter. Source: http://emedicine.medscape.com/article/290686-overview 99. Which of the following interventions is important for a patient experiencing paranoid personality disorder taking olanzapine (Zyprexa)? Stem: Paranoid personality disorder taking Olanzapine (Zyprexa) Answer: (C) Explain that the drug is less affective if the client smokes Rationale: Olanzapine smoke cigarettes. (Zyprexa) is less effective for clients who

Distractor: (B) Teach the client to watch for extrapyramidal adverse reaction Rationale: Serotonin syndrome occurs with clients who take a combination of antidepressant medications. Olanzapine doesnt cause euphoria, and extrapyramidal adverse reactions arent a problem. However, the client should be aware of adverse effects such as tardive dyskinesia. Source: http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601213.html 100. Francis tells the nurse that her coworkers are sabotaging the computer. When the nurse asks questions, the client becomes argumentative. This behavior shows personality traits associated with which of the following personality disorder? Stem: Type of Personality Disorder

Answer: (C) Paranoid Rationale: Because of their suspiciousness, paranoid personalities ascribe malevolent activities to others and tent to be defensive, becoming quarrelsome and argumentative. Distractor: (D) Schizotypal Rationale: Clients with antisocial personality disorder can also be antagonistic and argumentative but are less suspicious than paranoid personalities. Clients with histrionic personality disorder are dramatic, not suspicious and argumentative. Clients with schizoid personality disorder are usually detached from other and tend to have eccentric behavior. Source: http://en.wikipedia.org/wiki/Personality_disorder