1.

A male client with a history of medication noncompliance is receiving outpatient treatment for chronic
undifferentiated schizophrenia. The physician is most likely to prescribe which medication for this client?

a. Chlorpromazine (Thorazine)
b. Imipramine (Tofranil)
c. Lithium carbonate (Lithane)
d. Fluphenazine decanoate (Prolixin Decanoate)

Fluphenazine decanoate is a long-acting antipsychotic agent given by injection. Because it has a 4-week
duration of action, it’s commonly prescribed for outpatients with a history of medication noncompliance.
Chlorpromazine, also an antipsychotic agent, must be administered daily to maintain adequate plasma
levels, which necessitates compliance with the dosage schedule. Imipramine, a tricyclic antidepressant, and
lithium carbonate, a mood stabilizer, are rarely used to treat clients with chronic schizophrenia.

2. Which of the following medications would the nurse in-charge expect the doctor to order to reverse a
dystonic reaction?

a. Procholorperazine (Compazine)
b. Diphenhydramine (Benadryl)
c. Haloperidol (Haldol)
d. Midazolam (Versed)

Diphenhydramine, 25 to 50 mg I.M. or I.V., would quickly reverse this condition. Prochlorperazine and
haloperidol are both capable of causing dystonia, not reversing it. Midazolam would make this patient
drowsy.

3. A nurse places a female client in full leather restraints. How often must the nurse check the client’s
circulation?

a. Once per hour

b. Once per shift
c. Every 10 to 15 minutes
d. Every 2 hours

Circulation as well as skin and nerve damage can occur within 15 minutes. Checking every hour, 2 hours, or
8 hours isn’t often enough and could result in permanent damage to the client’s extremities. Restraints
should be removed every 2 hours, and range-of-motion exercises should be performed.

4. The client tells the nurse he was involved in a car accident while he was intoxicated. What would be the
most therapeutic response from the nurse?

a. "Why didn't you get someone else to drive you?"

b. "Tell me how you feel about the accident."
c. "You should know better than to drink and drive."
d. "I recommend that you attend an Alcoholics Anonymous meeting."

An open-ended statement or question is the most therapeutic response. It encourages the widest range of
client responses, makes the client an active participant in the conversation, and shows the client that the
nurse is interested in his feelings. Asking the client why he drove while intoxicated can make him feel
defensive and intimidated. A judgmental approach isn't therapeutic. By giving advice, the nurse suggests
that the client isn't capable of making decisions, thus fostering dependency.

5. A client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake
interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours
before admission. Based on this response, the nurse should expect early withdrawal symptoms to:

a. begin after 7 days.

b. not occur at all because the time period for their occurrence has passed.
c. begin anytime within the next 1 to 2 days.
d. begin within 2 to 7 days.
Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1
to 2 days later. Delirium tremens may occur 2 to 4 days — even up to 7 days — after the last drink.

6. Which is the highest priority in the post ECT care?

a. Observe for confusion

b. Monitor respiratory status
c. Reorient to time, place and person
d. Document the client’s response to the treatment

A side effect of ECT which is life threatening is respiratory arrest. Options A and C, Confusion and
disorientation are side effects of ECT but these are not the highest priority.

7. Which of the following medical conditions is commonly found in clients with bulimia nervosa?

a. Allergies
b. Cancer
c. Diabetes mellitus
d. Hepatitis A

Bulimia nervosa can lead to many complications, including diabetes, heart disease, and hypertension. The
eating disorder isn't typically associated with allergies, cancer, or hepatitis A.

8. A client tends to be insensitive to others, engages in abusive behaviors and does not have a sense of
remorse. Which personality disorder is he likely to have?

a. Narcissistic
b. Paranoid
c. Histrionic
d. Antisocial

These are the characteristics of an individual with antisocial personality. A. Narcissistic personality disorder
is characterized by grandiosity and a need for constant admiration from others. B. Individuals with paranoid
personality demonstrate a pattern of distrust and suspiciousness and interprets others motives as
threatening. C. Individuals with histrionic have excessive emotionality, and attention-seeking behaviors.

9. The client on Haldol has pill rolling tremors and muscle rigidity. He is likely manifesting:

a. tardive dyskinesia
b. Pseudoparkinsonism
c. akinesia
d. dystonia

Pseudoparkinsonism is a side effect of antipsychotic drugs characterized by mask-like facies, pill rolling
tremors, muscle rigidity. Option A, Tardive dyskinesia is manifested by lip smacking, wormlike movement of
the tongue. Option C, Akinesia is characterized by feeling of weakness and muscle fatigue. Option D,
Dystonia is manifested by torticollis and rolling back of the eyes.

10. A client has approached the nurse asking for advice on how to deal with his alcohol addiction. The
nurse should tell the client that the only effective treatment for alcoholism is:

a. psychotherapy.
b. total abstinence.
c. Alcoholics Anonymous (AA).
d. aversion therapy.

Total abstinence is the only effective treatment for alcoholism. Psychotherapy, attendance at AA meetings,
and aversion therapy are all adjunctive therapies that can support the client in his efforts to abstain.

11. The nurse is caring for a male client with schizophrenia. Which outcome is the least desirable?

a. The client spends more time by himself

b. The client doesn’t engage in delusional thinking
c. The client doesn’t harm himself or others
d. The client demonstrates the ability to meet his own self-care needs

The client with schizophrenia is commonly socially isolated and withdrawn; therefore, having the client
spend more time by himself wouldn’t be a desirable outcome. Rather, a desirable outcome would specify
that the client spend more time with other clients and staff on the unit. Delusions are false personal beliefs.
Reducing or eliminating delusional thinking using talking therapy and antipsychotic medications would be a
desirable outcome. Protecting the client and others from harm is a desirable client outcome achieved by
close observation, removing any dangerous objects, and administering medications. Because the client with
schizophrenia may have difficulty meeting his or her own self-care needs, fostering the ability to perform
self-care independently is a desirable client outcome.

12. The client says to the nurse ” Pray for me” and entrusts her wedding ring to the nurse. The nurse
knows that this may signal which of the following:

a. anxiety
b. suicidal ideation
c. Major depression
d. Hopelessness

The client’s statement is a verbal cue of suicidal ideation not anxiety. While suicide is common among
clients with major depression, this occurs when their depression starts to lift. Hopelessness indicates no
alternatives available and may lead to suicide, the statement and non verbal cue of the client indicate
suicide.

13. The nurse asks a client to roll up his sleeves so she can take his blood pressure. The client replies, “If
you want I can go naked for you.” The most therapeutic response by the nurse is:

a. “You’re attractive but I’m not interested.”

b. “You wouldn’t be the first that I will see naked.”
c. “I will report you to the guard if you don’t control yourself.”
d. “I only need access to your arm. Putting up your sleeve is fine.”

“I only need access to your arm. Putting up your sleeve is fine.” The nurse needs to deal with the client with
sexually connotative behavior in a casual, matter of fact way. Options A and B, these responses are not
therapeutic because they are challenging and rejecting. Option C, threatening the client is not therapeutic.

14. Diana Gil is a 45 year old mother of three, is a patient on a burn unit. She received full thickness burn
on 20% of her body in a house fire in which two of her children died. Which behavior would most suggest to
the nurse that Mrs. Gil is still in the earliest stage of the grief process?

a. Outburst of anger toward her family and the staff

b. Questions about job retaining
c. Statements that “it’s a dream” and “it didn’t really happen”
d. Wanting to be left alone in a dark and quiet room

Early grief involves shock, disbelief and denial; therefore, statements such as “it’s a dream” and “it didn’t
really happen” are expected reactions in that stage. Job retaining questions are more suggestive of either
the acceptance phase or dysfunctional grief, in which the individual is failing to grieve. Anger is the second
phase of grief. Isolation is more suggestive of the depression phase of grief.

15. Shortly after midnight, Mrs. Gil is awakened by the sound of an arriving ambulance outside the window
of her room. She exhibits screaming, crying, vigorous attempts to get out of the bed, and incoherent speech.
These manifestations are most suggestive of which level of anxiety?

a. Mild
b. Moderate
c. Panic
d. Severe
Extreme behaviors such as Mrs. Gil distorted response to the ambulance are indicative of panic. In the
lesser degree of anxiety, the patient’s typical behavior is changed, but not exaggerated level that is seen in
panic.

16. During this episode, which nursing intervention is most appropriate?

a. Discuss appropriate coping mechanisms with Mrs. Gil.

b. Encourage Mrs. Gil to express her feelings about the event.
c. Have Mrs. Gil remain in bed and apply soft wrist restrains.
d. Stay with Mrs. Gil and provide assurance and safety.

When a patient is experiencing panic, it’s most important for the nurse to remain with the patient to provide
physical and verbal assurance as well as to protect her from further injury. During panic, teaching her to
discuss her feelings is less appropriate intervention because they can agitate the patient even more. Use of
restrains requires a doctors order and can cause injury to the skin and joints.

17. A 26 year old unemployed woman seeks help because she feels depressed and abandoned and
doesn't know what to do with her life. She says she has quit her last five jobs because her coworkers didn't
like her and didn't train her adequately. Last week, her boyfriend broke up with her after she drove his car
into a tree after an argument. The client's initial diagnosis is borderline personality disorder. Which nursing
observations support this diagnosis?

a. Flat affect, social withdrawal, and unusual dress

b. Suspiciousness, hypervigilance, and emotional coldness
c. Lack of self-esteem, strong dependency needs, and impulsive behavior
d. Insensitivity to others, sexual acting out, and violence

Borderline personality disorder is characterized by lack of self-esteem, strong dependency needs, and
impulsive behavior. Instability in interpersonal relationships, mood, and poor self-image also is common.
Typically, the client can't tolerate being alone and expresses feelings of emptiness or boredom. Flat affect,
social withdrawal, and unusual dress are characteristic of schizoid personality disorder. Suspiciousness,
hypervigilance, and emotional coldness are seen in paranoid personality disorders. In antisocial personality
disorder, clients are usually insensitive to others and act out sexually; they may also be violent

18. How soon after chlorpromazine administration should the nurse in charge expect to see a patient’s
delusion thoughts and hallucinations eliminated?

a. Several minutes
b. Several hours
c. Several days
d. Several weeks

Although most phenothiazine produces some effects within minutes to hours, their antipsychotic effects may
take several weeks to appear.

19. Dolores Moreno, a 21 year old mother of premature newborn, smoked cigarettes during her
pregnancy. Her son is a patient in NICU and has a diagnosis of acute respiratory distress syndrome. Ms.
Moreno is expressing guilt about her son’s illness. Which aspect of her role should the nurse most express
when addressing Ms. Moreno’s guilt?

a. Empathy
b. Guidance
c. Role modeling
d. Teaching

Empathy, the understanding of another’s perception of a situation, is key to establishing a therapeutic

rapport with a patient. Empathy encourages a patient’s trust and promotes the patient’s self-expression. In
this situation, it’s the most important aspect of the nursing role that should be expressed.

20. While pacing in the hall, a female patient with paranoid schizophrenia runs to the nurse and says,
“Why are you poisoning me? I know you work for central thought control! You can keep my thoughts. Give
me back my soul!” how should the nurse respond?
a. “I’m a nurse, I’m not poisoning you. It’s against the nursing code of ethics.”
b. “I’m a nurse, and you’re a patient in the hospital. I’m not going to harm you.”
c. “I’m not poisoning you. And how could I possibly steal your soul?”
d. “I sense anger, Are you feeling angry today?”

The nurse should directly orient a delusional patient to reality, especially to place and person. Options A and
C encourage further delusions by denying poisoning and offering information related to the delusion.
Validating the patient’s feeling, as in option D, occurs during a later stage in the therapeutic process.

21. Conditions necessary for the development of a positive sense of self-esteem include:

a. Consistent limits
b. Critical environment
c. Inconsistent boundaries
d. Physical discipline

A structured lifestyle demonstrates acceptance and caring provides a sense of security. A critical
environment erodes a person’s esteem. Inconsistent boundaries lead to feelings of insecurity and lack of
concern. Physical discipline can decrease self-esteem.

22. During which phase of alcoholism is loss of control and physiologic dependence evident?

A. Prealcoholic phase
B. Early alcoholic phase
C. Crucial phase
D. Chronic phase

The crucial phase is marked by physical dependence. The prealcoholic phase is characterized by drinking to
medicate feelings and for relief from stress. The early phase is characterized by sneaking drinks, blackouts,
rapidly gulping drinks, and preoccupation with alcohol. The chronic phase is characterized by emotional and
physical deterioration.

23. A client tells the nurse that he is having suicidal thoughts every day. In conferring with the treatment
team, the nurse should make which of the following recommendations?

a. A no-suicide contract
b. Weekly outpatient therapy
c. A second psychiatric opinion
d. Intensive inpatient treatment

Inpatient care is the best intervention for a client who is thinking about suicide every day. Implementing a no-
suicide contract is an important strategy, but this client requires additional care. Weekly therapy wouldn't
provide the intensity of care that this case warrants. Obtaining a second opinion would take time; this client
requires immediate intervention.

24. During a private conversation, a client with borderline personality disorder asks the nurse to keep his
secret and then displays multiple, self-inflicted, superficial lacerations on the forearms. What is the nurse's
best response?

a. "That's it! You're on suicide precautions."

b. "I'm going to tell your physician. Do you want to tell me why you did that?"
c. "Tell me what type of instrument you used. I'm concerned about infection."
d. "The team needs to know when something important occurs in treatment. I need to tell the others, but let's
talk about it first."

This response informs the client of the nurse's planned actions and allows time to discuss the client's
actions. Options A and B put the client on the defensive and may lead to a power struggle. Option C ignores
the psychological implications of the client's actions.

25. Flumazenil (Romazicon) has been ordered for a client who has overdosed on oxazepam (Serax).
Before administering the medication, the nurse should be prepared for which common adverse effect?
a. Seizures
b. Shivering
c. Anxiety
d. Chest pain

Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine
overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine
overdose. Less common adverse effects include shivering, anxiety, and chest pain.