NCLEX Psychiatric Nursing Practice Exam #02 In Text Mode: All questions and answers are given for reading and answering at your own pace.
Question 1. 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). Managing their financial concern and problems.
C). Recognizing the client’s weakness.
D). Feeling more guilty about the client’s illness.
Question 1 Answer: A). Developing a support network with other families.
Question 1 Explanation: Psychoeducational groups for families develop a support network. They provide education about the biochemical etiology of psychiatric disease to reduce, not increase family guilt.
Question 2. 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). Clang associations.
B). Flight of ideas.
Question 2 Answer: B). Flight of ideas.
Question 2 Explanation: Flight of ideas is speech pattern of rapid transition from topic to topic, often without finishing one idea. It is common in mania.
Question 3. 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). Enhance intelligence.
B). Accentuated premorbid traits.
C). Increased inhibitions.
D). Hyper vigilance.
Question 3 Answer: B). Accentuated premorbid traits.
Question 3 Explanation: 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.
Question 4. Within a few hours of alcohol withdrawal, nurse John should assess the male client for the presence of:
A). Yawning, anxiety, convulsions.
B). Tremors, fever, profuse diaphoresis.
C). Disorientation, paranoia, tachycardia.
D). Irritability, heightened alertness, jerky movements.
Question 4 Answer: D). Irritability, heightened alertness, jerky movements.
Question 4 Explanation: Alcohol is a central nervous system depressant. These symptoms are the body’s neurologic adaptation to the withdrawal of alcohol.
Question 5. When planning care for Dory with schizotypal personality disorder, which of the following would help the client become involved with others?
A). Being involved with primarily one to one activities.
B). Leading a sing a long in the afternoon.
C). Participating solely in group activities.
D). Attending an activity with the nurse.
Question 5 Answer: C). Participating solely in group activities.
Question 5 Explanation: 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.
Question 6. Jerome who has eating disorder often exhibits similar symptoms.Nurse Lhey would expect an adolescent client with anorexia to exhibit:
A). Dishered, unkempt physical appearance.
B). Repetitive motor mechanisms.
C). Affective instability.
D). Depersonalization and derealization.
Question 6 Answer: C). Affective instability.
Question 6 Explanation: Individuals with anorexia often display irritability, hospitality, and a depressed mood.
Question 7. 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). Late childhood.
C). Early childhood.
Question 7 Answer: D). Adolescence.
Question 7 Explanation: The usual age of onset of schizophrenia is adolescence or early childhood.
Question 8. Nurse Tony should first discuss terminating the nurse-client relationship with a client during the:
A). Working phase when the client shows some progress..
B). Orientation phase when a contract is established..
C). Termination phase when discharge plans are being made..
D). Working phase when the client brings it up..
Question 8 Answer: B). Orientation phase when a contract is established..
Question 8 Explanation: 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.
Question 9. Which of the following would nurse Ronald use as the best measure to determine a client’s progress in rehabilitation?
A). The kinds of friends he makes.
B). The way he gets along with his parents.
C). The amount of responsibility his job entails.
D). The number of drug-free days he has.
Question 9 Answer: D). The number of drug-free days he has.
Question 9 Explanation: 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
Question 10. 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:
Question 10 Answer: B). Rejection.
Question 10 Explanation: An aloof, detached, withdrawn posture is a means of protecting the self by withdrawing and maintaining a safe, emotional distance.
Question 11. 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). Vital signs.
B). Sleeping pattern.
C). Mental alertness.
D). Nutritional status.
Question 11 Answer: A). Vital signs.
Question 11 Explanation: 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.
Question 12. 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). Recognizing each existing personality.
B). Eliminating defense mechanisms and phobia.
C). Verbalizing the need for anxiety medications.
D). Engaging in object-oriented activities.
Question 12 Answer: A). Recognizing each existing personality.
Question 12 Explanation: The client must recognize the existence of the sub personalities so that interpretation can occur.
Question 13. What is the priority care for a client with a dementia resulting from AIDS?
A). Providing basic intellectual stimulation.
B). Assessing pain frequently.
C). Planning for remotivational therapy.
D). Arranging for long term custodial care.
Question 13 Answer: A). Providing basic intellectual stimulation.
Question 13 Explanation: This action maintains for as long as possible, the clients intellectual functions by providing an opportunity to use them.
Question 14. 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.
Question 14 Answer: A). Somatic delusions.
Question 14 Explanation: Somatic delusion is a fixed false belief about one’s body.
Question 15. 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). Removing stress so that the client can relax.
C). Not placing any demands on the client.
D). Providing the client with activities in which success can be achieved.
Question 15 Answer: D). Providing the client with activities in which success can be achieved.
Question 15 Explanation: This will help the client develop self-esteem and reduce the use of paranoid ideation.
Question 16. Jose is diagnosed withamphetamine psychosis and was admitted in the emergency room.Nurse Ronald would most likely prepare to administer which of the following medication?
Question 16 Answer: C). Haldol.
Question 16 Explanation: 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.
Question 17. Which of the following activities would Nurse Trish recommend to the client who becomes very anxious when thoughts of suicide occur?
A). Reading comics.
B). Using exercise bicycle.
D). Watching TV.
Question 17 Answer: B). Using exercise bicycle.
Question 17 Explanation: Using exercise bicycle is appropriate for the client who becomes very anxious when thoughts of suicidal occur.
Question 18. 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). Tell the client it is not good for him to talk to himself.
C). Leave the client alone until he stops talking.
D). Ask the client why he is smiling and talking.
Question 18 Answer: C). Leave the client alone until he stops talking.
Question 18 Explanation: This provides a stimulus that competes with and reduces hallucination.
Question 19. Grace is exhibiting withdrawn patterns of behavior. Nurse Johnny is aware that this type of behavior eventually produces feeling of:
Question 19 Answer: D). Loneliness.
Question 19 Explanation: The withdrawn pattern of behavior presents the individual from reaching out to others for sharing the isolation produces feeling of loneliness.
Question 20. Which statement about an individual with a personality disorder is true?
A). The individual typically remains in the mainstream of society, although he has problems in social and occupational roles.
B). Psychotic behavior is common during acute episodes.
C). The individual usually seeks treatment willingly for symptoms that are personally distressful..
D). Prognosis for recovery is good with therapeutic intervention.
Question 20 Answer: A). The individual typically remains in the mainstream of society, although he has problems in social and occupational roles.
Question 20 Explanation: 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.
Question 21. 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). Mobilizing the individual’s support system.
C). Staying with the individuals involved.
D). Directing the individual’s activities at this time.
Question 21 Answer: C). Staying with the individuals involved.
Question 21 Explanation: This provides support until the individuals coping mechanisms and personal support systems can be immobilized.
Question 22. 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). Asking what kind of poison the client suspects is being used.
B). Serving foods that come in sealed packages.
C). Allowing the client to be the first to open the cart and get a tray.
D). Giving the client canned supplements until the delusion subsides.
Question 22 Answer: C). Allowing the client to be the first to open the cart and get a tray.
Question 22 Explanation: 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.
Question 23. When developing an initial nursing care plan for a male client with a Bipolar I disorder (manic episode) nurse Ron should plan to?
A). Encourage his participation in programs.
B). Provide foods, fluids and rest.
C). Isolate his gym tim.
D). Encourage his active participation in unit programs.
Question 23 Answer: B). Provide foods, fluids and rest.
Question 23 Explanation: 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.
Question 24. When assessing a male client for suicidal risk, which of the following methods of suicide would the nurse identify as most lethal?
A). Aspirin overdose.
B). Head banging.
C). Use of gun.
D). Wrist cutting.
Question 24 Answer: C). Use of gun.
Question 24 Explanation: 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.
Question 25. Nurse Gerry is aware that the defense mechanism commonly used by clients who are alcoholics is:
Question 25 Answer: B). Denial.
Question 25 Explanation: Denial is a method of resolving conflict or escaping unpleasant realities by ignoring their existence.
Question 26. 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). Helping the client to evaluate her sister’s behavior.
D). Telling the client to avoid details of the accident.
Question 26 Answer: A). Facilitating progressive review of the accident and its consequences.
Question 26 Explanation: 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.
Question 27. 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). Tired and probably did not sleep well last night.
B). Physically ill and experiencing abdominal discomfort.
C). Feeling more anxious today.
D). Attempting to hide from the nurse.
Question 27 Answer: C). Feeling more anxious today.
Question 27 Explanation: The fetal position represents regressed behavior. Regression is a way of responding to overwhelming anxiety.
Question 28. 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 couldn’t kill myself because I don’t want to go to hell.”.
B). “I don’t think about killing myself as much as I used to.”.
C). “I’m of no use to anyone anymore.”.
D). “I know my kids don’t need me anymore since they’re grown.”.
Question 28 Answer: B). “I don’t think about killing myself as much as I used to.”.
Question 28 Explanation: 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.
Question 29. Nurse John recognizes that paranoid delusions usually are related to the defense mechanism of:
Question 29 Answer: D). Projection.
Question 29 Explanation: 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.
Question 30. .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). Myocardial Infarction.
B). Respiratory failure.
D). Renal failure.
Question 30 Answer: B). Respiratory failure.
Question 30 Explanation: 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.
Question 31. 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). Flash back.
Question 31 Answer: B). Formication.
Question 31 Explanation: The feeling of bugs crawling under the skin is termed as formication, and is associated with cocaine use.
Question 32. 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.
Question 32 Answer: C). Resolving the loss.
Question 32 Explanation: 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.
Question 33. 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). Delirium and Sedation.
B). Urine retention and blurred vision.
C). Respiratory depression and convulsion.
D). Tremors and cardiac arrhythmias.
Question 33 Answer: B). Urine retention and blurred vision.
Question 33 Explanation: Anticholinergic effects, which result from blockage of the parasympathetic (craniosacral) nervous system including urine retention, blurred vision, dry mouth & constipation.
Question 34. 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 initiates simple activities without direction.
B). The client walks with the nurse to her room.
C). The client responds to verbal directions to eat.
D). The client is able to move all extremities occasionally.
Question 34 Answer: A). The client initiates simple activities without direction.
Question 34 Explanation: Although all the actions indicate improvement, the ability to initiate simple activities without directions indicates the most improvement in the catatonic behaviors.
Question 35. 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). Reality reinforcement.
B). Defensive behavior.
C). Impulse control.
D). Limit-setting behavior.
Question 35 Answer: B). Defensive behavior.
Question 35 Explanation: 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.
Question 36. 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?
C). Grape juice.
D). Cranberry Juice.
Question 36 Answer: D). Cranberry Juice.
Question 36 Explanation: 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.
Question 37. 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). Reading a book.
C). Cleaning dayroom tables.
D). Leading group activity.
Question 37 Answer: C). Cleaning dayroom tables.
Question 37 Explanation: The client with mania is very active & needs to have this energy channeled in a constructive task such as cleaning or tidying the room.
Question 38. 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). Antiseptic wash.
Question 38 Answer: A). Antiseptic wash.
Question 38 Explanation: Antiseptic mouthwash often contains alcohol & should be kept in locked area, unless labeling clearly indicates that the product does not contain alcohol.
Question 39. After administering naloxone (Narcan), an opioid antagonist, Nurse Ronald should monitor the female client carefully for which of the following?
A). Kidney failure.
B). Respiratory depression.
D). Cerebral edema.
Question 39 Answer: B). Respiratory depression.
Question 39 Explanation: 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.
Question 40. For a male client with dysthymic disorder, which of the following approaches would the nurse expect to implement?
A). Psychotherapeutic approach.
B). Antidepressant therapy.
Question 40 Answer: A). Psychotherapeutic approach.
Question 40 Explanation: 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.
Question 41. 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). Suggesting to apologize to others for his behavior.
B). Discussing his relationship with his mother.
C). Asking him to explain reasons for his seductive behavior.
D). Explaining the negative reactions of others toward his behavior.
Question 41 Answer: D). Explaining the negative reactions of others toward his behavior.
Question 41 Explanation: 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.
Question 42. 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). Music group.
B). Scrap book making.
C). Baking class.
D). Role playing.
Question 42 Answer: D). Role playing.
Question 42 Explanation: 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.
Question 43. 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). Take the client a lunch tray and let the client eat in his room.
B). Inform the client that he has 10 minutes to get to the dining room for lunch.
C). Tell the client he’ll need to wait until supper to eat if he misses lunch.
D). Invite the client to lunch and accompany him to the dining room.
Question 43 Answer: D). Invite the client to lunch and accompany him to the dining room.
Question 43 Explanation: 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.
Question 44. 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?
C). Roasted chicken.
D). Fresh fish.
Question 44 Answer: B). Salami.
Question 44 Explanation: 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.
Question 45. 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). Wait for the client to begin the conversation.
B). Question the client until he responds.
C). Sit outside the clients room.
D). Initiate contact with the client frequently.
Question 45 Answer: D). Initiate contact with the client frequently.
Question 45 Explanation: 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.
Question 46. In recognizing common behaviors exhibited by male client who has a diagnosis of schizophrenia, nurse Josie can anticipate:
A). Withdrawal, regressed behavior and lack of social skills.
B). Grandiosity, arrogance and distractibility.
C). Disorientation, forgetfulness and anxiety.
D). Slumped posture, pessimistic out look and flight of ideas.
Question 46 Answer: A). Withdrawal, regressed behavior and lack of social skills.
Question 46 Explanation: These are the classic behaviors exhibited by clients with a diagnosis of schizophrenia.
Question 47. 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). Paroxetine (Paxil).
B). Olanzapine (Zyprexa).
C). Lorazepam (Ativan).
D). Benztropine mesylate (Cogentin).
Question 47 Answer: D). Benztropine mesylate (Cogentin).
Question 47 Explanation: 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.
Question 48. 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). Explaining the importance of hygiene to the client.
B). Asking the client if he is ready to take shower.
C). Stating to the client that it’s time for him to take a shower.
D). Waiting until the client’s family can participate in the client’s care.
Question 48 Answer: C). Stating to the client that it’s time for him to take a shower.
Question 48 Explanation: 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.
Question 49. 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). After going to bed.
B). During group activities.
C). During meal time.
D). While watching TV.
Question 49 Answer: A). After going to bed.
Question 49 Explanation: Auditory hallucinations are most troublesome when environmental stimuli are diminished and there are few competing distractions.
Question 50. 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.
Question 50 Answer: D). Impaired verbal communication related to depression.
Question 50 Explanation: Depressed clients demonstrate decreased communication because of lack of psychic or physical energy.