NCLEX Psychiatric Nursing Practice Exam #04 In Text Mode: All questions and answers are given for reading and answering at your own pace.
Question 1. A 32 year old male graduate student, who has become increasingly withdrawn and neglectful of his work and personal hygiene, is brought to the psychiatric hospital by his parents. After detailed assessment, a diagnosis of schizophrenia is made. It is unlikely that the client will demonstrate:
A). Concrete thinking.
B). Low self esteem.
C). Weak ego.
D). Effective self boundaries.
Question 1 Answer: D). Effective self boundaries.
Question 1 Explanation: A person with this disorder would not have adequate self-boundaries.
Question 2. A long term goal for a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs would be to help the client develop:
A). Insight into his behavior.
B). Better self control.
C). Faith in his wife.
D). Feeling of self worth.
Question 2 Answer: D). Feeling of self worth.
Question 2 Explanation: Helping the client to develop feeling of self worth would reduce the client’s need to use pathologic defenses.
Question 3. Nurse Anna can minimize agitation in a disturbed client by?
A). increasing appropriate sensory perception.
B). ensuring constant client and staff contact.
C). limiting unnecessary interaction.
D). Increasing stimulation.
Question 3 Answer: C). limiting unnecessary interaction.
Question 3 Explanation: Limiting unnecessary interaction will decrease stimulation and agitation.
Question 4. A nursing care plan for a male client with bipolar I disorder should include:
A). Engaging the client in conversing about current affairs.
B). Providing a structured environment.
C). Touching the client provide assurance.
D). Designing activities that will require the client to maintain contact with reality.
Question 4 Answer: B). Providing a structured environment.
Question 4 Explanation: Structure tends to decrease agitation and anxiety and to increase the client’s feeling of security.
Question 5. Which of the following foods would the nurse Trish eliminate from the diet of a client in alcohol withdrawal?
C). Regular Coffee.
D). Orange Juice.
Question 5 Answer: C). Regular Coffee.
Question 5 Explanation: Regular coffee contains caffeine which acts as psychomotor stimulants and leads to feelings of anxiety and agitation. Serving coffee top the client may add to tremors or wakefulness.
Question 6. A 20 year old client was diagnosed with dependent personality disorder. Which behavior is not most likely to be evidence of ineffective individual coping?
A). Recurrent self-destructive behavior.
B). Avoiding relationship.
C). Showing interest in solitary activities.
D). Inability to make choices and decision without advise.
Question 6 Answer: D). Inability to make choices and decision without advise.
Question 6 Explanation: Individual with dependent personality disorder typically shows indecisiveness submissiveness and clinging behavior so that others will make decisions with them.
Question 7. A male client is diagnosed with schizotypal personality disorder. Which signs would this client exhibit during social situation?
A). Aggressive behavior.
B). Paranoid thoughts.
C). Independence need.
D). Emotional affect.
Question 7 Answer: B). Paranoid thoughts.
Question 7 Explanation: Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts.
Question 8. When teaching parents about childhood depression Nurse Trina should say?
A). Looks almost identical to adult depression.
B). Is short in duration & resolves easily.
C). Does not respond to conventional treatment.
D). It may appear acting out behavio.
Question 8 Answer: D). It may appear acting out behavio.
Question 8 Explanation: Children have difficulty verbally expressing their feelings, acting out behavior, such as temper tantrums, may indicate underlying depression.
Question 9. Nurse Tina is caring for a client with depression who has not responded to antidepressant medication. The nurse anticipates that what treatment procedure may be prescribed?
A). Electroconvulsive therapy.
C). Short term seclusion.
D). Neuroleptic medication.
Question 9 Answer: A). Electroconvulsive therapy.
Question 9 Explanation: Electroconvulsive therapy is an effective treatment for depression that has not responded to medication.
Question 10. Nurse Jonel is providing information to a community group about violence in the family. Which statement by a group member would indicate a need to provide additional information?
A). “Abuse occurs more in low-income families”.
B). “Abuser Are often jealous or self-centered”.
C). “Abuser use fear and intimidation”.
D). “Abuser usually have poor self-esteem”.
Question 10 Answer: A). “Abuse occurs more in low-income families”.
Question 10 Explanation: Personal characteristics of abuser include low self-esteem, immaturity, dependence, insecurity and jealousy.
Question 11. A female client is admitted with a diagnosis of delusions of GRANDEUR. This diagnosis reflects a belief that one is:
A). Highly famous and important.
B). Responsible for evil world.
C). Connected to client unrelated to oneself.
D). Being Killed.
Question 11 Answer: A). Highly famous and important.
Question 11 Explanation: Delusion of grandeur is a false belief that one is highly famous and important.
Question 12. When planning care for a female client using ritualistic behavior, Nurse Gina must recognize that the ritual:
A). Is used by the client primarily for secondary gains.
B). Is under the client’s conscious control.
C). Helps the client focus on the inability to deal with reality.
D). Helps the client control the anxiety.
Question 12 Answer: D). Helps the client control the anxiety.
Question 12 Explanation: The rituals used by a client with obsessive compulsive disorder help control the anxiety level by maintaining a set pattern of action.
Question 13. Mario is complaining to other clients about not being allowed by staff to keep food in his room. Which of the following interventions would be most appropriate?
A). Reprimanding the client.
B). Ignoring the clients behavior.
C). Allowing a snack to be kept in his room.
D). Setting limits on the behavior.
Question 13 Answer: D). Setting limits on the behavior.
Question 13 Explanation: The nurse needs to set limits in the client’s manipulative behavior to help the client control dysfunctional behavior. A consistent approach by the staff is necessary to decrease manipulation.
Question 14. Nurse Tony was caring for a 41 year old female client. Which behavior by the client indicates adult cognitive development?
A). Has maximum ability to solve problems and learn new skills.
B). Generates new levels of awareness.
C). Assumes responsibility for her actions.
D). Her perception are based on reality.
Question 14 Answer: B). Generates new levels of awareness.
Question 14 Explanation: An adult age 31 to 45 generates new level of awareness.
Question 15. A client is experiencing anxiety attack. The most appropriate nursing intervention should include?
A). Ask the client to play with other clients.
B). Turning on the television.
C). Leaving the client alone.
D). Staying with the client and speaking in short sentences.
Question 15 Answer: D). Staying with the client and speaking in short sentences.
Question 15 Explanation: Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm and medicating as needed.
Question 16. A 60 year old female client who lives alone tells the nurse at the community health center “I really don’t need anyone to talk to”. The TV is my best friend. The nurse recognizes that the client is using the defense mechanism known as?
Question 16 Answer: C). Denial.
Question 16 Explanation: The client statement is an example of the use of denial, a defense that blocks problem by unconscious refusing to admit they exist.
Question 17. Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of prescribed antipsychotic medication. The most important piece of information the nurse in charge should obtain initially is the:
A). Name of the nearest relative & their phone number.
B). Name of the ingested medication & the amount ingested.
C). Length of time on the med..
D). Reason for the suicide attempt.
Question 17 Answer: B). Name of the ingested medication & the amount ingested.
Question 17 Explanation: In an emergency, lives saving facts are obtained first. The name and the amount of medication ingested are of outmost important in treating this potentially life threatening situation.
Question 18. Nurse Claire is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is?
A). Eat only three meals a day.
B). Avoid shopping plenty of groceries.
C). Identify anxiety causing situations.
D). Encourage to avoid foods.
Question 18 Answer: C). Identify anxiety causing situations.
Question 18 Explanation: Bulimia disorder generally is a maladaptive coping response to stress and underlying issues. The client should identify anxiety causing situation that stimulate the bulimic behavior and then learn new ways of coping with the anxiety.
Question 19. Nurse Benjie is communicating with a male client with substance-induced persisting dementia; the client cannot remember facts and fills in the gaps with imaginary information. Nurse Benjie is aware that this is typical of?
B). Flight of ideas.
D). Associative looseness.
Question 19 Answer: C). Confabulation.
Question 19 Explanation: Confabulation or the filling in of memory gaps with imaginary facts is a defense mechanism used by people experiencing memory deficits.
Question 20. Which of the following approaches would be most appropriate to use with a client suffering from narcissistic personality disorder when discrepancies exist between what the client states and what actually exist?
A). Supportive confrontation.
B). Limit setting.
Question 20 Answer: A). Supportive confrontation.
Question 20 Explanation: The nurse would specifically use supportive confrontation with the client to point out discrepancies between what the client states and what actually exists to increase responsibility for self.
Question 21. A 23 year old client has been admitted with a diagnosis of schizophrenia says to the nurse “Yes, its march, March is little woman”. That’s literal you know”. These statement illustrate:
A). Loosening of association.
B). Flight of ideas.
Question 21 Answer: A). Loosening of association.
Question 21 Explanation: Loose associations are thoughts that are presented without the logical connections usually necessary for the listening to interpret the message.
Question 22. Nurse Tina is caring for a client with delirium and states that “look at the spiders on the wall”. What should the nurse respond to the client?
A). “You’re having hallucination, there are no spiders in this room at all”.
B). “I know you are frightened, but I do not see spiders on the wall”.
C). “Would you like me to kill the spiders”.
D). “I can see the spiders on the wall, but they are not going to hurt you”.
Question 22 Answer: B). “I know you are frightened, but I do not see spiders on the wall”.
Question 22 Explanation: When hallucination is present, the nurse should reinforce reality with the client.
Question 23. Nurse Penny is aware that the symptoms that distinguish post traumatic stress disorder from other anxiety disorder would be
A). Re-experiencing the trauma in dreams or flashback.
B). Depression and a blunted affect when discussing the traumatic situation.
C). Avoidance of situation & certain activities that resemble the stress.
D). Lack of interest in family & others.
Question 23 Answer: A). Re-experiencing the trauma in dreams or flashback.
Question 23 Explanation: Experiencing the actual trauma in dreams or flashback is the major symptom that distinguishes post traumatic stress disorder from other anxiety disorder.
Question 24. Joey a client with antisocial personality disorder belches loudly. A staff member asks Joey, “Do you know why people find you repulsive?” this statement most likely would elicit which of the following client reaction?
Question 24 Answer: B). Defensiveness.
Question 24 Explanation: When the staff member ask the client if he wonders why others find him repulsive, the client is likely to feel defensive because the question is belittling. The natural tendency is to counterattack the threat to self image.
Question 25. A characteristic that would suggest to Nurse Anne that an adolescent may have bulimia would be:
A). Positive body image.
B). Badly stained teeth.
C). Frequent regurgitation & re-swallowing of food.
D). Previous history of gastritis.
Question 25 Answer: B). Badly stained teeth.
Question 25 Explanation: Dental enamel erosion occurs from repeated self-induced vomiting.
Question 26. Nurse Joey is aware that the signs & symptoms that would be most specific for diagnosis anorexia are?
A). Slow pulse, 10% weight loss & alopecia.
B). Compulsive behavior, excessive fears & nausea.
C). Excessive weight loss, amenorrhea & abdominal distension.
D). Excessive activity, memory lapses & an increased pulse.
Question 26 Answer: C). Excessive weight loss, amenorrhea & abdominal distension.
Question 26 Explanation: These are the major signs of anorexia nervosa. Weight loss is excessive (15% of expected weight).
Question 27. To establish open and trusting relationship with a female client who has been hospitalized with severe anxiety, the nurse in charge should?
A). Encourage the staff to have frequent interaction with the client.
B). Give client feedback about behavior.
C). Share an activity with the client.
D). Respect client’s need for personal space.
Question 27 Answer: D). Respect client’s need for personal space.
Question 27 Explanation: Moving to a client’s personal space increases the feeling of threat, which increases anxiety.
Question 28. A neuromuscular blocking agent is administered to a client before ECT therapy. The Nurse should carefully observe the client for?
A). Nausea and vomiting.
C). Respiratory difficulties.
Question 28 Answer: C). Respiratory difficulties.
Question 28 Explanation: Neuromuscular Blocker, such as SUCCINYLCHOLINE (Anectine) produces respiratory depression because it inhibits contractions of respiratory muscles.
Question 29. When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates achievement of the discharge maintenance goals. Which goal would be most appropriately having been included in the plan of care requiring evaluation?
A). The client identifies anxiety producing situations.
B). The client maintains contact with a crisis counselor.
C). The client eliminates all anxiety from daily situations.
D). The client ignores feelings of anxiety.
Question 29 Answer: A). The client identifies anxiety producing situations.
Question 29 Explanation: Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid specific stimulus.
Question 30. Which of the following would Nurse Hazel expect to assess for a client who is exhibiting late signs of heroin withdrawal?
A). Yawning & diaphoresis.
B). Restlessness & Irritability.
C). Constipation & steatorrhea.
D). Vomiting and Diarrhea.
Question 30 Answer: D). Vomiting and Diarrhea.
Question 30 Explanation: Vomiting and diarrhea are usually the late signs of heroin withdrawal, along with muscle spasm, fever, nausea, repetitive, abdominal cramps and backache.
Question 31. Nurse Monet is caring for a female client who has suicidal tendency. When accompanying the client to the restroom, Nurse Monet should…
A). Allow her to urinate.
B). Observe her.
C). Give her privacy.
D). Open the window and allow her to get some fresh air.
Question 31 Answer: B). Observe her.
Question 31 Explanation: The Nurse has a responsibility to observe continuously the acutely suicidal client. The Nurse should watch for clues, such as communicating suicidal thoughts, and messages; hoarding medications and talking about death.
Question 32. Conney with borderline personality disorder who is to be discharge soon threatens to “do something” to herself if discharged. Which of the following actions by the nurse would be most important?
A). Discuss the meaning of the client’s statement with her.
B). Request an immediate extension for the client.
C). Ask a family member to stay with the client at home temporarily.
D). Ignore the clients statement because it’s a sign of manipulation.
Question 32 Answer: A). Discuss the meaning of the client’s statement with her.
Question 32 Explanation: Any suicidal statement must be assessed by the nurse. The nurse should discuss the client’s statement with her to determine its meaning in terms of suicide.
Question 33. Marco approached Nurse Trish asking for advice on how to deal with his alcohol addiction. Nurse Trish should tell the client that the only effective treatment for alcoholism is:
A). Alcoholics anonymous (A.A.).
C). Aversion Therapy.
D). Total abstinence.
Question 33 Answer: D). Total abstinence.
Question 33 Explanation: Total abstinence is the only effective treatment for alcoholism.
Question 34. Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor. When Nurse Nina enters the client’s room, the client is found lying on the bed with a body pulled into a fetal position. Nurse Nina should?
A). Leave the client alone and continue with providing care to the other clients.
B). Ask the client direct questions to encourage talking.
C). Rake the client into the dayroom to be with other clients.
D). Sit beside the client in silence and occasionally ask open-ended question.
Question 34 Answer: D). Sit beside the client in silence and occasionally ask open-ended question.
Question 34 Explanation: Clients who are withdrawn may be immobile and mute, and require consistent, repeated interventions. Communication with withdrawn clients requires much patience from the nurse. The nurse facilitates communication with the client by sitting in silence, asking open-ended question and pausing to provide opportunities for the client to respond.
Question 35. Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis and hyperactivity. Blood pressure is 190/87 mmhg and pulse is 92 bpm. Which of the medications would the nurse expect to administer?
A). Lorazepam (Ativan).
B). Haloperidol (Haldol).
C). Benzlropine (Cogentin).
D). Naloxone (Narcan).
Question 35 Answer: A). Lorazepam (Ativan).
Question 35 Explanation: The nurse would most likely administer benzodiazepine, such as lorazepan (ativan) to the client who is experiencing symptom: The client’s experiences symptoms of withdrawal because of the rebound phenomenon when the sedation of the CNS from alcohol begins to decrease.
Question 36. To further assess a client’s suicidal potential. Nurse Katrina should be especially alert to the client expression of:
A). Anger & resentment.
B). Frustration & fear of death.
C). Helplessness & hopelessness.
D). Anxiety & loneliness.
Question 36 Answer: C). Helplessness & hopelessness.
Question 36 Explanation: The expression of these feeling may indicate that this client is unable to continue the struggle of life.
Question 37. Nurse Hazel is caring for a male client who experience false sensory perceptions with no basis in reality. This perception is known as:
C). Loose associations.
Question 37 Answer: D). Hallucinations.
Question 37 Explanation: Hallucinations are visual, auditory, gustatory, tactile or olfactory perceptions that have no basis in reality.
Question 38. A 75 year old client is admitted to the hospital with the diagnosis of dementia of the Alzheimer’s type and depression. The symptom that is unrelated to depression would be?
A). Shallow of labile effect.
B). Apathetic response to the environment.
C). “I don’t know” answer to questions.
D). Neglect of personal hygiene.
Question 38 Answer: A). Shallow of labile effect.
Question 38 Explanation: With depression, there is little or no emotional involvement therefore little alteration in affect.
Question 39. When working with a male client suffering phobia about black cats, Nurse Trish should anticipate that a problem for this client would be?
A). Distortion of reality when completing daily routines.
B). Anger toward the feared object.
C). Anxiety when discussing phobia.
D). Denying that the phobia exist.
Question 39 Answer: C). Anxiety when discussing phobia.
Question 39 Explanation: Discussion of the feared object triggers an emotional response to the object.
Question 40. Nurse Patricia is aware that the major health complication associated with intractable anorexia nervosa would be?
A). Cardiac dysrhythmias resulting to cardiac arrest.
B). Decreased metabolism causing cold intolerance.
C). Endocrine imbalance causing cold amenorrhea.
D). Glucose intolerance resulting in protracted hypoglycemia.
Question 40 Answer: A). Cardiac dysrhythmias resulting to cardiac arrest.
Question 40 Explanation: These clients have severely depleted levels of sodium and potassium because of their starvation diet and energy expenditure, these electrolytes are necessary for cardiac functioning.
Question 41. Nurse Maureen is developing a plan of care for a female client with anorexia nervosa. Which action should the nurse include in the plan?
A). Encourage client to exercise to reduce anxiety.
B). Set-up a strict eating plan for the client.
C). Restrict visits with the family.
D). Provide privacy during meals.
Question 41 Answer: B). Set-up a strict eating plan for the client.
Question 41 Explanation: Establishing a consistent eating plan and monitoring client’s weight are important to this disorder.
Question 42. Nurse Monette is aware that extremely depressed clients seem to do best in settings where they have:
A). Multiple stimuli.
B). Varied Activities.
C). Minimal decision making.
D). Routine Activities.
Question 42 Answer: D). Routine Activities.
Question 42 Explanation: Depression usually is both emotional & physical. A simple daily routine is the best, least stressful and least anxiety producing.
Question 43. During electroconvulsive therapy (ECT) the client receives oxygen by mask via positive pressure ventilation. The nurse assisting with this procedure knows that positive pressure ventilation is necessary because?
A). Muscle relaxations given to prevent injury during seizure activity depress respirations..
B). Decrease oxygen to the brain increases confusion and disorientation.
C). Anesthesia is administered during the procedure.
D). Grand mal seizure activity depresses respirations.
Question 43 Answer: A). Muscle relaxations given to prevent injury during seizure activity depress respirations..
Question 43 Explanation: A short acting skeletal muscle relaxant such as succinylcholine (Anectine) is administered during this procedure to prevent injuries during seizure.
Question 44. A 39 year old mother with obsessive-compulsive disorder has become immobilized by her elaborate hand washing and walking rituals. Nurse Trish recognizes that the basis of O.C. disorder is often:
A). Feelings of guilt and inadequacy.
B). Problems with anger and remorse.
C). Feeling of unworthiness and hopelessness.
D). Problems with being too conscientious.
Question 44 Answer: A). Feelings of guilt and inadequacy.
Question 44 Explanation: Ritualistic behavior seen in this disorder is aimed at controlling guilt and inadequacy by maintaining an absolute set pattern of behavior.
Question 45. Nurse Monette recognizes that the focus of environmental (MILIEU) therapy is to:
A). Manipulate the environment to bring about positive changes in behavior.
B). Allow the client’s freedom to determine whether or not they will be involved in activities.
C). Use natural remedies rather than drugs to control behavior.
D). Role play life events to meet individual needs.
Question 45 Answer: A). Manipulate the environment to bring about positive changes in behavior.
Question 45 Explanation: Environmental (MILIEU) therapy aims at having everything in the client’s surrounding area toward helping the client.
Question 46. A male client who is experiencing disordered thinking about food being poisoned is admitted to the mental health unit. The nurse uses which communication technique to encourage the client to eat dinner?
A). Verbalizing reasons that the client may not choose to eat.
B). Offering opinion about the need to eat.
C). Using open ended question and silence.
D). Focusing on self-disclosure of own food preference.
Question 46 Answer: C). Using open ended question and silence.
Question 46 Explanation: Open ended questions and silence are strategies used to encourage clients to discuss their problem in descriptive manner.
Question 47. Linda is pacing the floor and appears extremely anxious. The duty nurse approaches in an attempt to alleviate Linda’s anxiety. The most therapeutic question by the nurse would be?
A). Would you like to watch TV?.
B). Ignore the client.
C). Are you feeling upset now?.
D). Would you like me to talk with you?.
Question 47 Answer: D). Would you like me to talk with you?.
Question 47 Explanation: The nurse presence may provide the client with support & feeling of control.
Question 48. Nurse Perry is aware that language development in autistic child resembles:
C). Speech lag.
D). Scanning speech.
Question 48 Answer: A). Echolalia.
Question 48 Explanation: The autistic child repeat sounds or words spoken by others.
Question 49. Nurse Trish would expect a child with a diagnosis of reactive attachment disorder to:
A). Cling to mother & cry on separation.
B). Have more positive relation with the father than the mother.
C). Be able to develop only superficial relation with the others.
D). Have been physically abuse.
Question 49 Answer: C). Be able to develop only superficial relation with the others.
Question 49 Explanation: Children who have experienced attachment difficulties with primary caregiver are not able to trust others and therefore relate superficially
Question 50. Nurse Trish is working in a mental health facility; the nurse priority nursing intervention for a newly admitted client with bulimia nervosa would be to?
A). Monitor client continuously.
B). Involve client in planning daily meal.
C). Observe client during meals.
D). Teach client to measure I & O.
Question 50 Answer: A). Monitor client continuously.
Question 50 Explanation: These clients often hide food or force vomiting; therefore they must be carefully monitored.