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1. A client is admitted with Wernicke’s encephaiopathy. The nurse anticipates that the first
physician’s order will include:
a. Ordering an MRI
b. Administering a steroid medication, such as Decadron
c. Giving thiamine 100 mg IM STAT
d. Ordering an EEG
2. Which of the following statements, if made by a four year old child whose brother just died of
cancer, would be age-appropriate?
a. “I know i will never see my mother again.”
b. “I’m glad my mother isn’t crying anymore.”
c. “I can’t wait to go get pizza with my brother.”
d. “i know where my brother is buried.”
3. A patient who has AIzheimer’s disease is told by the nurse to brush his teeth. He shouts
angrily, “Tomato soup!” Which of the following actions by the nurse would be correct?
a. Focusing on the emotional reaction
b. Clarifying the meaning of his statement
c. Giving him step-by-step directions
d. Doing the procedure for him
4. A nurse should teach a patient who is taking chlorpromazine (Thorazine) to avoid:
a. Exposure to the sun
b. Swimming in a chlorinated pool
c. Drinking fluids high in sodium
d. Eating foods such as chocolate and aged cheese
5. in caring for a psychotic patient who is experiencing hallucinations, which of the following
interventions is considered critical?
a. Setting fewer limits in order to allow for more expressions of feeling
b. Maintaining constant observation.
c. Providing more frequent opportunities for interaction with others.
d. Constantly negating the patient’s hallucinatory Ideations.
6. A 22-year-old client is being admitted with a diagnosis of brief psychotic disorder. Two weeks
ago, his girlfriend broke off their engagement and cancelled the wedding. Given the Diagnosis
and Statistical Manual of Mental Disorders, edition, text’ revised (DSM-IV-TR) criteria for this
disorder the nurse expects to find which of the following data during the interview with the
client?
a. Current treatment for pneumonia
b. Regular use of alcohol and marijuana
c. Evidence of delusions and hallucinations
d. A history of chronic depression
7. A set of monozygotic twins who are 23 years old have begun attending groups at mental
health center. One twin is diagnosed with schizophrenia. Her twin has no diagnoses but has
been experiencing significant anxiety since becoming engaged. In counseling the engaged twin,
it would be crucial to include which of the following tacts?
a. Her future children will be at risk for developing schizophrenia
b. She may have a predisposition for schizophrenia
c. One of her parents may develop schizophrenia later in life
d. It is unlikely that she wil! develop schizophrenia, at her age
8. A client tells the nurse that her co-workers are sabotaging the computer. When the nurse
asks questions, the client becomes argumentative. This behavior shows personality traits
associated with which of the following personality disorders?
a. Antisocial
b. Histrionic
c. Paranoid
d. Schizotypal
9. Which of the following types of behavior is expected from a client diagnosed with paranoid
personality disorder?
a. Eccentric
b. Exploitative
c. Hypersensitive
d. Seductive
10. A nurse is reviewing the serum laboratory test results for a client with sickle cell anemia. The
nurse finding that which of the following values is elevated?
a. Hemoglobin F
b. Hemoglobin S
c. Hemoglobin C
d. Hemoglobin a
11. A parent with a daughter with bulimia nervosa asks a nurse, “How can my child have an
eating disorder when she isn’t underweight?” Which of the following responses is best?
a. “A person with bulimia nervosa can maintain a normal weight.”
b. It’s hard to face this type of problem in a person you love.”
c. “At first there is no weight loss; it comes later In the disease.”
d. “This is a serious problem even though there is no weight loss.”
12. A nurse is assessing an adolescent girl recently diagnosed with an eating disorder and
symptoms of bulimia nervosa. Which of the following findings is expected based on laboratory
test results?
a. Hypocalcemia
b. Hypoglycemia
c. Hypokalemia
d. Hypophosphatemia
13. Which of the following complications of bulimia nervosa Is life threatening?
a. Amenorrhea
b. Bradycardia
c. Electrolyte Imbalance
d. Yellow skin
14. A nurse is talking to a client with bulimia nervosa about the complications of Laxative abuse.
Which of the following complications should be included?
a. Loss of taste
b. Swollen glands
c. Dental problems
d. Malabsorption of nutrients
15. A nurse is assessing a client to determine the distress experienced after binge eating.
Which of the following symptoms are typical after bingeing?
a. Ageusia
b. Headache
c. Pain
d. Sore throat
16. Which of the following difficulties are frequently found in families with a member who has
bulimia nervosa?
a. Mental Illness
b. Multiple losses
c. Chronic anxiety
d. Substance abuse
17. A client with anorexia nervosa tells a nurse, “My parents never hug me or say I’ve done
anything right.” Which of the following Interventions is the best to use with this family?
a. Teach the family principles of assertive behavior.
b. Discuss the difficulties the family has in social situations.
c. Help the family convey a positive attitude toward the client.
d. Explore the family’s ability to express affection appropriately.
18. A client with anorexia nervosa tells a nurse she always feels fat. Which of the following
interventions is the best for this client?
a. Talk about how important the client is.
b. Encourage her to look at herself in a mirror.
c. Address the dynamics of the disorder.
d. Talk about how she’s different from her peers.
Ms. J.K. is a 24-year old woman admitted to the neurosurgery floor 2 days following a
hypophysectomy for a pituitary tumor. She is alert, oriented, and eager to return to her job as an
executive to the hospital director. She is alert, oriented and eager to return to her job as an
executive assistant to the hospital director. She calls the nurse to her room to express her
concern about the frequency of urination she is experiencing, as well as the feeling of weakness
that began this morning.
19. The most likely cause of her chief complaint this morning is
a. A decrease in postoperative stress causing polyuria
b. The onset of diabetes mellitus, an unusual complication
c. An expected result of the removal of the pituitary gland
d. A frequent complication of the hypophysectomy
20. Following hypophysectomy, patients require extensive teaching regarding this major
alteration in their lifestyle
a. Abnormal distribution of body hair
b. Lifetime dependency on hormone replacement
c. The need to drink many fluids to replace those lost
d. The need to undergo repeat surgical procedures
21. The Glasgow coma scale is used to .evaluate the level of consciousness in the neurological
and neurological patients. The three assessment factors included in this scale are:
a. pupil size, response to pain, motor responses
b. Pupil size, verbal response, motor response
c. Eye opening, verbal response, motor response
d. Eye opening, response to pain, motor response
J.E, is an 18-year old freshman admitted to the ICU following a motor vehicle accident in which
he sustained multiple trauma including a ruptured spleen, myocardial contusion, fractured
pelvis, and fractured right femur. He had a mild contusion, but is alert and oriented. His vital
signs BP 120/80, pulse 84, respirations 12, and temperature 99 F orally.
22. The nurse will monitor J.E. for the following signs and symptoms:
a. Change in the level of consciousness, tachypnea, tachycardia, petechiae
b. Onset of chest pain, tachycardia, diaphoresis, nausea and vomiting
c. Loss of consciousness, bradycardia, petechiae, and severe leg pain
d. Change in level of consciousness, bradycardia, chest pain and oliguria
23. Appropriate nursing interventions for J.E. would be
a. Skin care and position q2h and prn; maintain alignment of extremities; respiratory exercises
b. Skin care/bathe daily; passive leg exercises daily; respiratory therapy for intermittent positive
pressure breathing therapy
c. Skin care and position q2h; teach use of overhead trapeze; respiratory exercises, and
intermittent positive pressure breathing q2h
d. Skin care q2h; teach use of overhead trapeze; respiratory exercises; use pressure relief
devices
Ms. J., a 34-year old white female, is admitted via the emergency room complaining of
abdominal pain, fatigue, anorexia, muscle cramping, and nausea. She is a diabetic who been
managed at 30 U NPH insulin every AM and a 1200-calorie ADA diet. Her glucose in ER 700
mg/dL. Regular insulin 30 U was given and a repeat glucose were drawn. Results were not
avaiIable upon transfer to the unit.
24. Given the above Information, which nursing activities should be highest priority?
a. Monitoring vita i signs
b. Obtaining blood glucose results
c. Assessing neurological status
d. Assessing pedal pulses and feet
25. The nurse received the lab results from the blood sample drawn in ER. Her glucose is now-
100. However, her WBC count is 25,000. What conclusion can the nurse draw basing on this
information?
a. Lab results are within normal limits, no action Is necessary
b. Her diabetes is out of control
c. insulin administration increase WBC count
d. Infection has increased her insulin needs
26. Later that evening, Ms. J’s abdominal pain increased in intensity. A diagnosis of appendicitis
is made and Ms. J is scheduled for surgery in the morning. The physician has written the
following orders:
NPO after midnight
At 6 AM starting IVF of D5W to be infused at 250 ml/hr
15 U NPH insulin at 6AM
Draw FBS prior to initiating iV fluids
The statement that best describe the rationale for these orders Is:
a. To provide calories to offset the patient being NPO
b. To prevent a hypoglycemic reaction
c. To prevent a fluid volume deficit
d. To assist with the body’s response to stress
27. When ambulating a client following surgical removal of a protruded
intervertebral lumbar disc, the nurse would do which of the following?
a. Maintain proper body alignment
b. Administer analgesia after walking
c. Provide a cane for support
d. Immobilize the head and neck
28. Which of the following point scores on the post anesthesia chart, indicates that the client has
fulfilled minimal criteria for discharge from the PACU?
a. One point In each of the five areas .for a total score of 5.
b. One point in at least three areas” respiratory, circulatory, and consciousness – for a total of 3
c. A total score for the five areas of 7 or.above.
d. Two points each in each of the five areas for a total score of 10.
29. Which of the following statements would be the nurse’s response to a family member asking
questions about a client’s transient ischemic attack (TIA)?
a. “I think you should ask the doctor. Would you like me to call him for you?”
b. ” The blood supply to the brain has decreased causing permanent brain damage.”
c. “It Is a temporary interruption in the blood flow to the brain.”
d. “TIA means a transient ischemic attack.”
30. While receiving radiation therapy for the treatment of breast cancer, a client complains of
dysphagia and skin texture changes, at the radiation site. Which of the following instructions
would be most appropriate to suggest to minimize the risk of complications, and promote
healing?
a. Wash the radiation site vigorously with soap and water to remove dead cells.
b. Eat a diet high in protein and calories to optimize tissue repair.
c. Apply coo! compresses to the radiation site to reduce edema,
d. Drink warm fluids throughout the day to relieve discomfort in swallowing.
31. A client using an over-the counter nasal decongestant spray reports unrelieved and
worsening nasal congestion. The nurse should instruct the client to do which of the following?
a. Switch to a stronger dosage of the medication.
b. Discontinue the medication for a few weeks
c. Use the spray more frequently
d. Combine the spray with an oral decongestant.
32. Following a thyroidectomy, the client experiences hemorrhage. The nurse would prepare for
which of the following emergency interventions?
a. intravenous administration of calcium
b. insertion of an oral airway
c. Creation of a tracheostomy
d. Intravenous administration of thyroid hormone
33. After a client signs the form, giving informed consent for surgery and the physician !eaves
the room, the client asks the nurse, “When will this hotel bring me some food?” After confirming
that the client is confused, which of the following would be the nurse’s priority action?
a. Reporting that the consent has been obtained from a confused client.
b. Teaching preoperative moving, coughing, and deep-breathing,exercises.
c. Inserting a bladder catheter to urine output.
d. Administering preoperative medication immediately ,
34. At 16 weeks gestation, no fetal heart rate was detected during assessment of a pregnant
patient. An ultrasound confirmed a hydatidiform molar pregnancy. Which of the following actions
should the nurse tell the patient to expect during her one-year follow-up?
a. Multiple serum chorionic gonadotropin levels will be drawn
b. An Intrauterine device will be used to decrease vaginal bleeding
c. Pregnancy will be restricted for another year
d. Oral contraceptives will not be prescribed because they will increase the risk’ of cancer
35. Thirty minutes after the nurse removes a nasogastric tube that has been In place for seven
days, the patient experiences epistaxis (nosebleed). Which of the following nursing actions is
most appropriate to control the bleeding?
a. Apply pressure by pinching the anterior portion of the for five to ten minutes
b. Place the patient in a sitting position with the neck hyperextended
c. Pack the nostrils with gauze and keep the gauze in place for four to five days
d. Apply ice compresses to the patient’s forehead and back of the neck
36. The staff nurse calls a physician regarding an order to administer digoxin (Lanoxin) to a
patient with a pulse of 55 and a serum potassium level of 2.9 mEq/L The physician says to give
the medication, as ordered . The staff nurse’s best response would be
a. “I’ll give the medication but you will still be responsible if anything happens to the patient.”
b. “I will not give this medication.”
c. ‘”I think we should discuss this with the nursing supervisor.”
d. “I’m sorry, but if you want the medication given, you will have to give it yourself.”
37. During the night, shift report, the charge nurse learns that an elderly patient has become
very confused and is shouting obscenities and undressing himself. Which of the following
actions is the most appropriate Initial nursing response?
a. Restrain the patient with a Posey jacket
b. Medicate the patient with haloperidol (Haldol) as ordered.
c. Notify the physician
d. Complete a nursing assessment of the patient
38. When a woman is 10 weeks pregnant which of the following hematology test results would
need further Investigation?
a. Hemoglobin level of 9 mg/dL
b. white blood cell count of 15,000/cu mm
c. platelet count of 200,000/cu mm
d. red blood cell count of 4,200,000/ cu mm
39. Which of the following techniques would a nurse use when interviewing a 94-year-old
patient?
a. Using a low-pitched voice
b. Enunciating each word .slowly
c. Varying voice intonations
d. Reinforcing the words with pictures .
40. A patient who is receiving total parenteral nutrition has an elevated blood glucose eve! and
is to be administered intravenous insulin. Which of the following types of insulin should a nurse
has available?
a. Isophane insulin (NPH)
b. Regular insulin (Humulin R)
c. Insulin zinc suspension (Lente)
d. Semi-Lente Insulin (Semiterd)
41. A nurse is taking history from a patient who has just been admitted to the hospital withl an
acute myocardia! infarction. Which of the following questions would be most important for the
nurse to ask?
a. “At what time did the pain start?”
b. “When did you eat your last meal?”
c. “Have you experienced a pounding headache?”
d. “Did you feel fluttering in your chest”
42. An infant who weighs 11 lbs. is to receive 750 mg of an antibiotic in a 24-hour period. The
liquid antibiotic comes in a concentration of 125 mg/5ml. If the antibiotic were to be given three
times each day. how many ml would the nurse administer with each dose?
a. 2
b. 5
c. 6.25
d. 10
43. Spasm of the neck muscles developed in a patient who is taking phenothiazine (Nemazine).
Which of the following medications should the nurse administer?
a. Vistaril
b. Acetaminophen (Tyienol)
c. Acetylsalicylic acid (Aspirin)
d. Benztropine mesyiate (Cogentin)
Mr. Anthony Malailinelii is a 54-year old truck driver. He is admitted for possible gastric ulcer, He
is a heavy smoker.
44. When discussing his smoking habits with Mr. Martinelli. the nurse should advise him to:
a. Smoke low-tar, filter cigarettes
b. Smoke cigars instead
c. Smoke only right after meals
d. Chew gum instead
45. As the nurse preparing Ivlr. Martinelii for gastric analysis. You should know which of the
following Is not.correct concerning this test
a. The patient Is fasting 12 hours prior to test
b. Gastric contents are aspirated via a tube
c. Smoking for 8 hours prior to test is not allowed
d. Various position changes are necessary during the test
46. Mr. Martinelli had an Hgb of 9.8. You would not find which of the following assessments in a
patient with severe anemia?
a. Pallor
b. Cold sensitivity
c. Fatigue
d. Dyspnea only on exertion
47. When you report on duty, your team leader tells you that Mr. MartineHi accidentally received
1000 ml of fluids in 2 hours and that you are to be alert for signs of circulatory overload. Which
of the following signs would not be likely to occur?
a. moist gurgling respirations
b. Weak, slow pulse
c. Distended neck veins
d. Dyspnea and coughing
48. A new staff nurse is on an orientation tour with the head nurse. A client approaches her and
says, “I don’t belong here. Please try to get me out.” The staff nurse’s best response would be:
a. “What would you do if you were out of the hospital?”
b. “I am a. new staff member, and I’m on a tour. I’ll come back and talk with you later.”
c. “I think you should talk to the head nurse about that.’
d. “I can’t do anything about that.”
49. A 50 year-old male client has a history of many hospitalizations for schizophrenic disorder.
He has been on long-term phenothiazines (Thorazine), 400 mg/day. The nurse assessing this
client observes that he demonstrates a shuffling gait, drooling and exhibits general dystonic
symptoms.. From these symptoms and his history, the nurse concludes that the client has
developed:
a. Tardive dyskinesia
b. Parkinsonism
c. Dystonia
d. Akathisia
50. A client with antisocial personality disorder tells a nurse “Life has been full of problems since
childhood.” Which of the following situations or conditions would the nurse explore in the
assessment?
a. Birth defects
b. Distracted easily
c. Hypoactive behavior
d. Substance abuse
51. A client with antisocial personality disorder is trying to manipulate the healthcare team.
Which of the following strategies is important for the staff to use?
a. Focus on how to teach the client more effective behaviors for meeting basic needs.
b. Help the client verbalize underlying feelings of hopelessness and learn coping skills.
c. Remain calm and don’t emotionally respond to the client’s manipulative actions.
d. Help the client eliminate the intense desire to have everything in life turn out perfectly.
52. A client with antisocial personality disorder is beginning to practice several socially
acceptable behaviors in the group setting. Which of the following outcomes will result from this
change?
a. Fewer panic attacks
b. Acceptance of reality
c. Improved self-esteem
d. decreased physical symptoms
53. Which of the following discharge instructions would be most accurate to provide to a female
client who has suffered a spinal cord injury at the C4 level?
a. After a spinal cord injury, women usually remain fertile; therefore, you may consider
contraception if you don’t want to become pregnant.
b. After a spinal cord injury, women usually are unable to conceive a child.
c. Sexual intercourse shouldn’t be different for you.
d. After a spinal cord injury, menstruation usually stops.
54.A client with chronic obstructive pulmonary disease (COPD) tells the nurse, “I no longer have
enough energy to make love to my husband.” Which of the following nursing interventions would
be most appropriate?
a. Refer the couple to a sex therapist.
b. Advise the woman to seek a gynecologic consult
c. Suggest methods and measures that facilitate sexual activity.
d. Tell the client, “if you talk this over with your husband, he will understand.
55. A client tells the nurse she is having her menstrual period every 2 weeks and it lasts for 1
week. Which of the following conditions is best defined by this menstrual pattern?
a. Amenorrhea
b. Dyspareunia
c. Oligorrhagia
d. menororrhagia
Answers & Rationale
1. c. Giving thiamine 100 mg IM STAT
2. c. ”I can’t wait to go get pizza with my brother.”
3. c. Giving him step-by-step directions
4. a. Exposure to the sun
5. b. Maintaining constant observation.
6. c. Evidence of delusions and hallucinations
7. b. She may have a predisposition for schizophrenia
8. c. Paranoid
9. c. Hypersensitive
10. b. Hemoglobin S
11. a. ”A person with bulimia nervosa can maintain a normal weight.”
12. c. Hypokalemia
13. c. Electrolyte Imbalance
14. d. Malabsorption of nutrients
15. c. Pain
16. b. Multiple losses
17. d. Explore the family’s ability to express affection appropriately.
18. c. Address the dynamics of the disorder.
19. c. An expected result of the removal of the pituitary gland
20. b. Lifetime dependency on hormone replacement
21. c. Eye opening, verbal response, motor response
22. a. Change in the level of consciousness, tachypnea, tachycardia, petechiae
23. a. Skin care and position q2h and prn; maintain alignment of extremities; respiratory
exercises
24. b. Obtaining blood glucose results
25. d. Infection has increased her insulin needs
26. b. To prevent a hypoglycemic reaction
27. a. Maintain proper body alignment
28. c. A total score for the five areas of 7 or.above.
29. c. ”It Is a temporary interruption in the blood flow to the brain.”
30. b. Eat a diet high in protein and calories to optimize tissue repair.
31. b. Discontinue the medication for a few weeks
32. c. Creation of a tracheostomy
33. a. Reporting that the consent has been obtained from a confused client.
34. a. Multiple serum chorionic gonadotropin levels will be drawn
35. a. Apply pressure by pinching the anterior portion of the for five to ten minutes
36. b. ”I will not give this medication.”
37. d. Complete a nursing assessment of the patient
38. a. Hemoglobin level of 9 mg/dL
39. a. Using a low-pitched voice
40. b. Regular insulin (Humulin R)
41. a. ”At what time did the pain start?”
42. c. 6.25
43. d. Benztropine mesyiate (Cogentin)
44. c. Smoke only right after meals
45. d. Various position changes are necessary during the test
46. d. Dyspnea only on exertion
47. b. Weak, slow pulse
48. b. ”I am a. new staff member, and I’m on a tour. I’ll come back and talk with you later.”
49. a. Tardive dyskinesia
50. d. Substance abuse
51. c. Remain calm and don’t emotionally respond to the client’s manipulative actions.
52. c. Improved self-esteem
53. a. After a spinal cord injury, women usually remain fertile; therefore, you may consider
contraception if you don’t want to become pregnant.
54. c. Suggest methods and measures that facilitate sexual activity.
55. d. menorrhagia
1. Nurse Tony should first discuss terminating the nurse-client relationship with a client
during the:
a. Termination phase when discharge plans are being made.
b. Working phase when the client shows some progress.
c. Orientation phase when a contract is established.
d. Working phase when the client brings it up.
2. Malou is diagnosed with major depression spends majority of the day lying in bed with
the sheet pulled over his head. Which of the following approaches by the nurse would be
the most therapeutic?
a. Question the client until he responds
b. Initiate contact with the client frequently
c. Sit outside the clients room
d. Wait for the client to begin the conversation
3. Joe who is very depressed exhibits psychomotor retardation, a flat affect and apathy.
The nurse in charge observes Joe to be in need of grooming and hygiene. Which of the
following nursing actions would be most appropriate?
a. Waiting until the client’s family can participate in the client’s care
b. Asking the client if he is ready to take shower
c. Explaining the importance of hygiene to the client
d. Stating to the client that it’s time for him to take a shower
4. When teaching Mario with a typical depression about foods to avoid while taking
phenelzine(Nardil), which of the following would the nurse in charge include?
a. Roasted chicken
b. Fresh fish
c. Salami
d. Hamburger
5. When assessing a female client who is receiving tricyclic antidepressant therapy,
which of the following would alert the nurse to the possibility that the client is
experiencing anticholinergic effects?
a. Urine retention and blurred vision
b. Respiratory depression and convulsion
c. Delirium and Sedation
d. Tremors and cardiac arrhythmias
6. For a male client with dysthymic disorder, which of the following approaches would
the nurse expect to implement?
a. ECT
b. Psychotherapeutic approach
c. Psychoanalysis
d. Antidepressant therapy
7. Danny who is diagnosed with bipolar disorder and acute mania, states the nurse,
“Where is my daughter? I love Louis. Rain, rain go away. Dogs eat dirt.” The nurse
interprets these statements as indicating which of the following?
a. Echolalia
b. Neologism
c. Clang associations
d. Flight of ideas
8. Terry with mania is skipping up and down the hallway practically running into other
clients. Which of the following activities would the nurse in charge expect to include in
Terry’s plan of care?
a. Watching TV
b. Cleaning dayroom tables
c. Leading group activity
d. Reading a book
9. When assessing a male client for suicidal risk, which of the following methods of
suicide would the nurse identify as most lethal?
a. Wrist cutting
b. Head banging
c. Use of gun
d. Aspirin overdose
10. Jun has been hospitalized for major depression and suicidal ideation. Which of the
following statements indicates to the nurse that the client is improving?
a. “I’m of no use to anyone anymore.”
b. “I know my kids don’t need me anymore since they’re grown.”
c. “I couldn’t kill myself because I don’t want to go to hell.”
d. “I don’t think about killing myself as much as I used to.”
11. Which of the following activities would Nurse Trish recommend to the client who
becomes very anxious when thoughts of suicide occur?
a. Using exercise bicycle
b. Meditating
c. Watching TV
d. Reading comics
12. When developing the plan of care for a client receiving haloperidol, which of the
following medications would nurse Monet anticipate administering if the client developed
extra pyramidal side effects?
a. Olanzapine (Zyprexa)
b. Paroxetine (Paxil)
c. Benztropine mesylate (Cogentin)
d. Lorazepam (Ativan)
13. Jon a suspicious client states that “I know you nurses are spraying my food with
poison as you take it out of the cart.” Which of the following would be the best response
of the nurse?
a. Giving the client canned supplements until the delusion subsides
b. Asking what kind of poison the client suspects is being used
c. Serving foods that come in sealed packages
d. Allowing the client to be the first to open the cart and get a tray
14. A client is suffering from catatonic behaviors. Which of the following would the nurse
use to determine that the medication administered PRN have been most effective?
a. The client responds to verbal directions to eat
b. The client initiates simple activities without direction
c. The client walks with the nurse to her room
d. The client is able to move all extremities occasionally
15. Nurse Hazel invites new client’s parents to attend the psycho educational program for
families of the chronically mentally ill. The program would be most likely to help the
family with which of the following issues?
a. Developing a support network with other families
b. Feeling more guilty about the client’s illness
c. Recognizing the client’s weakness
d. Managing their financial concern and problems
16. When planning care for Dory with schizotypal personality disorder, which of the
following would help the client become involved with others?
a. Attending an activity with the nurse
b. Leading a sing a long in the afternoon
c. Participating solely in group activities
d. Being involved with primarily one to one activities
17. Which statement about an individual with a personality disorder is true?
a. Psychotic behavior is common during acute episodes
b. Prognosis for recovery is good with therapeutic intervention
c. The individual typically remains in the mainstream of society, although he has problems in
social and occupational roles
d. The individual usually seeks treatment willingly for symptoms that are personally distressful.
18. Nurse John is talking with a client who has been diagnosed with antisocial
personality about how to socialize during activities without being seductive. Nurse John
would focus the discussion on which of the following areas?
a. Discussing his relationship with his mother
b. Asking him to explain reasons for his seductive behavior
c. Suggesting to apologize to others for his behavior
d. Explaining the negative reactions of others toward his behavior
19. Tina with a histrionic personality disorder is melodramatic and responds to others
and situations in an exaggerated manner. Nurse Trish would recommend which of the
following activities for Tina?
a. Baking class
b. Role playing
c. Scrap book making
d. Music group
20. Joy has entered the chemical dependency unit for treatment of alcohol dependency.
Which of the following client’s possession will the nurse most likely place in a locked
area?
a. Toothpaste
b. Shampoo
c. Antiseptic wash
d. Moisturizer
21. Which of the following assessment would provide the best information about the
client’s physiologic response and the effectiveness of the medication prescribed
specifically for alcohol withdrawal?
a. Sleeping pattern
b. Mental alertness
c. Nutritional status
d. Vital signs
22. After administering naloxone (Narcan), an opioid antagonist, Nurse Ronald should
monitor the female client carefully for which of the following?
a. Respiratory depression
b. Epilepsy
c. Kidney failure
d. Cerebral edema
23. Which of the following would nurse Ronald use as the best measure to determine a
client’s progress in rehabilitation?
a. The way he gets along with his parents
b. The number of drug-free days he has
c. The kinds of friends he makes
d. The amount of responsibility his job entails
24. A female client is brought by ambulance to the hospital emergency room after taking
an overdose of barbiturates is comatose. Nurse Trish would be especially alert for which
of the following?
a. Epilepsy
b. Myocardial Infarction
c. Renal failure
d. Respiratory failure
25. Joey who has a chronic user of cocaine reports that he feels like he has cockroaches
crawling under his skin. His arms are red because of scratching. The nurse in charge
interprets these findings as possibly indicating which of the following?
a. Delusion
b. Formication
c. Flash back
d. Confusion
Psychiatric Nursing Exams: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | All
26. Jose is diagnosed with amphetamine psychosis and was admitted in the emergency
room. Nurse Ronald would most likely prepare to administer which of the following
medication?
a. Librium
b. Valium
c. Ativan
d. Haldol
27. Which of the following liquids would nurse Leng administer to a female client who is
intoxicated with phencyclidine (PCP) to hasten excretion of the chemical?
a. Shake
b. Tea
c. Cranberry Juice
d. Grape juice
28. When developing a plan of care for a female client with acute stress disorder who lost
her sister in a car accident. Which of the following would the nurse expect to initiate?
a. Facilitating progressive review of the accident and its consequences
b. Postponing discussion of the accident until the client brings it up
c. Telling the client to avoid details of the accident
d. Helping the client to evaluate her sister’s behavior
29. The nursing assistant tells nurse Ronald that the client is not in the dining room for
lunch. Nurse Ronald would direct the nursing assistant to do which of the following?
a. Tell the client he’ll need to wait until supper to eat if he misses lunch
b. Invite the client to lunch and accompany him to the dining room
c. Inform the client that he has 10 minutes to get to the dining room for lunch
d. Take the client a lunch tray and let the client eat in his room
30. The initial nursing intervention for the significant-others during shock phase of a
grief reaction should be focused on:
a. Presenting full reality of the loss of the individuals
b. Directing the individual’s activities at this time
c. Staying with the individuals involved
d. Mobilizing the individual’s support system
31. Joy’s stream of consciousness is occupied exclusively with thoughts of her father’s
death. Nurse Ronald should plan to help Joy through this stage of grieving, which is
known as:
a. Shock and disbelief
b. Developing awareness
c. Resolving the loss
d. Restitution
32. When taking a health history from a female client who has a moderate level of
cognitive impairment due to dementia, the nurse would expect to note the presence of:
a. Accentuated premorbid traits
b. Enhance intelligence
c. Increased inhibitions
d. Hyper vigilance
33. What is the priority care for a client with a dementia resulting from AIDS?
a. Planning for remotivational therapy
b. Arranging for long term custodial care
c. Providing basic intellectual stimulation
d. Assessing pain frequently
34. Jerome who has eating disorder often exhibits similar symptoms. Nurse Lhey would
expect an adolescent client with anorexia to exhibit:
a. Affective instability
b. Dishered, unkempt physical appearance
c. Depersonalization and derealization
d. Repetitive motor mechanisms
35. The primary nursing diagnosis for a female client with a medical diagnosis of major
depression would be:
a. Situational low self-esteem related to altered role
b. Powerlessness related to the loss of idealized self
c. Spiritual distress related to depression
d. Impaired verbal communication related to depression
36. When developing an initial nursing care plan for a male client with a Bipolar I disorder
(manic episode) nurse Ron should plan to?
a. Isolate his gym time
b. Encourage his active participation in unit programs
c. Provide foods, fluids and rest
d. Encourage his participation in programs
37. Grace is exhibiting withdrawn patterns of behavior. Nurse Johnny is aware that this
type of behavior eventually produces feeling of:
a. Repression
b. Loneliness
c. Anger
d. Paranoia
38. One morning a female client on the inpatient psychiatric service complains to nurse
Hazel that she has been waiting for over an hour for someone to accompany her to
activities. Nurse Hazel replies to the client “We’re doing the best we can. There are a lot
of other people on the unit who needs attention too.” This statement shows that the
nurse’s use of:
a. Defensive behavior
b. Reality reinforcement
c. Limit-setting behavior
d. Impulse control
39. A nursing diagnosis for a male client with a diagnosed multiple personality disorder
is chronic low self-esteem probably related to childhood abuse. The most appropriate
short term client outcome would be:
a. Verbalizing the need for anxiety medications
b. Recognizing each existing personality
c. Engaging in object-oriented activities
d. Eliminating defense mechanisms and phobia
40. A 25 year old male is admitted to a mental health facility because of inappropriate
behavior. The client has been hearing voices, responding to imaginary companions and
withdrawing to his room for several days at a time. Nurse Monette understands that the
withdrawal is a defense against the client’s fear of:
a. Phobia
b. Powerlessness
c. Punishment
d. Rejection
41. When asking the parents about the onset of problems in young client with the
diagnosis of schizophrenia, Nurse Linda would expect that they would relate the client’s
difficulties began in:
a. Early childhood
b. Late childhood
c. Adolescence
d. Puberty
42. Jose who has been hospitalized with schizophrenia tells Nurse Ron, “My heart has
stopped and my veins have turned to glass!” Nurse Ron is aware that this is an example
of:
a. Somatic delusions
b. Depersonalization
c. Hypochondriasis
d. Echolalia
43. In recognizing common behaviors exhibited by male client who has a diagnosis of
schizophrenia, nurse Josie can anticipate:
a. Slumped posture, pessimistic out look and flight of ideas
b. Grandiosity, arrogance and distractibility
c. Withdrawal, regressed behavior and lack of social skills
d. Disorientation, forgetfulness and anxiety
44. One morning, nurse Diane finds a disturbed client curled up in the fetal position in
the corner of the dayroom. The most accurate initial evaluation of the behavior would be
that the client is:
a. Physically ill and experiencing abdominal discomfort
b. Tired and probably did not sleep well last night
c. Attempting to hide from the nurse
d. Feeling more anxious today
45. Nurse Bea notices a female client sitting alone in the corner smiling and talking to
herself. Realizing that the client is hallucinating. Nurse Bea should:
a. Invite the client to help decorate the dayroom
b. Leave the client alone until he stops talking
c. Ask the client why he is smiling and talking
d. Tell the client it is not good for him to talk to himself
46. When being admitted to a mental health facility, a young female adult tells Nurse
Mylene that the voices she hears frighten her. Nurse Mylene understands that the client
tends to hallucinate more vividly:
a. While watching TV
b. During meal time
c. During group activities
d. After going to bed
47. Nurse John recognizes that paranoid delusions usually are related to the defense
mechanism of:
a. Projection
b. Identification
c. Repression
d. Regression
48. When planning care for a male client using paranoid ideation, nurse Jasmin should
realize the importance of:
a. Giving the client difficult tasks to provide stimulation
b. Providing the client with activities in which success can be achieved
c. Removing stress so that the client can relax
d. Not placing any demands on the client
49. Nurse Gerry is aware that the defense mechanism commonly used by clients who are
alcoholics is:
a. Displacement
b. Denial
c. Projection
d. Compensation
50. Within a few hours of alcohol withdrawal, nurse John should assess the male client
for the presence of:
a. Disorientation, paranoia, tachycardia
b. Tremors, fever, profuse diaphoresis
c. Irritability, heightened alertness, jerky movements
d. Yawning, anxiety, convulsions
Answers & Rationale
1. C. When the nurse and client agree to work together, a contract should be established, the
length of the relationship should be discussed in terms of its ultimate termination.
2. B. The nurse should initiate brief, frequent contacts throughout the day to let the client know
that he is important to the nurse. This will positively affect the client’s self-esteem.
3. D. The client with depression is preoccupied, has decreased energy, and is unable to make
decisions. The nurse presents the situation, “It’s time for a shower”, and assists the client
with personal hygiene to preserve his dignity and self-esteem.
4. C. Foods high in tyramine, those that are fermented, pickled, aged, or smoked must be
avoided because when they are ingested in combination with MAOIs a hypertensive crisis
will occur.
5. A. Anticholinergic effects, which result from blockage of the parasympathetic (craniosacral)
nervous system including urine retention, blurred vision, dry mouth & constipation.
6. B. Dysthymia is a less severe, chronic depression diagnosed when a client has had a
depressed mood for more days than not over a period of at least 2 years. Client with
dysthymic disorder benefit from psychotherapeutic approaches that assist the client in
reversing the negative self image, negative feelings about the future.
7. D. Flight of ideas is speech pattern of rapid transition from topic to topic, often without
finishing one idea. It is common in mania.
8. B. The client with mania is very active & needs to have this energy channeled in a
constructive task such as cleaning or tidying the room.
9. C. A crucial factor is determining the lethality of a method is the amount of time that occurs
between initiating the method & the delivery of the lethal impact of the method.
10. D. The statement “I don’t think about killing myself as much as I used to.” Indicates a
lessening of suicidal ideation and improvement in the client’s condition.
11. A. Using exercise bicycle is appropriate for the client who becomes very anxious when
thoughts of suicidal occur.
12. C. The drug of choice for a client experiencing extra pyramidal side effects from haloperidol
(Haldol) is benztropine mesylate (cogentin) because of its anti cholinergic properties.
13. D. Allowing the client to be the first to open the cart & take a tray presents the client with the
reality that the nurses are not touching the food & tray, thereby dispelling the delusion.
14. B. Although all the actions indicate improvement, the ability to initiate simple activities
without directions indicates the most improvement in the catatonic behaviors.
15. A. Psychoeducational groups for families develop a support network. They provide education
about the biochemical etiology of psychiatric disease to reduce, not increase family guilt.
16. C. Attending activity with the nurse assists the client to become involved with others slowly.
The client with schizotypal personality disorder needs support, kindness & gentle suggestion
to improve social skills & interpersonal relationship.
17. C. An individual with personality disorder usually is not hospitalized unless a coexisting Axis I
psychiatric disorder is present. Generally, these individuals make marginal adjustments and
remain in society, although they typically experience relationship and occupational problems
related to their inflexible behaviors. Personality disorders are chronic lifelong patterns of
behavior; acute episodes do not occur. Psychotic behavior is usually not common, although
it can occur in either schizotypal personality disorder or borderline personality disorder.
Because these disorders are enduring and evasive and the individual is inflexible, prognosis
for recovery is unfavorable. Generally, the individual does not seek treatment because he
does not perceive problems with his own behavior. Distress can occur based on other
people’s reaction to the individual’s behavior.
18. D. The nurse would explain the negative reactions of others towards the client’s behaviors to
make the clients aware of the impact of his seductive behaviors on others.
19. B. The nurse would use role-playing to teach the client appropriate responses to others and
in various situations. This client dramatizes events, drawn attention to self, and is unaware of
and does not deal with feelings. The nurse works to help the client clarify true feelings &
learn to express them appropriately.
20. C. Antiseptic mouthwash often contains alcohol & should be kept in locked area, unless
labeling clearly indicates that the product does not contain alcohol.
21. D. Monitoring of vital signs provides the best information about the client’s overall physiologic
status during alcohol withdrawal & the physiologic response to the medication used.
22. A. After administering naloxone (Narcan) the nurse should monitor the client’s respiratory
status carefully, because the drug is short acting & respiratory depression may recur after its
effects wear off.
23. B. The best measure to determine a client’s progress in rehabilitation is the number of drug-
free days he has. The longer the client is free of drugs, the better the prognosis is.
24. D. Barbiturates are CNS depressants; the nurse would be especially alert for the possibility
of respiratory failure. Respiratory failure is the most likely cause of death from barbiturate
over dose.
25. B. The feeling of bugs crawling under the skin is termed as formication, and is associated
with cocaine use.
26. D. The nurse would prepare to administer an antipsychotic medication such as Haldol to a
client experiencing amphetamine psychosis to decrease agitation & psychotic symptoms,
including delusions, hallucinations & cognitive impairment.
27. C. An acid environment aids in the excretion of PCP. The nurse will definitely give the client
with PCP intoxication cranberry juice to acidify the urine to a ph of 5.5 & accelerate
excretion.
28. A. The nurse would facilitate progressive review of the accident and its consequence to help
the client integrate feelings & memories and to begin the grieving process.
29. B. The nurse instructs the nursing assistant to invite the client to lunch & accompany him to
the dinning room to decrease manipulation, secondary gain, dependency and reinforcement
of negative behavior while maintaining the client’s worth.
30. C. This provides support until the individuals coping mechanisms and personal support
systems can be immobilized.
31. C. Resolving a loss is a slow, painful, continuous process until a mental image of the dead
person, almost devoid of negative or undesirable features emerges.
32. A. A moderate level of cognitive impairment due to dementia is characterized by increasing
dependence on environment & social structure and by increasing psychologic rigidity with
accentuated previous traits & behaviors.
33. C. This action maintains for as long as possible, the clients intellectual functions by providing
an opportunity to use them.
34. A. Individuals with anorexia often display irritability, hospitality, and a depressed mood.
35. D. Depressed clients demonstrate decreased communication because of lack of psychic or
physical energy.
36. C. The client in a manic episode of the illness often neglects basic needs, these needs are a
priority to ensure adequate nutrition, fluid, and rest.
37. B. The withdrawn pattern of behavior presents the individual from reaching out to others for
sharing the isolation produces feeling of loneliness.
38. A. The nurse’s response is not therapeutic because it does not recognize the client’s needs
but tries to make the client feel guilty for being demanding.
39. B. The client must recognize the existence of the sub personalities so that interpretation can
occur.
40. D. An aloof, detached, withdrawn posture is a means of protecting the self by withdrawing
and maintaining a safe, emotional distance.
41. C. The usual age of onset of schizophrenia is adolescence or early childhood.
42. A. Somatic delusion is a fixed false belief about one’s body.
43. C. These are the classic behaviors exhibited by clients with a diagnosis of schizophrenia.
44. D. The fetal position represents regressed behavior. Regression is a way of responding to
overwhelming anxiety.
45. B. This provides a stimulus that competes with and reduces hallucination.
46. D. Auditory hallucinations are most troublesome when environmental stimuli are diminished
and there are few competing distractions.
47. A. Projection is a mechanism in which inner thoughts and feelings are projected onto the
environment, seeming to come from outside the self rather than from within.
48. B. This will help the client develop self-esteem and reduce the use of paranoid ideation.
49. B. Denial is a method of resolving conflict or escaping unpleasant realities by ignoring their
existence.
50. C. Alcohol is a central nervous system depressant. These symptoms are the body’s
neurologic adaptation to the withdrawal of alcohol.
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.”
RATIONALE
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. 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.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.”
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 behavior4. 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.”5. How soon after chlorpromazine (Thorazine) administration should the nurse expect to see a client’s delusional thoughts and hallucinations eliminatedA. Several minutesB. Several hoursC. Several daysD. Several weeks6. 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.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.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.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 tomorrow10. 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.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.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.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.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.”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 communication16. 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.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.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.”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.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.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.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)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.”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.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 sayingPsychiatric Nursing Exams: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | All
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 movements27. 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.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.”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 irreversible30. 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. Akathisia31. 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)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 needs33. 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?”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.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)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 interactions37. 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.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 times39. 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 loss40. 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).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.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.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 transient44. 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.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 attackB. ProjectionC. HallucinationD. Delusion46. 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.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.48. A client with paranoid type schizophrenia becomes angry and tells the nurse to leave him alone. The nurse shouldA. 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 him49. 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.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.
Answers & Rationale1. 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 behaviorRationale: 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 eliminatedA. Several minutesB. Several hoursC. Several daysD. Several weeksRationale: 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 tomorrowRationale: 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 communicationRationale: 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 sayingRationale: 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 movementsRationale: 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 irreversibleRationale: 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. AkathisiaRationale: 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 needsRationale: 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 interactionsRationale: 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 timesRationale: 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 lossRationale: 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 disorders43. 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 transientRationale: 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 immediately44. 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 attackB. ProjectionC. HallucinationD. DelusionRationale: 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 stimulation46. 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 shouldA. 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 himRationale: 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 situation49. 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
