NCLEX Psychiatric Nursing Practice Exam #03 In Text Mode: All questions and answers are given for reading and answering at your own pace.
Question 1. Barbara with bipolar disorder is being treated with lithium for the first time. Nurse Clint should observe the client for which common adverse effect of lithium?
B). Sexual dysfunction.
Question 1 Answer: D). Polyuria.
Question 1 Explanation: Polyuria commonly occurs early in the treatment with lithium and could result in fluid volume deficit.
Question 2. Nursing preparation for a client undergoing electroconvulsive therapy (ECT) resemble those used for:
A). Physical therapy.
B). General anesthesia.
C). Cardiac stress testing.
D). Neurologic examination.
Question 2 Answer: B). General anesthesia.
Question 2 Explanation: The nurse should prepare a client for ECT in a manner similar to that for general anesthesia.
Question 3. A client refuses to remain on psychotropic medications after discharge from an inpatient psychiatric unit. Which information should the community health nurse assess first during the initial follow-up with this client?
A). Income level and living arrangements.
B). Reason for refusal to take medications.
C). Reason for inpatient admission.
D). Involvement of family and support systems.
Question 3 Answer: B). Reason for refusal to take medications.
Question 3 Explanation: The first are for assessment would be the client’s reason for refusing medication. The client may not understand the purpose for the medication, may be experiencing distressing side effects, or may be concerned about the cost of medicine. In any case, the nurse cannot provide appropriate intervention before assessing the client’s problem with the medication. The patient’s income level, living arrangements, and involvement of family and support systems are relevant issues following determination of the client’s reason for refusing medication. The nurse providing follow-up care would have access to the client’s medical record and should already know the reason for inpatient admission.
Question 4. A nurse who explains that a client’s psychotic behavior is unconsciously motivated understands that the client’s disordered behavior arises from which of the following?
A). Abnormal thinking.
B). Altered neurotransmitters.
C). Response to stimuli.
D). Internal needs.
Question 4 Answer: D). Internal needs.
Question 4 Explanation: The concept that behavior is motivated and has meaning comes from the psychodynamic framework. According to this perspective, behavior arises from internal wishes or needs. Much of what motivates behavior comes from the unconscious. The remaining responses do not address the internal forces thought to motivate behavior.
Question 5. Which of the following is the most distinguishing feature of a client with an antisocial personality disorder?
A). Attention to detail and order.
B). Bizarre mannerisms and thoughts.
C). Submissive and dependent behavior.
D). Disregard for social and legal norms.
Question 5 Answer: D). Disregard for social and legal norms.
Question 5 Explanation: Disregard for established rules of society is the most common characteristic of a client with antisocial personality disorder. Attention to detail and
order is characteristic of someone with obsessive compulsive disorder. Bizarre mannerisms and thoughts are characteristics of a client with schizoid or
schizotypal disorder. Submissive and dependent behaviors are characteristic of someone with a dependent personality.
Question 6. The most critical factor for nurse Linda to determine during crisis intervention would be the client’s:
A). Available situational supports.
B). Willingness to restructure the personality.
C). Developmental theory.
D). Underlying unconscious conflict.
Question 6 Answer: A). Available situational supports.
Question 6 Explanation: Personal internal strength and supportive individuals are critical factors that can be employed to assist the individual to cope with a crisis.
Question 7. Before helping a male client who has been sexually assaulted, nurse Maureen should recognize that the rapist is motivated by feelings of:
Question 7 Answer: B). Hostility.
Question 7 Explanation: Rapists are believed to harbor and act out hostile feelings toward all women through the act of rape.
Question 8. Erlinda, age 85, with major depression undergoes a sixth electroconvulsive therapy (ECT) treatment. When assessing the client immediately after ECT, the nurse expects to find:
A). Permanent short-term memory loss and hypertension.
B). Permanent long-term memory loss and hypomania.
C). Transitory short and long term memory loss and confusion.
D). Transitory short-term memory loss and permanent long-term memory loss.
Question 8 Answer: C). Transitory short and long term memory loss and confusion.
Question 8 Explanation: ECT commonly causes transitory short and long term memory loss and confusion, especially in geriatric clients. It rarely results in permanent short and long term memory loss.
Question 9. Initial interventions for Marco with acute anxiety include all except which of the following?
A). Providing the client with a safe, quiet and private place.
B). Touching the client in an attempt to comfort him.
C). Approaching the client in calm, confident manner.
D). Encouraging the client to verbalize feelings and concerns.
Question 9 Answer: B). Touching the client in an attempt to comfort him.
Question 9 Explanation: The emergency nurse must establish rapport and trust with the anxious client before using therapeutic touch. Touching an anxious client may actually increase anxiety.
Question 10. When working with children who have been sexually abused by a family member it is important for the nurse to understand that these victims usually are overwhelmed with feelings of:
B). Self blame.
Question 10 Answer: B). Self blame.
Question 10 Explanation: These children often have nonsexual needs met by individual and are powerless to refuse.Ambivalence results in self-blame and also guilt.
Question 11. Nurse Trish suggests a crisis intervention group to a client experiencing a developmental crisis.These groups are successful because the:
A). Client is encouraged to talk about personal problems.
B). Crisis intervention worker is a psychologist and understands behavior patterns.
C). Client is assisted to investigate alternative approaches to solving the identified problem.
D). Crisis group supplies a workable solution to the client’s problem.
Question 11 Answer: C). Client is assisted to investigate alternative approaches to solving the identified problem.
Question 11 Explanation: Crisis intervention group helps client reestablish psychologic equilibrium by assisting them to explore new alternatives for coping. It considers realistic situations using rational and flexible problem solving methods.
Question 12. Which nursing diagnosis is most appropriate for a client with anorexia nervosa who expresses feelings of guilt about not meeting family expectations?
B). Defensive coping.
D). Disturbed body image.
Question 12 Answer: A). Powerlessness.
Question 12 Explanation: The client with anorexia typically feels powerless, with a sense of having little control over any aspect of life besides eating behavior. Often, parental
expectations and standards are quite high and lead to the clients’ sense of guilt over not measuring up.
Question 13. Which of the following statements should be included when teaching clients about monoamine oxidase inhibitor (MAOI) antidepressants?
A). Avoid strenuous activity because of the cardiac effects of the drug.
B). Don’t take aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs).
C). Have blood levels screened weekly for leucopenia.
D). Don’t take prescribed or over the counter medications without consulting the physician.
Question 13 Answer: D). Don’t take prescribed or over the counter medications without consulting the physician.
Question 13 Explanation: MAOI antidepressants when combined with a number of drugs can cause life-threatening hypertensive crisis. It’s imperative that a client checks with his physician and pharmacist before taking any other medications.
Question 14. In the diagnosis of a possible pervasive developmental autistic disorder. The nurse would find it most unusual for a 3 year old child to demonstrate:
A). Ritualistic behavior.
B). An attachment to odd objects.
C). Responsiveness to the parents.
D). An interest in music.
Question 14 Answer: C). Responsiveness to the parents.
Question 14 Explanation: One of the symptoms of autistic child displays a lack of responsiveness to others. There is little or no extension to the external environment.
Question 15. A client with depressive symptoms is given prescribed medications and talks with his therapist about his belief that he is worthless and unable to cope with life. Psychiatric care in this treatment plan is based on which framework?
A). Behavioral framework.
B). Interpersonal framework.
C). Psychodynamic framework.
D). Cognitive framework.
Question 15 Answer: D). Cognitive framework.
Question 15 Explanation: Cognitive thinking therapy focuses on the client’s misperceptions about self, others and the world that impact functioning and contribute to symptoms. Using medications to alter neurotransmitter activity is a psychobiologic approachto treatment. The other answer choices are frameworks for care, but hey are not applicable to this situation.
Question 16. Francis who is addicted to cocaine withdraws from the drug. Nurse Ron should expect to observe:
Question 16 Answer: C). Depression.
Question 16 Explanation: There is no set of symptoms associated with cocaine withdrawal, only the depression that follows the high caused by the drug.
Question 17. The home health psychiatric nurse visits a client with chronic schizophrenia who was recently discharged after a prolong stay in a state hospital. The client lives in a boarding home, reports no family involvement, and has little social interaction. The nurse plan to refer the client to a day treatment program in order to help him with:
A). Vocational training.
B). Social skills training.
C). Managing his hallucinations.
D). Medication teaching.
Question 17 Answer: B). Social skills training.
Question 17 Explanation: Day treatment programs provide clients with chronic, persistent mental illness training in social skills, such as meeting and greeting people, asking
questions or directions, placing an order in a restaurant, taking turns in a group setting activity. Although management of hallucinations and medication teaching may also be part of the program offered in a day treatment, the nurse is referring the client in this situation because of his need for socialization skills. Vocational training generally takes place in a rehabilitation facility; the client described in this situation would not be a candidate for this service.
Question 18. Which activity would be most appropriate for a severely withdrawn client?
A). Team sport in the gym.
B). Art activity with a staff member.
C). Watching TV in the dayroom.
D). Board game with a small group of clients.
Question 18 Answer: B). Art activity with a staff member.
Question 18 Explanation: The best approach with a withdrawn client is to initiate brief, nondemanding activities on a one-to-one basis. This approach gives the nurse an opportunity to establish a trusting relationship with the client. A board game with a group clients or playing a team sport in the gym may overwhelm a severely withdrawn client. Watching TV is a solitary activity that will reinforce the client’s withdrawal from others.
Question 19. Nurse Fred is assessing a client who has just been admitted to the ER department.Which signs would suggest an overdose of an antianxiety agent?
A). Suspiciousness, dilated pupils and incomplete BP.
B). Combativeness, sweating and confusion.
C). Emotional lability, euphoria and impaired memory.
D). Agitation, hyperactivity and grandiose ideation.
Question 19 Answer: C). Emotional lability, euphoria and impaired memory.
Question 19 Explanation: Signs of anxiety agent overdose include emotional lability, euphoria and impaired memory.
Question 20. A client with major depression has not verbalized problem areas to staff or peers since admission to a psychiatric unit. Which activity should the nurse recommend to help this client express himself?
A). Watching movie with the peer group.
B). Basketball game with peers on the unit.
C). Art therapy in a small group.
D). Reading a self-help book on depression.
Question 20 Answer: C). Art therapy in a small group.
Question 20 Explanation: Art therapy provides a nonthreatening vehicle for the expression of feelings, and use of a small group will help the client become comfortable with
peers in a group setting. Basketball is a competitive game that requires energy; the client with major depression is not likely to participate in this activity.
Recommending that the client read a self-help book may increase, not decrease his isolation. Watching movie with a peer group does not guarantee that
interaction will occur; therefore, the client may remain isolated.
Question 21. Tony with agoraphobia has been symptom-free for 4 months. Classicsigns and symptoms of phobia include:
A). Insomnia and inability to concentrate.
B). Withdrawal and failure to distinguish reality from fantasy.
C). Severe anxiety and fear.
D). Depression and weight loss.
Question 21 Answer: C). Severe anxiety and fear.
Question 21 Explanation: Phobias cause severe anxiety (such as panic attack) that is out of proportion to the threat of the feared object or situation. Physical signs and symptoms of phobias include profuse sweating, poor motor control, tachycardia and elevated B.P.
Question 22. Which nursing action is most appropriate when trying to diffuse a client’s impending violent behavior?
A). Involving the client in a quiet activity to divert attention.
B). Helping the client identify and express feelings of anxiety and anger.
C). Place the client in seclusion.
D). Leaving the client alone until he can talk about his feelings.
Question 22 Answer: B). Helping the client identify and express feelings of anxiety and anger.
Question 22 Explanation: In many instances, the nurse can diffuse impending violence by helping the client identify and express feelings of anger and anxiety. Such statement as “What happened to get you this angry?” may help the client verbalizes feelings rather than act on them.
Question 23. A client with depression has been hospitalized for treatment after taking a leave of absence from work. The client’s employer expects the client to return to work following inpatient treatment. The client tells the nurse, “I’m no good. I’m a failure”. According to cognitive theory, these statements reflect:
A). Faulty thought processes that govern behavior.
B). Learned behavior.
C). Punitive superego and decreased self-esteem.
D). Evidence of difficult relationships in the work environment.
Question 23 Answer: A). Faulty thought processes that govern behavior.
Question 23 Explanation: The client is demonstrating faulty thought processes that are negative and that govern his behavior in his work situation – issues that are typically examined using a cognitive theory approach. Issues involving learned behavior are best explored through behavior theory, not cognitive theory. Issues involving ego development are the focus of psychoanalytic theory.There is no evidence in this situation that the client has conflictual relationships in the work environment.
Question 24. A tentative diagnosis of opiate addiction, Nurse Candy should assess a recently hospitalized client for signs of opiate withdrawal. These signs would include:
A). Lacrimation, vomiting, drowsiness.
B). Muscle aches, papillary constriction, yawning.
C). Rhinorrhea, convulsions, subnormal temperature.
D). Nausea, dilated pupils, constipation.
Question 24 Answer: B). Muscle aches, papillary constriction, yawning.
Question 24 Explanation: These adaptations are associated with opiate withdrawal which occurs after cessation or reduction of prolonged moderate or heavy use of opiates.
Question 25. Nurse John is aware that a serious effect of inhaling cocaine is?
A). Deterioration of nasal septum.
B). Esophageal varices.
C). Extra pyramidal tract symptoms.
D). Acute fluid and electrolyte imbalances.
Question 25 Answer: A). Deterioration of nasal septum.
Question 25 Explanation: Cocaine is a chemical that when inhaled, causes destruction of the mucous membranes of the nose.
Question 26. When performing a physicalexamination on a female anxious client, nurse Nelli would expect to find which of the following effects produced by the parasympathetic system?
A). Hyperactive bowel sounds.
B). Muscle tension.
D). Decreased urine output.
Question 26 Answer: A). Hyperactive bowel sounds.
Question 26 Explanation: The parasympathetic nervous system would produce incomplete G.I. motility resulting in hyperactive bowel sounds, possibly leading to diarrhea.
Question 27. Nurse John is aware that the therapy that has the highest success rate for people with phobias would be:
A). Psychotherapy aimed at rearranging maladaptive thought process.
B). Psychoanalytical exploration of repressed conflicts of an earlier development phase.
C). Systematic desensitization using relaxation technique.
D). Insight therapy to determine the origin of the anxiety and fear.
Question 27 Answer: C). Systematic desensitization using relaxation technique.
Question 27 Explanation: The most successful therapy for people with phobias involves behavior modification techniques using desensitization.
Question 28. Which medication can control the extra pyramidal effects associated with antipsychotic agents?
A). Amantadine (Symmetrel).
B). Clorazepate (Tranxene).
C). Doxepin (Sinequan).
D). Perphenazine (Trilafon).
Question 28 Answer: A). Amantadine (Symmetrel).
Question 28 Explanation: Amantadine is an anticholinergic drug used to relive drug-induced extra pyramidal adverse effects such as muscle weakness, involuntary muscle movements, pseudoparkinsonism and tar dive dyskinesia.
Question 29. The nurse is caring for a client with an autoimmune disorder at a medical clinic, where alternative medicine is used as an adjunct to traditional therapies. Which information should the nurse teach the client to help foster a sense of control over his symptoms?
A). Pathophysiology of disease process.
B). Stress management techniques.
C). Side effects of medications.
D). Principles of good nutrition.
Question 29 Answer: B). Stress management techniques.
Question 29 Explanation: In autoimmune disorders, stress and the response to stress can exacerbate symptoms. Stress management techniques can help the client reduce the psychological response to stress, which in turn will help reduce the physiologic stress response. This will afford the client an increased sense of control over his symptoms. The nurse can address the remaining answer choices in her teaching about the client’s disease and treatment; however, knowledge alone will not help the client to manage his stress effectively enough to control symptoms.
Question 30. A client with a phobic disorder is treated by systematic desensitization. The nurse understands that this approach will do which of the following?
A). Help the client execute actions that are feared.
B). Help the client decrease anxiety.
C). Help the client develop insight into irrational fears.
D). Help the client substitutes one fear for another.
Question 30 Answer: A). Help the client execute actions that are feared.
Question 30 Explanation: Systematic desensitization is a behavioral therapy technique that helps clients with irrational fears and avoidance behavior to face the thing they fear, without experiencing anxiety. There is no attempt to promote insight with this procedure, and the client will not be taught to substitute one fear for another.
Although the client’s anxiety may decrease with successful confrontation of irrational fears, the purpose of the procedure is specifically related to performing
activities that typically are avoided as part of the phobic response.
Question 31. When nurse Hazel considers a client’s placement on the continuum of anxiety, a key in determining the degree of anxiety being experienced is the client’s:
A). Perceptual field.
B). Creativity level.
C). Memory state.
D). Delusional system.
Question 31 Answer: A). Perceptual field.
Question 31 Explanation: Perceptual field is a key indicator of anxiety level because the perceptual fields narrow as anxiety increases.
Question 32. Which of the following drugs have been known to be effective in treating obsessive-compulsive disorder (OCD)?
A). Chlordiazepoxide (Librium) and diazepam (valium).
B). Divalproex (depakote) and Lithium (lithobid).
C). Fluvoxamine (Luvox) and clomipramine (anafranil).
D). Benztropine (Cogentin) and diphenhydramine (benadryl).
Question 32 Answer: C). Fluvoxamine (Luvox) and clomipramine (anafranil).
Question 32 Explanation: The antidepressants fluvoxamine and clomipramine have been effective in the treatment of OCD.
Question 33. Joy who has just experienced her second spontaneous abortion expresses anger towards her physician, the hospital and the “rotten nursing care”. When assessing the situation, the nurse recognizes that the client may be using the coping mechanism of:
A). Reaction formation.
Question 33 Answer: B). Displacement.
Question 33 Explanation: The client’s anger over the abortion is shifted to the staff and the hospital because she is unable to deal with the abortion at this time.
Question 34. Important teaching for women in their childbearing years who are receiving antipsychotic medications includes which of the following?
A). Instruction that amenorrhea is irreversible.
B). Continuing previous use of contraception during periods of amenorrhea.
C). Increased incidence of dysmenorrhea while taking the drug.
D). Occurrence of incomplete libido due to medication adverse effects.
Question 34 Answer: B). Continuing previous use of contraception during periods of amenorrhea.
Question 34 Explanation: Women may experience amenorrhea, which is reversible, while taking antipsychotics. Amenorrhea doesn’t indicate cessation of ovulation thus, the client can still be pregnant.
Question 35. The nurse understands that the therapeutic effects of typical antipsychotic medications are associated with which neurotransmitter change?
A). Stimulation of GABA.
B). Decreased dopamine level.
C). Increased acetylcholine level.
D). Stabilization of serotonin.
Question 35 Answer: B). Decreased dopamine level.
Question 35 Explanation: Excess dopamine is thought to be the chemical cause for psychotic thinking. The typical antipsychotics act to block dopamine receptors and therefore decrease the amount of neurotransmitter at the synapses. The typical antipsychotics do not increase acetylcholine, stabilize serotonin, stimulate GABA.
Question 36. Nurse Jessie is assessing a client suffering from stress and anxiety. A common physiological response to stress and anxiety is:
Question 36 Answer: C). Diarrhea.
Question 36 Explanation: Diarrhea is a common physiological response to stress and anxiety.
Question 37. Nurse Ronald could evaluate that the staff’s approach to setting limits for a demanding, angry client was effective if the client:
A). Discuss concerns regarding the emotional condition that required hospitalizations.
B). Understands the reason why frequent calls to the staff were made.
C). Apologizes for disrupting the unit’s routine when something is needed.
D). No longer calls the nursing staff for assistance.
Question 37 Answer: A). Discuss concerns regarding the emotional condition that required hospitalizations.
Question 37 Explanation: This would document that the client feels comfortable enough to discuss the problems that have motivated the behavior.
Question 38. Jose who is receiving monoamine oxidase inhibitor antidepressant should avoid tyramine, a compound found in which of the following foods?
A). Green leafy vegetables.
B). Figs and cream cheese.
C). Fruits and yellow vegetables.
D). Aged cheese and Chianti wine.
Question 38 Answer: D). Aged cheese and Chianti wine.
Question 38 Explanation: Aged cheese and Chianti wine contain high concentrations of tyramine.
Question 39. Malou with schizophrenia tells Nurse Melinda, “My intestines are rotted from worms chewing on them.” This statement indicates a:
A). Delusion of persecution.
B). Somatic delusion.
C). Jealous delusion.
D). Delusion of grandeur.
Question 39 Answer: B). Somatic delusion.
Question 39 Explanation: Somatic delusions focus on bodily functions or systems and commonly include delusion about foul odor emissions, insect manifestations, internal parasites and misshapen parts.
Question 40. A nurse is evaluating therapy with the family of a client with anorexia nervosa. Which of the following would indicate that the therapy was successful?
A). The parents reinforced increased decision making by the client.
B). The parents clearly verbalize their expectations for the client.
C). The client tells her parents about feelings of low-self esteem.
D). The client verbalizes that family meals are now enjoyable.
Question 40 Answer: A). The parents reinforced increased decision making by the client.
Question 40 Explanation: One of the core issues concerning the family of a client with anorexia is control. The family’s acceptance of the client’s ability to make independent decisions is key to successful family intervention. Although the remaining options may occur during the process of therapy, they would not necessarily indicate a successful outcome; the central family issues of dependence and independence are not addresses on these responses.
Question 41. PROPRANOLOL (Inderal) is used in the mental health setting to manage which of the following conditions?
A). Antipsychotic – induced akathisia and anxiety.
B). Delusions for clients suffering from schizophrenia.
C). Obsessive – compulsive disorder (OCD) to reduce ritualistic behavior.
D). The manic phase of bipolar illness as a mood stabilizer.
Question 41 Answer: A). Antipsychotic – induced akathisia and anxiety.
Question 41 Explanation: Propranolol is a potent beta adrenergic blocker and producing a sedating effect, therefore it is used to treat antipsychotic induced akathisia and anxiety.
Question 42. Andy is admitted to the psychiatric unit with a diagnosis of borderline personality disorder. Nurse Hilary should expects the assessment to reveal:
A). Unpredictable behavior and intense interpersonal relationships.
B). Somatic symptoms.
C). Inability to function as responsible parent.
D). Coldness, detachment and lack of tender feelings.
Question 42 Answer: A). Unpredictable behavior and intense interpersonal relationships.
Question 42 Explanation: A client with borderline personality 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.
Question 43. Kris periodically has acute panic attacks. These attacks are unpredictable and have no apparent association with a specific object or situation. During an acute panic attack, Kris may experience:
A). Decreased perceptual field.
B). Decreased respiratory rate.
C). Decreased cardiac rate.
D). Heightened concentration.
Question 43 Answer: A). Decreased perceptual field.
Question 43 Explanation: Panic is the most severe level of anxiety. During panic attack, the client experiences a decrease in the perceptual field, becoming more focused on self, less aware of surroundings and unable to process information from the environment. The decreased perceptual field contributes to impaired attention and inability to concentrate.
Question 44. Which of the following best explains why tricyclic antidepressants are used with caution in elderly patients?
A). Serotonin syndrome effects.
B). Cardiovascular system effects.
C). Gastrointestinal system effects.
D). Central Nervous System effects.
Question 44 Answer: B). Cardiovascular system effects.
Question 44 Explanation: The TCAs affect norepinephrine as well as other neurotransmitters, and thus have significant cardiovascular side effects. Therefore, they are used with caution in elderly clients who may have increased risk factors for cardiac problems because of their age and other medical conditions. The remaining side effects would apply to any client taking a TCA and are not particular to an elderly person.
Question 45. Which client outcome would best indicate successful treatment for a client with an antisocial personality disorder?
A). The client makes statements of self-satisfaction.
B). The client’s statements indicate no remorse for behaviors.
C). The client has decreased episodes of impulsive behaviors.
D). The client exhibits charming behavior when around authority figures.
Question 45 Answer: C). The client has decreased episodes of impulsive behaviors.
Question 45 Explanation: A client with antisocial personality disorder typically has frequent episodes of acting impulsively with poor ability to delay self-gratification. Therefore, decreased frequency of impulsive behaviors would be evidence of improvement. Charming behavior when around authority figures and statements indicating no
remorse are examples of symptoms typical of someone with this disorder and would not indicate successful treatment. Self-satisfaction would be viewed as a
positive change if the client expresses low self-esteem; however this is not a characteristic of a client with antisocial personality disorder.
Question 46. Rosana is in the second stage of Alzheimer’s disease who appears to be in pain. Which question by Nurse Jenny would best elicit information about the pain?
A). “Can you describe your pain?”.
B). “Where do you hurt?”.
C). “Do you hurt? (pause) “Do you hurt?”.
D). “Where is your pain located?”.
Question 46 Answer: C). “Do you hurt? (pause) “Do you hurt?”.
Question 46 Explanation: When speaking to a client with Alzheimer’s disease, the nurse should use close-ended questions.Those that the client can answer with “yes” or “no” whenever possible and avoid questions that require the client to make choices. Repeating the question aids comprehension.
Question 47. A 48 year old male client is brought to the psychiatric emergency room after attempting to jump off a bridge. The client’s wife states that he lost his job several months ago and has been unable to find another job. The primary nursing intervention at this time would be to assess for:
A). A past history of depression.
B). Current plans to commit suicide.
C). The presence of marital difficulties.
D). Feelings of excessive failure.
Question 47 Answer: B). Current plans to commit suicide.
Question 47 Explanation: Whether there is a suicide plan is a criterion when assessing the client’s determination to make another attempt.
Question 48. A client with dysthymic disorder reports to a nurse that his life is hopeless and will never improve in the future. How can the nurse best respond using a cognitive approach?
A). Agree with the client’s painful feelings.
B). Present a cheerful attitude.
C). Challenge the accuracy of the client’s belief.
D). Deny that the situation is hopeless.
Question 48 Answer: C). Challenge the accuracy of the client’s belief.
Question 48 Explanation: Use of cognitive techniques allows the nurse to help the client recognize that this negative beliefs may be distortions and that, by changing his thinking, he can adopt more positive beliefs that are realistic and hopeful. Agreeing with the client’s feelings and presenting a cheerful attitude are not consistent with a cognitive approach and would not be helpful in this situation. Denying the client’s feelings is belittling and may convey that the nurse does not understand the depth of the client’s distress.
Question 49. Discharge instructions for a male client receiving tricyclic antidepressants include which of the following information?
A). Restrict fluid and sodium intake.
B). Restrict fluids and sodium intake.
C). Discontinue if dry mouth and blurred vision occur.
D). Don’t consume alcohol.
Question 49 Answer: D). Don’t consume alcohol.
Question 49 Explanation: Drinking alcohol can potentiate the sedating action of tricyclic antidepressants. Dry mouth and blurred vision are normal adverse effects of tricyclic antidepressants.
Question 50. The nurse describes a client as anxious. Which of the following statement about anxiety is true?
A). Anxiety is usually pathological.
B). Anxiety is a response to a threat.
C). Anxiety is usually harmful.
D). Anxiety is directly observable.
Question 50 Answer: B). Anxiety is a response to a threat.
Question 50 Explanation: Anxiety is a response to a threat arising from internal or external stimuli.