In Text Mode: All questions and answers are given for reading and answering at your

own pace. You can also copy this exam and make a print out.

1. Flumazenil (Romazicon) has been ordered for a male client who has overdosed on
oxazepam (Serax). Before administering the medication, nurse Gina should be
prepared for which common adverse effect?

A. Seizures
B. Shivering
C. Anxiety
D. Chest pain

2. Nurse Tamara is caring for a client diagnosed with bulimia. The most appropriate
initial goal for a client diagnosed with bulimia is to:

A. Avoid shopping for large amounts of food

B. Control eating impulses
C. Identify anxiety-causing situations
D. Eat only three meals per day

3. A female client who�s at high risk for suicide needs close supervision. To best
ensure the client�s safety, Nurse Mary should:

A. Check the client frequently at irregular intervals throughout the night

B. Assure the client that the nurse will hold in confidence anything the client
says
C. Repeatedly discuss previous suicide attempts with the client
D. Disregard decreased communication by the client because this is common with
suicidal clients

4. Which of the following drugs should Nurse Mary prepare to administer to a client
with a toxic acetaminophen (Tylenol) level?

A. Deferoxamine mesylate (Desferal)

B. Succimer (Chemet)
C. Flumazenil (Romazicon)
D. Acetylcysteine (Mucomyst)

5. A male client is admitted to the substance abuse unit for alcohol

detoxification. Which of the following medications is Nurse Alice most likely to
administer to reduce the symptoms of alcohol withdrawal?

A. Naloxone (Narcan)
B. Haloperidol (Haldol)
C. Magnesium sulfate
D. Chlordiazepoxide (Librium)

6. During postprandial monitoring, a female client with bulimia nervosa tells the
nurse, �You can sit with me, but you�re just wasting your time. After you had sat
with me yesterday, I was still able to purge. Today, my goal is to do it twice.�
What is the nurse�s best response?

A. �I trust you not to purge.�

B. �How are you purging and when do you do it?�
C. �Don�t worry. I won�t allow you to purge today.�
D. �I know it�s important for you to feel in control, but I�ll monitor you for 90
minutes after you eat.�

7. A male client admitted to the psychiatric unit for treatment of substance abuse
says to the nurse, �It felt so wonderful to get high.� Which of the following is
the most appropriate response?

A. �If you continue to talk like that, I�m going to stop speaking to you.�
B. �You told me you got fired from your last job for missing too many days after
taking drugs all night.�
C. �Tell me more about how it felt to get high.�
D. �Don�t you know it�s illegal to use drugs?�

8. For a female client with anorexia nervosa, Nurse Jimmy is aware that which goal
takes the highest priority?

A. The client will establish adequate daily nutritional intake

B. The client will make a contract with the nurse that sets a target weight
C. The client will identify self-perceptions about body size as unrealistic
D. The client will verbalize the possible physiological consequences of self-
starvation

9. When interviewing the parents of an injured child, which of the following is the
strongest indicator that child abuse may be a problem?

A. The injury isn�t consistent with the history or the child�s age
B. The mother and father tell different stories regarding what happened
C. The family is poor
D. The parents are argumentative and demanding with emergency department personnel

10. For a female client with anorexia nervosa, nurse Rose plans to include the
parents in therapy sessions along with the client. What fact should the nurse
remember to be typical of parents of clients with anorexia nervosa?

A. They tend to overprotect their children

B. They usually have a history of substance abuse
C. They maintain emotional distance from their children
D. They alternate between loving and rejecting their children

11. In the emergency department, a client with facial lacerations states that her
husband beat her with a shoe. After the health care team repairs her lacerations,
she waits to be seen by the crisis intake nurse, who will evaluate the continued
threat of violence. Suddenly the client�s husband arrives, shouting that he wants
to �finish the job.� What is the first priority of the health care worker who
witnesses this scene?

A. Remaining with the client and staying calm

B. Calling a security guard and another staff member for assistance
C. Telling the client�s husband that he must leave at once
D. Determining why the husband feels so angry

12. Nurse Mary is caring for a client with bulimia. Strict management of dietary
intake is necessary. Which intervention is also important?

A. Fill out the client�s menu and make sure she eats at least half of what is on
her tray.
B. Let the client eat her meals in private. Then engage her in social activities
for at least 2 hours after each meal
C. Let the client choose her own food. If she eats everything she orders, then stay
with her for 1 hour after each meal
D. Let the client eat food brought in by the family if she chooses, but she should
keep a strict calorie count.
13. Nurse Mary is assigned to care for a suicidal client. Initially, which is the
nurse�s highest care priority?

A. Assessing the client�s home environment and relationships outside the hospital
B. Exploring the nurse�s own feelings about suicide
C. Discussing the future with the client
D. Referring the client to a clergyperson to discuss the moral implications of
suicide

14. A 24-year old client with anorexia nervosa tells the nurse, �When I look in the
mirror, I hate what I see. I look so fat and ugly.� Which strategy should the nurse
use to deal with the client�s distorted perceptions and feelings?

A. Avoid discussing the client�s perceptions and feelings

B. Focus discussions on food and weight
C. Avoid discussing unrealistic cultural standards regarding weight
D. Provide objective data and feedback regarding the client�s weight and
attractiveness

15. Nurse Alice is caring for a client being treated for alcoholism. Before
initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he
must read labels carefully on which of the following products?

A. Carbonated beverages
B. Aftershave lotion
C. Toothpaste
D. Cheese

16. Nurse Harry is developing a plan of care for a client with anorexia nervosa.
Which action should the nurse include in the plan?

A. Restrict visits with the family until the client begins to eat
B. Provide privacy during meals
C. Set up a strict eating plan for the client
D. Encourage the client to exercise, which will reduce her anxiety

17. Nurse Taylor is aware that the victims of domestic violence should be assessed
for what important information?

A. Reasons they stay in the abusive relationship (for example, lack of financial
autonomy and isolation)
B. Readiness to leave the perpetrator and knowledge of resources
C. Use of drugs or alcohol
D. History of previous victimization

18. A male client is hospitalized with fractures of the right femur and right
humerus sustained in a motorcycle accident. Police suspect the client was
intoxicated at the time of the accident. Laboratory tests reveal a blood alcohol
level of 0.2% (200 mg/dl). The client later admits to drinking heavily for years.
During hospitalization, the client periodically complains of tingling and numbness
in the hands and feet. Nurse Gian realizes that these symptoms probably result
from:

A. Acetate accumulation
B. Thiamine deficiency
C. Triglyceride buildup.
D. A below-normal serum potassium level

19. A parent brings a preschooler to the emergency department for treatment of a

dislocated shoulder, which allegedly happened when the child fell down the stairs.
Which action should make the nurse suspect that the child was abused?

A. The child cries uncontrollably throughout the examination

B. The child pulls away from contact with the physician.
C. The child doesn�t cry when the shoulder is examined
D. The child doesn�t make eye contact with the nurse.

20. When planning care for a client who has ingested phencyclidine (PCP), nurse
Wayne is aware that the following is the highest priority?

A. Client�s physical needs

B. Client�s safety needs
C. Client�s psychosocial needs
D. Client�s medical needs

21. The nurse is aware that the outcome criteria would be appropriate for a child
diagnosed with oppositional defiant disorder?

A. Accept responsibility for own behaviors

B. Be able to verbalize own needs and assert rights.
C. Set firm and consistent limits with the client
D. Allow the child to establish his own limits and boundaries

22. A male client is found sitting on the floor of the bathroom in the day
treatment clinic with moderate lacerations on both wrists. Surrounded by broken
glass, he sits staring blankly at his bleeding wrists while staff members call for
an ambulance. How should Nurse Anuktakanuk approach her initially?

A. Enter the room quietly and move beside him to assess his injuries
B. Call for staff back-up before entering the room and restraining him
C. Move as much glass away from him as possible and sit next to him quietly
D. Approach him slowly while speaking in a calm voice, calling him name, and
telling him that the nurse is here to help him

23. A female client with anorexia nervosa describes herself as �a whale.� However,
the nurse�s assessment reveals that the client is 5' 8? (1.7 m) tall and weighs
only 90 lb (40.8 kg). Considering the client�s unrealistic body image, which
intervention should nurse Angel be included in the plan of care?

A. Asking the client to compare her figure with magazine photographs of women her
age
B. Assigning the client to group therapy in which participants provide realistic
feedback about her weight
C. Confronting the client about her actual appearance during one-on-one sessions,
scheduled during each shift
D. Telling the client of the nurse�s concern for her health and desire to help her
make decisions to keep her healthy

24. Eighteen hours after undergoing an emergency appendectomy, a client with a

reported history of social drinking displays these vital signs: temperature, 101.6�
F (38.7� C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and
blood pressure, 140/96 mm Hg. The client exhibits gross hand tremors and is
screaming for someone to kill the bugs in the bed. Nurse Melinda should suspect:

A. A postoperative infection
B. Alcohol withdrawal
C. Acute sepsis.
D. Pneumonia.
25. Clonidine (Catapres) can be used to treat conditions other than hypertension.
Nurse Sally is aware that the following conditions might the drug be administered?

A. Phencyclidine (PCP) intoxication

B. Alcohol withdrawal
C. Opiate withdrawal
D. Cocaine withdrawal

26. A male client with a history of cocaine addiction is admitted to the coronary
care unit for evaluation of substernal chest pain. The electrocardiogram (ECG)
shows a 1-mm ST-segment elevation the anteroseptal leads and T-wave inversion in
leads V3 to V5. Considering the client�s history of drug abuse, nurse Greg expects
the physician to prescribe:

A. Lidocaine (Xylocaine).
B. Procainamide (Pronestyl).
C. Nitroglycerin (Nitro-Bid IV).
D. Epinephrine.

27. A 14-year-old client was brought to the clinic by her mother. Her mother
expresses concern about her daughter�s weight loss and constant dieting. Nurse Kris
conducts a health history interview. Which of the following comments indicates that
the client may be suffering from anorexia nervosa?

A. �I like the way I look. I just need to keep my weight down because I�m a
cheerleader.�
B. �I don�t like the food my mother cooks. I eat plenty of fast food when I�m out
with my friends.�
C. �I just can�t seem to get down to the weight I want to be. I�m so fat compared
to other girls.�
D. �I do diet around my periods; otherwise, I just get so bloated.�

28. Nurse Fey is aware that the drug of choice for treating Tourette syndrome?

A. Fluoxetine (Prozac)
B. Fluvoxamine (Luvox)
C. Haloperidol (Haldol)
D. Paroxetine (Paxil)

29. A male client tells the nurse he was involved in a car accident while he was
intoxicated. What would be the most therapeutic response from nurse Julia?

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.�

30. A male adult client voluntarily admits himself to the substance abuse unit. He
confesses that he drinks one (1) qt or more of vodka each day and uses cocaine
occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal.
What are some early signs of this condition?

A. Vomiting, diarrhea, and bradycardia

B. Dehydration, temperature above 101� F (38.3� C), and pruritus
C. Hypertension, diaphoresis, and seizures
D. Diaphoresis, tremors, and nervousness

31. When monitoring a female client recently admitted for treatment of cocaine
addiction, nurse Aaron notes sudden increases in the arterial blood pressure and
heart rate. To correct these problems, the nurse expects the physician to
prescribe:

A. Norepinephrine (Levophed) and Lidocaine (Xylocaine)

B. Nifedipine (Procardia) and Lidocaine.
C. Nitroglycerin (Nitro-Bid IV) and Esmolol (Brevibloc)
D. Nifedipine and Esmolol

32. A 25 �year old client experiencing alcohol withdrawal is upset about going
through detoxification. Which of the following goals is a priority?

A. The client will commit to a drug-free lifestyle

B. The client will work with the nurse to remain safe
C. The client will drink plenty of fluids daily
D. The client will make a personal inventory of strength

33. A male client is admitted to a psychiatric facility by court order for

evaluation for antisocial personality disorder. This client has a long history of
initiating fights and abusing animals and recently was arrested for setting a
neighbor�s dog on fire. When evaluating this client for the potential for violence,
nurse Perry should assess for which behavioral clues?

A. A rigid posture, restlessness, and glaring

B. Depression and physical withdrawal
C. Silence and noncompliance
D. Hypervigilance and talk of past violent acts

34. A male client is brought to the psychiatric clinic by family members, who tell
the admitting nurse that the client repeatedly drives while intoxicated despite
their pleas to stop. During an interview with the nurse Linda, which statement by
the client most strongly supports a diagnosis of psychoactive substance abuse?

A. �I�m not addicted to alcohol. In fact, I can drink more than I used to without
being affected.�
B. �I only spend half of my paycheck at the bar.�
C. �I just drink to relax after work.�
D. �I know I�ve been arrested three times for drinking and driving, but the police
are just trying to hassle me.�

35. A female client with borderline personality disorder is admitted to the

psychiatric unit. Initial nursing assessment reveals that the client�s wrists are
scratched from a recent suicide attempt. Based on this finding, the nurse Lenny
should formulate a nursing diagnosis of:

A. Ineffective individual coping related to feelings of guilt.

B. Situational low self-esteem related to feelings of loss of control
C. Risk for violence: Self-directed related to impulsive mutilating acts
D. Risk for violence: Directed toward others related to verbal threats

36. A male client recently admitted to the hospital with sharp, substernal chest
pain suddenly complains of palpitations. Nurse Ryan notes a rise in the client�s
arterial blood pressure and a heart rate of 144 beats/minute. On further
questioning, the client admits to having used cocaine recently after previously
denying use of the drug. The nurse concludes that the client is at high risk for
which complication of cocaine use?

A. Coronary artery spasm

B. Bradyarrhythmias
C. Neurobehavioral deficits
D. Panic disorder

37. A male 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 six (6) hours before
admission. Based on this response, nurse Lorena should expect early withdrawal
symptoms to:

A. Begin after seven (7) days

B. Not occur at all because the time period for their occurrence has passed
C. Begin anytime within the next one (1) to two (2) days
D. Begin within two (2) to seven (7) days

38. Nurse Helen is assigned to care for a client with anorexia nervosa. Initially,
which nursing intervention is most appropriate for this client?

A. Providing one-on-one supervision during meals and for one (1) hour afterward
B. Letting the client eat with other clients to create a normal mealtime atmosphere
C. Trying to persuade the client to eat and thus restore nutritional balance
D. Giving the client as much time to eat as desired

39. A female client begins to experience alcoholic hallucinosis. Nurse Joy is aware
that the best nursing intervention at this time?

A. Keeping the client restrained in bed

B. Checking the client�s blood pressure every 15 minutes and offering juices
C. Providing a quiet environment and administering medication as needed and
prescribed
D. Restraining the client and measuring blood pressure every 30 minutes

40. Nurse Bella is aware that assessment finding is most consistent with early
alcohol withdrawal?

A. Heart rate of 120 to 140 beats/minute

B. Heart rate of 50 to 60 beats/minute
C. Blood pressure of 100/70 mmHg
D. Blood pressure of 140/80 mmHg

41. Nurse Amy is aware that the client is at highest risk for suicide?

A. One who appears depressed frequently thinks of dying and gives away all personal
possessions
B. One who plans a violent death and has the means readily available
C. One who tells others that he or she might do something if life doesn�t get
better soon
D. One who talks about wanting to die

42. Nurse Penny is aware that the following medical conditions is commonly found in
clients with bulimia nervosa?

A. Allergies
B. Cancer
C. Diabetes mellitus
D. Hepatitis A

43. Kellan, a high school student is referred to the school nurse for suspected
substance abuse. Following the nurse�s assessment and interventions, what would be
the most desirable outcome?
A. The student discusses conflicts over drug use
B. The student accepts a referral to a substance abuse counselor
C. The student agrees to inform his parents of the problem
D. The student reports increased comfort with making choice

44. A male client who reportedly consumes one (1) qt of vodka daily is admitted
for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, Dr.
Smith is most likely to prescribe which drug?

A. Clozapine (Clozaril)
B. Thiothixene (Navane)
C. Lorazepam (Ativan)
D. Lithium carbonate (Eskalith)

45. A male client is being treated for alcoholism. After a family meeting, the
client�s spouse asks the nurse about ways to help the family deal with the effects
of alcoholism. Nurse Lily should suggest that the family join which organization?

A. Al-Anon
B. Make Today Count
C. Emotions Anonymous
D. Alcoholics Anonymous

46. A female client is admitted to the psychiatric clinic for treatment of anorexia
nervosa. To promote the client�s physical health, nurse Tair should plan to:

A. Severely restrict the client�s physical activities

B. Weigh the client daily, after the evening meal
C. Monitor vital signs, serum electrolyte levels, and acid-base balance
D. Instruct the client to keep an accurate record of food and fluid intake

47. Kevin is remanded by the courts for psychiatric treatment. His police record,
which dates to his early teenage years, includes delinquency, running away, auto
theft, and vandalism. He dropped out of school at age 16 and has been living on his
own since then. His history suggests maladaptive coping, which is associated with:

A. Antisocial personality disorder

B. Borderline personality disorder
C. Obsessive-compulsive personality disorder
D. Narcissistic personality disorder

48. Macoy and Helen seek emergency crisis intervention because he slapped her
repeatedly the night before. The husband indicates that his childhood was marred by
an abusive relationship with his father. When intervening with this couple, nurse
Gerry knows they are at risk for repeated violence because the husband:

A. Has only moderate impulse control

B. Denies feelings of jealousy or possessiveness
C. Has learned violence as an acceptable behavior
D. Feels secure in his relationship with his wife

49. A client whose husband just left her has a recurrence of anorexia nervosa.
Nurse Vic caring for her realizes that this exacerbation of anorexia nervosa
results from the client�s effort to:

A. Manipulate her husband

B. Gain control of one part of her life
C. Commit suicide
D. Live up to her mother�s expectations

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

A. Psychotherapy
B. Total abstinence
C. Alcoholics Anonymous (AA)
D. Aversion therapy

Answers and Rationale

1. Answer A. Seizures

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.

Options B, C, and D: Less common adverse effects include shivering, anxiety, and
chest pain.

2. Answer C. Identify anxiety-causing situations

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.

Option A: Controlling shopping for large amounts of food isn�t a goal early in
treatment.
Option B: Managing eating impulses and replacing them with adaptive coping
mechanisms can be integrated into the plan of care after initially addressing
stress and underlying issues.
Option D: Eating three meals per day isn�t a realistic goal early in treatment.
3. Answer A. Check the client frequently at irregular intervals throughout the
night

Checking the client frequently but at irregular intervals prevents the client from
predicting when observation will take place and altering behavior in a misleading
way at these times.

Option B may encourage the client to try to manipulate the nurse or seek attention
for having a secret suicide plan.
Option C may reinforce suicidal ideas.
Option D: Decreased communication is a sign of withdrawal that may indicate the
client has decided to commit suicide; the nurse shouldn�t disregard it.
4. Answer D. Acetylcysteine (Mucomyst)

The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion

of toxic metabolites to nontoxic metabolites.

Option A: Deferoxamine mesylate is the antidote for iron intoxication.

Option B: Succimer is an antidote for lead poisoning.
Option C: Flumazenil reverses the sedative effects of benzodiazepines.
5. Answer D. Chlordiazepoxide (Librium)

Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of

alcohol withdrawal.

Option A: Naloxone (Narcan) is administered for narcotic overdose.

Option B: Haloperidol (Haldol) may be given to treat clients with psychosis,
severe agitation, or delirium.
Option C: Magnesium sulfate and other anticonvulsant medications are only
administered to treat seizures if they occur during withdrawal.
6. Answer D. �I know it�s important for you to feel in control, but I�ll monitor
you for 90 minutes after you eat.�

This response acknowledges that the client is testing limits and that the nurse is
setting them by performing postprandial monitoring to prevent self-induced emesis.
Clients with bulimia nervosa need to feel in control of the diet because they feel
they lack control over all other aspects of their lives.

Option A: Because their therapeutic relationships with caregivers are less

important than their need to purge, they don�t fear betraying the nurse�s trust by
engaging in the activity. They commonly plot to purge and rarely share their
secrets about it.
Options B and C: An authoritarian or challenging response may trigger a power
struggle between the nurse and client.
7. Answer B. �You told me you got fired from your last job for missing too many
days after taking drugs all night.�

Confronting the client with the consequences of substance abuse helps to break
through denial.

Option A: Making threats isn�t an effective way to promote self-disclosure or

establish a rapport with the client.
Option C: Although the nurse should encourage the client to discuss feelings, the
discussion should focus on how the client felt before, not during, an episode of
substance abuse. Encouraging elaboration about his experience while getting high
may reinforce the abusive behavior.
Option D: The client undoubtedly is aware that drug use is illegal; a reminder to
this effect is unlikely to alter behavior.
8. Answer A. The client will establish adequate daily nutritional intake

According to Maslow�s hierarchy of needs, all humans need to meet basic

physiological needs first. Because a client with anorexia nervosa eats little or
nothing, the nurse must first plan to help the client meet this basic, immediate
physiological need.

Options B, C, and D: The nurse may give lesser priority to goals that address long-
term plans, self-perception, and potential complications.
9. Answer A. The injury isn�t consistent with the history or the child�s age

When the child�s injuries are inconsistent with the history given or impossible
because of the child�s age and developmental stage, the emergency department nurse
should be suspicious that child abuse is occurring.

Option B: The parents may tell different stories because their perception may be
different regarding what happened. If they change their story when different health
care workers ask the same question, this is a clue that child abuse may be a
problem.
Option C: Child abuse occurs in all socioeconomic groups.
Option D: Parents may argue and be demanding because of the stress of having an
injured child.
10. Answer A. They tend to overprotect their children

Clients with anorexia nervosa typically come from a family with parents who are
controlling and overprotective. These clients use eating to gain control of an
aspect of their lives.
The characteristics described in options B, C, and D isn�t typical of parents of
children with anorexia.
11. Answer B. Calling a security guard and another staff member for assistance

The health care worker who witnesses this scene must take precautions to ensure
personal as well as client safety but shouldn�t attempt to manage a physically
aggressive person alone. Therefore, the first priority is to call a security guard
and another staff member.

Option A: After doing this, the health care worker should inform the husband what
is expected, speaking in concise statements and maintaining a firm but calm
demeanor. This approach makes it clear that the health care worker is in control
and may diffuse the situation until the security guard arrives.
Option C: Telling the husband to leave would probably be ineffective because of his
agitated and irrational state.
Option D: Exploring his anger doesn�t take precedence over safeguarding the client
and staff.
12. Answer C. Let the client choose her own food. If she eats everything she
orders, then stay with her for 1 hour after each meal

Allowing the client to select her own food from the menu will help her feel some
sense of control.

Option A: She must then eat 100% of what she selected.

Option B: Remaining with the client for at least 1 hour after eating will prevent
purging.
Option D: Bulimic clients should only be allowed to eat food provided by the
dietary department.
13. Answer B. Exploring the nurse�s own feelings about suicide

The nurse�s values, beliefs, and attitudes toward self-destructive behavior

influence responses to a suicidal client; such responses set the overall mood for
the nurse-client relationship. Therefore, the nurse initially must explore personal
feelings about suicide to avoid conveying negative feelings to the client.

Option A: Assessment of the client�s home environment and relationships may reveal
the need for family therapy; however, conducting such an assessment isn�t a nursing
priority.
Option C: Discussing the future and providing anticipatory guidance can help the
client prepare for future stress, but this isn�t a priority.
Option D: Referring the client to a clergyperson may increase the client�s trust or
alleviate guilt; however, it isn�t the highest priority.
14. Answer D. Provide objective data and feedback regarding the client�s weight and
attractiveness

By focusing on reality, this strategy may help the client develop a more realistic
body image and gain self-esteem.

Option A is inappropriate because discussing the client�s perceptions and feeling

wouldn�t help her to identify, accept, and work through them.
Option B: Focusing discussions on food and weight would give the client attention
for not eating.
Option C is inappropriate because recognizing unrealistic cultural standards
wouldn�t help the client establish more realistic weight goals.
15. Answer B. Aftershave lotion

Disulfiram may be given to clients with chronic alcohol abuse who wish to curb
impulse drinking. Disulfiram works by blocking the oxidation of alcohol, inhibiting
the conversion of acetaldehyde to acetate. As acetaldehyde builds up in the blood,
the client experiences noxious and uncomfortable symptoms. Even alcohol rubbed onto
the skin can produce a reaction. The client receiving disulfiram must be taught to
read ingredient labels carefully to avoid products containing alcohol such as
aftershave lotions.

Options A, C, and D: Carbonated beverages, toothpaste, and cheese don�t contain

alcohol and don�t need to be avoided by the client.
16. Answer C. Set up a strict eating plan for the client

Establishing a consistent eating plan and monitoring the client�s weight are
important for this disorder.

Option A: The family should be included in the client�s care.

Option B: The client should be monitored during meals � not given privacy.
Option D: Exercise must be limited and supervised.
17. Answer B. Readiness to leave the perpetrator and knowledge of resources

Victims of domestic violence must be assessed for their readiness to leave the
perpetrator and their knowledge of the resources available to them. Nurses can then
provide the victims with information and options to enable them to leave when they
are ready.

Option A: The reasons they stay in the relationship are complex and can be explored
at a later time.
Option C: The use of drugs or alcohol is irrelevant.
Option D: There is no evidence to suggest that previous victimization results in a
person�s seeking or causing abusive relationships.
18. Answer B. Thiamine deficiency

Numbness and tingling in the hands and feet are symptoms of peripheral
polyneuritis, which results from inadequate intake of vitamin B1 (thiamine)
secondary to prolonged and excessive alcohol intake. Treatment includes reducing
alcohol intake, correcting nutritional deficiencies through diet and vitamin
supplements, and preventing such residual disabilities as foot and wrist drop.

Options A, C, and D: Acetate accumulation, triglyceride buildup, and a below-normal

serum potassium level are unrelated to the client�s symptoms.
19. Answer C. The child doesn�t cry when the shoulder is examined

A characteristic behavior of abused children is the lack of crying when they

undergo a painful procedure or are examined by a health care professional.
Therefore, the nurse should suspect child abuse.

Options A, B, and D: Crying throughout the examination, pulling away from the
physician, and not making eye contact with the nurse are normal behaviors for
preschoolers.
20. Answer B. Client�s safety needs

The highest priority for a client who has ingested PCP is meeting safety needs of
the client as well as the staff. Drug effects are unpredictable and prolonged, and
the client may lose control easily.

Options A, C, and D: After safety needs have been met, the client�s physical,
psychosocial, and medical needs can be met.

21. Answer A. Accept responsibility for own behaviors

Children with oppositional defiant disorder frequently violate the rights of

others. They are defiant, disobedient, and blame others for their actions.
Accountability for their actions would demonstrate progress for the oppositional
child.

Option B is incorrect as the oppositional child usually, focuses on his own needs.
Options C and D aren�t outcome criteria but interventions.
22. Answer D. Approach her slowly while speaking in a calm voice, calling her name,
and telling her that the nurse is here to help her

Ensuring the safety of the client and the nurse is the priority at this time.
Therefore, the nurse should approach the client cautiously while calling her name
and talking to her in a calm, confident manner.

Option A: The nurse should keep in mind that the client shouldn�t be startled or
overwhelmed. After explaining that the nurse is there to help, the nurse should
observe the client�s response carefully.
Option B: If the client shows signs of agitation or confusion or poses a threat,
the nurse should retreat and request assistance.
Option C: The nurse shouldn�t attempt to sit next to the client or examine injuries
without first announcing the nurse�s presence and assessing the dangers of the
situation.
23. Answer D. Telling the client of the nurse�s concern for her health and desire
to help her make decisions to keep her healthy

A client with anorexia nervosa has an unrealistic body image that causes
consumption of little or no food. Therefore, the client needs assistance with
making decisions about health.

Instead of protecting the client�s health, options A, B, and C may serve to make
the client defensive and more entrenched in her unrealistic body image.
24. Answer B. Alcohol withdrawal

The client�s vital signs and hallucinations suggest delirium tremens or alcohol
withdrawal syndrome.

Options A, C, and D: Although infection, acute sepsis, and pneumonia may arise as
postoperative complications; they wouldn�t cause this client�s signs and symptoms
and typically would occur later in the postoperative course

25. Answer C. Opiate withdrawal

Clonidine is used as adjunctive therapy in opiate withdrawal.

Option A: Benzodiazepines and neuroleptic agents are typically used to treat PCP
intoxication.
Option B: Benzodiazepines, such as chlordiazepoxide (Librium), and neuroleptic
agents, such as haloperidol, are used to treat alcohol withdrawal.
Option D: Antidepressants and medications with dopaminergic activity in the brain,
such as fluoxetine (Prozac), are used to treat cocaine withdrawal.
26. Answer C. Nitroglycerin (Nitro-Bid IV).

The elevated ST segments in this client�s ECG indicate myocardial ischemia. To

reverse this problem, the physician is most likely to prescribe an infusion of
nitroglycerin to dilate the coronary arteries.

Options A and B: Lidocaine and procainamide are cardiac drugs that may be indicated
for this client at some point but aren�t used for coronary artery dilation.
Option D: If a cocaine user experiences ventricular fibrillation or asystole, the
physician may prescribe epinephrine. However, this drug must be used with caution
because cocaine may potentiate its adrenergic effects.
27. Answer C. �I just can�t seem to get down to the weight I want to be. I�m so fat
compared to other girls.�

Low self-esteem is the highest risk factor for anorexia nervosa. Constant dieting
to get down to a �desirable weight� is characteristic of the disorder. Feeling
inadequate when compared to peers indicates poor self-esteem.

Option A: Most clients with anorexia nervosa don�t like the way they look, and
their self-perception may be distorted. A girl with cachexia may perceive herself
to be overweight when she looks in the mirror.
Option B: Preferring fast food over healthy food is common in this age-group.
Option D: Because of the absence of body fat necessary for proper hormone
production, amenorrhea is common for a client with anorexia nervosa.
28. Answer C. Haloperidol (Haldol)

Haloperidol is the drug of choice for treating Tourette syndrome.

Options A, B, and D: Prozac, Luvox, and Paxil are antidepressants and aren�t used
to treat Tourette syndrome
29. Answer B. �Tell me how you feel about the accident.�

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.

Option A: Asking the client why he drove while intoxicated can make him feel
defensive and intimidated.
Option C: A judgmental approach isn�t therapeutic.
Option D: By giving advice, the nurse suggests that the client isn�t capable of
making decisions, thus fostering dependency.
30. Answer D. Diaphoresis, tremors, and nervousness

Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic hallucinosis,

and alcohol withdrawal delirium (formerly delirium tremens). Signs of alcohol
withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise,
increased blood pressure and pulse rate, sleep disturbance, and irritability.

Option A: Although diarrhea may be an early sign of alcohol withdrawal, tachycardia

� not bradycardia � is associated with alcohol withdrawal.
Option B: Dehydration and an elevated temperature may be expected, but a
temperature above 101� F indicates an infection rather than alcohol withdrawal.
Pruritus rarely occurs in alcohol withdrawal.
Option C: If withdrawal symptoms remain untreated, seizures may arise later.
31. Answer D. Nifedipine and Esmolol

This client requires a vasodilator, such as nifedipine, to treat hypertension, and

a beta-adrenergic blocker, such as esmolol, to reduce the heart rate.

Options A and B: Lidocaine, an antiarrhythmic, isn�t indicated because the client

doesn�t have an arrhythmia.
Option C: Although nitroglycerin may be used to treat coronary vasospasm, it isn�t
the drug of choice in hypertension.
32. Answer B. The client will work with the nurse to remain safe

The priority goal in alcohol withdrawal is maintaining the client�s safety.

Options A, C, and D: Committing to a drug-free lifestyle, drinking plenty of

fluids, and identifying personal strengths are important goals, but ensuring the
client�s safety is the nurse�s top priority.

33. Answer A. A rigid posture, restlessness, and glaring

Behavioral clues that suggest the potential for violence includes: a rigid posture,
restlessness, glaring, a change in usual behavior, clenched hands, overtly
aggressive actions, physical withdrawal, noncompliance, overreaction, hostile
threats, recent alcohol ingestion or drug use, talk of past violent acts, inability
to express feelings, repetitive demands and complaints, argumentativeness,
profanity, disorientation, inability to focus attention, hallucinations or
delusions, paranoid ideas or suspicions, and somatic complaints.

Options B, C, and D: Violent clients rarely exhibit depression, silence, or

hypervigilance.
34. Answer D. �I know I�ve been arrested three times for drinking and driving, but
the police are just trying to hassle me.�

According to the Diagnostic and Statistical Manual of Mental Disorders, 4th

edition, diagnostic criteria for psychoactive substance abuse include a maladaptive
pattern of such use, indicated either by continued use despite knowledge of having
a persistent or recurrent social, occupational, psychological, or physical problem
caused or exacerbated by substance abuse or recurrent use in dangerous situations
(for example, while driving).

For this client, psychoactive substance dependence must be ruled out; criteria for
this disorder include a need for increasing amounts of the substance to achieve
intoxication (option A), increased time and money spent on the substance (option
B), inability to fulfill role obligations (option C), and typical withdrawal
symptoms.
35. Answer C. Risk for violence: Self-directed related to impulsive mutilating acts

The predominant behavioral characteristic of the client with borderline personality

disorder is impulsiveness, especially of a physically self-destructive sort. The
observation that the client has scratched wrists doesn�t substantiate the other
options.

36. Answer A. Coronary artery spasm

Cocaine use may cause such cardiac complications as coronary artery spasm,
myocardial infarction, dilated cardiomyopathy, acute heart failure, endocarditis,
and sudden death. Cocaine blocks reuptake of norepinephrine, epinephrine, and
dopamine, causing an excess of these neurotransmitters at postsynaptic receptor
sites.

Option B: Consequently, the drug is more likely to cause tachyarrhythmias than

bradyarrhythmias.
Option C: Although neurobehavioral deficits are common in neonates born to cocaine
users, they are rare in adults.
Option D: As craving for the drug increases, a person who�s addicted to cocaine
typically experiences euphoria followed by depression, not panic disorder
37. Answer C. Begin anytime within the next one (1) to two (2) 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.

38. Answer A. Providing one-on-one supervision during meals and for one (1) hour
afterward
Because the client with anorexia nervosa may discard food or induce vomiting in the
bathroom, the nurse should provide one-on-one supervision during meals and for 1
hour afterward.

Option B wouldn�t be therapeutic because other clients may urge the client to eat
and give attention for not eating.
Option C would reinforce control issues, which are central to this client�s
underlying psychological problem.
Instead of giving the client unlimited time to eat, the nurse should set limits and
let the client know what is expected.
39. Answer C. Providing a quiet environment and administering medication as needed
and prescribed

Manifestations of alcoholic hallucinosis are best treated by providing a quiet

environment for reducing stimulation and administering prescribed central nervous
system depressants in dosages that control symptoms without causing oversedation.

Option A: Although bed rest is indicated, restraints are unnecessary unless the
client poses a danger to himself or others. Also, restraints may increase agitation
and make the client feel trapped and helpless when hallucinating.
Option B: Offering juice is appropriate, but measuring blood pressure every 15
minutes would interrupt the client�s rest.
Option D: To avoid overstimulating the client, the nurse should check blood
pressure every 2 hours.
40. Answer A. Heart rate of 120 to 140 beats/minute

Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign of alcohol

withdrawal. Blood pressure may be labile throughout withdrawal, fluctuating at
different stages. Hypertension typically occurs in early withdrawal. Hypotension,
although rare during the early withdrawal stages, may occur in later stages.
Hypotension is associated with cardiovascular collapse and most commonly occurs in
clients who don�t receive treatment. The nurse should monitor the client�s vital
signs carefully throughout the entire alcohol withdrawal process.

41. Answer B. One who plans a violent death and has the means readily available

The client at highest risk for suicide is one who plans a violent death (for
example, by gunshot, jumping off a bridge, or hanging), has a specific plan (for
example, after the spouse leaves for work), and has the means readily available
(for example, a rifle hidden in the garage).

Options A, C, and D: A client who gives away possessions thinks about death, or
talks about wanting to die or attempting suicide is considered at a lower risk for
suicide because this behavior typically serves to alert others that the client is
contemplating suicide and wishes to be helped.
42. Answer C. Diabetes mellitus

Bulimia nervosa can lead to many complications, including diabetes, heart disease,
and hypertension.

Options A, B, and D: The eating disorder isn�t typically associated with allergies,
cancer, or hepatitis A.
43. Answer B. The student accepts a referral to a substance abuse counselor

All of the outcomes stated are desirable; however, the best outcome is that the
student would agree to seek the assistance of a professional substance abuse
counselor

44. Answer C. Lorazepam (Ativan)

The best choice for preventing or treating alcohol withdrawal symptoms is
lorazepam, a benzodiazepine.

Options A, B and D: Clozapine, and Thiothixene are antipsychotic agents, and

lithium carbonate is an antimanic agent; these drugs aren�t used to manage alcohol
withdrawal syndrome.
45. Answer A. Al-Anon

Al-Anon is an organization that assists family members to share common experiences

and increase their understanding of alcoholism.

Option B: Make Today Count is a support group for people with life-threatening or
chronic illnesses.
Option C: Emotions Anonymous is a support group for people experiencing depression,
anxiety, or similar conditions.
Option D: Alcoholics Anonymous is an organization that helps alcoholics recover by
using a twelve-step program.
46. Answer C. monitor vital signs, serum electrolyte levels, and acid-base balance

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 client�s vital signs, serum electrolyte level, and acid-base balance
is crucial.

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.
47. Answer A. Antisocial personality disorder

The client�s history of delinquency, running away from home, vandalism, and
dropping out of school are characteristic of antisocial personality disorder. This
maladaptive coping pattern is manifested by a disregard for societal norms of
behavior and an inability to relate meaningfully to others.

Option B: In borderline personality disorder, the client exhibits mood instability,

poor self-image, identity disturbance, and labile affect.
Option C: Obsessive-compulsive personality disorder is characterized by a
preoccupation with impulses and thoughts that the client realizes are senseless but
can�t control.
Option D: Narcissistic personality disorder is marked by a pattern of self-
involvement, grandiosity, and demand for constant attention.
48. Answer C. Has learned violence as an acceptable behavior

Family violence usually is a learned behavior, and violence typically leads to

further violence, putting this couple at risk.

Option A: Repeated slapping may indicate poor, not moderate, impulse control.
Options B and D: Violent people commonly are jealous and possessive and feel
insecure in their relationships
49. Answer B. Gain control of one part of her life

By refusing to eat, a client with anorexia nervosa is unconsciously attempting to

gain control over the only part of her life she feels she can control.
Option A: This eating disorder doesn�t represent an attempt to manipulate others or
live up to their expectations (although anorexia nervosa has a high incidence in
families that emphasize achievement).
Option C: The client isn�t attempting to commit suicide through starvation; rather,
by refusing to eat, she is expressing feelings of despair, worthlessness, and
hopelessness.
50. Answer B. Total abstinence

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.

Options A, C, and D: Psychotherapy, attendance at AA meetings, and aversion therapy

are all adjunctive therapies that can support the client in his efforts to abstain.