1. Situation : The nurse assigned in the detoxification unit attends to stealing her things.

things.” Which response by the nurse will be most

various patients with substance-related disorders. A 45 years old male therapeutic?
revealed that he experienced a marked increase in his intake of alcohol to
achieve the desired effect This indicates: a. ”Don’t take it personally. Your mother does not mean it.”
b. “Have you tried discussing this with your mother?”
a. withdrawal c. “This must be difficult for you and your mother.”
b. tolerance d. “Next time ask your mother where her things were last seen.”
c. intoxication
d. psychological dependence
8. The primary nursing intervention in working with a client with moderate
stage dementia is ensuring that the client:
2. The client admitted for alcohol detoxification develops increased
tremors, irritability, hypertension and fever. The nurse should be alert for a. receives adequate nutrition and hydration
impending: b. will reminisce to decrease isolation
c. remains in a safe and secure environment
a. delirium tremens d. independently performs self care
b. Korsakoff’s syndrome
c. esophageal varices
d. Wernicke’s syndrome 9. She says to the nurse who offers her breakfast, “Oh no, I will wait for my
husband. We will eat together” The therapeutic response by the nurse is:

3. The care for the client places priority to which of the following:
a. Monitoring his vital signs every hour
b. Providing a quiet, dim room
c. Encouraging adequate fluids and nutritious foods
d. Administering Librium as ordered
a. “Your husband is dead. Let me serve you your breakfast.”
b. “I’ve told you several times that he is dead. It’s time to eat.”
c. “You’re going to have to wait a long time.”
d. “What made you say that your husband is alive?
10. Dementia unlike delirium is characterized by:

4. Another client is brought to the emergency room by friends who state a. slurred speech
that he took something an hour ago. He is actively hallucinating, agitated, b. insidious onset
with irritated nasal septum. c. clouding of consciousness
d. sensory perceptual change
a. Heroin
b. cocaine
c. LSD 11. Situation: A 17 year old gymnast is admitted to the hospital due to
d. marijuana weight loss and dehydration secondary to starvation. Which of the
following nursing diagnoses will be given priority for the client?

5. A client is admitted with needle tracts on his arm, stuporous and with a. altered self-image
pin point pupil will likely be managed with: b. fluid volume deficit
c. altered nutrition less than body requirements
a. Naltrexone (Revia) d. altered family process
b. Narcan (Naloxone)
c. Disulfiram (Antabuse)
d. Methadone (Dolophine) 12. What is the best intervention to teach the client when she feels the
need to starve?

6. Situation: An old woman was brought for evaluation due to the hospital a. Allow her to starve to relieve her anxiety
for evaluation due to increasing forgetfulness and limitations in daily b. Do a short term exercise until the urge passes
function. The daughter revealed that the client used her toothbrush to c. Approach the nurse and talk out her feelings
comb her hair. She is manifesting: d. Call her mother on the phone and tell her how she feels

a. apraxia
b. aphasia 13. The client with anorexia nervosa is improving if:
c. agnosia
d. amnesia a. She eats meals in the dining room.
b. Weight gain
c. She attends ward activities.
7. She tearfully tells the nurse “I can’t take it when she accuses me of d. She has a more realistic self concept.

14. The characteristic manifestation that will differentiate bulimia nervosa
from anorexia nervosa is that bulimic individuals
a. have episodic binge eating and purging
b. have repeated attempts to stabilize their weight
c. have peculiar food handling patterns
d. have threatened self-esteem
15. A nursing diagnosis for bulimia nervosa is powerlessness related to
feeling not in control of eating habits. The goal for this problem is:
a. Patient will learn problem solving skills
b. Patient will have decreased symptoms of anxiety.
c. Patient will perform self care activities daily.
d. Patient will verbalize how to set limits on others.
16. In the management of bulimic patients, the following nursing
interventions will promote a therapeutic relationship EXCEPT:
a. Establish an atmosphere of trust
b. Discuss their eating behavior.
c. Help patients identify feelings associated with binge-purge behavior
d. Teach patient about bulimia nervosa
17. Situation: A 35 year old male has intense fear of riding an elevator. He
claims “ As if I will die inside.” This has affected his studies The client is
suffering from:
a. agoraphobia
b. social phobia
c. Claustrophobia
d. xenophobia
18. Initial intervention for the client should be to:
a. Encourage to verbalize his fears as much as he wants.
b. Assist him to find meaning to his feelings in relation to his past.
c. Establish trust through a consistent approach.
d. Accept her fears without criticizing.
19. The nurse develops a countertransference reaction. This is evidenced
by:
a. Revealing personal information to the client
b. Focusing on the feelings of the client.
c. Confronting the client about discrepancies in verbal or non-verbal
behavior
d. The client feels angry towards the nurse who resembles his mother.
20. Which is the desired outcome in conducting desensitization:
a. The client verbalize his fears about the situation
b. The client will voluntarily attend group therapy in the social hall.
c. The client will socialize with others willingly
d. The client will be able to overcome his disabling fear.
21. Which of the following should be included in the health teachings
among clients receiving Valium:
a. Avoid taking CNS depressant like alcohol.
b. There are no restrictions in activities.
c. Limit fluid intake.
d. Any beverage like coffee may be taken
22. Situation: A 20 year old college student is admitted to the medical ward
because of sudden onset of paralysis of both legs. Extensive examination
revealed no physical basis for the complaint. The nurse plans intervention
based on which correct statement about conversion disorder?
a. The symptoms are conscious effort to control anxiety
b. The client will experience high level of anxiety in response to the
paralysis.
c. The conversion symptom has symbolic meaning to the client
d. A confrontational approach will be beneficial for the client.
23. Nina reveals that the boyfriend has been pressuring her to engage in
premarital sex. The most therapeutic response by the nurse is:
a. “I can refer you to a spiritual counselor if you like.”
b. “You shouldn’t allow anyone to pressure you into sex.”
c. “It sounds like this problem is related to your paralysis.”
d. “How do you feel about being pressured into sex by your boyfriend?”
24. Malingering is different from somatoform disorder because the
former:
a. Has evidence of an organic basis.
b. It is a deliberate effort to handle upsetting events
c. Gratification from the environment are obtained.
d. Stress is expressed through physical symptoms.
25. Unlike psychophysiologic disorder Linda may be best managed with:
a. medical regimen
b. milieu therapy
c. stress management techniques
d. psychotherapy
·Answer: (B) tolerance
tolerance refers to the increase in the amount of the substance to achieve
the same effects. A. Withdrawal refers to the physical signs and symptoms
that occur when the addictive substance is reduced or withheld. B.
Intoxication refers to the behavioral changes that occur upon recent
ingestion of a substance. D. Psychological dependence refers to the intake
of the substance to prevent the onset of withdrawal symptoms.
·Answer: (A) delirium tremens
Delirium Tremens is the most extreme central nervous system irritability
due to withdrawal from alcohol B. This refers to an amnestic syndrome
associated with chronic alcoholism due to a deficiency in Vit. B C. This is a
complication of liver cirrhosis which may be secondary to alcoholism . D.
This is a complication of alcoholism characterized by irregularities of eye
movements and lack of coordination.
·Answer: (A) Monitoring his vital signs every hour
Pulse and blood pressure are usually elevated during withdrawal, Elevation
may indicate impending delirium tremens B. Client needs quiet, well
lighted, consistent and secure environment. Excessive stimulation can
aggravate anxiety and cause illusions and hallucinations. C. Adequate
nutrition with sulpplement of Vit. B should be ensured. D. Sedatives are
used to relieve anxiety.
·Answer: (B) cocaine
The manifestations indicate intoxication with cocaine, a CNS stimulant. A.
Intoxication with heroine is manifested by euphoria then impairment in
judgment, attention and the presence of papillary constriction. C.
Intoxication with hallucinogen like LSD is manifested by grandiosity,
hallucinations, synesthesia and increase in vital signs D. Intoxication with
Marijuana, a cannabinoid is manifested by sensation of slowed time,
conjunctival redness, social withdrawal, impaired judgment and
hallucinations.
·Answer: (B) Narcan (Naloxone)
Narcan is a narcotic antagonist used to manage the CNS depression due to
overdose with heroin. A. This is an opiate receptor blocker used to relieve
the craving for heroine C. Disulfiram is used as a deterrent in the use of
alcohol. D. Methadone is used as a substitute in the withdrawal from
heroine
·Answer: (C) agnosia
This is the inability to recognize objects. A. Apraxia is the inability to
execute motor activities despite intact comprehension. B. Aphasia is the
loss of ability to use or understand words. D. Amnesia is loss of memory.
·Answer: (C) “This must be difficult for you and your mother.”
This reflecting the feeling of the daughter that shows empathy. A and D.
Giving advise does not encourage verbalization. B. This response does not
encourage verbalization of feelings.
·Answer: (C) remains in a safe and secure environment
Safety is a priority consideration as the client’s cognitive ability
deteriorates.. A is appropriate interventions because the client’s cognitive
impairment can affect the client’s ability to attend to his nutritional needs,
but it is not the priority B. Patient is allowed to reminisce but it is not the
priority. D. The client in the moderate stage of Alzheimer’s disease will
have difficulty in performing activities independently
·Answer: (A) “Your husband is dead. Let me serve you your breakfast.”
The client should be reoriented to reality and be focused on the here and
now.. B. This is not a helpful approach because of the short term memory
of the client. C. This indicates a pompous response. D. The cognitive
limitation of the client makes the client incapable of giving explanation.
·Answer: (B) insidious onset
Dementia has a gradual onset and progressive deterioration. It causes
pronounced memory and cognitive disturbances. A,C and D are all
characteristics of delirium.
·Answer: (B) fluid volume deficit
Fluid volume deficit is the priority over altered nutrition (A) since the
situation indicates that the client is dehydrated. A and D are psychosocial
needs of a client with anorexia nervosa but they are not the priority.
·Answer: (C) Approach the nurse and talk out her feelings
The client with anorexia nervosa uses starvation as a way of managing
anxiety. Talking out feelings with the nurse is an adaptive coping. A.
Starvation should not be encouraged. Physical safety is a priority. Without
adequate nutrition, a life threatening situation exists. B. The client with
anorexia nervosa is preoccupied with losing weight due to disturbed body
image. Limits should be set on attempts to lose more weight. D. The client
may have a domineering mother which causes the client to feel
ambivalent. The client will not discuss her feelings with her mother.
·Answer: (B) Weight gain
Weight gain is the best indication of the client’s improvement. The goal is
for the client to gain 1-2 pounds per week. (A)The client may purge after
eating. (C) Attending an activity does not indicate improvement in
nutritional state. (D) Body image is a factor in anorexia nervosa but it is not
an indicator for improvement.
·Answer: (A) have episodic binge eating and purging
Bulimia is characterized by binge eating which is characterized by taking in
a large amount of food over a short period of time. B and C are
characteristics of a client with anorexia nervosa D. Low esteem is noted in
both eating disorders
·Answer: (A) Patient will learn problem solving skills
if the client learns problem solving skills she will gain a sense of control
over her life. (B) Anxiety is caused by powerlessness. (C) Performing self
care activities will not decrease ones powerlessness (D) Setting limits to
control imposed by others is a necessary skill but problem solving skill is
the priority.
·Answer: (B) Discuss their eating behavior.
The client is often ashamed of her eating behavior. Discussion should focus
on feelings. A,C and D promote a therapeutic relationship
·Answer: (C) Claustrophobia
Claustrophobia is fear of closed space. A. Agoraphobia is fear of open
space or being a situation where escape is difficult. B. Social phobia is fear
of performing in the presence of others in a way that will be humiliating or
embarrassing. D. Xenophobia is fear of strangers.
·Answer: (D) Accept her fears without criticizing.
The client cannot control her fears although the client knows its silly and
can joke about it. A. Allow expression of the client’s fears but he should
focus on other productive activities as well. B and C. These are not the
initial interventions.
·Answer: (A) Revealing personal information to the client
A. Countertransference is an emotional reaction of the nurse on the client
based on her unconscious needs and conflicts. B and C. These are
therapeutic approaches. D. This is transference reaction where a client has
an emotional reaction towards the nurse based on her past.
·Answer: (D) The client will be able to overcome his disabling fear.
The client will overcome his disabling fear by gradual exposure to the
feared object. A,B and C are not the desired outcome of desensitization.
·Answer: (A) Avoid taking CNS depressant like alcohol.
Valium is a CNS depressant. Taking it with other CNS depressants like
alcohol; potentiates its effect. B. The client should be taught to avoid
activities that require alertness. C. Valium causes dry mouth so the client
must increase her fluid intake. D. Stimulants must not be taken by the
client because it can decrease the effect of Valium.
·Answer: (C) The conversion symptom has symbolic meaning to the client
the client uses body symptoms to relieve anxiety. A. The condition occurs
unconsciously. B. The client is not distressed by the lost or altered body
function. D. The client should not be confronted by the underlying cause of
his condition because this can aggravate the client’s anxiety.
·Answer: (D) “How do you feel about being pressured into sex by your
boyfriend?”
Focusing on expression of feelings is therapeutic. The central force of the
client’s condition is anxiety. A. This is not therapeutic because the nurse
passes the responsibility to the counselor. B. Giving advice is not
therapeutic. C. This is not therapeutic because it confronts the underlying
cause.
·Answer: (B) It is a deliberate effort to handle upsetting events
Malingering is a conscious simulation of an illness while somatoform
disorder occurs unconscious. A. Both disorders do not have an organic or
structural basis. C. Both have primary gains. D. This is a characteristic of
somatoform disorder.
·Answer: (C) stress management techniques
Stree management techniques is the best management of somatoform
disorder because the disorder is related to stress and it does not have a
medical basis. A. This disorder is not supported by organic pathology so no
medical regimen is required. B and D. Milieu therapy and psychotherapy
may be used a therapeutic modalities but these are not the best.