StuffedNurse : PSYCHIATRIC EXAM PRACTICE TEST [ 2569 Views ] Posted by : admin 1

. The nurse is caring for a client who experiences false sensory perceptions wit
h no basis in reality. These perceptions are known as: a. delusions. b. hallucin
ations. c. loose associations. d. neologisms. RATIONALE: Hallucinations are visu
al, auditory, gustatory, tactile, or olfactory perceptions that have no basis in
reality. Delusions are false beliefs, rather than perceptions, that the client
accepts as real. Loose associations are rapid shifts among unrelated ideas. Neol
ogisms are bizarre words that have meaning only to the client. 2. The nurse is c
aring for a client who is suicidal. When accompanying the client to the bathroom
, the nurse should: a. give him privacy in the bathroom. b. allow him to shave.
c. open the window and allow him to get some fresh air. d. observe him. RATIONAL
E: The nurse has a responsibility to observe continuously the acutely suicidal c
lient not provide privacy. The nurse should watch for clues, such as communicati
ng suicidal thoughts, threats, and messages; hoarding medications; and talking a
bout death. By accompanying the client to the bathroom, the nurse will naturally
prevent hanging or other injury. The nurse will check the client's area and fix
dangerous conditions, such as exposed pipes and windows without safety glass. T
he nurse will also remove potentially dangerous objects, such as belts, razors,
suspenders, glass, and knives. 3. The nurse is developing a care plan for a clie
nt 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 priva
cy during meals. c. Set up a strict eating plan for the client. d. Encourage the
client to exercise, which will reduce her anxiety. RATIONALE: Establishing a co
nsistent eating plan and monitoring the client's weight are important for this d
isorder. The family should be included in the client's care. The client should b
e monitored during meals not given privacy. Exercise must be limited and supervi
sed. 4. A client whose husband recently left her is admitted to the hospital wit
h severe depression. The nurse suspects that the client is at risk for suicide.
Which of the following questions would be most appropriate and helpful for the n
urse to ask during an assessment for suicide risk? a. "Are you sure you want to
kill yourself?" b. "I know if my husband left me, I'd want to kill myself. Is th
at what you think?" c. "How do you think you would kill yourself?" d. "Why don't
you just look at the positives in your life?" RATIONALE: To determine if a clie
nt is at risk for suicide, ask, "How do you think you would kill yourself?" If t
he client has a plan, she may be closer to carrying out the act. Option 1 requir
es a
yes-or-no response and is self-limiting. In option 2, the nurse is telling the c
lient what to think and feel. Option 4 dismisses the client's feelings 5. The nu
rse is caring for a client who she believes has been abusing opiates. Assessment
findings in a client abusing opiates, such as morphine, include: a. dilated pup
ils and slurred speech. b. rapid speech and agitation. c. dilated pupils and agi
tation. d. euphoria and constricted pupils. RATIONALE: Assessment findings in a
client abusing opiates include agitation, slurred speech, euphoria, and constric
ted pupils. 6. The nurse is caring for a client experiencing an anxiety attack.
Appropriate nursing interventions include: a. turning on the lights and opening
the windows so that the client doesn't feel crowded. b. leaving the client alone
. c. staying with the client and speaking in short sentences. d. turning on ster
eo music. RATIONALE: Appropriate nursing interventions for an anxiety attack inc
lude using short sentences, staying with the client, decreasing stimuli, remaini
ng calm, and medicating as needed. Leaving the client alone, turning on a stereo
or lights, and opening windows may increase the client's anxiety. 7. The nurse
is teaching a new group of mental health aides. The nurse should teach the aides
that setting limits is most important for: a. a depressed client. b. a manic cl
ient. c. a suicidal client. d. an anxious client. RATIONALE: Setting limits for
unacceptable behavior is most important in a manic client. Typically, depressed,
anxious, or suicidal clients don't physically or mentally test the limits of th
e caregiver. 8. A client is admitted with a diagnosis of delusions of grandeur.
This diagnosis reflects a belief that one is: a. highly important or famous. b.
being persecuted. c. connected to events unrelated to oneself. d. responsible fo
r the evil in the world. RATIONALE: A delusion of grandeur is a false belief tha
t one is highly important or famous. A delusion of persecution is a false belief
that one is being persecuted. A delusion of reference is a false belief that on
e is connected to events unrelated to oneself or a belief that one is responsibl
e for the evil in the world.
9. The nurse is caring for a client, a Vietnam veteran, who exhibits signs and s
ymptoms of posttraumatic stress disorder. Signs and symptoms of posttraumatic st
ress disorder include: a. hyperalertness and sleep disturbances. b. memory loss
of traumatic event and somatic distress. c. feelings of hostility and violent be
havior. d. sudden behavioral changes and anorexia. RATIONALE: Signs and symptoms
of posttraumatic stress disorder include hyperalertness, sleep disturbances, ex
aggerated startle, survival guilt, and memory impairment. Also, the client reliv
es the traumatic event through dreams and recollections. Hostility, violent beha
vior, and anorexia aren't usual signs or symptoms of posttraumatic stress disord
er 10. The nurse is caring for a client with manic depression. The care plan for
a client in a manic state would include: a. offering high-calorie meals and str
ongly encouraging the client to finish all food. b. insisting that the client re
main active throughout the day so that he'll sleep at night. c. allowing the cli
ent to exhibit hyperactive, demanding, manipulative behavior without setting lim
its. d. listening attentively with a neutral attitude and avoiding power struggl
es. RATIONALE: The nurse should listen to the client's requests, express willing
ness to seriously consider the requests, and respond later. The nurse should enc
ourage the client to take short daytime naps because he expends so much energy.
The nurse shouldn't try to restrain the client when he feels the need to move ar
ound as long as his activity isn't harmful. High-calorie finger foods should be
offered to supplement the client's diet, if he can't remain seated long enough t
o eat a complete meal. The client shouldn't be forced to stay seated at the tabl
e to finish a meal. The nurse should set limits in a calm, clear, and self-confi
dent tone of voice 11. A client is a Vietnam War veteran with a diagnosis of pos
ttraumatic stress disorder. He has a history of nightmares, depression, hopeless
ness, and alcohol abuse. Which option offers the client the most lasting relief
of his symptoms? a. The opportunity to verbalize memories of trauma to a sympath
etic listener b. Family support c. Prescribed medications taken as ordered d. Al
coholics Anonymous (AA) meetings RATIONALE: Although it's difficult, clients wit
h posttraumatic stress disorder can obtain the most lasting relief if they verba
lize memories of the trauma to a sympathetic listener. Family members are common
ly frightened by the information and can't be consistently supportive. Antidepre
ssants may help but these drugs can mask feelings and can't provide lasting reli
ef. Treatment for alcohol abuse, including AA meetings, must be considered when
planning care but alone doesn't provide lasting relief 12. A client is admitted
for detoxification after a cocaine overdose. The client tells the nurse that he
frequently uses cocaine but that he can control his use if he chooses. Which cop
ing mechanism is he using? a. Withdrawal b. Logical thinking c. Repression
d. Denial RATIONALE: Denial is an unconscious defense mechanism in which emotion
al conflict and anxiety is avoided by refusing to acknowledge feelings, desires,
impulses, or external facts that are consciously intolerable. Withdrawal is a c
ommon response to stress, characterized by apathy. Logical thinking is the abili
ty to think rationally and make responsible decisions, which would lead the clie
nt to admitting the problem and seeking help. Repression is suppressing past eve
nts from the consciousness because of guilty association 13. A 22-year-old clien
t is diagnosed with dependent personality disorder. Which behavior is most likel
y evidence of ineffective individual coping? a. Inability to make choices and de
cisions without advice b. Showing interest only in solitary activities c. Avoidi
ng developing relationships d. Recurrent self-destructive behavior with history
of depression RATIONALE: Individuals with dependent personality disorder typical
ly show indecisiveness, submissiveness, and clinging behaviors so that others wi
ll make decisions for them. These clients feel helpless and uncomfortable when a
lone and don't show interest in solitary activities. They also pursue relationsh
ips in order to have someone to take care of them. Although clients with depende
nt personality disorder may become depressed and suicidal if their needs aren't
met, this isn't a typical response 14. A 38-year-old client is admitted for alco
hol 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. RATIONALE: Perceptual disorders, especially frightening
visual hallucinations, are very common with alcohol withdrawal. Coma isn't an i
mmediate consequence. Manipulative behaviors are part of the alcoholic client's
personality but not a sign of alcohol withdrawal. Suppression is a conscious eff
ort to conceal unacceptable thoughts, feelings, impulses, or acts and serves as
a coping mechanism for most alcoholics 15. A client is admitted with a diagnosis
of schizotypal personality disorder. Which signs would this client exhibit duri
ng social situations? a. Aggressive behavior b. Paranoid thoughts c. Emotional a
ffect d. Independence needs RATIONALE: Clients with schizotypal personality diso
rder experience excessive social anxiety that can lead to paranoid thoughts. Agg
ressive behavior is uncommon, although these clients may experience agitation wi
th anxiety. Their behavior is emotionally cold with a flattened affect, regardle
ss of the situation. These clients demonstrate a reduced capacity for close or d
ependent relationships
16. The nurse is caring for a client in an acute manic state. What's the most ef
fective nursing action for this client? a. Assigning him to group activities b.
Reducing his stimulation c. Assisting him with self-care d. Helping him express
his feelings RATIONALE: Reducing stimuli helps to reduce hyperactivity during a
manic state. Group activities would provide too much stimulation. Trying to assi
st the client with self-care could cause increased agitation. When in a manic st
ate, these clients aren't able to express their inner feelings in a productive,
introspective manner. The focus of treatment for a client in the manic state is
behavior control 17. The nurse is caring for a client diagnosed with bulimia. Th
e most appropriate initial goal for a client diagnosed with bulimia is to: a. av
oid shopping for large amounts of food. b. control eating impulses. c. identify
anxiety-causing situations. d. eat only three meals per day. RATIONALE: Bulimic
behavior is generally a maladaptive coping response to stress and underlying iss
ues. The client must identify anxiety-causing situations that stimulate the buli
mic behavior and then learn new ways of coping with the anxiety. Controlling sho
pping 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 i
nto the care plan after initially addressing stress and underlying issues. Eatin
g three meals per day isn't a realistic goal early in treatment 18. The nurse is
caring for a 40-year-old client. Which behavior by the client indicates adult c
ognitive development? a. Has perceptions based on reality b. Assumes responsibil
ity for actions c. Generates new levels of awareness d. Has maximum ability to s
olve problems and learn new skills RATIONALE: Adults between ages 31 and 45 gene
rate new levels of awareness. Having perceptions based on reality and assuming r
esponsibility for actions indicate socialization development not cognitive devel
opment. Demonstrating maximum ability to solve problems and learning new skills
occur in young adults between ages 20 and 30 19. A client with bipolar disorder
is being treated with lithium for the first time. The nurse should observe the c
lient for which common adverse effect of lithium? a. Sexual dysfunction b. Const
ipation c. Polyuria d. Seizures RATIONALE: Polyuria commonly occurs early in the
treatment with lithium and could result in fluid volume deficit. Sexual dysfunc
tion isn't a common adverse effect of lithium; it's more common with sedatives a
nd tricyclic antidepressants. Diarrhea, not constipation, occurs with lithium. C
onstipation can occur with other psychiatric drugs, such as antipsychotic drugs.
Seizures may be a later sign of lithium toxicity 20. A client is admitted for an
overdose of amphetamines. When assessing this client, the nurse should expect t
o see: a. tension and irritability. b. slow pulse. c. hypotension. d. constipati
on. RATIONALE: An amphetamine is a nervous system stimulant that's subject to ab
use because of its ability to produce wakefulness and euphoria. An overdose incr
eases tension and irritability. Options B and C are incorrect because amphetamin
es stimulate norepinephrine, which increases the heart rate and blood flow. Diar
rhea is a common adverse effect, so option D is incorrect 21. During a shift rep
ort, the nurse learns that she'll be providing care for a client who is vulnerab
le to panic attack. Treatment for panic attacks includes behavioral therapy, sup
portive psychotherapy, and medication such as: a. barbiturates. b. antianxiety d
rugs. c. depressants. d. amphetamines. RATIONALE: Antianxiety drugs provide symp
tomatic relief. Barbiturates and amphetamines can precipitate panic attacks. Dep
ressants aren't appropriate for treating panic attacks 22. A client comes to the
emergency department while experiencing a panic attack. The nurse can best resp
ond to a client having a panic attack by: a. staying with the client until the a
ttack subsides. b. telling the client everything is under control. c. telling th
e client to lie down and rest. d. talking continually to the client by explainin
g what's happening. RATIONALE: The nurse should remain with the client until the
attack subsides. If the client is left alone, he may become more anxious. Givin
g false reassurance is inappropriate in this situation. The client should be all
owed to move around and pace to help expend energy. The client may be so overwhe
lmed that he can't follow lengthy explanations or instructions, so the nurse sho
uld use short phrases and slowly give one direction at a time. 23. A 24-year-old
client is experiencing an acute schizophrenic episode. He has vivid hallucinati
ons that are making him agitated. The nurse's best response at this time would b
e to: a. take the client's vital signs. b. explore the content of the hallucinat
ions. c. tell him his fear is unrealistic. d. engage the client in reality-orien
ted activities. RATIONALE: Exploring the content of the hallucinations will help
the nurse understand the client's perspective on the situation. The client shou
ldn't be touched, such as in taking vital signs, without telling him exactly wha
t's going to happen. Debating with the client about his emotions
isn't therapeutic. When the client is calm, engage him in reality-based activiti
es 24. A client with paranoid type schizophrenia becomes angry and tells the nur
se to leave him alone. The nurse should: a. tell him that she'll leave for now b
ut will return soon. b. ask him if it's okay if she sits quietly with him. c. as
k him why he wants to be left alone. d. tell him that she won't let anything hap
pen to him. RATIONALE: If the client tells the nurse to leave, the nurse should
leave but let the client know that she'll return so that he doesn't feel abandon
ed. Not heeding the client's request can agitate him further. Also, challenging
the client isn't therapeutic and may increase his anger. False reassurance isn't
warranted in this situation 25. A client begins taking haloperidol (Haldol). Af
ter a few days, he experiences severe tonic contractures of muscles in the neck,
mouth, and tongue. The nurse should recognize this as: a. psychotic symptoms. b
. parkinsonism. c. akathisia. d. dystonia. RATIONALE: These symptoms describe dy
stonia, which commonly occurs after a few days of treatment with haloperidol. Th
e symptoms may be confused with psychotic symptoms and misdiagnosed. Parkinsonis
m results in muscle rigidity, shuffling gait, stooped posture, flat-faced affect
, tremors, and drooling. Signs and symptoms of akathisia are restlessness, pacin
g, and inability to sit still 26. The nurse must administer a medication to reve
rse or prevent Parkinson-type symptoms in a client receiving an antipsychotic. T
he medication the client will likely receive is: a. benztropine (Cogentin). b. d
iphenhydramine (Benadryl). c. propranolol (Inderal). d. haloperidol (Haldol). RA
TIONALE: Benztropine, trihexyphenidyl, or amantadine is prescribed for a client
with Parkinson-type symptoms. Diphenhydramine provides rapid relief for dystonia
. Propranolol relieves akathisia. Haloperidol can cause Parkinson-type symptoms
27. Which information is most important for the nurse to include in a teaching p
lan for a schizophrenic client taking clozapine (Clozaril)? a. Monthly blood tes
ts will be necessary. b. Report a sore throat or fever to the physician immediat
ely. c. Blood pressure must be monitored for hypertension. d. Stop the medicatio
n when symptoms subside. RATIONALE: A sore throat and fever are indications of a
n infection caused by agranulocytosis, a potentially life-threatening complicati
on of clozapine. Because of the risk of agranulocytosis, white blood cell (WBC)
counts are necessary weekly, not monthly. If the WBC count drops below 3,000/ml,
the medication must be stopped. Hypotension may occur in clients taking this
medication. Warn the client to stand up slowly to avoid dizziness from orthostat
ic hypotension. The medication should be continued, even when symptoms have been
controlled. If the medication must be stopped, it should be slowly tapered over
1 to 2 weeks and only under the supervision of a physician 28. A client with ma
nic episodes is taking lithium. Which electrolyte level should the nurse check b
efore administering this medication? a. Calcium b. Sodium c. Chloride d. Potassi
um RATIONALE: Lithium is chemically similar to sodium. When sodium levels are re
duced, such as from sweating or diuresis, lithium is reabsorbed by the kidneys,
increasing the risk of toxicity. Clients taking lithium shouldn't restrict their
intake of sodium and should drink adequate amounts of fluid each day. The other
electrolytes are important for normal body functions, but sodium is most import
ant to the absorption of lithium 29. A client is admitted to the inpatient unit
of the mental health center with a diagnosis of paranoid schizophrenia. He's sho
uting that the government of France is trying to assassinate him. Which of the f
ollowing responses is most appropriate? a. "I think you're wrong. France is a fr
iendly country and an ally of the United States. Their government wouldn't try t
o kill you." b. "I find it hard to believe that a foreign government or anyone e
lse 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? P
lease tell me more about it." RATIONALE: Responses should focus on reality while
acknowledging the client's feelings. Arguing with the client or denying his bel
ief isn't therapeutic. Arguing can also inhibit development of a trusting relati
onship. Continuing to talk about delusions may aggravate the psychosis. Asking t
he client if a foreign government is trying to kill him may increase his anxiety
level and can reinforce his delusions 30. A client has been receiving chlorprom
azine (Thorazine), an antipsychotic, to treat his psychosis. Which finding shoul
d alert the nurse that the client is experiencing pseudoparkinsonism? a. Restles
sness, difficulty sitting still, pacing b. Involuntary rolling of the eyes c. Tr
emors, shuffling gait, masklike face d. Extremity and neck spasms, facial grimac
ing, jerky movements RATIONALE: Pseudoparkinsonism may appear 1 to 5 days after
starting an antipsychotic and may also include drooling, rigidity, and pill roll
ing. 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 hour
s after receiving an antipsychotic and may include extremity and neck spasms, je
rky muscle movements, and facial grimacing
31. A 54-year-old female was found unconscious on the floor of her bathroom with
self-inflicted wrist lacerations. An ambulance was called and the client was ta
ken to the emergency department. When she was stable, the client was transferred
to the inpatient psychiatric unit for observation and treatment with antidepres
sants. Now that the client is feeling better, which nursing intervention is most
appropriate? a. Observing for extrapyramidal symptoms b. Beginning a therapeuti
c relationship c. Canceling any no-suicide contracts d. Continuing suicide preca
utions RATIONALE: As antidepressants begin to take effect and the client feels b
etter, she may have the energy to initiate and complete another suicide attempt.
As the client's energy level increases, the nurse must continue to be vigilant
to the risk of suicide. Extrapyramidal symptoms may occur with antipsychotics an
d aren't adverse effects of antidepressants. A therapeutic relationship should b
e initiated upon admission to the psychiatric unit, after suicide precautions ha
ve been instituted. It's through this relationship that the client develops feel
ings of self-worth and trust and problem-solving takes place. In a no-suicide co
ntract, the client states verbally or in writing that she won't attempt suicide
and will seek out staff if she has suicidal thoughts. When the time period for a
contract has expired, a new contract should be obtained from the client 32. A 2
6-year-old male reports losing his sight in both eyes. He's diagnosed as having
a conversion disorder and is admitted to the psychiatric unit. Which nursing int
ervention would be most appropriate for this client? a. Not focusing on his blin
dness b. Providing self-care for him c. Telling him that his blindness isn't rea
l d. Teaching eye exercises to strengthen his eyes
QUESTIONS 1. Flumazenil (Romazicon) has been ordered for a male client who has o
verdosed on oxazepam (Serax). Before administering the medication, nurse Gina sh
ould be prepared for which common adverse effect? a. Seizures b. Shivering c. An
xiety d. Chest pain 2. Nurse Tim 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 female client wh
o's at high risk for suicide needs close supervision. To best ensure the client's sa
fety, nurse Gio should: a. check the client frequently at irregular intervals th
roughout the night b. assure the client that the nurse will hold in confidence a
nything the client says
c. d.
repeatedly discuss previous suicide attempts with the client disregard decreased
communication by the client because this is common in suicidal clients
4. Which of the following drugs should nurse Marlyn prepare to administer to a c
lient with a toxic acetaminophen (Tylenol) level? a. deferoxamine mesylate (Desf
eral) b. succimer (Chemet) c. flumazenil (Romazicon) d. acetylcysteine (Mucomyst
) 5. A male client is admitted to the substance abuse unit for alcohol detoxific
ation. Which of the following medications is nurse Apple most likely to administ
er to reduce the symptoms of alcohol withdrawal? a. naloxone (Narcan) b. haloper
idol (Haldol) c. magnesium sulfate d. chlordiazepoxide (Librium) 6. During postp
randial monitoring, a female 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 be
st 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 male clie
nt 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 appro
priate response? a. If you continue to talk like that, I'm going to stop speaking t
o you. b. You told me you got fired from your last job for missing too many days a
fter taking drugs all night. c. Tell me more about how it felt to get high. d. Don't y
ou know it's illegal to use drugs? 8. For a female client with anorexia nervosa, nu
rse Jay is aware that which goal takes the highest priority? a. The client will
establish adequate daily nutritional intake b. The client will make a contract w
ith the nurse that sets a target weight c. The client will identify self-percept
ions about body size as unrealistic d. The client will verbalize the possible ph
ysiological consequences of self-starvation 9. When interviewing the parents of
an injured child, which of the following is the strongest indicator that child a
buse may be a problem? a. The injury isn't consistent with the history or the chil
d'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 emergenc
y department personnel 10. For a female client with anorexia nervosa, nurse Rose
plans to include the parents in therapy sessions along with the client. What fa
ct should the nurse remember to be typical of parents of clients with anorexia n
ervosa? a. They tend to overprotect their children b. They usually have a histor
y 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 he
r husband beat her with a shoe. After the health care team repairs her laceratio
ns, she waits to be seen by the crisis intake nurse, who will evaluate the conti
nued threat of violence. Suddenly the client's husband arrives, shouting that he w
ants to finish the job. What is the first priority of the health care worker who w
itnesses 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 hus
band that he must leave at once d. Determining why the husband feels so angry 12
. . Nurse Venus is caring for a client with bulimia. Strict management of dietar
y intake is necessary. Which intervention is also important? a. Fill out the cli
ent'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 le
ast 2 hours after each meal c. Let the client choose her own food. If she eats e
verything she orders, then stay with her for 1 hour after each meal d. Let the c
lient eat food brought in by the family if she chooses, but she should keep a st
rict calorie count. 13. Nurse Mary is assigned to care for a suicidal client. In
itially, 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 fe
elings about suicide c. Discussing the future with the client d. Referring the c
lient to a clergyperson to discuss the moral implications of suicide 14. A 24-ye
ar old 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. Avoi
d discussing unrealistic cultural standards regarding weight d. Provide objectiv
e data and feedback regarding the client's weight and attractiveness 15. Nurse Des
mond is caring for a client being treated for alcoholism. Before initiating ther
apy with disulfiram (Antabuse), the nurse teaches the client that he must read l
abels carefully on which of the following products? a. Carbonated beverages b. A
ftershave lotion c. Toothpaste d. Cheese 16. Nurse Faith 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. Nurse Tina i
s aware that the victims of domestic violence should be assessed for what import
ant 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. d.
Use of drugs or alcohol History of previous victimization
18. A male client is hospitalized with fractures of the right femur and right hu
merus sustained in a motorcycle accident. Police suspect the client was intoxica
ted at the time of the accident. Laboratory tests reveal a blood alcohol level o
f 0.2% (200 mg/dl). The client later admits to drinking heavily for years. Durin
g hospitalization, the client periodically complains of tingling and numbness in
the hands and feet. Nurse Gio realizes that these symptoms probably result from
: a. acetate accumulation b. thiamine deficiency c. triglyceride buildup. d. a b
elow-normal serum potassium level 19. A parent brings a preschooler to the emerg
ency 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 exa
mination b. The child pulls away from contact with the physician. c. The child d
oesn'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 (P
CP), nurse Wayne is aware that the following is the highest priority? a. Client's
physical needs b. Client's safety needs c. Client's psychosocial needs d. Client's med
ical needs 21. The nurse is aware that the outcome criteria would be appropriate
for a child diagnosed with oppositional defiant disorder? a. Accept responsibil
ity for own behaviors b. Be able to verbalize own needs and assert rights. c. Se
t firm and consistent limits with the client d. Allow the child to establish his
own limits and boundaries 22. A male client is found sitting on the floor of th
e bathroom in the day treatment clinic with moderate lacerations on both wrists.
Surrounded by broken glass, she sits staring blankly at her bleeding wrists whi
le staff members call for an ambulance. How should nurse Grace approach her init
ially? a. Enter the room quietly and move beside her to assess her injuries b. C
all for staff back-up before entering the room and restraining her c. Move as mu
ch glass away from her as possible and sit next to her quietly d. Approach her s
lowly while speaking in a calm voice, calling her name, and telling her that the
nurse is here to help her 23. A female client with anorexia nervosa describes h
erself 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 bod
y image, which intervention should nurse Angel be included in the plan of care?
a. Asking the client to compare her figure with magazine photographs of women he
r age b. Assigning the client to group therapy in which participants provide rea
listic feedback about her weight c. Confronting the client about her actual appe
arance during one-on-one sessions, scheduled during each shift d. Telling the cl
ient of the nurse's concern for her health and desire to help her make decisions t
o keep her healthy
24. Eighteen hours after undergoing an emergency appendectomy, a client with a r
eported 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; a
nd blood pressure, 140/96 mm Hg. The client exhibits gross hand tremors and is s
creaming for someone to kill the bugs in the bed. Nurse Melinda 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 hypertensi
on. Nurse Sally is aware that the following conditions might the drug be adminis
tered? a. Phencyclidine (PCP) intoxication b. Alcohol withdrawal c. Opiate withd
rawal d. Cocaine withdrawal ANSWER 1. Answer A. Seizures are the most common ser
ious adverse effect of using flumazenil to reverse benzodiazepine overdose. The
effect is magnified if the client has a combined tricyclic antidepressant and be
nzodiazepine overdose. Less common adverse effects include shivering, anxiety, a
nd chest pain. 2. Answer C. Bulimic behavior is generally a maladaptive coping r
esponse to stress and underlying issues. The client must identify anxiety-causin
g situations that stimulate the bulimic behavior and then learn new ways of copi
ng with the anxiety. Controlling shopping for large amounts of food isn't a goal e
arly in treatment. Managing eating impulses and replacing them with adaptive cop
ing mechanisms can be integrated into the plan of care after initially addressin
g stress and underlying issues. Eating three meals per day isn't a realistic goal
early in treatment. 3. Answer A. 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. Answer D. The antidote for acetam
inophen toxicity is acetylcysteine. It enhances conversion of toxic metabolites
to nontoxic metabolites. Deferoxamine mesylate is the antidote for iron intoxica
tion. Succimer is an antidote for lead poisoning. Flumazenil reverses the sedati
ve effects of benzodiazepines. 5. Answer D. Chlordiazepoxide (Librium) and other
tranquilizers help reduce the symptoms of alcohol withdrawal. Haloperidol (Hald
ol) 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. Answer D. This response acknowledges that the clien
t is testing limits and that the nurse is setting them by performing postprandia
l monitoring to prevent self-induced emesis. Clients with bulimia nervosa need t
o 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 t
heir secrets about it. An authoritarian or challenging response may trigger a po
wer struggle between the nurse and client. 7. Answer B. Confronting the client w
ith the consequences of substance abuse helps to break through denial. Making th
reats (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 discu
ss feelings, the discussion should focus on how the client felt before, not duri
ng, 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 us
e is illegal; a reminder to this effect (option D) is unlikely to alter behavior
. 8. Answer A. According to Maslow's hierarchy of needs, all humans need to meet b
asic physiological needs first. Because a client with anorexia nervosa eats litt
le or nothing, the nurse must first plan to help the client meet this basic, imm
ediate physiological need. The nurse may give lesser priority to goals that addr
ess long-term plans (as in option B), self-perception (as in option C), and pote
ntial complications (as in option D). 9. Answer A. When the child's injuries are i
nconsistent with the history given or impossible because of the child's age and de
velopmental stage, the emergency department nurse should be suspicious that chil
d abuse is occurring. The parents may tell different stories because their perce
ption 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 a
buse may be a problem. Child abuse occurs in all socioeconomic groups. Parents m
ay argue and be demanding because of the stress of having an injured child. 10.
Answer A. Clients with anorexia nervosa typically come from a family with parent
s who are controlling and overprotective. These clients use eating to gain contr
ol of an aspect of their lives. The characteristics described in options B, C, a
nd D isn't typical of parents of children with anorexia. 11. Answer B. 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 pe
rson alone. Therefore, the first priority is to call a security guard and anothe
r staff member. After doing this, the health care worker should inform the husba
nd what is expected, speaking in concise statements and maintaining a firm but c
alm demeanor. This approach makes it clear that the health care worker is in con
trol and may diffuse the situation until the security guard arrives. Telling the
husband to leave would probably be ineffective because of his agitated and irra
tional state. Exploring his anger doesn't take precedence over safeguarding the cl
ient and staff. 12. Answer C. Allowing the client to select her own food from th
e 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 pr
event purging. Bulimic clients should only be allowed to eat food provided by th
e dietary department. 13. Answer B. The nurse's values, beliefs, and attitudes tow
ard self-destructive behavior influence responses to a suicidal client; such res
ponses set the overall mood for the nurse-client relationship. Therefore, the nu
rse initially must explore personal feelings about suicide to avoid conveying ne
gative feelings to the client. Assessment of the client's home environment and rel
ationships may reveal the need for family therapy; however, conducting such an a
ssessment isn't a nursing priority. Discussing the future and providing anticipato
ry guidance can help the client prepare for future stress, but this isn't a priori
ty. Referring the client to a clergyperson may increase the client's trust or alle
viate guilt; however, it isn't the highest priority. 14. Answer D. By focusing on
reality, this strategy may help the client develop a more realistic body image a
nd gain self-esteem. Option A is inappropriate because discussing the client's per
ceptions 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 recognizin
g unrealistic cultural standards wouldn't help the client establish more realistic
weight goals. 15. Answer B. Disulfiram may be given to clients with chronic alc
ohol abuse who wish to curb impulse drinking. Disulfiram works by blocking the o
xidation of alcohol, inhibiting the conversion of acetaldehyde to acetate. As ac
etaldehyde builds up in the blood, the client experiences noxious and uncomforta
ble symptoms. Even alcohol rubbed onto the skin can produce a reaction. The clie
nt receiving disulfiram must be taught to read ingredient labels carefully to av
oid 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 c
lient. 16. Answer C. Establishing a consistent eating plan and monitoring the cl
ient's weight are important for this disorder. The family should be included in th
e client's care. The client should be monitored during meals not given privacy. Ex
ercise must be limited and supervised. 17. Answer B. Victims of domestic violenc
e must be assessed for their readiness to leave the perpetrator and their knowle
dge 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 abusi
ve relationships. 18. Answer B. Numbness and tingling in the hands and feet are
symptoms of peripheral polyneuritis, which results from inadequate intake of vit
amin B1 (thiamine) secondary to prolonged and excessive alcohol intake. Treatmen
t 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 s
erum potassium level are unrelated to the client's symptoms. 19. Answer C. A chara
cteristic behavior of abused children is lack of crying when they undergo a pain
ful procedure or are examined by a health care professional. Therefore, the nurs
e should suspect child abuse. Crying throughout the examination, pulling away fr
om the physician, and not making eye contact with the nurse are normal behaviors
for preschoolers. 20. Answer B. The highest priority for a client who has inges
ted 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. Answer A. Children with oppositional defiant disorder frequentl
y violate the rights of others. They are defiant, disobedient, and blame others
for their actions. Accountability for their actions would demonstrate progress f
or the oppositional child. Options C and D aren't outcome criteria but interventio
ns. Option B is incorrect as the oppositional child usually focuses on his own n
eeds. 22. Answer D. Ensuring the safety of the client and the nurse is the prior
ity at this time. Therefore, the nurse should approach the client cautiously whi
le calling her name and talking to her in a calm, confident manner. The nurse sh
ould keep in mind that the client shouldn't be startled or overwhelmed. After expl
aining that the nurse is there to help, the nurse should observe the client's resp
onse carefully. If the client shows signs of agitation or confusion or poses a t
hreat, the nurse should retreat and request assistance. The nurse shouldn't attemp
t to sit next to the client or examine injuries without first announcing the nur
se's presence and assessing the dangers of the situation. 23. Answer D. A client w
ith anorexia nervosa has an unrealistic body image that causes consumption of li
ttle or no food. Therefore, the client needs assistance with making decisions ab
out health. Instead of protecting the client's health, options A, B, and C may ser
ve to make the client defensive and more entrenched in her unrealistic body imag
e. 24. Answer B. The client's vital signs and hallucinations suggest delirium trem
ens or alcohol withdrawal syndrome. Although infection, acute sepsis, and pneumo
nia may arise as postoperative complications, they wouldn't cause this client's sign
s and symptoms and typically would occur later in the postoperative course 25. A
nswer C. Clonidine is used as adjunctive therapy in opiate withdrawal. Benzodiaz
epines, such as chlordiazepoxide (Librium), and neuropleptic agents, such as hal
operidol, are used to treat alcohol withdrawal. Benzodiazepines and neuropleptic
agents are typically used to treat PCP intoxication. Antidepressants and medica
tions with dopaminergic activity in the brain, such as fluoxotine (Prozac), are
used to treat cocaine withdrawal.
---------------QUESTION 1. A male client with a history of cocaine addiction is
admitted to the coronary care unit for evaluation of substernal chest pain. The
electrocardiogram (ECG) shows a 1-mm ST-segment
elevation the anteroseptal leads and T-wave inversion in leads V3 to V5. Conside
ring the client's history of drug abuse, nurse Greg expects the physician to presc
ribe: a. lidocaine (Xylocaine). b. procainamide (Pronestyl). c. nitroglycerin (N
itro-Bid IV). d. epinephrine. 2. A 14-year-old client is brought to the clinic b
y her mother. Her mother expresses concern about her daughter's weight loss and co
nstant dieting. Nurse Kris conducts a health history interview. Which of the fol
lowing comments indicates that the client may be suffering from anorexia nervosa
? a. "I like the way I look. I just need to keep my weight down because I'm a chee
rleader." b. "I don't like the food my mother cooks. I eat plenty of fast food whe
n I'm out with my friends." c. "I just can't seem to get down to the weight I want t
o be. I'm so fat compared to other girls." d. "I do diet around my periods; otherw
ise, I just get so bloated." 3. a. b. c. d. Nurse Fey is aware that the drug of
choice for treating Tourette syndrome? fluoxetine (Prozac) fluvoxamine (Luvox) h
aloperidol (Haldol) paroxetine (Paxil)
4. A male client tells the nurse he was involved in a car accident while he was
intoxicated. What would be the most therapeutic response from nurse Julia? a. "W
hy didn't you get someone else to drive you?" b. "Tell me how you feel about the a
ccident." c. "You should know better than to drink and drive." d. "I recommend t
hat you attend an Alcoholics Anonymous meeting." 5. A male adult client voluntar
ily admits himself to the substance abuse unit. He confesses that he drinks 1 qt
or more of vodka each day and uses cocaine occasionally. Later that afternoon,
he begins to show signs of alcohol withdrawal. What are some early signs of this
condition? a. Vomiting, diarrhea, and bradycardia b. Dehydration, temperature a
bove 101 F (38.3 C), and pruritus c. Hypertension, diaphoresis, and seizures d. Di
aphoresis, tremors, and nervousness 6. When monitoring a female client recently
admitted for treatment of cocaine addiction, nurse Aaron notes sudden increases
in the arterial blood pressure and heart rate. To correct these problems, the nu
rse expects the physician to prescribe: a. norepinephrine (Levophed) and lidocai
ne (Xylocaine) b. nifedipine (Procardia) and lidocaine. c. nitroglycerin (Nitro-
Bid IV) and esmolol (Brevibloc) d. nifedipine and esmolol 7. A 25 year old client
experiencing alcohol withdrawal is upset about going through detoxification. Wh
ich of the following goals is a priority? a. The client will commit to a drug-fr
ee lifestyle b. The client will work with the nurse to remain safe c. The client
will drink plenty of fluids daily d. The client will make a personal inventory
of strength 8. A male client is admitted to a psychiatric facility by court orde
r for evaluation for antisocial personality disorder. This client has a long his
tory of initiating fights and abusing animals and recently was arrested for sett
ing a neighbor's dog on fire. When evaluating this client for the potential for vi
olence, nurse Perry should assess for which behavioral clues?
a. b. c. d.
A rigid posture, restlessness, and glaring Depression and physical withdrawal Si
lence and noncompliance Hypervigilance and talk of past violent acts
9. A male client is brought to the psychiatric clinic by family members, who tel
l the admitting nurse that the client repeatedly drives while intoxicated despit
e their pleas to stop. During an interview with the nurse Linda, which statement
by the client most strongly supports a diagnosis of psychoactive substance abus
e? a. "I'm not addicted to alcohol. In fact, I can drink more than I used to witho
ut being affected." b. "I only spend half of my paycheck at the bar." c. "I just
drink to relax after work." d. "I know I've been arrested three times for drinkin
g and driving, but the police are just trying to hassle me." 10. A female client
with borderline personality disorder is admitted to the psychiatric unit. Initi
al nursing assessment reveals that the client's wrists are scratched from a recent
suicide attempt. Based on this finding, the nurse Lenny should formulate a nurs
ing diagnosis of: a. Ineffective individual coping related to feelings of guilt.
b. Situational low self-esteem related to feelings of loss of control c. Risk f
or violence: Self-directed related to impulsive mutilating acts d. Risk for viol
ence: Directed toward others related to verbal threats 11. A male client recentl
y admitted to the hospital with sharp, substernal chest pain suddenly complains
of palpitations. Nurse Ryan notes a rise in the client's arterial blood pressure a
nd a heart rate of 144 beats/minute. On further questioning, the client admits t
o having used cocaine recently after previously denying use of the drug. The nur
se concludes that the client is at high risk for which complication of cocaine u
se? a. Coronary artery spasm b. Bradyarrhythmias c. Neurobehavioral deficits d.
Panic disorder 12. A male client is being admitted to the substance abuse unit f
or alcohol detoxification. As part of the intake interview, the nurse asks him w
hen he had his last alcoholic drink. He says that he had his last drink 6 hours
before admission. Based on this response, nurse Lorena should expect early withd
rawal symptoms to: a. begin after 7 days b. not occur at all because the time pe
riod for their occurrence has passed c. begin anytime within the next 1 to 2 day
s d. begin within 2 to 7 days 13. Nurse Helen is assigned to care for a client w
ith anorexia nervosa. Initially, which nursing intervention is most appropriate
for this client? a. Providing one-on-one supervision during meals and for 1 hour
afterward b. Letting the client eat with other clients to create a normal mealt
ime atmosphere c. Trying to persuade the client to eat and thus restore nutritio
nal balance d. Giving the client as much time to eat as desired 14. A female cli
ent begins to experience alcoholic hallucinosis. Nurse Joy is aware that the bes
t nursing intervention at this time? a. Keeping the client restrained in bed b.
Checking the client's blood pressure every 15 minutes and offering juices c. Provi
ding a quiet environment and administering medication as needed and prescribed d
. Restraining the client and measuring blood pressure every 30 minutes
15. Nurse Bella is aware that assessment finding is most consistent with early a
lcohol withdrawal? a. Heart rate of 120 to 140 beats/minute b. Heart rate of 50
to 60 beats/minute c. Blood pressure of 100/70 mm Hg d. Blood pressure of 140/80
mm Hg 16. Nurse Amy is aware that the client is at highest risk for suicide? a.
One who appears depressed, frequently thinks of dying, and gives away all perso
nal possessions b. One who plans a violent death and has the means readily avail
able c. One who tells others that he or she might do something if life doesn't get
better soon d. One who talks about wanting to die 17. Nurse Penny is aware that
the following medical conditions is commonly found in clients with bulimia nerv
osa? a. Allergies b. Cancer c. Diabetes mellitus d. Hepatitis A 18. Ken, a high
school student is referred to the school nurse for suspected substance abuse. Fo
llowing the nurse's assessment and interventions, what would be the most desirable
outcome? a. The student discusses conflicts over drug use b. The student accept
s a referral to a substance abuse counselor c. The student agrees to inform his
parents of the problem d. The student reports increased comfort with making choi
ce 19. A male client who reportedly consumes 1 qt of vodka daily is admitted for
alcohol detoxification. To try to prevent alcohol withdrawal symptoms, Dr. Smit
h is most likely to prescribe which drug? a. clozapine (Clozaril) b. thiothixene
(Navane) c. lorazepam (Ativan) d. lithium carbonate (Eskalith) 20. A male clien
t is being treated for alcoholism. After a family meeting, the client's spouse ask
s the nurse about ways to help the family deal with the effects of alcoholism. N
urse Lily should suggest that the family join which organization? a. Al-Anon b.
Make Today Count c. Emotions Anonymous d. Alcoholics Anonymous 21. A female clie
nt is admitted to the psychiatric clinic for treatment of anorexia nervosa. To p
romote the client's physical health, nurse Tair should plan to: a. severely restri
ct the client's physical activities b. weigh the client daily, after the evening m
eal c. monitor vital signs, serum electrolyte levels, and acid-base balance d. i
nstruct the client to keep an accurate record of food and fluid intake 22. Kevin
is remanded by the courts for psychiatric treatment. His police record, which d
ates to his early teenage years, includes delinquency, running away, auto theft,
and vandalism. He dropped out of school at age 16 and has been living on his ow
n since then. His history suggests maladaptive coping, which is associated with:
a. antisocial personality disorder
b. c. d.
borderline personality disorder obsessive-compulsive personality disorder narcis
sistic personality disorder
23. Mark and May seek emergency crisis intervention because he slapped her repea
tedly the night before. The husband indicates that his childhood was marred by a
n abusive relationship with his father. When intervening with this couple, nurse
Gerry knows they are at risk for repeated violence because the husband: a. has
only moderate impulse control b. denies feelings of jealousy or possessiveness c
. has learned violence as an acceptable behavior d. feels secure in his relation
ship with his wife 24. A client whose husband just left her has a recurrence of
anorexia nervosa. Nurse Vic caring for her realizes that this exacerbation of an
orexia nervosa results from the client's effort to: a. manipulate her husband b. g
ain control of one part of her life c. commit suicide d. live up to her mother's e
xpectations 25. A male client has approached the nurse asking for advice on how
to deal with his alcohol addiction. Nurse Sally should tell the client that the
only effective treatment for alcoholism is: a. Psychotherapy b. total abstinence
c. Alcoholics Anonymous (AA) d. aversion therapy ANSWER 1. Answer C. The elevat
ed ST segments in this client's ECG indicate myocardial ischemia. To reverse this
problem, the physician is most likely to prescribe an infusion of nitroglycerin
to dilate the coronary arteries. Lidocaine and procainamide are cardiac drugs th
at may be indicated for this client at some point but aren't used for coronary art
ery dilation. If a cocaine user experiences ventricular fibrillation or asystole
, the physician may prescribe epinephrine. However, this drug must be used with
caution because cocaine may potentiate its adrenergic effects. 2. Answer C. Low
self-esteem is the highest risk factor for anorexia nervosa. Constant dieting to
get down to a "desirable weight" is characteristic of the disorder. Feeling ina
dequate when compared to peers indicates poor self-esteem. Most clients with ano
rexia nervosa don't like the way they look, and their self-perception may be disto
rted. A girl with cachexia may perceive herself to be overweight when she looks
in the mirror. Preferring fast food over healthy food is common in this age-grou
p. Because of the absence of body fat necessary for proper hormone production, a
menorrhea is common in a client with anorexia nervosa. 3. Answer C. Haloperidol
is the drug of choice for treating Tourette syndrome. Prozac, Luvox, and Paxil a
re antidepressants and aren't used to treat Tourette syndrome 4. Answer B. An open
-ended statement or question is the most therapeutic response. It encourages the
widest range of client responses, makes the client an active participant in the
conversation, and shows the client that the nurse is interested in his feelings
. Asking the client why he drove while intoxicated can make him feel defensive a
nd intimidated. A judgmental approach isn't therapeutic. By giving advice, the nur
se suggests that the client isn't capable of making decisions, thus fostering depe
ndency.
5. Answer D. Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic
hallucinosis, and alcohol withdrawal delirium (formerly delirium tremens). Signs
of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiti
ng, malaise, increased blood pressure and pulse rate, sleep disturbance, and irr
itability. Although diarrhea may be an early sign of alcohol withdrawal, tachyca
rdia not bradycardia is associated with alcohol withdrawal. Dehydration and an e
levated temperature may be expected, but a temperature above 101 F indicates an i
nfection rather than alcohol withdrawal. Pruritus rarely occurs in alcohol withd
rawal. If withdrawal symptoms remain untreated, seizures may arise later. 6. Ans
wer D. This client requires a vasodilator, such as nifedipine, to treat hyperten
sion, and a beta-adrenergic blocker, such as esmolol, to reduce the heart rate.
Lidocaine, an antiarrhythmic, isn't indicated because the client doesn't have an arr
hythmia. Although nitroglycerin may be used to treat coronary vasospasm, it isn't
the drug of choice in hypertension. 7. Answer B. The priority goal in alcohol wi
thdrawal is maintaining the client's safety. Committing to a drug-free lifestyle,
drinking plenty of fluids, and identifying personal strengths are important goal
s, but ensuring the client's safety is the nurse's top priority. 8. Answer A. Behavi
oral clues that suggest the potential for violence include a rigid posture, rest
lessness, glaring, a change in usual behavior, clenched hands, overtly aggressiv
e actions, physical withdrawal, noncompliance, overreaction, hostile threats, re
cent alcohol ingestion or drug use, talk of past violent acts, inability to expr
ess feelings, repetitive demands and complaints, argumentativeness, profanity, d
isorientation, inability to focus attention, hallucinations or delusions, parano
id ideas or suspicions, and somatic complaints. Violent clients rarely exhibit d
epression, silence, or hypervigilance. 9. Answer D. According to the Diagnostic
and Statistical Manual of Mental Disorders, 4th edition, diagnostic criteria for
psychoactive substance abuse include a maladaptive pattern of such use, indicat
ed either by continued use despite knowledge of having a persistent or recurrent
social, occupational, psychological, or physical problem caused or exacerbated
by substance abuse or recurrent use in dangerous situations (for example, while
driving). For this client, psychoactive substance dependence must be ruled out;
criteria for this disorder include a need for increasing amounts of the substanc
e to achieve intoxication (option A), increased time and money spent on the subs
tance (option B), inability to fulfill role obligations (option C), and typical
withdrawal symptoms. 10. Answer C. The predominant behavioral characteristic of
the client with borderline personality disorder is impulsiveness, especially of
a physically self-destructive sort. The observation that the client has scratche
d wrists doesn't substantiate the other options. 11. Answer A. Cocaine use may cau
se such cardiac complications as coronary artery spasm, myocardial infarction, d
ilated cardiomyopathy, acute heart failure, endocarditis, and sudden death. Coca
ine blocks reuptake of norepinephrine, epinephrine, and dopamine, causing an exc
ess of these neurotransmitters at postsynaptic receptor sites. Consequently, the
drug is more likely to cause tachyarrhythmias than bradyarrhythmias. Although n
eurobehavioral deficits are common in neonates born to cocaine users, they are r
are in adults. As craving for the drug increases, a person who's addicted to cocai
ne typically experiences euphoria followed by depression, not panic disorder 12.
Answer C. Acute withdrawal symptoms from alcohol may begin 6 hours after the cl
ient has stopped drinking and peak 1 to 2 days later. Delirium tremens may occur
2 to 4 days even up to 7 days after the last drink. 13. Answer A. Because the c
lient with anorexia nervosa may discard food or induce vomiting in the bathroom,
the nurse should provide one-on-one supervision during meals and for 1 hour aft
erward. Option B wouldn't be therapeutic because other clients may urge the client
to eat and
give attention for not eating. Option C would reinforce control issues, which ar
e central to this client's underlying psychological problem. Instead of giving the
client unlimited time to eat, as in option D, the nurse should set limits and l
et the client know what is expected. 14. Answer C. Manifestations of alcoholic h
allucinosis are best treated by providing a quiet environment to reduce stimulat
ion and administering prescribed central nervous system depressants in dosages t
hat control symptoms without causing oversedation. Although bed rest is indicate
d, restraints are unnecessary unless the client poses a danger to himself or oth
ers. Also, restraints may increase agitation and make the client feel trapped an
d helpless when hallucinating. Offering juice is appropriate, but measuring bloo
d pressure every 15 minutes would interrupt the client's rest. To avoid overstimul
ating the client, the nurse should check blood pressure every 2 hours. 15. Answe
r A. Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign of a
lcohol withdrawal. Blood pressure may be labile throughout withdrawal, fluctuati
ng at different stages. Hypertension typically occurs in early withdrawal. Hypot
ension, although rare during the early withdrawal stages, may occur in later sta
ges. Hypotension is associated with cardiovascular collapse and most commonly oc
curs in clients who don't receive treatment. The nurse should monitor the client's v
ital signs carefully throughout the entire alcohol withdrawal process. 16. Answe
r B. The client at highest risk for suicide is one who plans a violent death (fo
r example, by gunshot, jumping off a bridge, or hanging), has a specific plan (f
or example, after the spouse leaves for work), and has the means readily availab
le (for example, a rifle hidden in the garage). A client who gives away possessi
ons, thinks about death, or talks about wanting to die or attempting suicide is
considered at a lower risk for suicide because this behavior typically serves to
alert others that the client is contemplating suicide and wishes to be helped.
17. Answer C. Bulimia nervosa can lead to many complications, including diabetes
, heart disease, and hypertension. The eating disorder isn't typically associated
with allergies, cancer, or hepatitis A. 18. Answer B. All of the outcomes stated
are desirable; however, the best outcome is that the student would agree to see
k the assistance of a professional substance abuse counselor 19. Answer C. The b
est choice for preventing or treating alcohol withdrawal symptoms is lorazepam,
a benzodiazepine. Clozapine and thiothixene are antipsychotic agents, and lithiu
m carbonate is an antimanic agent; these drugs aren't used to manage alcohol withd
rawal syndrome. 20. Answer A. Al-Anon is an organization that assists family mem
bers to share common experiences and increase their understanding of alcoholism.
Make Today Count is a support group for people with life-threatening or chronic
illnesses. Emotions Anonymous is a support group for people experiencing depres
sion, anxiety, or similar conditions. Alcoholics Anonymous is an organization th
at helps alcoholics recovers by using a twelve-step program. 21. Answer C. An an
orexic client who requires hospitalization is in poor physical condition from st
arvation and may die as a result of arrhythmias, hypothermia, malnutrition, infe
ction, or cardiac abnormalities secondary to electrolyte imbalances. Therefore,
monitoring the client's vital signs, serum electrolyte level, and acid base balanc
e is crucial. Option A may worsen anxiety. Option B is incorrect because a weigh
t obtained after breakfast is more accurate than one obtained after the evening
meal. Option D would reward the client with attention for not eating and reinfor
ce the control issues that are central to the underlying psychological problem;
also, the client may record food and fluid intake inaccurately. 22. Answer A. Th
e client's history of delinquency, running away from home, vandalism, and dropping
out of school are characteristic of antisocial personality disorder. This malad
aptive
coping pattern is manifested by a disregard for societal norms of behavior and a
n inability to relate meaningfully to others. In borderline personality disorder
, the client exhibits mood instability, poor self-image, identity disturbance, a
nd labile affect. Obsessive-compulsive personality disorder is characterized by
a preoccupation with impulses and thoughts that the client realizes are senseles
s but can't control. Narcissistic personality disorder is marked by a pattern of s
elf-involvement, grandiosity, and demand for constant attention. 23. Answer C. F
amily violence usually is a learned behavior, and violence typically leads to fu
rther violence, putting this couple at risk. Repeated slapping may indicate poor
, not moderate, impulse control. Violent people commonly are jealous and possess
ive and feel insecure in their relationships 24. Answer B. By refusing to eat, a
client with anorexia nervosa is unconsciously attempting to gain control over t
he only part of her life she feels she can control. This eating disorder doesn't r
epresent an attempt to manipulate others or live up to their expectations (altho
ugh anorexia nervosa has a high incidence in families that emphasize achievement
). The client isn't attempting to commit suicide through starvation; rather, by re
fusing to eat, she is expressing feelings of despair, worthlessness, and hopeles
sness. 25. Answer B. Total abstinence is the only effective treatment for alcoho
lism. Psychotherapy, attendance at AA meetings, and aversion therapy are all adj
unctive therapies that can support the client in his efforts to abstain.
----------------
QUESTION