1.

Which nursing intervention is best for facilitating communication with a

psychiatric client who speaks a foreign language?

A. Rely on nonverbal communication.

B. Select symbolic pictures as aids.
C. Speak in universal phrases.
D. Use the services of an interpreter.
2. The nurse explains to a mental health care technician that a client’s
obsessive-compulsive behaviors are related to unconscious conflict between id
impulses and the superego (or conscience). On which of the following theories does
the nurse base this statement?

A. Behavioral theory
B. Cognitive theory
C. Interpersonal theory
D. Psychoanalytic theory
3. The nurse observes a client pacing in the hall. Which statement by the nurse
may help the client recognize his anxiety?

A. “I guess you’re worried about something, aren’t you?

B. “Can I get you some medication to help calm you?”
C. “Have you been pacing for a long time?”
D. “I notice that you’re pacing. How are you feeling?”
4. A client with obsessive-compulsive disorder is hospitalized on an inpatient unit.
Which nursing response is most therapeutic?

A. Accepting the client’s obsessive-compulsive behaviors

B. Challenging the client’s obsessive-compulsive behaviors
C. Preventing the client’s obsessive-compulsive behaviors
D. Rejecting the client’s obsessive-compulsive behaviors
5. A 45-year-old woman with a history of depression tells a nurse in her doctor’s
office that she has difficulty with sexual arousal and is fearful that her husband will
have an affair. Which of the following factors would the nurse identify as least
significant in contributing to the client’s sexual difficulty?

A. Education and work history

B. Medication used
C. Physical health status
D. Quality of spousal relationship
6. Which nursing intervention is most appropriate for a client with anorexia
nervosa during initial hospitalization on a behavioral therapy unit?

A. Emphasize the importance of good nutrition to establish normal weight.

B. Ignore the client’s mealtime behavior and focus instead on issues of
dependence and independence.
C. Help establish a plan using privileges and restrictions based on compliance
with refeeding.
D. Teach the client information about the long-term physical consequence of
anorexia.
7. A nurse is evaluating therapy with the family of a client with anorexia nervosa.
Which of the following would indicate that the therapy was successful?

A. The parents reinforce increased decision making by the client.

B. The parents clearly verbalize their expectations for the client.
C. The client verbalizes that family meals are now enjoyable.
D. The client tells her parents about feelings of low-self-esteem.
8. The nurse is working with a client with a somatoform disorder. Which client
outcome goal would the nurse most likely establish in this situation?

A. The client will recognize signs and symptoms of physical illness.

B. The client will cope with physical illness.
C. The client will take prescribed medications.
D. The client will express anxiety verbally rather than through physical
symptoms.
9. Which method would a nurse use to determine a client’s potential risk for
suicide?

A. Wait for the client to bring up the subject of suicide.

B. Observe the client’s behavior for cues of suicide ideation.
C. Question the client directly about suicidal thoughts.
D. Question the client about future plans.
10. A client with a bipolar disorder exhibits manic behavior. The nursing diagnosis
is Disturbed thought processes related to difficulty concentrating, secondary to
flight of ideas. Which of the following outcome criteria would indicate
improvement in the client?

A. The client verbalizes feelings directly during treatment.

B. The client verbalizes positive “self” statement.
C. The client speaks in coherent sentences.
D. The client reports feelings calmer.
11. A client tells a nurse. “Everyone would be better off if I wasn’t alive.” Which
nursing diagnosis would be made based on this statement?

A. Disturbed thought processes

B. Ineffective coping
C. Risk for self-directed violence
D. Impaired social interaction
12. Which information is most essential in the initial teaching session for the family
of a young adult recently diagnosed with schizophrenia?

A. Symptoms of this disease imbalance in the brain.

B. Genetic history is an important factor related to the development of
schizophrenia.
C. Schizophrenia is a serious disease affecting every aspect of a person’s
functioning.
D. The distressing symptoms of this disorder can respond to treatment with
medications.
13. A nurse is working with a client who has schizophrenia, paranoid type. Which
of the following outcomes related to the client’s delusional perceptions would the
nurse establish?

A. The client will demonstrate realistic interpretation of daily events in the

unit.
B. The client will perform daily hygiene and grooming without assistance.
C. The client will take prescribed medications without difficulty.
D. The client will participate in unit activities.
14. A client with bipolar disorder, manic type, exhibits extreme excitement,
delusional thinking, and command hallucinations. Which of the following is the
priority nursing diagnosis?
A. Anxiety
B. Impaired social interaction
C. Disturbed sensory-perceptual alteration (auditory)
D. Risk for other-directed violence

15. A client who abuses alcohol and cocaine tells a nurse that he only uses
substances because of his stressful marriage and difficult job. Which defense
mechanisms is this client using?

A. Displacement
B. Projection
C. Rationalization
D. Sublimation
16. An 11-year-old child diagnosed with conduct disorder is admitted to the
psychiatric unit for treatment. Which of the following behaviors would the nurse
assess?

A. Restlessness, short attention span, hyperactivity

B. Physical aggressiveness, low stress tolerance disregard for the rights of
others
C. Deterioration in social functioning, excessive anxiety and worry, bizarre
behavior
D. Sadness, poor appetite and sleeplessness, loss of interest in activities
17. The nurse understands that if a client continues to be dependent on heroin
throughout her pregnancy, her baby will be at high risk for:

A. Mental retardation.
B. Heroin dependence.
C. Addiction in adulthood.
D. Psychological disturbances.
18. The emergency department nurse is assigned to provide care for a victim of a
sexual assault. When following legal and agency guidelines, which intervention is
most important?

A. Determine the assailant’s identity.

B. Preserve the client’s privacy.
C. Identify the extent of injury.
D. Ensure an unbroken chain of evidence.
19. Which factor is least important in the decision regarding whether a victim of
family violence can safely remain in the home?

A. The availability of appropriate community shelters

B. The nonabusing caretaker’s ability to intervene on the client’s behalf
C. The client’s possible response to relocation
D. The family’s socioeconomic status
20. The nurse would expect a client with early Alzheimer’s disease to have
problems with:

A. Balancing a checkbook.
B. Self-care measures.
C. Relating to family members.
D. Remembering his own name
21. Which nursing intervention is most appropriate for a client with Alzheimer’s
disease who has frequent episodes emotional lability?

A. Attempt humor to alter the client mood.

B. Explore reasons for the client’s altered mood.
C. Reduce environmental stimuli to redirect the client’s attention.
D. Use logic to point out reality aspects.
22. Which neurotransmitter has been implicated in the development of
Alzheimer’s disease?

A. Acetylcholine
B. Dopamine
C. Epinephrine
D. Serotonin
23. Which factors are most essential for the nurse to assess when providing crisis
intervention foe a client?

A. The client’s communication and coping skills

B. The client’s anxiety level and ability to express feelings
C. The client’s perception of the triggering event and availability of situational
supports
D. The client’s use of reality testing and level of depression
24. The nurse considers a client’s response to crisis intervention successful if the
client:

A. Changes coping skills and behavioral patterns.

B. Develops insight into reasons why the crisis occurred.
C. Learns to relate better to others.
D. Returns to his previous level of functioning.

25. Two nurses are co-leading group therapy for seven clients in the psychiatric
unit. The leaders observe that the group members are anxious and look to the
leaders for answers. Which phase of development is this group in?

A. Conflict resolution phase

B. Initiation phase
C. Working phase
D. Termination phase
26. Group members have worked very hard, and the nurse reminds them that
termination is approaching. Termination is considered successful if group
members:

A. Decide to continue.
B. Elevate group progress
C. Focus on positive experience
D. Stop attending prior to termination.
27. The nurse is teaching a group of clients about the mood-stabilizing medications
lithium carbonate. Which medications should she instruct the clients to avoid
because of the increased risk of lithium toxicity?

A. Antacids
B. Antibiotics
C. Diuretics
D. Hypoglycemic agents
28. When providing family therapy, the nurse analyzes the functioning of healthy
family systems. Which situations would not increase stress on a healthy family
system?

A. An adolescent’s going away to college

B. The birth of a child
C. The death of a grandparent
D. Parental disagreement
29. A client taking the monoamine oxidase inhibitor (MAOI) antidepressant
isocarboxazid (Marplan) is instructed by the nurse to avoid which foods and
beverages?

A. Aged cheese and red wine

B. Milk and green, leaf vegetables
C. Carbonated beverages and tomato products
D. Lean red meats and fruit juices
30. Prior to administering chlorpromazine (Thorazine) to an agitated client, the
nurse should:

A. Assess skin color and sclera

B. Assess the radial pulse
C. Take the client’s blood pressure
D. Ask the client to void
31. The nurse understands that electroconvulsive therapy is primary used in
psychiatric care for the treatment of:

A. Anxiety disorders.
B. Depression.
C. Mania.
D. Schizophrenia.
32. A client taking the MAOI phenelzine (Nardil) tells the nurse that he routinely
takes all of the medications listed below. Which medication would cause the nurse
to express concern and therefore initiate further teaching?

A. Acetaminophen (Tylenol)
B. Diphenhydramine (Benadryl)
C. Furosemide (Lasix)
D. Isosorbide dinitrate (Isordil)
33. The nurse is administering a psychotropic drug to an elderly client who has
history of benign prostatic hypertrophy. It is most important for the nurse to
teach this client to:

A. Add fiber to his diet.

B. Exercise on a regular basis.
C. Report incomplete bladder emptying
D. Take the prescribed dose at bedtime.
34. The nurse correctly teaches a client taking the benzodiazepine oxazepam
(Serax) to avoid excessive intake of:

A. Cheese
B. Coffee
C. Sugar
D. Shellfish

35. The nurse provides a referral to Alcoholics Anonymous to a client who

describes a 20-year history of alcohol abuse. The primary function of this group is
to:

A. Encourage the use of a 12-step program.

B. Help members maintain sobriety.
C. Provide fellowship among members.
D. Teach positive coping mechanisms.
36. Which client outcome is most appropriately achieved in a community
approach setting in psychiatric nursing?
A. The client performs activities of daily living and learns about crafts.
B. The client’s is able to prevent aggressive behavior and monitors his use of
medications.
C. The client demonstrates self-reliance and social adaptation.
D. The client experience experiences anxiety relief and learns about his
symptoms.
37. A client with panic disorder experiences an acute attack while the nurse is
completing an admission assessment. List the following interventions according to
their level of priority.

A. Remain with the client.

B. Encourage physical activity.
C. Encourage low, deep breathing.
D. Reduce external stimuli.
E. Teach coping measures.
38. The doctor has prescribed haloperidol (Haldol) 2.5 mg. I.M. for an agitated
client. The medication is labeled haloperidol 10 mg/2 ml. The nurse prepares the
correct dose by drawing up how many milliliters in the syringe?

A. 0.3
B. 0.4
C. 0.5
D. 0.6

39. The nurse enters the room of a client with a cognitive impairment disorder
and asks what day of the week it is: what the date, month, and year are; and
where the client is. The nurse is attempting to assess:

A. Confabulation
B. Delirium
C. Orientation
D. Perseveration
40. Which of the following will the nurse use when communicating with a client
who has a cognitive impairment?

A. Complete explanations with multiple details

B. Picture or gestures instead of words
C. Stimulating words and phrases to capture the client’s attention
D. Short words and simple sentences
41. A 75-year-old client has dementia of the Alzheimer’s type and confabulates.
The nurse understands that this client:

A. Denies confusion by being jovial.

B. Pretends to be someone else.
C. Rationalizes various behaviors.
D. Fills in memory gaps with fantasy.
42. An elderly client with Alzheimer’s disease becomes agitated and combative
when a nurse approaches to help with morning care. The most appropriate nursing
intervention in this situation would be to:

A. Tell the client family that it is time to get dressed.

B. Obtain assistance to restrain the client for safety.
C. Remain calm and talk quietly to the client.
D. Call the doctor and request an order for sedation.
43. In clients with a cognitive impairment disorder, the phenomenon of increased
confusion in the early evening hours is called:

A. Aphasia
B. Agnosia
C. Sundowning
D. Confabulation

44. Which of the following outcome criteria is appropriate for the client with
dementia?

A. The client will return to an adequate level of self-functioning.

B. The client will learn new coping mechanisms to handle anxiety.
C. The client will seek out resources in the community for support.
D. The client will follow an establishing schedule for activities of daily living.
45. The school guidance counselor refers a family with an 8-year-old child to the
mental health clinic because of the child’s frequent fighting in school and truancy.
Which of the following data would be a priority to the nurse doing the initial
family assessment?

A. The child’s performance in school

B. Family education and work history
C. The family’s perception of the current problem
D. The teacher’s attempts to solve the problem
46. The parents of a young man with schizophrenia express feelings of
responsibility and guilt for their son’s problems. How can the nurse best educate
the family?

A. Acknowledge the parent’s responsibility.

B. Explain the biological nature of schizophrenia.
C. Refer the family to a support group
D. Teach the parents various ways they must change.
47. The nurse collecting family assessment data asks. “Who is in your family and
where do they live?” which of the following is the nurse attempting o identify?

A. Boundaries
B. Ethnicity
C. Relationships
D. Triangles
48. According to the family systems theory, which of the following best describes
the process of differentiation?

A. Cooperative action among members of the family

B. Development of autonomy within the family
C. Incongruent massages wherein the recipient is a victim
D. Maintenance of system continuity or equilibrium

49. The nurse is interacting with a family consisting of a mother, a father, and a
hospitalized adolescent who has a diagnosis of alcohol abuse. The nurse analyzes the
situation and agrees with the adolescent’s view about family rules. Which
intervention is most appropriate?

A. The nurse should align with the adolescent, who is the family scapegoat.
B. The nurse should encourage the parents to adopt more realistic rules.
C. The nurse should encourage the adolescent to comply with parental rules.
D. The nurse should remain objective and encourage mutual negotiation of
issues.
50. A 16-year-old girl has retuned home following hospitalization for treatment
of anorexia nervosa. The parents tell the family nurse performing a home visit that
their child has always done everything to please them and they cannot understand
her current stubbornness about eating. The nurse analyzes the family situation and
determines it is characteristic of which relationship style?

A. Differentiation
B. Disengagement
C. Enmeshment
D. Scapegoating

II. 1. Marco approached Nurse Trish asking for advice on how to deal with his
alcohol addiction. Nurse Trish should tell the client that the only effective
treatment for alcoholism is:

A. Psychotherapy
B. Alcoholics anonymous (A.A.)
C. Total abstinence
D. Aversion Therapy
2.Nurse Hazel is caring for a male client who experience false sensory perceptions
with no basis in reality. This perception is known as:

A. Hallucinations
B. Delusions
C. Loose associations
D. Neologisms
3. Nurse Monet is caring for a female client who has suicidal tendency. When
accompanying the client to the restroom, Nurse Monet should…

A. Give her privacy

B. Allow her to urinate
C. Open the window and allow her to get some fresh air
D. Observe her
4. Nurse Maureen is developing a plan of care for a female client with anorexia
nervosa. Which action should the nurse include in the plan?

A. Provide privacy during meals

B. Set-up a strict eating plan for the client
C. Encourage client to exercise to reduce anxiety
D. Restrict visits with the family
5. A client is experiencing anxiety attack. The most appropriate nursing
intervention should include?

A. Turning on the television

B. Leaving the client alone
C. Staying with the client and speaking in short sentences
D. Ask the client to play with other clients
6. A female client is admitted with a diagnosis of delusions of GRANDEUR. This
diagnosis reflects a belief that one is:

A. Being Killed
B. Highly famous and important
C. Responsible for evil world
D. Connected to client unrelated to oneself
7.A 20 year old client was diagnosed with dependent personality disorder. Which
behavior is most likely to be evidence of ineffective individual coping?

A. Recurrent self-destructive behavior

B. Avoiding relationship
C. Showing interest in solitary activities
D. Inability to make choices and decision without advise
8. A male client is diagnosed with schizotypal personality disorder. Which signs
would this client exhibit during social situation?

A. Paranoid thoughts
B. Emotional affect
C. Independence need
D. Aggressive behavior
9. Nurse Claire is caring for a client diagnosed with bulimia. The most appropriate
initial goal for a client diagnosed with bulimia is?

A. Encourage to avoid foods

B. Identify anxiety causing situations
C. Eat only three meals a day
D. Avoid shopping plenty of groceries
10. Nurse Tony was caring for a 41 year old female client. Which behavior by the
client indicates adult cognitive development?

A. Generates new levels of awareness

B. Assumes responsibility for her actions
C. Has maximum ability to solve problems and learn new skills
D. Her perception are based on reality
11. A neuromuscular blocking agent is administered to a client before ECT therapy.
The Nurse should carefully observe the client for?

A. Respiratory difficulties
B. Nausea and vomiting
C. Dizziness
D. Seizures
12. A 75 year old client is admitted to the hospital with the diagnosis of dementia
of the Alzheimer’s type and depression. The symptom that is unrelated to
depression would be?

A. Apathetic response to the environment

B. “I don’t know” answer to questions
C. Shallow of labile effect
D. Neglect of personal hygiene

13. Nurse Trish is working in a mental health facility; the nurse priority nursing
intervention for a newly admitted client with bulimia nervosa would be to?

A. Teach client to measure I & O

B. Involve client in planning daily meal
C. Observe client during meals
D. Monitor client continuously
14. Nurse Patricia is aware that the major health complication associated with
intractable anorexia nervosa would be?

A. Cardiac dysrhythmias resulting to cardiac arrest

B. Glucose intolerance resulting in protracted hypoglycemia
C. Endocrine imbalance causing cold amenorrhea
D. Decreased metabolism causing cold intolerance
15. Nurse Anna can minimize agitation in a disturbed client by?

A. Increasing stimulation
B. limiting unnecessary interaction
C. increasing appropriate sensory perception
D. ensuring constant client and staff contact
16. A 39 year old mother with obsessive-compulsive disorder has become
immobilized by her elaborate hand washing and walking rituals. Nurse Trish
recognizes that the basis of O.C. disorder is often:

A. Problems with being too conscientious

B. Problems with anger and remorse
C. Feelings of guilt and inadequacy
D. Feeling of unworthiness and hopelessness
17. Mario is complaining to other clients about not being allowed by staff to keep
food in his room. Which of the following interventions would be most appropriate?

A. Allowing a snack to be kept in his room

B. Reprimanding the client
C. Ignoring the clients behavior
D. Setting limits on the behavior

18. Conney with borderline personality disorder who is to be discharge soon

threatens to “do something” to herself if discharged. Which of the following actions
by the nurse would be most important?

A. Ask a family member to stay with the client at home temporarily

B. Discuss the meaning of the client’s statement with her
C. Request an immediate extension for the client
D. Ignore the clients statement because it’s a sign of manipulation
19. Joey a client with antisocial personality disorder belches loudly. A staff
member asks Joey, “Do you know why people find you repulsive?” this statement
most likely would elicit which of the following client reaction?

A. Defensiveness
B. Embarrassment
C. Shame
D. Remorseful
20. Which of the following approaches would be most appropriate to use with a
client suffering from narcissistic personality disorder when discrepancies exist
between what the client states and what actually exist?

A. Rationalization
B. Supportive confrontation
C. Limit setting
D. Consistency
21. Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis and
hyperactivity. Blood pressure is 190/87 mmhg and pulse is 92 bpm. Which of the
medications would the nurse expect to administer?

A. Naloxone (Narcan)
B. Benzlropine (Cogentin)
C. Lorazepam (Ativan)
D. Haloperidol (Haldol)
22. Which of the following foods would the nurse Trish eliminate from the diet of a
client in alcohol withdrawal?

A. Milk
B. Orange Juice
C. Tea
D. Regular Coffee
23. Which of the following would Nurse Hazel expect to assess for a client who is
exhibiting late signs of heroin withdrawal?

A. Yawning & diaphoresis

B. Restlessness & Irritability
C. Constipation & steatorrhea
D. Vomiting and Diarrhea
24. To establish open and trusting relationship with a female client who has been
hospitalized with severe anxiety, the nurse in charge should?

A. Encourage the staff to have frequent interaction with the client

B. Share an activity with the client
C. Give client feedback about behavior
D. Respect client’s need for personal space
25. Nurse Monette recognizes that the focus of environmental (MILIEU) therapy is
to:

A. Manipulate the environment to bring about positive changes in behavior

B. Allow the client’s freedom to determine whether or not they will be
involved in activities
C. Role play life events to meet individual needs
D. Use natural remedies rather than drugs to control behavior
26. Nurse Trish would expect a child with a diagnosis of reactive attachment
disorder to:

A. Have more positive relation with the father than the mother
B. Cling to mother & cry on separation
C. Be able to develop only superficial relation with the others
D. Have been physically abuse
27. When teaching parents about childhood depression Nurse Trina should say?

A. It may appear acting out behavior

B. Does not respond to conventional treatment
C. Is short in duration & resolves easily
D. Looks almost identical to adult depression

28. Nurse Perry is aware that language development in autistic child resembles:

A. Scanning speech
B. Speech lag
C. Shuttering
D. Echolalia
29. A 60 year old female client who lives alone tells the nurse at the community
health center “I really don’t need anyone to talk to”. The TV is my best friend.
The nurse recognizes that the client is using the defense mechanism known as?

A. Displacement
B. Projection
C. Sublimation
D. Denial
30. When working with a male client suffering phobia about black cats, Nurse Trish
should anticipate that a problem for this client would be?

A. Anxiety when discussing phobia

B. Anger toward the feared object
C. Denying that the phobia exist
D. Distortion of reality when completing daily routines
31. Linda is pacing the floor and appears extremely anxious. The duty nurse
approaches in an attempt to alleviate Linda’s anxiety. The most therapeutic
question by the nurse would be?

A. Would you like to watch TV?

B. Would you like me to talk with you?
C. Are you feeling upset now?
D. Ignore the client
32. Nurse Penny is aware that the symptoms that distinguish post traumatic
stress disorder from other anxiety disorder would be:

A. Avoidance of situation & certain activities that resemble the stress

B. Depression and a blunted affect when discussing the traumatic situation
C. Lack of interest in family & others
D. Re-experiencing the trauma in dreams or flashback

33. Nurse Benjie is communicating with a male client with substance-induced

persisting dementia; the client cannot remember facts and fills in the gaps with
imaginary information. Nurse Benjie is aware that this is typical of?

A. Flight of ideas
B. Associative looseness
C. Confabulation
D. Concretism
34. Nurse Joey is aware that the signs & symptoms that would be most specific for
diagnosis anorexia are?

A. Excessive weight loss, amenorrhea & abdominal distension

B. Slow pulse, 10% weight loss & alopecia
C. Compulsive behavior, excessive fears & nausea
D. Excessive activity, memory lapses & an increased pulse
35. A characteristic that would suggest to Nurse Anne that an adolescent may
have bulimia would be:

A. Frequent regurgitation & re-swallowing of food

B. Previous history of gastritis
C. Badly stained teeth
D. Positive body image
36. Nurse Monette is aware that extremely depressed clients seem to do best in
settings where they have:

A. Multiple stimuli
B. Routine Activities
C. Minimal decision making
D. Varied Activities
37. To further assess a client’s suicidal potential. Nurse Katrina should be especially
alert to the client expression of:

A. Frustration & fear of death

B. Anger & resentment
C. Anxiety & loneliness
D. Helplessness & hopelessness

38. A nursing care plan for a male client with bipolar I disorder should include:

A. Providing a structured environment

B. Designing activities that will require the client to maintain contact with
reality
C. Engaging the client in conversing about current affairs
D. Touching the client provide assurance
39. When planning care for a female client using ritualistic behavior, Nurse Gina
must recognize that the ritual:

A. Helps the client focus on the inability to deal with reality

B. Helps the client control the anxiety
C. Is under the client’s conscious control
D. Is used by the client primarily for secondary gains
40. A 32 year old male graduate student, who has become increasingly withdrawn
and neglectful of his work and personal hygiene, is brought to the psychiatric
hospital by his parents. After detailed assessment, a diagnosis of schizophrenia is
made. It is unlikely that the client will demonstrate:

A. Low self esteem

B. Concrete thinking
C. Effective self boundaries
D. Weak ego
41. A 23 year old client has been admitted with a diagnosis of schizophrenia says
to the nurse “Yes, its march, March is little woman”. That’s literal you know”.
These statement illustrate:

A. Neologisms
B. Echolalia
C. Flight of ideas
D. Loosening of association
42. A long term goal for a paranoid male client who has unjustifiably accused his
wife of having many extramarital affairs would be to help the client develop:

A. Insight into his behavior

B. Better self control
C. Feeling of self worth
D. Faith in his wife
43. A male client who is experiencing disordered thinking about food being
poisoned is admitted to the mental health unit. The nurse uses which
communication technique to encourage the client to eat dinner?

A. Focusing on self-disclosure of own food preference

B. Using open ended question and silence
C. Offering opinion about the need to eat
D. Verbalizing reasons that the client may not choose to eat
44. Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor.
When Nurse Nina enters the client’s room, the client is found lying on the bed with
a body pulled into a fetal position. Nurse Nina should?

A. Ask the client direct questions to encourage talking

B. Rake the client into the dayroom to be with other clients
C. Sit beside the client in silence and occasionally ask open-ended question
D. Leave the client alone and continue with providing care to the other clients
45. Nurse Tina is caring for a client with delirium and states that “look at the
spiders on the wall”. What should the nurse respond to the client?
A. “You’re having hallucination, there are no spiders in this room at all”
B. “I can see the spiders on the wall, but they are not going to hurt you”
C. “Would you like me to kill the spiders”
D. “I know you are frightened, but I do not see spiders on the wall”
46. Nurse Jonel is providing information to a community group about violence in
the family. Which statement by a group member would indicate a need to provide
additional information?

A. “Abuse occurs more in low-income families”

B. “Abuser Are often jealous or self-centered”
C. “Abuser use fear and intimidation”
D. “Abuser usually have poor self-esteem”
47. During electroconvulsive therapy (ECT) the client receives oxygen by mask via
positive pressure ventilation. The nurse assisting with this procedure knows that
positive pressure ventilation is necessary because?

A. Anesthesia is administered during the procedure

B. Decrease oxygen to the brain increases confusion and disorientation
C. Grand mal seizure activity depresses respirations
D. Muscle relaxations given to prevent injury during seizure activity depress
respirations.
48. When planning the discharge of a client with chronic anxiety, Nurse Chris
evaluates achievement of the discharge maintenance goals. Which goal would be
most appropriately having been included in the plan of care requiring evaluation?

A. The client eliminates all anxiety from daily situations

B. The client ignores feelings of anxiety
C. The client identifies anxiety producing situations
D. The client maintains contact with a crisis counselor
49. Nurse Tina is caring for a client with depression who has not responded to
antidepressant medication. The nurse anticipates that what treatment procedure
may be prescribed?

A. Neuroleptic medication
B. Short term seclusion
C. Psychosurgery
D. Electroconvulsive therapy
50. Mario is admitted to the emergency room with drug-included anxiety related
to over ingestion of prescribed antipsychotic medication. The most important piece
of information the nurse in charge should obtain initially is the:

A. Length of time on the med.

B. Name of the ingested medication & the amount ingested
C. Reason for the suicide attempt
D. Name of the nearest relative & their phone number