1. The nurse is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as: 

 a. delusions.  b. hallucinations.  c. loose associations.  d. neologisms.  

2. The nurse is caring for a client who is suicidal. When accompanying the client to the bathroom, the nurse should: 

a. give him privacy in the bathroom. b. allow him to shave. c. open the window and allow him to get some fresh air. d. observe him. 

 3. The nurse is developing a care plan 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. 

4. A client whose husband recently left her is admitted to the hospital with severe depression. The nurse suspects that the client is at risk for suicide. Which of the following questions would be most appropriate and helpful for the nurse to ask during an assessment for suicide risk? 

a. "Are you sure you want to kill yourself?" b. "I know if my husband left me, I'd want to kill myself. Is that what you think?" c. "How do you think you would kill yourself?" d. "Why don't you just look at the positives in your life?" 

 5. The nurse is caring for a client who she believes has been abusing opiates. Assessment findings in a client abusing opiates, such as morphine, include: 

a. dilated pupils and slurred speech. b. rapid speech and agitation. 

c. dilated pupils and agitation. d. euphoria and constricted pupils.  

6. The nurse is caring for a client experiencing an anxiety attack. Appropriate nursing interventions include: 

a. turning on the lights and opening the windows so that the client doesn't feel crowded. b. leaving the client alone. c. staying with the client and speaking in short sentences. d. turning on stereo music.  

7.  The nurse is teaching a new group of mental health aides. The nurse should teach the aides that setting limits is most important for: 

a. a depressed client. b. a manic client. c. a suicidal client. d. an anxious client. 

 8. A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects a belief that one is: 

a. highly important or famous. b. being persecuted. c. connected to events unrelated to oneself. d. responsible for the evil in the world.  

9. The nurse is caring for a client, a Vietnam veteran, who exhibits signs and symptoms of posttraumatic stress disorder. Signs and symptoms of posttraumatic stress disorder include: 

a. hyper alertness and sleep disturbances. b. memory loss of traumatic event and somatic distress. c. feelings of hostility and violent behavior. d. sudden behavioral changes and anorexia.   

10. The nurse is caring for a client with manic depression. The care plan for a client in a manic state would include: 

a. offering high-calorie meals and strongly encouraging the client to finish all food. b. insisting that the client remain active throughout the day so that he'll sleep at night. c. allowing the client to exhibit hyperactive, demanding, manipulative behavior without setting limits. d. listening attentively with a neutral attitude and avoiding power struggles.  

11.  A client is a Vietnam War veteran with a diagnosis of posttraumatic stress disorder. He has a history of nightmares, depression, hopelessness, and alcohol abuse. Which option offers the client the most lasting relief of his symptoms? 

a. The opportunity to verbalize memories of trauma to a sympathetic listener b. Family support c. Prescribed medications taken as ordered d. Alcoholics Anonymous (AA) meetings 

12. A client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but that he can control his use if he chooses. Which coping mechanism is he using? 

a. Withdrawal b. Logical thinking c. Repression d. Denial  

13. A 22-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely evidence of ineffective individual coping? 

a. Inability to make choices and decisions without advice b. Showing interest only in solitary activities c. Avoiding developing relationships d. Recurrent self-destructive behavior with history of depression  

14. A 38-year-old client is admitted for alcohol withdrawal. The most common early sign or symptom that this client is likely to experience is: 

a. impending coma. b. manipulating behavior. c. suppression. d. perceptual disorders. 

15. A client is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations? 

a. Aggressive behavior b. Paranoid thoughts c. Emotional affect d. Independence needs  

16. The nurse is caring for a client in an acute manic state. What's the most effective nursing action for this client? 

a. Assigning him to group activities b. Reducing his stimulation c. Assisting him with self-care d. Helping him express his feelings  

17. The nurse 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.  

18. The nurse is caring for a 40-year-old client. Which behavior by the client indicates adult cognitive development? 

a. Has perceptions based on reality b. Assumes responsibility for actions c. Generates new levels of awareness d. Has maximum ability to solve problems and learn new skills  

19. A client with bipolar disorder is being treated with lithium for the first time. The nurse should observe the client for which common adverse effect

of lithium? 

a. Sexual dysfunction b. Constipation c. Polyuria d. Seizures  

20. A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see: 

a. tension and irritability. b. slow pulse. c. hypotension. d. constipation.  

21. During a shift report, the nurse learns that she'll be providing care for a client who is vulnerable to panic attack. Treatment for panic attacks includes behavioral therapy, supportive psychotherapy, and medication such as: 

a. barbiturates. b. antianxiety drugs. c. depressants. d. amphetamines.   

22. A client comes to the emergency department while experiencing a panic attack. The nurse can best respond to a client having a panic attack by: 

a. staying with the client until the attack subsides. b. telling the client everything is under control. c. telling the client to lie down and rest. d. talking continually to the client by explaining what's happening.  

23. A 24-year-old client is experiencing an acute schizophrenic episode. He has vivid hallucinations that are making him agitated. The nurse's best response at this time would be to: 

a. take the client's vital signs. b. explore the content of the hallucinations. c. tell him his fear is unrealistic. d. engage the client in reality-oriented activities. 

  

24. A client with paranoid type schizophrenia becomes angry and tells the nurse to leave him alone. The nurse should: 

a. tell him that she'll leave for now but will return soon. b. ask him if it's okay if she sits quietly with him. c. ask him why he wants to be left alone. d. tell him that she won't let anything happen to him. 

25. Tonic contractures of muscles in the neck, mouth, and tongue. The nurse should recognize this as: 

a. psychotic symptoms b. parkinsonism c. akathisia d. dystonia 

26. The nurse must administer a medication to reverse or prevent Parkinson-type symptoms in a client receiving an antipsychotic. The medication the client will likely receive is: 

a. benztropine (Cogentin). b. diphenhydramine (Benadryl). c. propranolol (Inderal). d. haloperidol (Haldol).   

27. Which information is most important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)? 

a. Monthly blood tests will be necessary. b. Report a sore throat or fever to the physician immediately. c. Blood pressure must be monitored for hypertension. d. Stop the medication when symptoms subside.  

28. A client with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication? 

a. Calcium b. Sodium 

c. Chloride d. Potassium  

29. A client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He's shouting that the government of France is trying to assassinate him. Which of the following responses is most appropriate? 

a. "I think you're wrong. France is a friendly country and an ally of the United States. Their government wouldn't try to kill you." b. "I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this." c. "You're wrong. Nobody is trying to kill you." d. "A foreign government is trying to kill you? Please tell me more about it."  

30. A client has been receiving chlorpromazine (Thorazine), an antipsychotic, to treat his psychosis. Which finding should alert the nurse that the client is experiencing pseudoparkinsonism? 

a. Restlessness, difficulty sitting still, pacing b. Involuntary rolling of the eyes c. Tremors, shuffling gait, mask like face d. Extremity and neck spasms, facial grimacing, jerky movements 

31. A 54-year-old female was found unconscious on the floor of her bathroom with self-inflicted wrist lacerations. An ambulance was called and the client was taken to the emergency department. When she was stable, the client was transferred to the inpatient psychiatric unit for observation and treatment with antidepressants. Now that the client is feeling better, which nursing intervention is most appropriate? 

a. Observing for extrapyramidal symptoms b. Beginning a therapeutic relationship c. Canceling any no-suicide contracts d. Continuing suicide precautions  

32. A 26-year-old male reports losing his sight in both eyes. He's diagnosed as having a conversion disorder and is admitted to the psychiatric unit. Which nursing intervention would be most appropriate for this client? 

a. Not focusing on his blindness b. Providing self-care for him c. Telling him that his blindness isn't real d. Teaching eye exercises to strengthen his eyes  

33. A client has a diagnosis of borderline personality disorder. She has attached herself to one nurse and refuses to speak with other staff members. She tells the nurse that the other nurses are mean, withhold her medication, and mistreat her. The staff is discussing this problem at their weekly conference. Which intervention would be most appropriate for the nursing staff to implement? 

a. Provide an unstructured environment for the client. b. Rotate the nurses who are assigned to the client. c. Ignore the client's behaviors. d. Bend unit rules to meet the client's needs.  

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

a. not occur at all because the time period for their occurrence has passed. b. begin anytime within the next 1 to 2 days. c. begin within 2 to 7 days. d. begin after 7 days.  

35. Which of the following factors would have the most influence on the outcome of a crisis situation? 

a. Age b. Previous coping skills c. Self-esteem d. Perception of the problem

36. The nurse is caring for an elderly client in a long-term care facility. The client has a history of attempted suicide. The nurse observes the client giving away personal belongings and has heard the client express feelings of hopelessness to other residents. Which intervention should the nurse

perform first? 

a. Setting aside time to listen to the client b. Removing items that the client could use in a suicide attempt c. Communicating a nonjudgmental attitude d. Referring the client to a mental health professional  

37. The nurse is caring for an adolescent female who reports amenorrhea, weight loss, and depression. Which additional assessment finding would suggest that the woman has an eating disorder? 

a. Wearing tight-fitting clothing b. Increased blood pressure c. Oily skin d. Excessive and ritualized exercise  

38. 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 choices.  

39. The nurse is using drawing, puppetry, and other forms of play therapy while treating a terminally ill, school-age child. The purpose of these techniques is to help the child: 

a. internalize his feelings about death and dying. b. accept responsibility for his situation. c. express feelings that he can't articulate. d. have a good time while he's in the hospital.  

40. The nurse is working with a client who abuses alcohol. Which of the following facts should the nurse communicate to the client? 

a. Abstinence is the basis for successful treatment. b. Attendance at Alcoholics Anonymous (AA) meetings every day will cure alcoholism. 

c. For treatment to be successful, family members must participate. d. An occasional social drink is acceptable behavior for the alcoholic.  

41. One staff member in a psychiatric unit says to the nurse, "Why are we carrying out suicide precautions for someone who is dying? It's pointless and a waste of time." The nurse should: 

a. Assign the staff member to other clients. b. Ask the psychiatric clinical nurse specialist to meet with the staff member. c. Agree with the staff member and discontinue suicide precautions.d. Call for a multidisciplinary staff meeting.  

42. The client with dual diagnoses of major depression and alcohol abuse states, "I only drink when I can't sleep." An initial outcome for this client is that the client will: 

a. Describe adaptive methods of coping to induce sleep. b. Verbalize negative effects of alcohol on the body. c. Describe dangerous effects when combining alcohol and antidepressant medication. d. Verbalize the desire to stop drinking alcohol.    43. The nurse will conduct a psycho educational group for family members about depression. Which of the following topics would be of little help to the family members? 

a. Managing the depressed client at home. b. Drug classifications. c. Support and self-help groups. d. Education about depression.  

44. In teaching a client about Alcoholics Anonymous, the nurse states that Alcoholics Anonymous has helped in the rehabilitation of many alcoholics, probably because many people find it easier to change their behavior when they: 

a. Have the support of rehabilitated alcoholics. b. Know that rehabilitated alcoholics will sympathize with them. c. Can depend on rehabilitated alcoholics to help them identify personal problems related to alcoholism. 

d. Realize that rehabilitated alcoholics will help them develop defense mechanisms to cope with their alcoholism.  

45. A client walks into the mental health clinic and states to the nurse, "I guess I can't make it without my wife. I can't even sleep without her." Which of the following responses by the nurse would be most therapeutic? 

a. "Things always look worse before they get better." b. "I'd say that you're not giving yourself a fair chance." c. "I'll ask the doctor for some sleeping pills for you." d. "Tell me more about what you mean when you say you can't make it without your wife." 

 46. During the conversation with the nurse, a victim of physical abuse says, "Let me try to explain why I stay with my husband." Which of the following reasons would the client be LEAST likely to mention? 

a. "I'm responsible for keeping my family together." b. "When it's not too bad, the abuse adds spice to our relationship." c. "I love my husband."d. "I'm not sure I could get a job that pays even minimum wage."  

47. During a home visit, the client tells the nurse she's not taking prescribed doses of haloperidol (Haldol) because she's tired of bothering with it and doesn't need it. The nurse's best action is to: 

a. Explain the negative effects of skipping the medication. b. Consult with the physician about changing the medication to haloperidol decanoate (Haldol Decanoate) injections. c. Have the client's family begin commitment procedures so that her medication regimen can be supervised more closely. d. Refer the client to a partial hospitalization program so that she can participate regularly in group therapy sessions. 

 48. The client has been taking the monoamine oxidase inhibitor (MAOI) phenelzine (Nardil), 10 mg bid. The physician orders a selective serotonin reuptake inhibitor (SSRI), paroxetine (Paxil), 20 mg given every morning. The nurse: 

a. Gives the medication as ordered. b. Questions the physician about the order. 

c. Questions the dosage ordered. d. Asks the physician to order benztropine (Cogentin) for the side effects.  

49. A voluntary client has been taking haloperidol (Haldol) as prescribed. One morning, she refuses to take the Haldol. Which of the following actions should the nurse take? 

a. Summon another nurse to help ensure that the client takes her medicine. b. Tell the client that she can take the medication either orally or by injection. c. Withhold the medication until it is determined why the client is refusing to take it. d. Tell the client that she needs to take her "vitamin" to stay healthy.  

50. The client is taking fluoxetine (Prozac) 20 mg at bedtime. He states that Prozac is not helping him to sleep. The nurse judges: 

a. That the client should take Prozac in the morning. b. That dose is too high. c. That the client's symptoms of depression seem to be getting worse. d. That the client is on the wrong medication. 

1. b. hallucinations. 

2. d. observe him. 

3. c. Set up a strict eating plan for the client. 

4. c. "How do you think you would kill yourself?" 

5. a. dilated pupils and slurred speech. 

6. c. staying with the client and speaking in short sentences. 

7. b. a manic client. 

8. a. highly important or famous. 

9. a. hyper alertness and sleep disturbances.

10. d. listening attentively with a neutral attitude and avoiding power struggles. 

11. a. The opportunity to verbalize memories of trauma to a sympathetic listener 

12. d. Denial 

13. a. Inability to make choices and decisions without advice 

14. d. perceptual disorders. 

15. b. Paranoid thoughts 

16. b. Reducing his stimulation 

17. c. identify anxiety-causing situations. 

18. c. Generates new levels of awareness 

19. c. Polyuria 

20.a. tension and irritability.

21. b. antianxiety drugs. 

22. a. staying with the client until the attack subsides.

23. b. explore the content of the hallucinations. 

24. a. tell him that she'll leave for now but will return soon. 

25. d. dystonia 

26. a. benztropine (Cogentin). 

27. b. Report a sore throat or fever to the physician immediately. 

28. b. Sodium 

29. d. "A foreign government is trying to kill you? Please tell me more about it." 

30. b. Involuntary rolling of the eyes 

31. d. Continuing suicide precautions 

32. a. Not focusing on his blindness 

33. b. Rotate the nurses who are assigned to the client. 

34. b. begin anytime within the next 1 to 2 days. 

35. b. Previous coping skills 

36. b. Removing items that the client could use in a suicide attempt 

37. d. Excessive and ritualized exercise 

38. b. The student accepts a referral to a substance abuse counselor. 

39. c. express feelings that he can't articulate. 

40. a. Abstinence is the basis for successful treatment. 

41. d. Call for a multidisciplinary staff meeting. 

42. d. Verbalize the desire to stop drinking alcohol. 

43. a. Managing the depressed client at home. 

44. a. Have the support of rehabilitated alcoholics. 

45. d. "Tell me more about what you mean when you say you can't make it without your wife." 

46. a. "I'm responsible for keeping my family together." 

47. b. Consult with the physician about changing the medication to haloperidol decanoate (Haldol Decanoate) injections. 

48. b. Questions the physician about the order. 

49. c. Withhold the medication until it is determined why the client is refusing to take it.

50. a. That the client should take Prozac in the morning. 

1. 1. A psychotic client reports to the evening nurse that the day nurse put something suspicious in his water with his medication. The nurse replies, "You're worried about your medication?" The nurse's communication is:

A. an example of presenting reality.B. reinforcing the client's delusions.C. focusing on emotional content.D. a nontherapeutic technique called mind reading.

Rationale: The nurse should help the client focus on the emotional content rather than delusional material. Presenting reality isn't helpful because it can lead to confrontation and disengagement. Agreeing with the client and

supporting his beliefs are reinforcing delusions. Mind reading isn't therapeutic.

2. A client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He's shouting that the government of France is trying to assassinate him. Which of the following responses is most appropriate?

A. "I think you're wrong. France is a friendly country and an ally of the United States. Their government wouldn't try to kill you."B. "I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this."C. "You're wrong. Nobody is trying to kill you."D. "A foreign government is trying to kill you? Please tell me more about it."

Rationale: Responses should focus on reality while acknowledging the client's feelings. Arguing with the client or denying his belief isn't therapeutic. Arguing can also inhibit development of a trusting relationship. Continuing to talk about delusions may aggravate the psychosis. Asking the client if a foreign government is trying to kill him may increase his anxiety level and can reinforce his delusions.

3. Propranolol (Inderal) is used in the mental health setting to manage which of the following conditions?

A. Antipsychotic-induced akathisia and anxietyB. The manic phase of bipolar illness as a mood stabilizerC. Delusions for clients suffering from schizophreniaD. Obsessive-compulsive disorder (OCD) to reduce ritualistic behavior

Rationale: Propranolol is a potent beta-adrenergic blocker and produces a sedating effect; therefore, it's used to treat antipsychotic induced akathisia and anxiety. Lithium (Lithobid) is used to stabilize clients with bipolar illness. Antipsychotics are used to treat delusions. Some antidepressants have been effective in treating OCD.

4. A client with borderline personality disorder becomes angry when he is told that today's psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse would be most helpful in dealing with the client's anger?

A. "If it had been your emergency, I would have made the other client wait."B. "I know it's frustrating to wait. I'm sorry this happened."C. "You had to wait. Can we talk about how this is making you feel right now?"D. "I really care about you and I'll never let this happen again."

Rationale: This response may diffuse the client's anger by helping to maintain a therapeutic relationship and addressing the client's feelings. Option A

wouldn't address the client's anger. Option B is incorrect because the client with a borderline personality disorder blames others for things that happen, so apologizing reinforces the client's misconceptions. The nurse can't promise that a delay will never occur again, as in option D, because such matters are outside the nurse's control.

5. How soon after chlorpromazine (Thorazine) administration should the nurse expect to see a client's delusional thoughts and hallucinations eliminated

A. Several minutesB. Several hoursC. Several daysD. Several weeks

Rationale: Although most phenothiazines produce some effects within minutes to hours, their antipsychotic effects may take several weeks to appear.

6. A client receiving haloperidol (Haldol) complains of a stiff jaw and difficulty swallowing. The nurse's first action is to:

A. reassure the client and administer as needed lorazepam (Ativan) I.M.B. administer as needed dose of benztropine (Cogentin) I.M. as ordered.C. administer as needed dose of benztropine (Cogentin) by mouth as ordered.D. administer as needed dose of haloperidol (Haldol) by mouth.

Rationale: The client is most likely suffering from muscle rigidity due to haloperidol. I.M. benztropine should be administered to prevent asphyxia or aspiration. Lorazepam treats anxiety, not extrapyramidal effects. Another dose of haloperidol would increase the severity of the reaction.

7. A client with a diagnosis of paranoid schizophrenia comments to the nurse, "How do I know what is really in those pills?" Which of the following is the best response?

A. Say, "You know it's your medicine."B. Allow him to open the individual wrappers of the medication.C. Say, "Don't worry about what is in the pills. It's what is ordered."D. Ignore the comment because it's probably a joke.

Rationale: Option B is correct because allowing a paranoid client to open his medication can help reduce suspiciousness. Option A is incorrect because the client doesn't know that it's his medication and he's obviously suspicious. Telling the client not to worry or ignoring the comment isn't supportive and doesn't offer reassurance.

8. The nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who

isn't visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is the most appropriate?

A. Approach the client and touch him to get his attention.B. Encourage the client to go to his room where he'll experience fewer distractions.C. Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices.D. Ask the client to describe what the voices are saying.

Rationale: By acknowledging that the client hears voices, the nurse conveys acceptance of the client. By letting the client know that the nurse doesn't hear the voices, the nurse avoids reinforcing the hallucination. The nurse shouldn't touch the client with schizophrenia without advance warning. The hallucinating client may believe that the touch is a threat or act of aggression and respond violently. Being alone in his room encourages the client to withdraw and may promote more hallucinations. The nurse should provide an activity to distract the client. By asking the client what the voices are saying, the nurse is reinforcing the hallucination. The nurse should focus on the client's feelings, rather than the content of the hallucination.

9. Yesterday, a client with schizophrenia began treatment with haloperidol (Haldol). Today, the nurse notices that the client is holding his head to one side and complaining of neck and jaw spasms. What should the nurse do?

A. Assume that the client is posturing.B. Tell the client to lie down and relax.C. Evaluate the client for adverse reactions to haloperidol.D. Put the client on the list for the physician to see tomorrow

Rationale: An antipsychotic agent, such as haloperidol, can cause muscle spasms in the neck, face, tongue, back, and sometimes legs as well as torticollis (twisted neck position). The nurse should be aware of these adverse reactions and assess for related reactions promptly. Although posturing may occur in clients with schizophrenia, it isn't the same as neck and jaw spasms. Having the client relax can reduce tension-induced muscle stiffness but not drug-induced muscle spasms. When a client develops a new sign or symptom, the nurse should consider an adverse drug reaction as the possible cause and obtain treatment immediately, rather than have the client wait.

10. A client with paranoid schizophrenia has been experiencing auditory hallucinations for many years. One approach that has proven to be effective for hallucinating clients is to: 

A. take an as-needed dose of psychotropic medication whenever they hear voices.B. practice saying "Go away" or "Stop" when they hear voices.C. sing loudly to drown out the voices and provide a distraction.D. go to their room until the voices go away.

Rationale: Researchers have found that some clients can learn to control bothersome hallucinations by telling the voices to go away or stop. Taking an as needed dose of psychotropic medication whenever the voices arise may lead to overmedication and put the client at risk for adverse effects. Because the voices aren't likely to go away permanently, the client must learn to deal with the hallucinations without relying on drugs. Although distraction is helpful, singing loudly may upset other clients and would be socially unacceptable after the client is discharged. Hallucinations are most bothersome in a quiet environment when the client is alone, so sending the client to his room would increase, rather than decrease, the hallucinations.

11. A client with catatonic schizophrenia is mute, can't perform activities of daily living, and stares out the window for hours. What is the nurse's first priority?

A. Assist the client with feeding.B. Assist the client with showering.C. Reassure the client about safety.D. Encourage socialization with peers.

Rationale: According to Maslow's hierarchy of needs, the need for food is among the most important. Other needs, in order of decreasing importance, include hygiene, safety, and a sense of belonging.

12. A client tells the nurse that the television newscaster is sending a secret message to her. The nurse suspects the client is experiencing:

A. a delusion.B. flight of ideas.C. ideas of reference.D. a hallucination.

Rationale: Ideas of reference refers to the mistaken belief that neutral stimuli have special meaning to the individual such as the television newscaster sending a message directly to the individual. A delusion is a false belief. Flight of ideas is a speech pattern in which the client skips from one unrelated subject to another. A hallucination is a sensory perception, such as hearing voices and seeing objects, that only the client experiences.

13. The nurse knows that the physician has ordered the liquid form of the drug chlorpromazine (Thorazine) rather than the tablet form because the liquid:

A. has a more predictable onset of action.B. produces fewer anticholinergic effects.C. produces fewer drug interactions.D. has a longer duration of action.

Rationale: A liquid phenothiazine preparation will produce effects in 2 to 4 hours. The onset with tablets is unpredictable.

14. A client who has been hospitalized with disorganized type schizophrenia for 8 years can't complete activities of daily living (ADLs) without staff direction and assistance. The nurse formulates a nursing diagnosis of Self-care deficient: Dressing/grooming related to inability to function without assistance. What is an appropriate goal for this client?

A. "Client will be able to complete ADLs independently within 1 month."B. "Client will be able to complete ADLs with only verbal encouragement within 1 month."C. "Client will be able to complete ADLs with assistance in organizing grooming items and clothing within 1 month."D. "Client will be able to complete ADLs with complete assistance within 1 month."

Rationale: The client's disorganized personality and history of hospitalization have affected the ability to perform self-care activities. Interventions should be directed at helping the client complete ADLs with the assistance of staff members, who can provide needed structure by helping the client select grooming items and clothing. This goal promotes realistic independence. As the client improves and achieves the established goal, the nurse can set new goals that focus on the client completing ADLs with only verbal encouragement and, ultimately, completing them independently. The client's condition doesn't indicate a need for complete assistance, which would only foster dependence.

15. The nurse is planning care for a client admitted to the psychiatric unit with a diagnosis of paranoid schizophrenia. Which nursing diagnosis should receive the highest priority?

A. Risk for violence toward self or othersB. Imbalanced nutrition: Less than body requirementsC. Ineffective family copingD. Impaired verbal communication

Rationale: Because of such factors as suspiciousness, anxiety, and hallucinations, the client with paranoid schizophrenia is at risk for violence toward himself or others. The other options are also appropriate nursing diagnoses but should be addressed after the safety of the client and those around him is established.

16. The nurse is preparing for the discharge of a client who has been hospitalized for paranoid schizophrenia. The client's husband expresses concern over whether his wife will continue to take her daily prescribed medication. The nurse should inform him that:

A. his concern is valid but his wife is an adult and has the right to make her own decisions.B. he can easily mix the medication in his wife's food if she stops taking it.C. his wife can be given a long-acting medication that is

administered every 1 to 4 weeks.D. his wife knows she must take her medication as prescribed to avoid future hospitalizations.

Rationale: Long-acting psychotropic drugs can be administered by depot injection every 1 to 4 weeks. These agents are useful for noncompliant clients because the client receives the injection at the outpatient clinic. A client has the right to refuse medication, but this issue isn't the focus of discussion at this time. Medication should never be hidden in food or drink to trick the client into taking it; besides destroying the client's trust, doing so would place the client at risk for overmedication or undermedication because the amount administered is hard to determine. Assuming the client knows she must take the medication to avoid future hospitalizations would be unrealistic.

17. Benztropine (Cogentin) is used to treat the extrapyramidal effects induced by antipsychotics. This drug exerts its effect by:

A. decreasing the anxiety causing muscle rigidity.B. blocking the cholinergic activity in the central nervous system (CNS).C. increasing the level of acetylcholine in the CNS.D. increasing norepinephrine in the CNS.

Rationale: Option B is the action of Cogentin. Anxiety doesn't cause extrapyramidal effects. Overactivity of acetylcholine and lower levels of dopamine are the causes of extrapyramidal effects. Benztropine doesn't increase norepinephrine in the CNS.

18. A client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He's shouting that the government of France is trying to assassinate him. Which of the following responses is most appropriate?

A. "I think you're wrong. France is a friendly country and an ally of the United States. Their government wouldn't try to kill you."B. "I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this."C. "You're wrong. Nobody is trying to kill you."D. "A foreign government is trying to kill you? Please tell me more about it."

Rationale: Responses should focus on reality while acknowledging the client's feelings. Arguing with the client or denying his belief isn't therapeutic. Arguing can also inhibit development of a trusting relationship. Continuing to talk about delusions may aggravate the psychosis. Asking the client if a foreign government is trying to kill him may increase his anxiety level and can reinforce his delusions.

19. A dopamine receptor agonist such as bromocriptine (Parlodel) relieves muscle rigidity caused by antipsychotic medication by:

A. blocking dopamine receptors in the central nervous system (CNS).B. blocking acetylcholine in the CNS.C. activating norepinephrine in the CNS.D. activating dopamine receptors in the CNS.

Rationale: Extrapyramidal effects and the muscle rigidity induced by antipsychotic medications are caused by a low level of dopamine. Dopamine receptor agonists stimulate dopamine receptors and thereby reduce rigidity. They don't affect norepinephrine or acetylcholine.

20. Most antipsychotic medications exert which of following effects on the central nervous system (CNS)?

A. Stimulate the CNS by blocking postsynaptic dopamine, norepinephrine, and serotonin receptors.B. Sedate the CNS by stimulating serotonin at the synaptic cleft.C. Depress the CNS by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine.D. Depress the CNS by stimulating the release of acetylcholine.

Rationale: The exact mechanism of antipsychotic medication action is unknown, but appear to depress the CNS by blocking the transmission of three neurotransmitters: dopamine, serotonin, and norepinephrine. They don't sedate the CNS by stimulating serotonin, and they don't stimulate neurotransmitter action or acetylcholine release.

21. A client is admitted to the psychiatric unit of a local hospital with chronic undifferentiated schizophrenia. During the next several days, the client is seen laughing, yelling, and talking to herself. This behavior is characteristic of:

A. delusion.B. looseness of association.C. illusion.D. hallucination.

Rationale: Auditory hallucination, in which one hears voices when no external stimuli exist, is common in schizophrenic clients. Such behaviors as laughing, yelling, and talking to oneself suggest such a hallucination. Delusions, also common in schizophrenia, are false beliefs or ideas that arise without external stimuli. Clients with schizophrenia may exhibit looseness of association, a pattern of thinking and communicating in which ideas aren't clearly linked to one another. Illusion is a less severe perceptual disturbance in which the client misinterprets actual external stimuli. Illusions are rarely associated with schizophrenia.

22. Which of the following medications would the nurse expect the physician to order to reverse a dystonic reaction?

A. prochlorperazine (Compazine)

B. diphenhydramine (Benadryl)C. haloperidol (Haldol)D. midazolam (Versed)

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

23. A schizophrenic client states, "I hear the voice of King Tut." Which response by the nurse would be most therapeutic?

A. "I don't hear the voice, but I know you hear what sounds like a voice." B. "You shouldn't focus on that voice."C. "Don't worry about the voice as long as it doesn't belong to anyone real."D. "King Tut has been dead for years."

Rationale: This response states reality about the client's hallucination. The other options are judgmental, flippant, or dismissive.

24. A psychotic client reports to the evening nurse that the day nurse put something suspicious in his water with his medication. The nurse replies, "You're worried about your medication?" The nurse's communication is:

A. an example of presenting reality.B. reinforcing the client's delusions.C. focusing on emotional content.D. a nontherapeutic technique called mind reading.

Rationale: The nurse should help the client focus on the emotional content rather than delusional material. Presenting reality isn't helpful because it can lead to confrontation and disengagement. Agreeing with the client and supporting his beliefs are reinforcing delusions. Mind reading isn't therapeutic.

25. The nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is the most appropriate?

A. Approach the client and touch him to get his attention.B. Encourage the client to go to his room where he'll experience fewer distractions.C. Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices.D. Ask the client to describe what the voices are saying

Rationale: By acknowledging that the client hears voices, the nurse conveys acceptance of the client. By letting the client know that the nurse doesn't hear the voices, the nurse avoids reinforcing the hallucination. The nurse

shouldn't touch the client with schizophrenia without advance warning. The hallucinating client may believe that the touch is a threat or act of aggression and respond violently. Being alone in his room encourages the client to withdraw and may promote more hallucinations. The nurse should provide an activity to distract the client. By asking the client what the voices are saying, the nurse is reinforcing the hallucination. The nurse should focus on the client's feelings, rather than the content of the hallucination.

26. A client has been receiving chlorpromazine (Thorazine), an antipsychotic, to treat his psychosis. Which findings should alert the nurse that the client is experiencing pseudoparkinsonism?

A. Restlessness, difficulty sitting still, and pacingB. Involuntary rolling of the eyesC. Tremors, shuffling gait, and masklike faceD. Extremity and neck spasms, facial grimacing, and jerky movements

Rationale: Pseudoparkinsonism may appear 1 to 5 days after starting an antipsychotic and may also include drooling, rigidity, and "pill rolling." Akathisia may occur several weeks after starting antipsychotic therapy and consists of restlessness, difficulty sitting still, and fidgeting. An oculogyric crisis is recognized by uncontrollable rolling back of the eyes and, along with dystonia, should be considered an emergency. Dystonia may occur minutes to hours after receiving an antipsychotic and may include extremity and neck spasms, jerky muscle movements, and facial grimacing.

27. For several years, a client with chronic schizophrenia has received 10 mg of fluphenazine hydrochloride (Prolixin) by mouth four times per day. Now the client has a temperature of 102° F (38.9° C), a heart rate of 120 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 210/140 mm Hg. Because the client also is confused and incontinent, the nurse suspects malignant neuroleptic syndrome. What steps should the nurse take?

A. Give the next dose of fluphenazine, call the physician, and monitor vital signs.B. Withhold the next dose of fluphenazine, call the physician, and monitor vital signs.C. Give the next dose of fluphenazine and restrict the client to the room to decrease stimulation.D. Withhold the next dose of fluphenazine, administer an antipyretic agent, and increase the client's fluid intake.

Rationale: Malignant neuroleptic syndrome is a dangerous adverse effect of neuroleptic drugs such as fluphenazine. The nurse should withhold the next dose, notify the physician, and continue to monitor vital signs. Although an antipyretic agent may be used to reduce fever, increased fluid intake is contraindicated because it may increase the client's fluid volume further, raising blood pressure even higher.

28. A schizophrenic client with delusions tells the nurse, "There is a man wearing a red coat who's out to get me." The client exhibits increasing anxiety when focusing on the delusions. Which of the following would be the best response?

A. "This subject seems to be troubling you. Let's walk to the activity room."B. "Describe the man who's out to get you. What does he look like?"C. "There is no reason to be afraid of that man. This hospital is very secure."D. "There is no need to be concerned with a man who isn't even real."

Rationale: This remark distracts the client from the delusion by engaging the client in a less threatening or more comforting activity at the first sign of anxiety. The nurse should reinforce reality and discourage the false belief. The other options focus on the content of the delusion rather than the meaning, feeling, or intent that it provokes.

29. Important teaching for women in their childbearing years who are receiving antipsychotic medications includes which of the following?

A. Occurrence of increased libido due to medication adverse effectsB. Increased incidence of dysmenorrhea while taking the drugC. Continuing previous use of contraception during periods of amenorrheaD. Instruction that amenorrhea is irreversible

Rationale: Women may experience amenorrhea, which is reversible, while taking antipsychotics. Amenorrhea doesn't indicate cessation of ovulation; therefore, the client can still become pregnant. The client should be instructed to continue contraceptive use even when experiencing amenorrhea. Dysmenorrhea isn't an adverse effect of antipsychotics, and libido generally decreases because of the depressant effect.

30. A client is admitted to a psychiatric facility with a diagnosis of chronic schizophrenia. The history indicates that the client has been taking neuroleptic medication for many years. Assessment reveals unusual movements of the tongue, neck, and arms. Which condition should the nurse suspect?

A. Tardive dyskinesiaB. DystoniaC. Neuroleptic malignant syndromeD. Akathisia

Rationale: Unusual movements of the tongue, neck, and arms suggest tardive dyskinesia, an adverse reaction to neuroleptic medication. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Neuroleptic malignant syndrome causes rigidity, fever, hypertension, and diaphoresis. Akathisia causes restlessness, anxiety, and jitteriness.

31. What medication would probably be ordered for the acutely aggressive schizophrenic client?

A. chlorpromazine (Thorazine)B. haloperidol (Haldol)C. lithium carbonate (Lithonate)D. amitriptyline (Elavil)

Rationale: Haloperidol administered I.M. or I.V. is the drug of choice for acute aggressive psychotic behavior. Chlorpromazine is also an antipsychotic drug; however, it causes more pronounced sedation than haloperidol. Lithium carbonate is useful in bipolar or manic disorder, and amitriptyline is used for depression.

32. A client is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations?

A. Aggressive behaviorB. Paranoid thoughtsC. Emotional affectD. Independence needs

Rationale: Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts. Aggressive behavior is uncommon, although these clients may experience agitation with anxiety. Their behavior is emotionally cold with a flattened affect, regardless of the situation. These clients demonstrate a reduced capacity for close or dependent relationships.

33. During the initial interview, a client with schizophrenia suddenly turns to the empty chair beside him and whispers, "Now just leave. I told you to stay home. There isn't enough work here for both of us!" What is the nurse's best initial response?

A. "When people are under stress, they may see things or hear things that others don't. Is that what just happened?"B. "I'm having a difficult time hearing you. Please look at me when you talk."C. "There is no one else in the room. What are you doing?"D. "Who are you talking to? Are you hallucinating?"

Rationale: This response makes the client feel that experiencing hallucinations is acceptable and promotes an open, therapeutic relationship. Directing the client to look at the nurse wouldn't address the obvious issue of the hallucination. Confrontational approaches, such as in options C and D, are likely to elicit an uninformative or negative response.

34. The definition of nihilistic delusions is:

A. a false belief about the functioning of the body.

B. belief that the body is deformed or defective in a specific way.C. false ideas about the self, others, or the worldD. the inability to carry out motor activities.

Rationale: Nihilistic delusions are false ideas about the self, others, or the world. Somatic delusions involve a false belief about the functioning of the body. Body dysmorphic disorder is characterized by a belief that the body is deformed or defective in a specific way. Apraxia is the inability to carry out motor activities.

35. A client who's taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. The nurse suspects what complication of antipsychotic therapy?

A. AgranulocytosisB. Extrapyramidal effectsC. Anticholinergic effectsD. Neuroleptic malignant syndrome (NMS)

Rationale: A rare but potentially fatal condition of antipsychotic medication is called NMS. It generally starts with an elevated temperature and severe extrapyramidal effects. Agranulocytosis is a blood disorder. Anticholinergic effects include blurred vision, drowsiness, and dry mouth. Symptoms of extrapyramidal effects include tremors, restlessness, muscle spasms, and pseudoparkinsonism.

36. The nurse formulates a nursing diagnosis of Impaired social interaction related to disorganized thinking for a client with schizotypal personality disorder. Based on this nursing diagnosis, which nursing intervention takes highest priority?

A. Helping the client to participate in social interactionsB. Establishing a one-on-one relationship with the clientC. Exploring the effects of the client's behavior on social interactionsD. Developing a schedule for the client's participation in social interactions

Rationale: By establishing a one-on-one relationship, the nurse helps the client learn how to interact with people in new situations. The other options are appropriate but should take place only after the nurse-client relationship is established.

37. A client with schizophrenia hears a voice telling him he is evil and must die. The nurse understands that the client is experiencing:

A. a delusion.B. flight of ideas.C. ideas of reference.D. a hallucination.

Rationale: A hallucination is a sensory perception, such as hearing voices and seeing objects, that only the client experiences. A delusion is a false belief. Flight of ideas refers to a speech pattern in which the client skips from one unrelated subject to another. Ideas of reference refers to the mistaken belief that someone or something outside the client is controlling the client's ideas or behavior.

38. A client with delusional thinking shows a lack of interest in eating at meal times. She states that she is unworthy of eating and that her children will die if she eats. Which nursing action would be most appropriate for this client?

A. Telling the client that she may become sick and die unless she eatsB. Paying special attention to the client's rituals and emotions associated with mealsC. Restricting the client's access to food except at specified meal and snack timesD. Encouraging the client to express her feelings at meal times

Rationale: Restricting access to food except at specified times prevents the client from eating when she feels anxious, guilty, or depressed; this, in turn, decreases the association between these emotions and food. Telling the client she may become sick or die may reinforce her behavior because illness or death may be her goal. Paying special attention to rituals and emotions associated with meals also would reinforce undesirable behavior. Encouraging the client to express feelings at meal times would increase the association between emotions and food; instead, the nurse should encourage her to express feelings at other times.

39. Which of the following groups of characteristics would the nurse expect to see in the client with schizophrenia?

A. Loose associations, grandiose delusions, and auditory hallucinationsB. Periods of hyperactivity and irritability alternating with depressionC. Delusions of jealousy and persecution, paranoia, and mistrustD. Sadness, apathy, feelings of worthlessness, anorexia, and weight loss

Rationale: Loose associations, grandiose delusions, and auditory hallucinations are all characteristic of the classic schizophrenic client. These clients aren't able to care for their physical appearance. They frequently hear voices telling them to do something either to themselves or to others. Additionally, they verbally ramble from one topic to the next. Periods of hyperactivity and irritability alternating with depression are characteristic of bipolar or manic disease. Delusions of jealousy and persecution, paranoia, and mistrust are characteristics of paranoid disorders. Sadness, apathy, feelings of worthlessness, anorexia, and weight loss are characteristics of depression.

40. The nurse must administer a medication to reverse or prevent Parkinson-type symptoms in a client receiving an antipsychotic. The medication the

client will likely receive is:

A. Benztropine (Cogentin).B. diphenhydramine (Benadryl).C. propranolol (Inderal).D. haloperidol (Haldol).

Rationale: Benztropine, trihexyphenidyl, or amantadine are prescribed for a client with Parkinson-type symptoms. Diphenhydramine provides rapid relief for dystonia. Propranolol relieves akathisia. Haloperidol can cause Parkinson-type symptoms.

41. A client is receiving haloperidol (Haldol) to reduce psychotic symptoms. As he watches television with other clients, the nurse notes that he has trouble sitting still. He seems restless, constantly moving his hands and feet and changing position. When the nurse asks what is wrong, he says he feels jittery. How should the nurse manage this situation?

A. Ask the client to sit still or leave the room because he is distracting the other clients.B. Ask the client if he is nervous or anxious about something.C. Give an as needed dose of a prescribed anticholinergic agent to control akathisia.D. Administer an as needed dose of haloperidol to decrease agitation.

Rationale: Akathisia, characterized by restlessness, is a common but often overlooked adverse reaction to haloperidol and other antipsychotic agents; it may be confused with psychotic agitation. To control akathisia, the nurse should give an as needed dose of a prescribed anticholinergic agent. The client can't control the movements, so asking him to sit still would be pointless. Asking him to leave the room wouldn't address the underlying cause of the problem. Encouraging him to talk about the symptoms wouldn't stop them from occurring. Giving more antipsychotic medication would worsen akathisia.

42. A man is brought to the hospital by his wife, who states that for the past week her husband has refused all meals and accused her of trying to poison him. During the initial interview, the client's speech, only partly comprehensible, reveals that his thoughts are controlled by delusions that he is possessed by the devil. The physician diagnoses paranoid schizophrenia. Schizophrenia is best described as a disorder characterized by:

A. disturbed relationships related to an inability to communicate and think clearly.B. severe mood swings and periods of low to high activity.C. multiple personalities, one of which is more destructive than the others.D. auditory and tactile hallucinations.

Rationale: Schizophrenia is best described as one of a group of psychotic reactions characterized by disturbed relationships with others and an inability

to communicate and think clearly. Schizophrenic thoughts, feelings, and behavior commonly are evidenced by withdrawal, fluctuating moods, disordered thinking, and regressive tendencies. Severe mood swings and periods of low to high activity are typical of bipolar disorder. Multiple personality, sometimes confused with schizophrenia, is a dissociative personality disorder, not a psychotic illness. Many schizophrenic clients have auditory hallucinations; tactile hallucinations are more common in organic or toxic disorders

43. A client has a history of chronic undifferentiated schizophrenia. Because she has a history of noncompliance with antipsychotic therapy, she'll receive fluphenazine decanoate (Prolixin Decanoate) injections every 4 weeks. Before discharge, what should the nurse include in her teaching plan?

A. Asking the physician for droperidol (Inapsine) to control any extrapyramidal symptoms that occurB. Sitting up for a few minutes before standing to minimize orthostatic hypotensionC. Notifying the physician if her thoughts don't normalize within 1 weekD. Expecting symptoms of tardive dyskinesia to occur and to be transient

Rationale: The nurse should teach the client how to manage common adverse reactions, such as orthostatic hypotension and anticholinergic effects. Antipsychotic effects of the drug may take several weeks to appear. Droperidol increases the risk of extrapyramidal effects when given in conjunction with phenothiazines such as fluphenazine. Tardive dyskinesia is a possible adverse reaction and should be reported immediately

44. A client with chronic schizophrenia who takes neuroleptic medication is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. These findings suggest which life-threatening reaction:

A. tardive dyskinesia.B. dystonia.C. neuroleptic malignant syndrome.D. akathisia.

Rationale: The client's signs and symptoms suggest neuroleptic malignant syndrome, a life-threatening reaction to neuroleptic medication that requires immediate treatment. Tardive dyskinesia causes involuntary movements of the tongue, mouth, facial muscles, and arm and leg muscles. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Akathisia causes restlessness, anxiety, and jitteriness.

45. While looking out the window, a client with schizophrenia remarks, "That school across the street has creatures in it that are waiting for me." Which of the following terms best describes what the creatures represent?

A. Anxiety attack

B. ProjectionC. HallucinationD. Delusion

Rationale: A delusion is a false belief based on a misrepresentation of a real event or experience. Although anxiety can increase delusional responses, it isn't considered the primary symptom. Projection is falsely attributing to another person one's own unacceptable feelings. Hallucinations, which characterize most psychoses, are perceptual disorders of the five senses; the client may see, taste, feel, smell, or hear something in the absence of external stimulation

46. A client with schizophrenia tells the nurse, "My intestines are rotted from the worms chewing on them." This statement indicates a:

A. delusion of persecution.B. delusion of grandeur.C. somatic delusion.D. jealous delusion.

Rationale: Somatic delusions focus on bodily functions or systems and commonly include delusions about foul odor emissions, insect infestations, internal parasites, and misshapen parts. Delusions of persecution are morbid beliefs that one is being mistreated and harassed by unidentified enemies. Delusions of grandeur are gross exaggerations of one's importance, wealth, power, or talents. Jealous delusions are delusions that one's spouse or lover is unfaithful.

47. During the assessment stage, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. His action shows evidence of:

A. somatic delusions.B. waxy flexibility.C. neologisms.D. nihilistic delusions.

Rationale: The correct answer is waxy flexibility, which is defined as retaining any position that the body has been placed in. Somatic delusions involve a false belief about the functioning of the body. Neologisms are invented meaningless words. Nihilistic delusions are false ideas about self, others, or the world.

48. A client with paranoid type schizophrenia becomes angry and tells the nurse to leave him alone. The nurse should

A. tell him that she'll leave for now but will return soon.B. ask him if it's okay if she sits quietly with him.C. ask him why he wants to be left alone.D. tell him that she won't let anything happen to him

Rationale: If the client tells the nurse to leave, the nurse should leave but let the client know that she'll return so that he doesn't feel abandoned. Not heeding the client's request can agitate him further. Also, challenging the client isn't therapeutic and may increase his anger. False reassurance isn't warranted in this situation

49. Nursing care for a client with schizophrenia must be based on valid psychiatric and nursing theories. The nurse's interpersonal communication with the client and specific nursing interventions must be:

A. clearly identified with boundaries and specifically defined roles.B. warm and nonthreatening.C. centered on clearly defined limits and expression of empathy.D. flexible enough for the nurse to adjust the plan of care as the situation warrants.

Rationale: A flexible plan of care is needed for any client who behaves in a suspicious, withdrawn, or regressed manner or who has a thought disorder. Because such a client communicates at different levels and is in control of himself at various times, the nurse must be able to adjust nursing care as the situation warrants. The nurse's role should be clear; however, the boundaries or limits of this role should be flexible enough to meet client needs. Because a client with schizophrenia fears closeness and affection, a warm approach may be too threatening. Expressing empathy is important, but centering interventions on clearly defined limits is impossible because the client's situation may change without warning.

50. When discharging a client after treatment for a dystonic reaction, the emergency department nurse must ensure that the client understands which of the following?

A. Results of treatment are rapid and dramatic but may not last.B. Although uncomfortable, this reaction isn't serious.C. The client shouldn't buy drugs on the street.D. The client must take benztropine (Cogentin) as prescribed to prevent a return of symptoms.

Rationale: An oral anticholinergic agent such as benztropine (Cogentin) is commonly prescribed to control and prevent the return of symptoms. Dystonic reactions are typically acute and reversible. Dystonic reactions can be life-threatening when airway patency is compromised. Lecturing the client about buying drugs on the street isn't appropriate

1. Flumazenil (Romazicon) has been ordered for a client who has overdosed on oxazepam (Serax). Before administering the medication, the nurse should be prepared for which common adverse effect?  A. Seizures B. Shivering C. Anxiety D. Chest pain  

2. The nurse 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 client who's at high risk for suicide needs close supervision. To best ensure the client's safety, the nurse 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 in suicidal clients.  

4. Which of the following drugs should the nurse 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 client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is the nurse 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 client with bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting your time. After you 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 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 client with anorexia nervosa, 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 client with anorexia nervosa, the nurse 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. The nurse 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. The nurse 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 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. The nurse 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. The nurse 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. 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 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. The nurse 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), which of 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. Which 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 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, she sits staring blankly at her bleeding wrists while staff members call for an ambulance. How should the nurse approach her initially? 

A. Enter the room quietly and move beside her to assess her injuries. B. Call for staff back-up before entering the room and restraining her. C. Move as much glass away from her as possible and sit next to her quietly. D. Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her.   23. A 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 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. The nurse 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. For which of the following conditions might the drug be administered?  A. Phencyclidine (PCP) intoxication B. Alcohol withdrawal C. Opiate withdrawal D. Cocaine withdrawal   26. One of the goals for a client with anorexia nervosa is that the client will demonstrate increased individual coping by responding to stress in constructive ways. Which of the following actions is the best indicator that the client is working toward meeting the goal?  A. The client drinks 4 L of fluid per day. B. The client paces around the unit most of the day. C. The client keeps a journal and discusses it with the nurse. D. The client talks almost constantly with friends by telephone.  

27. The nurse in the substance abuse unit is trying to encourage a client to attend Alcoholics Anonymous meetings. When the client asks the nurse what he must do to become a member, the nurse should respond:  A. "You must first stop drinking." B. "Your physician must refer you to this program." C. "Admit you're powerless over alcohol and that you need help." D. "You must bring along a friend who will support you."  

28. An attorney who throws books and furniture around the office after losing a case is referred to the psychiatric nurse in the law firm's employee assistance program. The nurse knows that the client's behavior most likely represents the use of which defense mechanism?  A. Regression B. Projection C. Reaction-formation D. Intellectualization 

  29. After completing chemical detoxification and a 12-step program to treat crack addiction, a client is being prepared for discharge. Which remark by the client indicates a realistic view of the future?  A. "I'm never going to use crack again." B. "I know what I have to do. I have to limit my crack use." C. "I'm going to take 1 day at a time. I'm not making any promises." D. "I will substitue crack for something else"   30. The nurse is assessing a client on admission to the chemical dependency unit for alcohol detoxification. When the nurse asks about alcohol use, this client is most likely to:  A. accurately describe the amount consumed. B. underestimate the amount consumed. C. overestimate the amount consumed. D. deny any consumption of alcohol.   31. The nurse is assessing a 15-year-old female who's being admitted for treatment of anorexia nervosa. Which clinical manifestation is the nurse most likely to find?  A. Tachycardia B. Warm, flushed extremities C. Parotid gland tenderness D. Coarse hair growth   32. A 38-year-old client is admitted for alcohol withdrawal. The most common early sign or symptom that this client is likely to experience is:  A. impending coma. B. manipulating behavior. C. suppression. D. perceptual disorders.   33. The nurse is caring for an adolescent female who reports amenorrhea, weight loss, and depression. Which additional assessment finding would suggest that the woman has an eating disorder?  

A. Wearing tight-fitting clothing B. Increased blood pressure C. Oily skin D. Excessive and ritualized exercise  

34. A client with a history of polysubstance abuse is admitted to the facility. She complains of nausea and vomiting 24 hours after admission. The nurse assesses the client and notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through which of the following withdrawals?  A. Alcohol withdrawal B. Cannibis withdrawal C. Cocaine withdrawal D. Opioid withdrawal  

35. A client is admitted to the psychiatric unit with a diagnosis of anorexia nervosa. Although she is 5′ 8" (1.7 m) tall and weighs only 103 lb (46.7 kg), she talks incessantly about how fat she is. Which measure should the nurse take first when caring for this client?  A. Teach the client about nutrition, calories, and a balanced diet. B. Establish a trusting relationship with the client.  C. Discuss cultural stereotypes regarding thinness and attractiveness. D. Explore the reasons why the client doesn't eat.   36. A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see:  A. tension and irritability. B. slow pulse. C. hypotension. D. constipation.  

37. Which of the following drugs may be abused because of tolerance and physiologic dependence.  A. lithium (Lithobid) and divalproex (Depakote). B. verapamil (Calan) and chlorpromazine (Thorazine) 

C. alprazolam (Xanax) and phenobarbital (Luminal) D. clozapine (Clozaril) and amitriptyline (Elavil)   38. Which of the following groups are considered to be at highest risk for suicide?  A. Adolescents, men over age 45, and persons who have made previous suicide attempts B. Teachers, divorced persons, and substance abusers C. Alcohol abusers, widows, and young married men D. Depressed persons, physicians, and persons living in rural areas   39. Tourette syndrome is characterized by the presence of multiple motor and vocal tics. A vocal tic that involves repeating one's own sounds or words is known as:  A. echolalia. B. palilalia. C. apraxia. D. aphonia.  

40. A client is admitted to the psychiatric unit with a diagnosis of borderline personality disorder. The nurse expects the assessment to reveal:  A. unpredictable behavior and intense interpersonal relationships. B. inability to function as a responsible parent. C. somatic symptoms. D. coldness, detachment, and lack of tender feelings.  

41. A client with disorganized type schizophrenia has been hospitalized for the past 2 years on a unit for chronic mentally ill clients. The client's behavior is labile and fluctuates from childishness and incoherence to loud yelling to slow but appropriate interaction. The client needs assistance with all activities of daily living. Which behavior is characteristic of disorganized type schizophrenia?  A. Extreme social impairment B. Suspicious delusions 

C. Waxy flexibility D. Elevated affect   42. The nurse is providing care for a female client with a history of schizophrenia who's experiencing hallucinations. The physician orders 200 mg of haloperidol (Haldol) orally or I.M. every 4 hours as needed. What is the nurse's best action?  A. Administer the haloperidol orally if the client agrees to take it. B. Call the physician to clarify whether the haloperidol should be given orally or I.M. C. Call the physician to clarify the order because the dosage is too high. D. Withhold haloperidol because it may worsen hallucinations.  

43. A client receiving haloperidol (Haldol) complains of a stiff jaw and difficulty swallowing. The nurse's first action is to:  A. reassure the client and administer as needed lorazepam (Ativan) I.M. B. administer as needed dose of benztropine (Cogentin) I.M. as ordered. C. administer as needed dose of benztropine (Cogentin) by mouth as ordered. D. administer as needed dose of haloperidol (Haldol) by mouth.   44. A 24-year-old client is experiencing an acute schizophrenic episode. He has vivid hallucinations that are making him agitated. The nurse's best response at this time would be to:  A. take the client's vital signs. B. explore the content of the hallucinations. C. tell him his fear is unrealistic. D. engage the client in reality-oriented activities.   45. Which medication can control the extrapyramidal effects associated with antipsychotic agents?  A. perphenazine (Trilafon) B. doxepin (Sinequan) C. amantadine (Symmetrel) D. clorazepate (Tranxene) 

  46. A client with paranoid schizophrenia has been experiencing auditory hallucinations for many years. One approach that has proven to be effective for hallucinating clients is to:  A. take an as-needed dose of psychotropic medication whenever they hear voices. B. practice saying "Go away" or "Stop" when they hear voices. C. sing loudly to drown out the voices and provide a distraction. D. go to their room until the voices go away.   47. A dystonic reaction can be caused by which of the following medications?  A. diazepam (Valium) B. haloperidol (Haldol) C. amitriptyline (Elavil) D. clonazepam (Klonopin)  

48. While pacing in the hall, a client with paranoid schizophrenia runs to the nurse and says, "Why are you poisoning me? I know you work for central thought control! You can keep my thoughts. Give me back my soul!" How should the nurse respond during the early stage of the therapeutic process?  A. "I'm a nurse. I'm not poisoning you. It's against the nursing code of ethics." B. "I'm a nurse, and you're a client in the hospital. I'm not going to harm you." C. "I'm not poisoning you. And how could I possibly steal your soul?" D. "I sense anger. Are you feeling angry today?"  

49. A client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He's shouting that the government of France is trying to assassinate him. Which of the following responses is most appropriate?  A. "I think you're wrong. France is a friendly country and an ally of the United States. Their government wouldn't try to kill you." B. "I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this." 

C. "You're wrong. Nobody is trying to kill you." D. "A foreign government is trying to kill you? Please tell me more about it." 

1. A. Seizures Rationale: Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. Less common adverse effects include shivering, anxiety, and chest pain.  2. C. identify anxiety-causing situations. Rationale: 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. Controlling shopping for large amounts of food isn't a goal early in treatment. 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. Eating three meals per day isn't a realistic goal early in treatment.  3. A. check the client frequently at irregular intervals throughout the night. Rationale: 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. Decreased communication is a sign of withdrawal that may indicate the client has decided to commit suicide; the nurse shouldn't disregard it (option D  4.D. acetylcysteine (Mucomyst) Rationale: The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion of toxic metabolites to nontoxic metabolites. Deferoxamine mesylate is the antidote for iron intoxication. Succimer is an antidote for lead poisoning. Flumazenil reverses the sedative effects of benzodiazepines.  5. D. chlordiazepoxide (Librium) Rationale: Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of alcohol withdrawal. Haloperidol (Haldol) may be given to treat clients with psychosis, severe agitation, or delirium. Naloxone (Narcan) is administered for narcotic overdose. Magnesium sulfate and other anticonvulsant medications are only administered to treat seizures if they occur during withdrawal. 

6. D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat." Rationale: 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. 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 purging and rarely share their secrets about it. An authoritarian or challenging response may trigger a power struggle between the nurse and client.  7. B. "You told me you got fired from your last job for missing too many days after taking drugs all night." Rationale: Confronting the client with the consequences of substance abuse helps to break through denial. Making threats (option A) isn't an effective way to promote self-disclosure or establish a rapport with the client. 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 (option C). Encouraging elaboration about his experience while getting high may reinforce the abusive behavior. The client undoubtedly is aware that drug use is illegal; a reminder to this effect (option D) is unlikely to alter behavior.  8. A. The client will establish adequate daily nutritional intake. Rationale: 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. The nurse may give lesser priority to goals that address long-term plans (as in option B), self-perception (as in option C), and potential complications (as in option D).  9. A. The injury isn't consistent with the history or the child's age. Rationale: 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. 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. Child abuse occurs in all socioeconomic groups. Parents may argue and be demanding because of the stress of having an injured child.  10.A. They tend to overprotect their children. Rationale: 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 aren't typical of parents of children with anorexia.  11. B. Calling a security guard and another staff member for assistance Rationale: 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. 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. Telling the husband to leave would probably be ineffective because of his agitated and irrational state. Exploring his anger doesn't take precedence over safeguarding the client and staff.

12. C. Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal. Rationale: Allowing the client to select her own food from the menu will help her feel some sense of control. She must then eat 100% of what she selected. Remaining with the client for at least 1 hour after eating will prevent purging. Bulimic clients should only be allowed to eat food provided by the dietary department.  13. B. Exploring the nurse's own feelings about suicide Rationale: 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. 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. Discussing the future and providing anticipatory guidance can help the client prepare for future stress, but this isn't a priority. Referring the client to a clergyperson may increase the client's trust or alleviate guilt; however, it isn't the highest priority.  14. D. Provide objective data and feedback regarding the client's weight and attractiveness. Rationale: 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. Focusing discussions on food and weight would give the client attention for not eating, making option B incorrect. Option C is inappropriate because recognizing unrealistic cultural standards wouldn't help the client establish more realistic weight goals.  15. B. Aftershave lotion Rationale: 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. Carbonated beverages, toothpaste, and cheese don't contain alcohol

and don't need to be avoided by the client.  16. C. Set up a strict eating plan for the client. Rationale: Establishing a consistent eating plan and monitoring the client's weight are important for this disorder. The family should be included in the client's care. The client should be monitored during meals — not given privacy. Exercise must be limited and supervised. 

17. B. Readiness to leave the perpetrator and knowledge of resources Rationale: 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. The reasons they stay in the relationship are complex and can be explored at a later time. The use of drugs or alcohol is irrelevant. There is no evidence to suggest that previous victimization results in a person's seeking or causing abusive relationships.  18.B. thiamine deficiency. Rationale: 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. Acetate accumulation, triglyceride buildup, and a below-normal serum potassium level are unrelated to the client's symptoms.  19. C. The child doesn't cry when the shoulder is examined. Rationale: A characteristic behavior of abused children is lack of crying when they undergo a painful procedure or are examined by a health care professional. Therefore, the nurse should suspect child abuse. Crying throughout the examination, pulling away from the physician, and not making eye contact with the nurse are normal behaviors for preschoolers.  20. B. Client's safety needs Rationale: 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. After safety needs have been met, the client's physical, psychosocial, and medical needs can be met.  21. A. Accept responsibility for own behaviors. Rationale: 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. Options C and D aren't outcome criteria but interventions. Option B is incorrect as the oppositional child usually focuses on his own

needs.  22. D. Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her. Rationale: 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. 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. If the client shows signs of agitation or confusion or poses a threat, the nurse should retreat and request assistance. 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. D. Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy Rationale: 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. B. alcohol withdrawal. Rationale: The client's vital signs and hallucinations suggest delirium tremens or alcohol withdrawal syndrome. 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. C. Opiate withdrawal Rationale: Clonidine is used as adjunctive therapy in opiate withdrawal. Benzodiazepines, such as chlordiazepoxide (Librium), and neuropleptic agents, such as haloperidol, are used to treat alcohol withdrawal. Benzodiazepines and neuropleptic agents are typically used to treat PCP intoxication. Antidepressants and medications with dopaminergic activity in the brain, such as fluoxotine (Prozac), are used to treat cocaine withdrawal.  26.C. The client keeps a journal and discusses it with the nurse. Rationale: The client is moving toward meeting the goal because recording and discussing feelings is a constructive way to manage stress. Although physical activity can reduce stress, the anorexic client is more likely to use pacing to burn calories and lose weight. Although talks with friends can decrease stress, constant talking is more likely a way of avoiding dealing with problems. Increased fluid intake may be an attempt by the client to curb her appetite and artificially increase her weight. 

27. C. "Admit you're powerless over alcohol and that you need help." Rationale: The first of the "Twelve Steps of Alcoholics Anonymous" is admitting that an individual is powerless over alcohol and that life has

become unmanageable. Although Alcoholics Anonymous promotes total abstinence, a client will still be accepted if he drinks. A physician referral isn't necessary to join. New members are assigned a support person who may be called upon when the client has the urge to drink.  28. A. Regression Rationale: An adult who throws temper tantrums, such as this one, is displaying regressive behavior, or behavior that is appropriate at a younger age. In projection, the client blames someone or something other than the source. In reaction formation, the client acts in opposition to his feelings. In intellectualization, the client overuses rational explanations or abstract thinking to decrease the significance of a feeling or event.  29. C. "I'm going to take 1 day at a time. I'm not making any promises." Rationale: Twelve-step programs focus on recovery 1 day at a time.Such programs discourage people from claiming that they will never again use a substance, because relapse is common. The belief that one may use a limited amount of an abused substance indicates denial. Substituting one abused substance for another predisposes the client to cross-addiction.  30. B. underestimate the amount consumed. Rationale: Most people who abuse substances underestimate their consumption in an attempt to conform to social norms or protect themselves. Few accurately describe or overestimate consumption; some may deny it. Therefore, on admission, quantitative and qualitative toxicology screens are done to validate information obtained from the client.  31. C. Parotid gland tenderness Rationale: Frequent vomiting causes tenderness and swelling of the parotid glands. The reduced metabolism that occurs with severe weight loss produces bradycardia and cold extremities. Soft, downlike hair (called lanugo) may cover the extremities, shoulders, and face of an anorexic client.  32. D. perceptual disorders. Rationale: Perceptual disorders, especially frightening visual hallucinations, are very common with alcohol withdrawal. Coma isn't an immediate consequence. Manipulative behaviors are part of the alcoholic client's personality but aren't signs of alcohol withdrawal. Suppression is a conscious effort to conceal unacceptable thoughts, feelings, impulses, or acts and serves as a coping mechanism for most alcoholics.  33.D. Excessive and ritualized exercise Rationale: A client with an eating disorder will normally exercise to excess in an effort to burn as many calories as possible. The client will usually wear loose-fitting clothing to hide what she considers to be a fat body. Skin and nails become dry and brittle and blood pressure and body temperature drop from excessive weight loss.  34. D. Opioid withdrawal 

Rationale: The symptoms listed are specific to opioid withdrawal. Alcohol withdrawal would show elevated vital signs. There is no real withdrawal from cannibis. Symptoms of cocaine withdrawal include depression, anxiety, and agitation.  35. B. Establish a trusting relationship with the client.  Rationale: A client with an eating disorder may be secretive and unwilling to admit that a problem exists. Therefore, the nurse first must establish a trusting relationship to elicit the client's feelings and thoughts. The anorexic client may spend long hours discussing nutrition or handling and preparing food in an effort to stall or avoid eating food; the nurse shouldn't reinforce her preoccupation with food, as in option A. Although cultural stereotypes may play a prominent role in anorexia nervosa, discussing these factors isn't the first action the nurse should take. Exploring the reasons why the client doesn't eat would increase her emotional investment in food and eating.  36. A. tension and irritability. Rationale: An amphetamine is a nervous system stimulant that is subject to abuse because of its ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Options B and C are incorrect because amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea is a common adverse effect, so option D is incorrect.  37. C. alprazolam (Xanax) and phenobarbital (Luminal) Rationale: Both benzodiazepines, such as alprazolam, and barbiturates, such as phenobarbital, are addictive, controlled substances. All the other drugs listed aren't addictive substances.  38. A. Adolescents, men over age 45, and persons who have made previous suicide attempts Rationale: Studies of those who commit suicide reveal the following high-risk groups: adolescents; men over age 45; persons who have made previous suicide attempts; divorced, widowed, and separated persons; professionals, such as physicians, dentists, and attorneys; students; unemployed persons; persons who are depressed, delusional, or hallucinating; alcohol or substance abusers; and persons who live in urban areas. Although more women attempt suicide than men, they typically choose less lethal means and therefore are less likely to succeed in their attempts.  39. B. palilalia. Rationale: Palilalia is defined as the repetition of sounds and words. Echolalia is the act of repeating the words of others. Apraxia is the inability to carry out motor activities, and aphonia is the inability to speak  

40. A. unpredictable behavior and intense interpersonal relationships. Rationale: A client with borderline personality disorder displays a pervasive

pattern of unpredictable behavior, mood, and self-image. Interpersonal relationships may be intense and unstable and behavior may be inappropriate and impulsive. Although the client's impaired ability to form relationships may affect parenting skills, inability to function as a responsible parent is more typical of antisocial personality disorder. Somatic symptoms characterize avoidant personality disorder. Coldness, detachment, and lack of tender feelings typify schizoid and schizotypal personality disorders.  41. A. Extreme social impairment Rationale: Disorganized type schizophrenia (formerly called hebephrenia) is characterized by extreme social impairment, marked inappropriate affect, silliness, grimacing, posturing, and fragmented delusions and hallucinations. A client with a paranoid disorder typically exhibits suspicious delusions, such as a belief that evil forces are after him. Waxy flexibility, a condition in which the client's limbs remain fixed in uncomfortable positions for long periods, characterizes catatonic schizophrenia. Elevated affect is associated withschizoaffective disorder.  42. C. Call the physician to clarify the order because the dosage is too high. Rationale: The dosage is too high (normal dosage ranges from 5 to 10 mg daily). Options A and B may lead to an overdose. Option D is incorrect because haloperidol helps with symptoms of hallucinations.  43. B. administer as needed dose of benztropine (Cogentin) I.M. as ordered. Rationale: The client is most likely suffering from muscle rigidity due to haloperidol. I.M. benztropine should be administered to prevent asphyxia or aspiration. Lorazepam treats anxiety, not extrapyramidal effects. Another dose of haloperidol would increase the severity of the reaction.  44. B. explore the content of the hallucinations. Rationale: Exploring the content of the hallucinations will help the nurse understand the client's perspective on the situation. The client shouldn't be touched, such as in taking vital signs, without telling him exactly what is going to happen. Debating with the client about his emotions isn't therapeutic. When the client is calm, engage him in reality-based activities.  45. C. amantadine (Symmetrel) Rationale: Amantadine is an anticholinergic drug used to relieve drug-induced extrapyramidal adverse effects, such as muscle weakness, involuntary muscle movement, pseudoparkinsonism, and tardive dyskinesia. Other anticholinergic agents used to control extrapyramidal reactions include benztropine mesylate (Cogentin), trihexyphenidyl (Artane), biperiden (Akineton), and diphenhydramine (Benadryl). Perphenazine is an antipsychotic agent; doxepin, an antidepressant; and chlorazepate, an antianxiety agent. Because these medications have no anticholinergic or neurotransmitter effects, they don't alleviate extrapyramidal reactions. 

 46. B. practice saying "Go away" or "Stop" when they hear voices. Rationale: Researchers have found that some clients can learn to control bothersome hallucinations by telling the voices to go away or stop. Taking an as needed dose of psychotropic medication whenever the voices arise may lead to overmedication and put the client at risk for adverse effects. Because the voices aren't likely to go away permanently, the client must learn to deal with the hallucinations without relying on drugs. Although distraction is helpful, singing loudly may upset other clients and would be socially unacceptable after the client is discharged. Hallucinations are most bothersome in a quiet environment when the client is alone, so sending the client to his room would increase, rather than decrease, the hallucinations.  47. B. haloperidol (Haldol) Rationale: Haloperidol is a phenothiazine and is capable of causing dystonic reactions. Diazepam and clonazepam are benzodiazepines, and amitriptyline is a tricyclic antidepressant. Benzodiazepines don't cause dystonic reactions; however, they can cause drowsiness, lethargy, and hypotension. Tricyclic antidepressants rarely cause severe dystonic reactions; however, they can cause a decreased level of consciousness, tachycardia, dry mouth, and dilated pupils.  48. B. "I'm a nurse, and you're a client in the hospital. I'm not going to harm you." Rationale: The nurse should directly orient a delusional client to reality, especially to place and person. Options A and C may encourage further delusions by denying poisoning and offering information related to the delusion. Validating the client's feelings, as in option D, occurs during a later stage in the therapeutic process. 

49. B. "I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this." Rationale: Responses should focus on reality while acknowledging the client's feelings. Arguing with the client or denying his belief isn't therapeutic. Arguing can also inhibit development of a trusting relationship. Continuing to talk about delusions may aggravate the psychosis. Asking the client if a foreign government is trying to kill him may increase his anxiety level and can reinforce his delusions.

1. An unemployed woman, age 24, seeks help because she feels depressed and abandoned and doesn't know what to do with her life. She says she has quit her last five jobs because her coworkers didn't like her and didn't train her adequately. Last week, her boyfriend broke up with her after she drove his car into a tree after an argument. The client's initial diagnosis is borderline personality disorder. Which nursing observations support this diagnosis?  A. Flat affect, social withdrawal, and unusual dress B. Suspiciousness, hypervigilance, and emotional coldness C. Lack of self-esteem, strong dependency needs, and impulsive behavior D. Insensitivity to others, sexual acting out, and violence  

2.In a toddler, which of the following injuries is most likely the result of child abuse?  A. A hematoma on the occipital region of the head B. A 1-inch forehead laceration C. Several small, dime-sized circular burns on the child's back D. A small isolated bruise on the right lower extremity   3. A client is admitted to the emergency department after being found unconscious. Her blood pressure is 82/50 mm Hg. She is 5′ 4" (1.6 m) tall, weighs 79 lb (35.8 kg), and appears dehydrated and emaciated. After regaining consciousness, she reports that she has had trouble eating lately and can't remember what she ate in the last 24 hours. She also states that she has had amenorrhea for the past year. She is convinced she is fat and refuses food. The nurse suspects that she has:  

A. bulimia nervosa. B. anorexia nervosa. C. depression. D. schizophrenia.   4. A 15-year-old girl with anorexia has been admitted to a mental health unit. She refuses to eat. Which of the following statements is the best response from the nurse?  A. "You don't have to eat. It's your choice." B. "I hope you'll eat your food by mouth. Tube feedings and I.V. lines can be uncomfortable." C. "Why do you think you're fat? You're underweight. Here — look in the mirror." D. "You really look terrible at this weight. I hope you'll eat."   5. A client with a history of substance abuse has been attending Alcoholics Anonymous meetings regularly in the psychiatric unit. One afternoon, the client tells the nurse, "I'm not going to those meetings anymore. I'm not like the rest of those people. I'm not a drunk. "What is the most appropriate response?  A. "If you aren't an alcoholic, why do you keep drinking and ending up in the hospital?" B. "It's your decision. If you don't want to go, you don't have to." C. "You seem upset about the meetings." D. "You have to go to the meetings. It's part of your treatment plan."   6. A client is admitted to the inpatient adolescent unit after being arrested for attempting to sell cocaine to an undercover police officer. The nurse plans to write a behavioral contract. To best promote compliance, the contract should be written:  A. abstractly. B. by the client alone. C. jointly by the client and nurse. D. jointly by the physician and nurse.   7. During which phase of alcoholism is loss of control and physiologic

dependence evident?  A. Prealcoholic phase B. Early alcoholic phaseC. Crucial phase D. Chronic phase   8. Which of the following is important when restraining a violent client?  A. Have three staff members present, one for each side of the body and one for the head. B. Always tie restraints to side rails. C. Have an organized, efficient team approach after the decision is made to restrain the client. D. Secure restraints to the gurney with knots to prevent escape.   9. A client who's actively hallucinating is brought to the hospital by friends. They say that the client used either lysergic acid diethylamide (LSD) or angel dust (phencyclidine [PCP]) at a concert. Which of the following common assessment findings indicates that the client may have ingested PCP?  A. Dilated pupils B. Nystagmus C. Paranoia D. Altered mood   10. A severely dehydrated teenager admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. Her history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the last month. She is 5′ 7" (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority?  A. Initiating caloric and nutritional therapy as ordered B. Instituting behavioral modification therapy as ordered C. Addressing the client's low self-esteem D. Regularly monitoring vital signs and weight   11. A client tells the nurse that he is having suicidal thoughts every day. In conferring with the treatment team, the nurse should make which of the following recommendations?  

A. A no-suicide contract B. Weekly outpatient therapy C. A second psychiatric opinion D. Intensive inpatient treatment   12. Which of the following etiologic factors predispose a client to Tourette syndrome?  A. No known etiology B. Abnormalities in brain neurotransmitters, structural changes in basal ganglia and caudate nucleus, and genetics C. Abnormalities in the structure and function of the ventricles D. Environmental factors and birth-related trauma  

13. A client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but he can control his use if he chooses. Which coping mechanism is he using?  A. Withdrawal B. Logical thinking C. Repression D. Denial   14. An 16-year-old boy is admitted to the facility after acting out his aggressions inappropriately at school. Predisposing factors to the expression of aggression include:  A. violence on television. B. passive parents. C. an internal locus of control. D. a single-parent family   15. A client is brought to the emergency department after being beaten by her husband, a prominent attorney. The nurse caring for this client understands that:  A. open boundaries are common in violent families. B. violence usually results from a power struggle. C. domestic violence and abuse span all socioeconomic classes. D. violent behavior is a genetic trait passed from one generation to the next. 

  16. On discharge after treatment for alcoholism, a client plans to take disulfiram (Antabuse) as prescribed. When teaching the client about this drug, the nurse emphasizes the need to:  A. avoid all products containing alcohol. B. adhere to concomitant vitamin B therapy. C. return for monthly blood drug level monitoring. D. limit alcohol consumption to a moderate level.   17. During a private conversation, a client with borderline personality disorder asks the nurse to keep his secret and then displays multiple, self-inflicted, superficial lacerations on the forearms. What is the nurse's best response?  A. "That's it! You're on suicide precautions." B. "I'm going to tell your physician. Do you want to tell me why you did that?" C. "Tell me what type of instrument you used. I'm concerned about infection." D. "The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first."   18. The nurse is providing care for a client undergoing opiate withdrawal. Opiate withdrawal causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with:  A. barbiturates. B. amphetamines. C. methadone. D. benzodiazepines. 

 19. The nurse is caring for a client who she believes has been abusing opiates. Assessment findings in a client abusing opiates such as morphine include:  A. dilated pupils and slurred speech. B. rapid speech and agitation. 

C. dilated pupils and agitation. D. euphoria and constricted pupils.  

20. Which of the following signs should the nurse expect in a client with known amphetamine overdose?  A. Hypotension B. Tachycardia C. Hot, dry skin D. Constricted pupils   21. A client is admitted to the psychiatric unit with a diagnosis of alcohol intoxication and suspected alcohol dependence. Other assessment findings include an enlarged liver, jaundice, lethargy, and rambling, incoherent speech. No other information about the client is available. After the nurse completes the initial assessment, what is the first priority?  A. Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output B. Checking the client's medical records for health history information C. Attempting to contact the client's family to obtain more information about the client D. Restricting fluids and leaving the client alone to "sleep off" the episode   22. Which nursing action is best when trying to diffuse a client's impending violent behavior?  A. Helping the client identify and express feelings of anxiety and anger B. Involving the client in a quiet activity to divert attention C. Leaving the client alone until the client can talk about feelings D. Placing the client in seclusion   23. The nurse is working with a client who abuses alcohol. Which of the following facts should the nurse communicate to the client?  A. Abstinence is the basis for successful treatment. B. Attendance at Alcoholics Anonymous meetings every day will cure alcoholism. C. For treatment to be successful, family members must participate. D. An occasional social drink is acceptable behavior for the alcoholic 

  24. Which psychosocial influence has been causally related to the development of aggressive behavior and conduct disorder?  A. An overbearing mother B. Rejection by peers C. A history of schizophrenia in the family D. Low socioeconomic status   25. In group therapy, a client who has used I.V. heroin every day for the past 14 years says, "I don't have a drug problem. I can quit whenever I want. I've done it before." Which defense mechanism is the client using?  A. Denial B. Obsession C. Compensation D. Rationalization   26. A 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, the nurse expects the physician to prescribe:  A. lidocaine (Xylocaine). B. procainamide (Pronestyl). C. nitroglycerin (Nitro-Bid IV). D. epinephrine.  

27. A 15-year-old client is brought to the clinic by her mother. Her mother expresses concern about her daughter's weight loss and constant dieting. The nurse 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. Which is the drug of choice for treating Tourette syndrome?  A. fluoxetine (Prozac) B. fluvoxamine (Luvox) C. haloperidol (Haldol) D. paroxetine (Paxil)  

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

A. "Why didn't you get someone else to drive you?" B. "Tell me how you feel about the accident." C. "You should know better than to drink and drive." D. "I recommend that you attend an Alcoholics Anonymous meeting."   30. A client voluntarily admits himself to the substance abuse unit. He confesses that he drinks 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 client recently admitted for treatment of cocaine addiction, the nurse 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 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 strengths  

33. A 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, the nurse 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 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, 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 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 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 client recently admitted to the hospital with sharp, substernal chest pain suddenly complains of palpitations. The nurse 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 spasmB. Bradyarrhythmias C. Neurobehavioral deficits D. Panic disorder   37. A client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to:  A. begin after 7 days. B. not occur at all because the time period for their occurrence has passed. C. begin anytime within the next 1 to 2 days. D. begin within 2 to 7 days.  

38. The nurse 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 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 client begins to experience alcoholic hallucinosis. What is 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. Which 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 mm Hg D. Blood pressure of 140/80 mm Hg   41. Which 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. Which of the following medical conditions is commonly found in clients with bulimia nervosa?  A. Allergies B. Cancer C. Diabetes mellitus D. Hepatitis A  

43. 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 choices.  

44. A client who reportedly consumes 1 qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, the physician is most likely to prescribe which drug? 

A. clozapine (Clozaril) B. thiothixene (Navane) 

C. lorazepam (Ativan) D. lithium carbonate (Eskalith)   45. A 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. The nurse should suggest that the family join which organization?  A. Al-Anon B. Make Today Count C. Emotions Anonymous D. Alcoholics Anonymous   46. A client is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the client's physical health, the nurse 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. A young man 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. A husband and wife 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, the nurse 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. The nurse 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 client has approached the nurse asking for advice on how to deal with his alcohol addiction. The nurse should tell the client that the only effective treatment for alcoholism is:  A. psychotherapy. B. total abstinence. C. Alcoholics Anonymous (AA). D. aversion therapy. 

1. C. Lack of self-esteem, strong dependency needs, and impulsive behavior Rationale: Borderline personality disorder is characterized by lack of self-esteem, strong dependency needs, and impulsive behavior. Instability in interpersonal relationships, mood, and poor self-image also is common. Typically, the client can't tolerate being alone and expresses feelings of emptiness or boredom. Flat affect, social withdrawal, and unusual dress are characteristic of schizoid personality disorder. Suspiciousness, hypervigilance, and emotional coldness are seen in paranoid personality disorders. In antisocial personality disorder, clients are usually insensitive to others and act out sexually; they may also be violent  2.C. Several small, dime-sized circular burns on the child's back Rationale: Small circular burns on a child's back are no accident and may be from cigarettes. Toddlers are injury prone because of their developmental stage, and falls are frequent because of their unsteady gait; head injuries aren't uncommon. A small area of ecchymosis isn't suspicious in this age-group.  3.B. anorexia nervosa. 

Rationale: Anorexia nervosa is an eating disorder characterized by self-imposed starvation with subsequent emaciation, nutritional deficiencies, and atrophic and metabolic changes. Typically, the client is hypotensive and dehydrated. Depending on the severity of the disorder, anorexic clients are at risk for circulatory collapse (indicated by hypotension), dehydration, and death. Bulimia nervosa is an eating disorder characterized by binge eating followed by self-induced vomiting. Although depression may be accompanied by weight loss, it isn't characterized by a body image disturbance or the intense fear of obesity seen in anorexia nervosa. Schizophrenia may cause bizarre eating patterns, but it rarely causes the full syndrome of anorexia nervosa.  4. B. "I hope you'll eat your food by mouth. Tube feedings and I.V. lines can be uncomfortable." Rationale: Clients with anorexia can refuse food to the point of cardiac damage. Tube feedings and I.V. infusions are ordered to prevent such damage. The nurse is informing her of her treatment options. Option A doesn't tell the client about the consequences of choosing not to eat. Telling clients that they are too thin won't change their self-image.  5. C. "You seem upset about the meetings." Rationale: The substance abuser uses the substance to cope with feelings and may deny the abuse. Asking if the client is upset about the meetings encourages the client to identify and deal with feelings instead of covering them up. Arguing with the client about the substance abuse (option A) or insisting that the client attend the meetings (option D) wouldn't help the client identify resistance to treatment. Option B isn't therapeutic behavior because it plays down the importance of attending meetings.  6. C. jointly by the client and nurse. Rationale: A contract written jointly by the client and nurse most successfully promotes cooperation and consistent behavior. The most effective contract — and the type least likely to allow for manipulation and misinterpretation — states the behavioral terms as concretely as possible. A contract written solely by the client may not be agreeable to staff members; one written by the physician and nurse may not be agreeable to the client.  7. C. Crucial phase Rationale: The crucial phase is marked by physical dependence. The prealcoholic phase is characterized by drinking to medicate feelings and for relief from stress. The early phase is characterized by sneaking drinks, blackouts, rapidly gulping drinks, and preoccupation with alcohol. The chronic phase is characterized by emotional and physical deterioration. 

 8. C. Have an organized, efficient team approach after the decision is made to restrain the client. Rationale: Emergency department personnel should use an organized, team approach when restraining violent clients so that no one is injured in the process. The leader, located at the client's head, should take charge; four staff members are required to hold and restrain the limbs. For safety reasons, restraints should be fastened to the bed frame instead of the side rails. For quick release, loops should be used instead of knots  9. B. Nystagmus Rationale: Phencyclidine is an anesthetic with severe psychological effects. It blocks the reuptake of dopamine and directly affects the midbrain and thalamus. Nystagmus and ataxia are common physical findings of PCP use. Dilated pupils are evidence of LSD ingestion. Paranoia and altered mood occur with both PCP and LSD ingestion.  10. A. Initiating caloric and nutritional therapy as ordered Rationale: The client with anorexia nervosa is at risk for death from self-starvation. Therefore, initiating caloric and nutritional therapy takes highest priority. Behavioral modification (in which client privileges depend on weight gain) and psychoanalysis (which addresses the client's low self-esteem, guilt, anxiety, and feelings of hopelessness and depression) are important aspects of care but are secondary to stabilizing the client's physical condition. Monitoring vital signs and weight is important in evaluating nutritional therapy but doesn't take precedence over providing adequate caloric intake to ensure survival  11. D. Intensive inpatient treatment Rationale: Inpatient care is the best intervention for a client who is thinking about suicide every day. Implementing a no-suicide contract is an important strategy, but this client requires additional care. Weekly therapy wouldn't provide the intensity of care that this case warrants. Obtaining a second opinion would take time; this client requires immediate intervention.  12. B. Abnormalities in brain neurotransmitters, structural changes in basal ganglia and caudate nucleus, and genetics Rationale: The etiology of Tourette syndrome includes genetics, abnormalities in neurotransmission, and structural changes in the basal ganglia and caudate nucleus. The ventricles in the brain, environmental factors, and birth trauma aren't involved.  13. D. Denial 

Rationale: Denial is an unconscious defense mechanism in which emotional conflict and anxiety are avoided by refusing to acknowledge feelings, desires, impulses, or external facts that are consciously intolerable. Withdrawal is a common response to stress, characterized by apathy. Logical thinking IS the ability to think rationally and make responsible decisions, which would lead the client to admitting the problem and seeking help. Repression is suppressing past events from the consciousness because of guilty association.  14. A. violence on television. Rationale: Violence on television has been correlated with an increase in aggressive behavior. Passive parents contribute to acting-out behaviors but not specifically to violence. An internal locus of control leads to a positive sense of self-esteem and isn't related to violence or aggression. There is no direct correlation between single-parent families and violence.  15. C. domestic violence and abuse span all socioeconomic classes. Rationale: Domestic violence and abuse affect all socioeconomic classes. Closed boundaries and an imbalance of power, with one member having control over the others, are common in violent families. Although violent behavior may be passed from one generation to the next, it's a learned behavior, not a genetic trait.  16. A. avoid all products containing alcohol. Rationale: To avoid severe adverse effects, the client taking disulfiram must strictly avoid alcohol and all products that contain alcohol. Vitamin B therapy and blood monitoring aren't necessary during disulfiram therapy.  17. D. "The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first." Rationale: This response informs the client of the nurse's planned actions and allows time to discuss the client's actions. Options A and B put the client on the defensive and may lead to a power struggle. Option C ignores the psychological implications of the client's actions.  18. C. methadone. Rationale: Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system but doesn't have the same deleterious effects as other opiates, such as cocaine, heroin, and morphine. Barbiturates, amphetamines, and benzodiazepines are highly addictive and would require detoxification treatment. 

 19. D. euphoria and constricted pupils. Rationale: Assessment findings in a client abusing opiates include agitation, slurred speech, euphoria, and constricted pupils.  20. B. Tachycardia Rationale: Amphetamines are central nervous system stimulants. They cause sympathetic stimulation, including hypertension, tachycardia, vasoconstriction, and hyperthermia. Hot, dry skin is seen with anticholinergic agents such as jimsonweed. Pupils will be dilated, not constricted.  21. A. Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output Rationale: A nurse who lacks adequate information to determine which level of care a client requires must take all possible precautions to ensure the client's physical safety and prevent complications. To do otherwise could place the client at risk for potential complications. After taking all possible precautions, the nurse can begin seeking health history information and, as needed, modify the plan of care. Fluids are typically increased unless contraindicated by a preexisting medical condition.   22. A. Helping the client identify and express feelings of anxiety and anger Rationale: In many instances, the nurse can diffuse impending violence by helping the client identify and express feelings of anger and anxiety. Such statements as "What happened to get you this angry?" may help the client verbalize feelings rather than act on them. Close interaction with the client in a quiet activity may place the nurse at risk for injury should the client suddenly become violent. An agitated and potentially violent client shouldn't be left alone or unsupervised because the danger of the client acting out is too great. The client should be placed in seclusion only if other interventions fail or the client requests this. Unlocked seclusion can be helpful for some clients because it reduces environmental stimulation and provides a feeling of security.  23. A. Abstinence is the basis for successful treatment. Rationale: The foundation of any treatment for alcoholism is abstinence. Attendance at Alcoholics Anonymous is helpful to some individuals to maintain strict abstinence. Participation in treatment by the family is beneficial to both the client and the family but isn't essential.

Abstinence requires refraining from social drinking.  24. B. Rejection by peers Rationale: Studies indicate that children who are rejected by their peers are more likely to behave aggressively. Aggression and conduct disorder are represented in all socioeconomic groups. Schizophrenia and an overbearing mother haven't been associated with aggression or conduct disorder  25. A. Denial Rationale: A client who states that he or she doesn't have a drug problem and can quit using drugs at any time — despite evidence to the contrary — is denying the drug addiction. Obsession isn't a defense mechanism. In compensation, the client emphasizes positive attributes to compensate for negative ones. In rationalization, the client justifies behaviors by faulty logic.  26. C. nitroglycerin (Nitro-Bid IV). Rationale: The elevated ST segments in this client's ECG indicate myocardial ischemia. To reverse this problem, the physician is mostlikely to prescribe an infusion of nitroglycerin to dilate the coronary arteries. Lidocaine and procainamide are cardiac drugs that may be indicated for this client at some point but aren't used for coronary artery dilation. 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. C. "I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls." Rationale: 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. 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. Preferring fast food over healthy food is common in this age-group. Because of the absence of body fat necessary for proper hormone production, amenorrhea is common in a client with anorexia nervosa.  28. C. haloperidol (Haldol) Rationale: Haloperidol is the drug of choice for treating Tourette syndrome. Prozac, Luvox, and Paxil are antidepressants and aren't used to treat Tourette syndrome 

 29. B. "Tell me how you feel about the accident." Rationale: An open-ended statement or question is the most therapeutic response. It encourages the widest range of client responses, makes the client an active participant in the conversation, and shows the client that the nurse is interested in his feelings. Asking the client why he drove while intoxicated can make him feel defensive and intimidated. A judgmental approach isn't therapeutic. By giving advice, the nurse suggests that the client isn't capable of making decisions, thus fostering dependency.  30. D. Diaphoresis, tremors, and nervousness Rationale: 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. Although diarrhea may be an early sign of alcohol withdrawal, tachycardia — not bradycardia — is associated with alcohol withdrawal. 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. If withdrawal symptoms remain untreated, seizures may arise later.  31. D. nifedipine and esmolol Rationale: This client requires a vasodilator, such as nifedipine, to treat hypertension, and a beta-adrenergic blocker, such as esmolol, to reduce the heart rate. Lidocaine, an antiarrhythmic, isn't indicated because the client doesn't have an arrhythmia. Although nitroglycerin may be used to treat coronary vasospasm, it isn't the drug of choice in hypertension. 32. B. The client will work with the nurse to remain safe. Rationale: The priority goal in alcohol withdrawal is maintaining the client's safety. 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. A. A rigid posture, restlessness, and glaring Rationale: Behavioral clues that suggest the potential for violence include 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. Violent clients rarely exhibit depression, silence, or hypervigilance.  34. D. "I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me." Rationale: 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. C. Risk for violence: Self-directed related to impulsive mutilating acts. Rationale: 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.A. Coronary artery spasmRationale: 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. Consequently, the drug is more likely to cause tachyarrhythmias than bradyarrhythmias. Although neurobehavioral deficits are common in neonates born to cocaine users, they are rare in adults. As craving for the drug increases, a person who's addicted to cocaine typically experiences euphoria followed by depression, not panic disorder.  37. C. begin anytime within the next 1 to 2 days. Rationale: 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. A. Providing one-on-one supervision during meals and for 1 hour afterward Rationale: 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, as in option D, the nurse should set limits and let the client know what is expected.  39. C. Providing a quiet environment and administering medication as needed and prescribed Rationale: Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment to reduce stimulation and administering prescribed central nervous system depressants in dosages that control symptoms without causing oversedation. 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. Offering juice is appropriate, but measuring blood pressure every 15 minutes would interrupt the client's rest. To avoid overstimulating the client, the nurse should check blood pressure every 2 hours.  40. A. Heart rate of 120 to 140 beats/minute Rationale: 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. B. One who plans a violent death and has the means readily available Rationale: 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). 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. C. Diabetes mellitus Rationale: Bulimia nervosa can lead to many complications, including diabetes, heart disease, and hypertension. The eating disorder isn't typically associated with allergies, cancer, or hepatitis A.  43. B. The student accepts a referral to a substance abuse counselor. Rationale: 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. C. lorazepam (Ativan) Rationale: The best choice for preventing or treating alcohol withdrawal symptoms is lorazepam, a benzodiazepine. Clozapine and thiothixene are antipsychotic agents, and lithium carbonate is an antimanic agent; these drugs aren't used to manage alcohol withdrawal syndrome.  45. A. Al-Anon Rationale: Al-Anon is an organization that assists family members to share common experiences and increase their understanding of alcoholism. Make Today Count is a support group for people with life-threatening or chronic illnesses. Emotions Anonymous is a support group for people experiencing depression, anxiety, or similar conditions. Alcoholics Anonymous is an organization that helps alcoholics recover by using a twelve-step program.  46. C. monitor vital signs, serum electrolyte levels, and acid-base balance. Rationale: 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. A. antisocial personality disorder. Rationale: 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. In borderline personality disorder, the client exhibits mood instability, poor self-image, identity disturbance, and labile affect. Obsessive-compulsive personality disorder is characterized by a preoccupation with impulses and thoughts that the client realizes are senseless but can't control. Narcissistic personality disorder is marked by a pattern of self-involvement, grandiosity, and demand for constant attention.  48. C. has learned violence as an acceptable behavior. Rationale: Family violence usually is a learned behavior, and violence typically leads to further violence, putting this couple at risk. Repeated slapping may indicate poor, not moderate, impulse control. Violent people commonly are jealous and possessive and feel insecure in their relationships.  49. B. gain control of one part of her life. Rationale: 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. 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). 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. B. total abstinence. Rationale: 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.