NP 5 answers PSYCHIATRIC NURSING

1. Riccos as-needed medication list includes several

drugs. Which of the following drugs is one of the most
widely used antianxiety agents?
a. Diphenhydramine
b. Flumazenil
c. Lorazepam
d. Methylphenidate
Answer is C. Lorazepam or Ativan is a widely used
antiaxiety agent. A, B and are not antianxiety
medications.
2. One of Marks nursing diagnoses is self-esteem
disturbance. Which of the following is the most
therapeutic nursing intervention?
a. Asking his friends to encourage his self-care
b. Enlisting him in the planning of his own care
c. Moving him to a different hospital environment
d. Teaching him how to perform self-care
measures
Answer is B. encouraging a patient to be independent as
possible will promote self-confidence and self-reliance
thus increasing his self-esteem.
3. In planning Nicas nursing care, which of the following
statements or questions by the nurse would most
effectively assess Nicas self-esteem?
a. Are you happy with your self and life in
general?
b. Share some of your likes and dislikes with me.
c. Tell me about your sense of satisfaction with
yourself.
d. What changes in your body most concern you?
Answer is C. Self-satisfaction is a factor in determining
ones self-esteem. A is a closed question, B may not
answer the diagnosis of self-esteem and D concerns with
body disturbance and not self-esteem.
4. In a weekly parenting class, the nurse teaches parents
ways to foster healthy self-concepts in their children.
Which method is most important?
a. Offering clear guidelines
b. Setting fluctuating limits
c. Providing frequent correction
d. Giving positive feedback
Answer is D. Giving positive feedback to a child promotes
healthy self-concept. B may limit childs ability to discover
his/her horizon. C limits childs initiative. A which is safety,
is not important in promoting healthy self-concept.
5. Ms. Santos is expressing guilt about her sons illness.
Which aspect of her role should the nurse most express
when addressing Ms. Santos guilt?
a. Empathy
b. Guidance
c. Role modeling
d. Teaching
Answer is A. Empathy is understanding clients situation.
And putting self to the situation.
6. Which response from the nurse is most therapeutic
when Mr. Reyes expresses a spiritual point of view with
which the nurse disagrees?
a. Can we talk about your plans when you leave
the hospital?
b. That sounds out of mainstream, Mr. Reyes.
c. The nurse actively listens to Mr. Reyes

d. Yes, Mr. Reyes, I respect your spiritual point of

view.
Answer is C. Listening is the most therapeutic approach
in nurse-client relationship.
7. Unresolved feelings related to loss most likely may be
recognized during which phase of the therapeutic nurseclient relationship?
a. orientation
b. working
c. termination
d. trusting
Answer is C. Termination is the end of the nurse-client
relationship and feelings of loss are felt most by the
patients.
8. A client with a diagnosis of major depression who
attempted suicide says to the nurse, I should have died.
Ive always been a failure. Nothing ever goes right for
me. The most therapeutic response to the client is:
a. I dont see you as a failure.
b. Feeling like this is all part of being ill.
c. Youve been feeling like a failure for a while?
d. You have everything to live for.
Answer is C. This is a therapeutic response because it
initiates a conversation which the client can talk about
his/her feelings.
9. The community health nurse visits a client at home.
The client states, I havent slept at all the last couple of
nights. Which response by the nurse illustrates the most
therapeutic communication technique for this client?
a. Go on
b. Sleeping?
c. The last couple of nights?
d. Youre having difficulty sleeping?
Answer is A. This response means that the nurse is
willing to listen to the clients sentiments and problems.
10. The nurse is performing an admission assessment on
a client and is attempting to obtain subjective data
regarding the clients sexual/reproductive status. The
client states, I dont want to discuss this; its private and
personal. Which statement, if made by the nurse
indicates that the nurse is therapeutic?
a. I hate being asked these sorts of questions
too.
b. I am a professional nurse, and as such Ill have
you know that all information is kept
confidential.
c. I know that some of these questions are difficult
for you, but as a professional nurse, I must
legally respect your confidentiality.
d. This is difficult for you to speak about, but I am
trying to perform a complete assessment and I
need this information.
Answer is C. Confidentiality is very important in a nurseclient relationship, and as a nurse, one has the duty to
respect clients privacy and confidentiality.
11. The nurse is caring for a client who says, I dont want
you to touch me. Ill take care of myself! I dont want you
to touch me. Which nursing response is most
therapeutic?
a. Okay. If thats what you want. Ill just leave this
cup for you to collect your urine in. After
breakfast, I will take more blood from you.

b. If you didnt want our care, why did you come

here?
c. Why are you so being difficult? I only want to
help you.
d. It sounds as though you want to take care of
yourself. Lets work together so you can do
things for yourself.
Answer is D. Reflecting is a form of therapeutic response.
D lets the client be aware of his/her actions and it let a
good nurse-patient relationship.
12. A client admitted to the mental health unit is
experiencing Disturbed Thought Processes. The client
believes that the food is being poisoned. Which
communication technique does the nurse plan to use to
encourage the client to eat?
a. using open-ended questions and silence
b. offering opinions about the necessity of
adequate nutrition.
c. identifying the reasons that the client may not
want to eat
d. focusing on self-disclosure regarding food
preferences
Answer is A. Open ended questions let the client express
his concerns and problems.
13. The nurse is working with a client who has sought
counseling after trying to rescue a neighbor involved in a
house fire. In spite of the clients efforts, the neighbor
died. Which action does the nurse engage in with the
client during the working phase of the nurse-client
relationship?
a. exploring the clients potential for self-harm
b. exploring the clients ability to function
c. inquiring about the clients perception or
appraisal of the neighbors death.
d. inquiring about and examining the clients
feelings that may block adaptive coping
Answer is D. A client who is experiencing guilt should be
examined for maladaptive coping.
14. A client who has just been sexually assaulted is quiet
and calm. The nurse analyzes this behavior as indicating
which defense mechanism?
a. denial
b. projection
c. rationalization
d. intellectualization
Answer is A. A client who experienced assault may use
denial as a defense mechanism. She doesnt want to
believe that she was sexually assaulted.
15. The nurse completes the initial assessment of a client
admitted to the mental health unit. The nurse analyzes
the data obtained on assessment and determines that
which of the following presents a priority concern?
a. the presence of bruises on the clients body
b. the clients report of not eating or sleeping
c. the clients report of suicidal thoughts
d. the significant others disapproving of the
treatment.
Answer is C. Safety is a priority.
16. Laboratory work is prescribed on a client who has
been experiencing delusions. When the nurse
approaches the client to obtain a specimen of the clients
blood, the client begins to shout Youre all vampires. Let
me out of here! The most appropriate nursing response
is which of the following?
a. I am not going to hurt you; I am going to help
you!

b. What makes you think that I am a vampire?

c. Ill leave and come back later for your blood.
d. It must be frightful to think others want to hurt
you.
Answer is D. It is the most therapeutic response.
17. An inebriated client is brought to the emergency
department by the local police. The client is told that the
physician will be in to see the client in about 30 minutes.
The client becomes loud and offensive and wants to be
seen by the physician immediately. The most appropriate
nursing intervention is which of the following?
a. attempt to talk with the client to deescalate
behavior
b. watch the behavior escalate before intervening
c. inform the client that he will be asked to leave if
the behavior continues
d. offer to take the client to an examination room
until the client can be treated.
Answer is D. Offering self.
18. A client is admitted to a mental health unit for
treatment of psychotic behavior. The client is at the
locked exit door and is shouting, Let me out. Theres
nothing wrong with me. I dont belong here. The nurse
analyzes this behavior as:
a. projection
b. denial
c. regression
d. rationalization
Answer is B. This reaction by the client is a form of denial
19. A home health nurse is talking to the spouse of a
client taking an antidepressant. The spouse says, Now
that my husband is responding to the antidepressant, the
suicidal risk is over and you can stop making these home
visits. After analyzing this statement, which of the
following is the most appropriate nursing response?
a. I agree with you. Clients who want to kill
themselves are only suicidal for a limited time.
No one can feel self-destructive forever.
b. I need to continue with my visits. Your comment
reflects a lack of knowledge that this disease
runs in families.
c. I agree with you. The suicidal threats were
really attention seeking. Continuing to visit
would reinforce your husbands use of
manipulation.
d. I need to continue with my visits. Most suicides
occur within 3 months after improvement begins
because the client now has the energy to carry
out the suicidal intentions.
Answer is D.
20. The supervisor reprimands the nurse in charge of the
nursing unit because the charge nurse has not adhered
to the unit budget. Later that afternoon, the charge nurse
accuses the nursing staff of wasting supplies. This
behavior is an example of:
a. denial
b. repression
c. suppression
d. displacement
Answer is D.
21. The client who is delusional says to the nurse, The
federal guards were sent to kill me. The nurses best
response is:
a. The guards are out to kill you
b. I dont believe this is true.
c. I dont know anything about the guards. Do you
feel afraid that people are trying to hurt you?

d. What makes you think the guards were sent to

hurt you?
Answer is C.
22. In a nurse patient relationship, more therapeutic
interactions occur during this phase:
a. Orientation
b. Working
c. Pre-interaction
d. Termination
Answer is B.
23. A woman who had a heated discussion with her
boyfriend says that she does not want to talk about it.
This defense mechanism is:
a. Reaction formation
b. Suppression
c. Regression
d. Denial
Answer is B.
24. A nurse in the mental health unit is performing an
assessment on a client who has a history of multiple
physical complaints involving several organ systems.
Diagnostic studies revealed no organic pathology. The
nurse plans care for this client knowing that the client is
experiencing which of the following disorders?
a. somatization disorder
b. depression
c. schizophrenia
d. obsessive-compulsive disorder
Answer is A.
25. A female client has been diagnosed with major
depression. The nurse notes that the client is not eating
adequately and at times refuses to eat. To meet the
clients nutritional needs, the nurse plans to do which of
the following?
a. Provide small frequent meals
b. Tell the client that social activities will be
restricted unless food intake is consumed
c. Force foods and fluids
d. Provides snacks and meals requested
Answer is A.
26. The level of anxiety associated with the tension of
everyday life is called:
a. Severe anxiety
b. Panic anxiety
c. Mild anxiety
d. Moderate anxiety
Answer is C.
27. A psychiatric client is repeating the words spoken by
the nurse. This speech pattern is known as:
a. Word salad
b. Neologism
c. Echolalia
d. Confabulation
Answer is C.
28. The client is unwilling to go out of the house for fear
of doing something crazy in public. Because of this fear
the client remains homebound except when accompanied
outside by the spouse. Based on this data, the nurse
determines that the client is experiencing:
a. social phobia
b. agoraphobia
c. claustrophobia
d. hypochondriasis
Answer is B.

29. A student who is upset with teacher writes a poem

about hatred, this defense mechanism used by the
student is called:
a. Conversion
b. Rationalization
c. Denial
d. Sublimation
Answer is D.
30. A teenager unconsciously desires to strike her
mother. She develops sudden paralysis of her arms.
Defense mechanism used was:
a. Conversion
b. Sublimation
c. Denial
d. Displacement
Answer is A.
31. The client says to the nurse, Im going to die, and I
wish my family would stop hoping for a cure! I get so
angry when they carry on like this! After all, Im the one
whos dying. The most therapeutic response by the
nurse is:
a. Youre feeling angry that your family continues
to hope for you to be cured?
b. I think we should talk more about your anger
with your family.
c. Well, it sounds like youre being pretty
pessimistic. After all, years ago people died of
pneumonia.
d. Have you shared you feelings with your family?
Answer is A.
32. The nurse employed in a mental health unit is
assigned to care for a client admitted to the unit 2 days
ago. On review of the clients record, the nurse notes that
the admission was voluntary admission. Based on this
type of admission, the nurse anticipates which of the
following?
a. the client will resist treatment measures
b. the clients family will resist treatment measures
c. the client will be angry and will refuse care
d. the client will participate in the planning of the
care and treatment plan.
Answer is D.
33. A nurse enters a clients room, and the client is
demanding release from the hospital. The nurse reviews
the clients record and notes that the client was admitted
2 days ago for treatment of an anxiety disorder and that
the admission was a voluntary admission. Which of the
following actions will the nurse take?
a. tell the client that discharge is not possible at
this time
b. call the clients family
c. contact the physician
d. persuade the client to stay a few more days.
Answer is C.
34. A client is admitted to the mental health unit. On
admission assessment the nurse notes that the client is
admitted by involuntary status. Based this type of
admission, the nurse would most likely expect that the
client:
a. presents a harm to self
b. requested the admission
c. consented to the admission
d. provided written application to the facility for
admission
Answer is A.

35. The nurse is caring for a client who is scheduled for

ECT. The nurse notes that an informed consent has not
been obtained for the procedure. On review of the record,
the nurse notes that the admission was an involuntary
hospitalization. Based on this information, the nurse
determines:
a. that an informed consent does not need to be
obtained
b. that an informed consent should be obtained
from the family
c. that an informed consent needs to be obtained
from the client
d. that the physician will obtain the informed
consent.
Answer is C.
36. Following a group therapy session, a client
approaches a nurse and verbalizes a need for seclusion
because of uncontrollable feelings. The most appropriate
nursing action would be to:
a. inform the client that seclusion has not been
prescribed
b. obtain an informed consent
c. call the clients family
d. place the client in seclusion immediately
Answer is B.
37. The nurse is providing care to a client admitted to the
hospital with a diagnosis of acute anxiety disorder. The
nurse in conversing with the client. The client says to the
nurse, I have a secret that I want to tell you. You wont
tell anyone about it, will you? the most appropriate
nursing response is which of the following?
a. No, I wont tell anyone
b. I cannot promise to keep a secret.
c. If you tell me the secret, I will tell it to your
doctor.
d. If you tell me the secret, I will need to document
it in your record.
Answer is B.
38. The nurse employed in a mental health clinic is
greeted by a neighbor in a local grocery store. The
neighbor says to the nurse, How is Sandy doing? She is
my best friend and is seen at your clinic every week. The
most appropriate nursing response is which of the
following?
a. I am not supposed to discuss this, but because
you are my neighbor, I can tell you that she is
going great!
b. Im not suppose to discuss this, but because
you are my neighbor, I can tell you that she
really has some problem!
c. If you want to know about Sandy, you need to
ask her yourself.
d. I cannot discuss any client situation with you.
Answer is D.
39. The client was admitted involuntarily to the mental
health unit because of episodes of extremely violent
behavior. The client is demanding to be discharged from
the hospital. The nurse does not allow the client to leave.
Which of the following represent the legal ramifications
associated with the nurses behavior?
a. the nurse will be charged with illegal detention
b. the nurse will be charged with assault
c. the nurse will be charged with slander
d. no charge will be made against the nurse.
Answer is D.
40. The nurse is preparing the client for the termination
phase of the nurse-client relationship. The nurse

prepares to implement which nursing task that is most

appropriate for this phase?
a. identifying expected outcomes
b. planning short term goals
c. making appropriate referrals
d. developing realistic solutions
Answer is C.
41. During the termination phase of the nurse-client
relationship, the clinic nurse observes that the client
continuously demonstrates bursts of anger. The most
appropriate interpretation of the behavior is that the client:
a. requires further treatment and is not ready to be
discharged
b. is displaying typical behaviors that can occur
during termination
c. needs to be admitted to the hospital
d. needs to be referred to the psychiatrist as soon
as possible.
Answer is B.
42. An individual who is fixated at this stage may have
difficulty trusting others and may demonstrate behaviors
such as nail biting and smoking.
a. oral stage
b. anal stage
c. phallic stage
d. latency stage
Answer is A.
43. A client is sting, cruel and has an obsessive
compulsive trait. This client is said to be fixated at what
stage of Freuds psychosexual development?
a. phallic stage
b. oral stage
c. anal stage
d. latency stage
Answer is C.
44. Autonomy versus shame and doubt is the central task
of a:
a. five year old rich girl
b. two year old cute child
c. ten year old gradeschool student
d. fifteen year old alcoholic
Answer is B.
45. According to Erik Eriksons theory, a sixty year old
maidens central task is:
a. industry versus inferiority
b. trust versus mistrust
c. initiative versus guilt
d. generativity versus stagnation
Answer is D.
46. A client taking MAOI suddenly developed
hypertensive crisis after ingestion of tyramine-rich foods.
Among which of the following drugs is given as antidote
for hypertensive crisis?
a. Aspirin
b. Aminophylline
c. Phentolamine
d. Thorazine
Answer is C. For hypertensive crisis, Phentolamine is the
drug of choice. Second drug choice is Nifedipine. Aspirin
is never used for hypertensive crisis after taking MAOIs,
B is a bronchodilator and D is an antipsychotic
medication.
47. The medication used to prevent symptoms of alcohol
withdrawal is:
a. Secobarbital (Seconal)

b. Naloxone (Narcan)
c. Chlorpromazine (Thorazine)
d. Chlordiazepoxide (Librium)
Answer is D. Chlordiazepoxide (Librium) is the
medication used for alcohol withdrawal.

b. acknowledge the contributions of each group

member
c. encourage accomplishment of the groups work
d. encourage problem-solving
Answer is B.

48. The term used to define an intense sexual arousal

from rubbing against a non-consenting person is:
a. fetishism
b. incest
c. frottage
d. scatophilia
Answer is C. Fetishism is sexual arousal after rubbing the
organ to a non-living object.

55. A client is admitted to the hospital with a diagnosis of

major depression, severe, single episode. The nurse
assesses the client and identifies a nursing diagnosis of
imbalanced nutrition related to poor nutritional intake. The
most appropriate nursing intervention related to this
diagnosis is:
a. explain to the client the importance of a good
nutritional intake
b. weigh the client 3 times per week before
breakfast
c. report the nutritional concern to the psychiatrist
and obtain a nutritional consultation as soon as
possible.
d. consult with the nutritionist, offer the client
several small meals per day, and schedule
brief nursing interactions with the client
during these times.
Answer is D.

49. Klismaphilia refers to sexual arousal involving:

a. fire
b. dead bodies
c. enemas
d. obscene languages
Answer is C. Klismaphilia is sexual arousal involving
feces. A is Pyrophilia, B is Necrophilia and D is
Scatophilia.
50. Which of the following are considered to be highest
risk for suicide?
a. a 35-year old married man
b. a 45-year old divorced alcoholic
c. a 16-year old who developed bronchitis
d. a 9-year old girl whose mother died
Answer is B. People who are greatly influenced by
alcohol and who have problems with family are high risk
for committing suicide.
51. The nurse is caring for a client with a phobia who is
being treated for the condition. The client is introduced to
short periods of exposure to the phobic object while in a
relaxed state. The nurse understands that this form of
behavior modification can be best described as:
a. systemic desensitization
b. self-control therapy
c. milieu therapy
d. aversion therapy
Answer is A.
52. The nurse is conducting a group therapy session, and
a client with manic disorder is monopolizing the group.
The most appropriate nursing action is which of the
following?
a. suggest that the client stop talking and try
listening to others.
b. ask the client to leave
c. tell the client to stop monopolizing the group
d. refer the client to another group.
Answer is A.
53. The nurse is planning to formulate a psychotherapy
group. Several clients are interested in attending the
session. The nurse plans the group, knowing that the
maximum numbers of group members to include is:
a. 10
b. 12
c. 14
d. 16
Answer is A.
54. A nurse employed in a mental health unit of a hospital
is the leader of group psychotherapy session. The
nurses role in the termination stage of group
development is to:
a. encourage members to become acquainted
with one another

56. In planning activities for the depressed client,

especially during the early stages of hospitalization,
which of the following plans is best?
a. provide an activity that is quiet and solitary to
avoid increased fatigue, such as working on
puzzle or reading a book.
b. plan nothing until the client asks to participate
in milieu.
c. offer the client a menu of daily activities and
insist the client participate in all of them.
d. provide a structured daily program of activities
and encourage the client to participate.
Answer is D.

57. A client who is delusional says to the nurse, the

federal guards were sent to kill me. The nurses best
response is:
a. The guards are not out to kill you.
b. I dont believe this is true.
c. I dont know anything about the guards. Do
you feel afraid that people are trying to hurt
you?
d. What makes you think the guards were sent to
hurt you?
Answer is C.
58. A woman comes into the emergency room in a severe
state of anxiety following a car accident. The most
appropriate nursing intervention is to:
a. remain with the client
b. put the client in a quiet room
c. teach the client deep breathing
d. encourage the client to talk about their feelings
and concerns.
Answer is A.
59. A male client with delirium becomes disoriented and
confused in his room at night. The best initial nursing
intervention is to:
a. use a night light and turn off the television.
b. keep the television and a soft light on during
the night
c. move the client next to the nurses station.
d. play soft music during the night, and maintain a
well-lit room.
Answer is A.

60. The nurse is performing an assessment on a client

with dementia. Which data gathered during the
assessment would indicate a manifestation associated
with dementia?
a. presence of personal hygienic care
b. improvement in sleeping
c. absence of sundown syndrome
d. confabulation
Answer is D.
61. The nurse observes that a client is pacing, agitated,
and presenting aggressive gestures. The clients speech
pattern is rapid, and affect is belligerent. Based on these
observations, the nurses immediate priority of care is to:
a. provide safety for the client and other clients on
the unit.
b. offer the client a less stimulated area to calm
down and gain control
c. provide the clients on the unit with a sense of
comfort and safety.
d. assist the staff in caring for the client in a
controlled environment.
Answer is A.
62. The nurse is caring for a male client diagnosed with
catatonic stupor. The client is lying on the bed with the
body pulled into a fetal position. The most appropriate
nursing intervention is which of the following?
a. leave the client alone and intermittently check on
him.
b. take the client into the dayroom with other clients
so they can help watch him
c. sit beside the client in silence with occasional
open ended questions.
d. ask direct questions to encourage talking.
Answer is C.
63. A client is admitted to the mental health unit with a
diagnosis of depression. The nurse develops a plan of
care for the client and includes which most appropriate
activity in the plan?
a. reading and writing most of the day
b. nothing until the client asks to participate in milieu
c. several activities that the client can choose from
d. a structured program of activities for the client to
participate in.
Answer is D.
64. The client is unwilling to go out of the house for fear
of doing something crazy in public. Because of this fear
the client remains homebound except when accompanied
outside by the spouse. Based on this data, the nurse
determines that the client is experiencing:
a. social phobia
b. agoraphobia
c. claustrophobia
d. hypochodriasis
Answer is B.
65. The nurse is caring for a female client who was
admitted to the mental health unit recently for anorexia
nervosa. The nurse enters the clients room and notes
that the client is engaged in rigorous push-ups. Which
nursing action is appropriate?
a. allow the client to complete her exercise
program.
b. tell the client that she is not allowed to exercise
rigorously.
c. interrupt the client and offer to take her for a
walk
d. interrupt the client and weigh her immediately.
Answer is C.

66. The nurse is reviewing a nursing care plan formulated

by a nursing student for a hospitalized client with bulimia
nervosa. The nurse would question which intervention
listed in the plan?
a. monitoring intake and output
b. monitoring electrolyte levels
c. observing for excessive exercise
d. checking for the presence of laxatives and
diuretics in the clients room.
Answer is C.
67. The spouse of a client admitted to the mental health
unit for alcohol withdrawal says to the nurse, I should get
out of this bad situation. The most helpful response by
the nurse would be:
a. I agree with you. You should get out of this
situation.
b. What do you find difficult about this situation.
c. Why dont you tell your husband about this?
d. This is not the best time to make that
decision.
Answer is B.
68. The client with a diagnosis of anorexia nervosa who is
in a state of starvation is in a two-bed room. A newly
admitted client will be assigned to this clients room.
Which of the following clients would be an appropriate
choice as this clients roommate?
a. a client with pneumonia
b. a client receiving diagnostic tests
c. a client who could benefit from the clients
assistance at mealtime
d. a client who thrives on managing others.
Answer is B.
69. The nurse is conducting an initial assessment on a
client in crisis. When assessing the clients perception of
the precipitating event that led to the crisis, the most
appropriate question to ask is?
a. What leads you to seek help now?
b. Who is available to help you?
c. What do you usually do to feel better?
d. With whom do you live?
Answer is A.
70. The nurse has been observing a client closely who
has been displaying aggressive behaviors. The nurse
observes that the behavior displayed by the client is
escalating. Which nursing intervention is least helpful to
this client at this time?
a. acknowledge the clients behavior
b. maintain a safe distance with the client
c. assist the client to an area that is quiet
d. initiate confinement measures.
Answer is D.
71. The police arrive at the emergency room with a client
who has seriously lacerated both wrists. The initial
nursing action is to:
a. examine and treat the wound sites
b. secure and record a detailed history
c. encourage and assist the client to ventilate
feelings.
d. administer an antianxiety agent.
Answer is A..
72. The nurse is monitoring a client who is in seclusion.
The nurse determines that the client is safe to come out
of seclusion when the client states:
a. I am no longer a threat to myself or others.
b. I need to go to the bathroom.

c. I want to be alone for a while in my own room.

d. I cant breathe in here. The walls are closing in
on me.
Answer is A.
73. The nurse is preparing a discharge plan for the client
who attempted suicide. The plan of care should focus on
which of the following?
a. follow-up appointments
b. contracts and immediate available crisis
resources
c. encouraging the family always to be with the
client
d. providing the hospital telephone number.
Answer is B.
74. The nurse is planning care for a client being admitted
to the nursing unit who attempted suicide. Which of the
following priority nursing interventions will the nurse
include in the plan of care?
a. check whereabouts of the client every 15
minutes
b. suicide precautions with 30 minute checks
c. one to one suicide precautions
d. ask the client to report suicidal thoughts
immediately.
Answer is C.
75. The nurse has been has been working with a victim of
rape in a clinic setting for the past 4 weeks. Which of the
following is unrealistic as a short term initial goal?
a. client will resolve feelings of fear and anxiety
b. physical wounds will heal
c. client will verbalize feelings about the vent
d. client will participate in the treatment plan.
Answer is A.
76. The nurse is reviewing the assessment data of a
client admitted to the mental health unit. The nurse notes
that the admission nurse has documented that the client
is experiencing anxiety as a result of a situational crisis.
The nurse determines that this type of crisis could be
caused by:
a. a fire that destroyed the clients home
b. a recent rape episode experienced by the client
c. the death of a loved one
d. witnessing a murder
Answer is C.
77. The nurse is conducting an initial assessment on a
client in crisis. When assessing the clients perception of
the precipitating event that led to the crisis, the most
appropriate question to ask is:
a. What leads you to seek help now?
b. Who is available to help you?
c. What do you usually do to feel better?
d. With whom do you live?
Answer is A.
78. The nurse is developing a plan of care for the client in
a crisis state. When developing the plan, the nurse
considers which of the following?
a. presenting symptoms in a crisis situation are
similar for all individuals experiencing a crisis
b. a crisis state indicates that the individual is
suffering from an emotional illness
c. a crisis state indicates that the individual is
suffering from a mental illness
d. a clients response to a crisis is individualized and
what constitutes a crisis for one person may not
constitute for another person.
Answer is D.

79. The nurse observes that a client with a potential for

violence is agitated, pacing up and down the hallway, and
is making aggressive and belligerent gestures at other
clients. Which statement would be most appropriate to
make to this client?
a. What is causing you to become agitated?
b. You need to stop that behavior now!
c. You will need to be restrained if you do not
change your behavior.
d. You will need to be placed in seclusion!
Answer is A.
80. During a conversation with a depressed client on an
inpatient unit, the client says to the nurse, My family
would be better off without me. The nurses best
response is:
a. Everyone feels this way when they are
depressed.
b. Have you talked to your family about this.
c. You sound very upset. Are you thinking of hurting
yourself.
d. You will better once your medication begins to
work.
Answer is C.
81. The nurse has been observing a client closely who
has been displaying aggressive behaviors. The nurse
observes that the behavior displayed by the client is
escalating. Which nursing intervention is least helpful to
this client at this time?
a. acknowledge the clients behavior
b. maintain a safe distance with the client
c. assist the client to an area that is quiet
d. initiate confinement measures.
Answer is D.
Kenneth Cole has become increasingly depressed
and is brought to the ER after slashing his wrists with a
razor blade. He is conscious and crying uncontrollably.
82. Mr. Coles condition stabilizes and he is admitted to
the psychiatric unit. He states dejectedly, I dont know
why they saved me. As soon as I can, I will try again.
Nothing in my life is ever going to get better. What would
be the best response by the nurse?
a. Youd feel differently after youve been here
awhile.
b. Youre feeling things are pretty hopeless right
now.
c. Youre quite angry at the people who saved you.
d. It sounds as if youve already made up your
mind.
Answer is b.
83. In assessing suicide potential as reflected in Mr.
Coles statement, what other information would be most
useful for the nurse to have?
a. Does he have a workable plan?
b. Have there been suicide attempts prior to this one?
c. Is there a family history of suicide?
d. What precipitated this attack?
Answer is b.
84. Which of the following suicide methods has a lower
rate of lethality than the others?
a. Ingestion of aspirin
b. Scratching her wrists with broken glass
c. Ingestion of INH and sedatives
d. Cutting the jugular vein
answer is A

answer is D
85. Which of the following groups has the lowest suicide
risk?
a. Alcoholics
c. Professionals
b. Depressed person
d. Single man
answer is C

86. Which of the following studies is based on qualitative

research?
a. A study examining clients reactions to stress after open
heart surgery
b. A study measuring nutrition and weight, loss/gain in
clients with cancer
c. A study examining oxygen levels after endotracheal
suctioning
d. A study measuring differences in blood pressure before
during and after a procedure
answer is A
87. An 85 year old client in a nursing home tells a nurse,
"I signed the papers for that research study because the
doctor was so insistent and I want: him to continue taking
care of me." Which client right is being violated?
a. Right of self determination
b. Right to privacy and confidentiality
c. Right to full disclosure
d. Right not to be harmed
answer is A
88. "A supposition or system of ideas that is proposed to
explain a given phenomenon," best defines:
a. a paradigm
b. a concept
c. a theory
d. a conceptual framework
answer is C
Brain tumor, whether malignant or benign, has serious
management implications nurse, you should be able to
understand the consequences of the disease and the
treatment.
89. You are caring for ryan who has a brain tumor and
increased intracranial Pressure (ICP). Which intervention
should you include in your plan to reduce ICP?
a. Administer bowel Softener
b. Position Conrad with his head turned toward the side
of the tumor
c. Provide sensory stimulation
d. Encourage coughing and deep breathing
answer is A
90. Keeping Ryans head and neck in alignment results
in:
a. increased intrathoracic pressure
b. increased venous outflow
c. decreased venous outflow
d. increased intra abdominal pressure
answer is B.
91. Which of the following activities may increase
intracranial pressure (ICP)?
a. Raising the head of the bed
b. Manual hyperventilation
c. Use of osmotic Diuretics
d. Valsava's maneuver

92. After you assessed ryan, you suspected increased

ICP. Your most appropriate respiratory goal is to:
a. maintain partial pressure of arterial 02 (PaO2) above
80 mmHg
b. lower arterial pH
c. prevent respiratory alkalosis
d. promote CO2 elimination
answer is D
93. Ryan underwent craniotomy. As his nurse; you know
that drainage on a craniotomy dressing must be
measured and marked. Which findings should you report
immediately to the surgeon?
a. Foul-smelling drainage
b. yellowish drainage
c. Greenish drainage
d. Bloody drainage
answer is A
94. if there is an accidental injury to the parathyroid gland
during a thyroidectomy which of the following might Leda
develops postoperative?
a. Cardiac arrest
b. Dyspnea
c. Respiratory failure
d. Tetany
answer is D
95. For a patient experiencing pruritus, you recommend
which type of bath:
a. Water
b. colloidal
c. saline
d. sodium bicarbonate
answer is B
.
96. A client receiving lithium carbonate (Lithobid)
complains of loose, watery stools, and difficulty walking.
The nurse would expect the serum lithium level to be
which of the following?
a. 0.7 mEq/L
c. 1 mEq/L
b. 1.3 mEq/L
d. 1.8 mEq/L
Answer is D.
97. The nurse is teaching a client who is being started on
Imipramine hydrochloride (Tofranil) about the medication.
The nurse informs the client that the maximum desired
effects may:
a. start during the first week of administration
b. start during the second week of administration
c. not occur for 2 to 3 weeks of administration
d. not o9ccur until after 2 months of administration
Answer is C.
98. A client receiving Thioridazine hydrochloride (Mellaril)
complains of feeling faint when trying to get out of bed
in the morning. The nurse recognizes this complaint as a
symptom of:
a. psychosomatic disorder
b. cardiac dysrhythmias
c. respiratory insufficiency
d. postural hypotension
Answer is D.
99. A client taking lithium carbonate (Eskalith) reports
vomiting, abdominal pain, diarrhea, blurred vision, tinnitus
and tremors. The lithium level is 2.5 mEq/L. the nurse
interprets this level as:
a. slightly above normal
c. normal
b. excessively below normal
d. toxic

Answer is D.
100. A hospitalized client is prescribed chloral hydrate
(Noctec). The nurse includes which action in the plan of
care?
a. monitor apical heart rate every 2 hours
b. monitor blood pressure every 4 hours
c. instruct the client to call for ambulation assistance
d. clear a path to the bathroom at bedtime
Answer is C.