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70 Solved Mental Health Nursing MCQ Trial Questions [1]
1. Mental health is defined as:
A. The ability to distinguish what is real from what is not.
B. A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work productively.
C. Is the promotion of mental health, prevention of mental disorders, nursing care of patients during illness and rehabilitation
D. Absence of mental illness
Answer: B. A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work productively.
Mental health is a state of emotional and psychosocial well being. A mentally healthy individual is self aware and self directive, has the ability to solve problems, can cope with crisis without assistance beyond the support of family and friends fulfill the capacity to love and work and sets goals and realistic limits. A. This describes the ego function reality testing. C. This is the definition of Mental Health and Psychiatric Nursing. D. Mental health is not just the absence of mental illness.
2. Which of the following describes the role of a technician?
A. Administers medications to a schizophrenic patient.
B. The nurse feeds and bathes a catatonic client
C. Coordinates diverse aspects of care rendered to the patient
D. Disseminates information about alcohol and its effects.
Answer: A. Administers medications to a schizophrenic patient.
Administration of medications and treatments, assessment, documentation are the activities of the nurse as a technician. B. Activities as a parent surrogate. C. Refers to the ward manager role. D. Role as a teacher.
3. Letty says, “Give me 10 minutes to recall the name of our college professor who failed many students in our anatomy class.” She is operating on her:
A. Subconscious
B. Conscious
C. Unconscious
D. Ego
: A. Subconscious
Subconscious refers to the materials that are partly remembered partly forgotten but these can be recalled spontaneously and voluntarily. B. This functions when one is awake. One is aware of his thoughts, feelings actions and what is going on in the environment. C. The largest portion of the mind that contains the memories of one’s past particularly the unpleasant. It is difficult to recall the unconscious content. D. The conscious self that deals and tests reality.
4. The superego is that part of the psyche that:
A. Uses defensive function for protection.
B. Is impulsive and without morals.
C. Determines the circumstances before making decisions.
D. The censoring portion of the mind.
Answer: D. The censoring portion of the mind.
The critical censoring portion of one’s personality; the conscience. A. This refers to the ego function that protects itself from anything that threatens it.. B. The Id is composed of the untamed, primitive drives and impulses. C. This refers to the ego that acts as the moderator of the struggle between the id and the superego.
5. Primary level of prevention is exemplified by:
A. Helping the client resume self care.
B. Ensuring the safety of a suicidal client in the institution.
C. Teaching the client stress management techniques
D. Case finding and surveillance in the community
Answer: C. Teaching the client stress management techniques
Primary level of prevention refers to the promotion of mental health and prevention of mental illness. This can be achieved by rendering health teachings such as modifying ones responses to stress. A. This is tertiary level of prevention that deals with rehabilitation. B and D. Secondary level of prevention which involves reduction of actual illness through early detection and treatment of illness.
6. Situation: In a home visit done by the nurse, she suspects that the wife and her child are victims of abuse. Which of the following is the most appropriate for the nurse to ask?
A. “Are you being threatened or hurt by your partner?
B. “Are you frightened of you partner”
C. “Is something bothering you?”
D. “What happens when you and your partner argue?”
Answer: A. “Are you being threatened or hurt by your partner?
The nurse validates her observation by asking simple, direct question. This also shows empathy. B, C, and D are indirect questions which may not lead to the discussion of abuse.
7. The wife admits that she is a victim of abuse and opens up about her persistent distaste for sex. This sexual disorder is:
A. Sexual desire disorder
B. Sexual arousal disorder
C. Orgasm disorder
D. Sexual Pain Disorder
Answer: A. Sexual desire disorder
Has little or no sexual desire or has distaste for sex. B. Failure to maintain the physiologic requirements for sexual intercourse. C. Persistent and recurrent inability to achieve an orgasm. D. Also called dyspareunia. Individuals with this disorder suffer genital pain before, during and after sexual intercourse
8. What would be the best approach for a wife who is still living with her abusive husband?
A. “Here’s the number of a crisis center that you can call for help .”
B. “Its best to leave your husband.”
C. “Did you discuss this with your family?”
D. “ Why do you allow yourself to be treated this way”
Answer: A. “Here’s the number of a crisis center that you can call for help .”
Protection is a priority concern in abuse. Help the victim to develop a plan to ensure safety. B. Do not give advice to leave the abuser. Making decisions for the victim further erodes her esteem. However discuss options available. C. The victim tends to isolate from friends and family. D. This is judgmental. Avoid in anyway implying that she is at fault.
9. Which comment about a 3-year-old child if made by the parent may indicate child abuse?
A. “Once my child is toilet trained, I can still expect her to have some”
B. “When I tell my child to do something once, I don’t expect to have to tell”
C. “My child is expected to try to do things such as, dress and feed.”
D. “My 3-year-old loves to say NO.”
Answer: B. “When I tell my child to do something once, I don’t expect to have to tell”
Abusive parents tend to have unrealistic expectations on the child. A,B and C are realistic expectations on a 3 year old.
10. The primary nursing intervention for a victim of child abuse is:
A. Assess the scope of the problem
B. Analyze the family dynamics
C. Ensure the safety of the victim
D. Teach the victim coping skills
Answer: C. Ensure the safety of the victim
The priority consideration is the safety of the victim. Attend to the physical injuries to ensure the physiologic safety and integrity of the child. Reporting suspected case of abuse may deter recurrence of abuse. A,B and D may be addressed later.
11. Situation: A 30-year-old male employee frequently complains of low back pain that leads to frequent absences from work. Consultation and tests reveal negative results. The client has which somatoform disorder?
A. Somatization Disorder
B. Hypochondriasis
C. Conversion Disorder
D. Somatoform Pain Disorder
Answer: D. Somatoform Pain Disorder
This is characterized by severe and prolonged pain that causes significant distress. A. This is a chronic syndrome of somatic symptoms that cannot be explained medically and is associated with psychosocial distress. B. This is an unrealistic preoccupation with a fear of having a serious illness. C. Characterized by alteration or loss in sensory or motor function resulting from a psychological conflict
12. Freud explains anxiety as:
A. Strives to gratify the needs for satisfaction and security
B. Conflict between id and superego
C. A hypothalamic-pituitary-adrenal reaction to stress
D. A conditioned response to stressors
Answer: B. Conflict between id and superego
Freud explains anxiety as due to opposing action drives between the id and the superego. A. Sullivan identified 2 types of needs, satisfaction and security. Failure to gratify these needs may result in anxiety. C. Biomedical perspective of anxiety. D. Explanation of anxiety using the behavioral model.
13. The following are appropriate nursing diagnosis for the client EXCEPT:
A. Ineffective individual coping
B. Alteration in comfort, pain
C. Altered role performance
D. Impaired social interaction
Answer: D. Impaired social interaction
The client may not have difficulty in social exchange. The cues do not support this diagnosis. A. The client maladaptively uses body symptoms to manage anxiety. B. The client will have discomfort due to pain. C. The client may fail to meet environmental expectations due to pain.
14. The following statements describe somatoform disorders:
A. Physical symptoms are explained by organic causes
B. It is a voluntary expression of psychological conflicts
C. Expression of conflicts through bodily symptoms
D. Management entails a specific medical treatment
Answer: C. Expression of conflicts through bodily symptoms
Bodily symptoms are used to handle conflicts. A. Manifestations do not have an organic basis. B. This occurs unconsciously. D. Medical treatment is not used because the disorder does not have a structural or organic basis
15. What would be the best response to the client’s repeated complaints of pain:
A. “I know the feeling is real tests revealed negative results.”
B. “I think you’re exaggerating things a little bit.”
C. “Try to forget this feeling and have activities to take it off your mind.”
D. “So tell me more about the pain.”
Answer: A. “I know the feeling is real tests revealed negative results.”
Shows empathy and offers information. B. This is a demeaning statement. C. This belittles the client’s feelings. D. Giving undue attention to the physical symptom reinforces the complaint.
16. Situation: A nurse may encounter children with mental disorders. Her knowledge of these various disorders is vital. When planning school interventions for a child with a diagnosis of attention deficit hyperactivity disorder, a guide to remember is to:
A. provide as much structure as possible for the child
B. ignore the child’s overactivity.
C. encourage the child to engage in any play activity to dissipate energy
D. remove the child from the classroom when disruptive behavior occurs
Answer: A. provide as much structure as possible for the child
Decrease stimuli for behavior control thru an environment that is free of distractions, a calm non –confrontational approach and setting limit to time allotted for activities. B. The child will not benefit from a lenient approach. C. Dissipate energy through safe activities. D. This indicates that the classroom environment lacks structure.
17. The child with conduct disorder will likely demonstrate:
A. Easy distractibility to external stimuli.
B. Ritualistic behaviors
C. Preference for inanimate objects.
D. Serious violations of age related norms.
Answer: D. Serious violations of age related norms.
This is a disruptive disorder among children characterized by more serious violations of social standards such as aggression, vandalism, stealing, lying and truancy. A. This is characteristic of attention deficit disorder. B and C. These are noted among children with autistic disorder
18. Ritalin is the drug of choice for children with ADHD. The side effects of the following may be noted:
A. increased attention span and concentration
B. increase in appetite
C. sleepiness and lethargy
D. bradycardia and diarrhea
Answer: A. increased attention span and concentration
The medication has a paradoxical effect that decrease hyperactivity and impulsivity among children with ADHD. B, C, D. Side effects of Ritalin include anorexia, insomnia, diarrhea and irritability.
19. School phobia is usually treated by:
A. Returning the child to the school immediately with family support.
B. Calmly explaining why attendance in school is necessary
C. Allowing the child to enter the school before the other children
D. Allowing the parent to accompany the child in the classroom
Answer: A. Returning the child to the school immediately with family support.
Exposure to the feared situation can help in overcoming anxiety. A. This will not help in relieving the anxiety due separation from a significant other. C. and C. Anxiety in school phobia is not due to being in school but due to separation from parents/caregivers so these interventions are not applicable. D. This will not help the child overcome the fear
20. A 10 year old child has very limited vocabulary and interaction skills. She has an I.Q. of 45. She is diagnosed to have Mental retardation of this classification:
A. Profound
B. Mild
C. Moderate
D. Severe
ANSWER: C. Moderate
The child with moderate mental retardation has an I.Q. of 35-50 Profound Mental retardation has an I.Q. of below 20; Mild mental retardation 50-70 and Severe mental retardation has an I.Q. of 20-35.
21. The nurse teaches the parents of a mentally retarded child regarding her care. The following guidelines may be taught except:
A. overprotection of the child
B. patience, routine and repetition
C. assisting the parents set realistic goals
D. giving reasonable compliments
Answer: A. overprotection of the child
The child with mental retardation should not be overprotected but need protection from injury and the teasing of other children. B,C, and D Children with mental retardation have learning difficulty. They should be taught with patience and repetition, start from simple to complex, use visuals and compliment them for motivation. Realistic expectations should be set and optimize their capability.
22. The parents express apprehensions on their ability to care for their maladaptive child. The nurse identifies what nursing diagnosis:
A. hopelessness
B. altered parenting role
C. altered family process
D. ineffective coping
Answer: B. altered parenting role
Altered parenting role refers to the inability to create an environment that promotes optimum growth and development of the child. This is reflected in the parent’s inability to care for the child. A. This refers to lack of choices or inability to mobilize one’s resources. C. Refers to change in family relationship and function. D. Ineffective coping is the inability to form valid appraisal of the stressor or inability to use available resources
23. A 5 year old boy is diagnosed to have autistic disorder. Which of the following manifestations may be noted in a client with autistic disorder?
A. argumentativeness, disobedience, angry outburst
B. intolerance to change, disturbed relatedness, stereotypes
C. distractibility, impulsiveness and overactivity
D. aggression, truancy, stealing, lying
Answer: B. intolerance to change, disturbed relatedness, stereotypes
These are manifestations of autistic disorder. A. These manifestations are noted in Oppositional Defiant Disorder, a disruptive disorder among children. C. These are manifestations of Attention Deficit Disorder D. These are the manifestations of Conduct Disorder
24. The therapeutic approach in the care of an autistic child include the following EXCEPT:
A. Engage in diversionary activities when acting -out
B. Provide an atmosphere of acceptance
C. Provide safety measures
D. Rearrange the environment to activate the child
Answer: D. Rearrange the environment to activate the child
The child with autistic disorder does not want change. Maintaining a consistent environment is therapeutic. A. Angry outburst can be re-channelled through safe activities. B. Acceptance enhances a trusting relationship. C. Ensure safety from self-destructive behaviors like head banging and hair pulling.
25. According to Piaget a 5 year old is in what stage of development:
A. Sensorimotor stage
B. Concrete operations
C. Pre-operational
D. Formal operation
Answer: C. Pre-operational
Preoperational stage (2-7 years) is the stage when the use of language, the use of symbols and the concept of time occur. A. Sensorimotor stage (0-2 years) is the stage when the child uses the senses in learning about the self and the environment through exploration. B. Concrete operations (7-12 years) when inductive reasoning develops. D. Formal operations (2 till adulthood) is when abstract thinking and deductive reasoning develop.
26. Situation : The nurse assigned in the detoxification unit attends to various patients with substance-related disorders. A 45 years old male revealed that he experienced a marked increase in his intake of alcohol to achieve the desired effect This indicates:
A. withdrawal
B. tolerance
C. intoxication
D. psychological dependence
Answer: B. tolerance
Tolerance refers to the increase in the amount of the substance to achieve the same effects. A. Withdrawal refers to the physical signs and symptoms that occur when the addictive substance is reduced or withheld. B. Intoxication refers to the behavioral changes that occur upon recent ingestion of a substance. D. Psychological dependence refers to the intake of the substance to prevent the onset of withdrawal symptoms.
27. The client admitted for alcohol detoxification develops increased tremors, irritability, hypertension and fever. The nurse should be alert for impending:
A. delirium tremens
B. Korsakoff’s syndrome
C. esophageal varices
D. Wernicke’s syndrome
Answer: A. delirium tremens
Delirium Tremens is the most extreme central nervous system irritability due to withdrawal from alcohol B. This refers to an amnestic syndrome associated with chronic alcoholism due to a deficiency in Vit. B C. This is a complication of liver cirrhosis which may be secondary to alcoholism . D. This is a complication of alcoholism characterized by irregularities of eye movements and lack of coordination.
28. The care for the client places priority to which of the following:
A. Monitoring his vital signs every hour
B. Providing a quiet, dim room
C. Encouraging adequate fluids and nutritious foods
D. Administering Librium as ordered
Answer: A. Monitoring his vital signs every hour
Pulse and blood pressure are usually elevated during withdrawal, Elevation may indicate impending delirium tremens B. Client needs quiet, well lighted, consistent and secure environment. Excessive stimulation can aggravate anxiety and cause illusions and hallucinations. C. Adequate nutrition with sulpplement of Vit. B should be ensured. D. Sedatives are used to relieve anxiety.
29. Another client is brought to the emergency room by friends who state that he took something an hour ago. He is actively hallucinating, agitated, with irritated nasal septum.
A. Heroin
B. cocaine
C. LSD
D. marijuana
Answer: B. cocaine
The manifestations indicate intoxication with cocaine, a CNS stimulant. A. Intoxication with heroine is manifested by euphoria then impairment in judgment, attention and the presence of papillary constriction. C. Intoxication with hallucinogen like LSD is manifested by grandiosity, hallucinations, synesthesia and increase in vital signs D. Intoxication with Marijuana, a cannabinoid is manifested by sensation of slowed time, conjunctival redness, social withdrawal, impaired judgment and hallucinations.
30. A client is admitted with needle tracts on his arm, stuporous and with pin point pupil will likely be managed with:
A. Naltrexone (Revia)
B. Narcan (Naloxone)
C. Disulfiram (Antabuse)
D. Methadone (Dolophine)
Answer: B. Narcan (Naloxone)
Narcan is a narcotic antagonist used to manage the CNS depression due to overdose with heroin. A. This is an opiate receptor blocker used to relieve the craving for heroin C. Disulfiram is used as a deterrent in the use of alcohol. D. Methadone is used as a substitute in the withdrawal from heroin
31. Situation: An old woman was brought for evaluation due to the hospital for evaluation due to increasing forgetfulness and limitations in daily function. The daughter revealed that the client used her toothbrush to comb her hair. She is manifesting:
A. apraxia
B. aphasia
C. agnosia
D. amnesia
Answer: C. agnosia
This is the inability to recognize objects. A. Apraxia is the inability to execute motor activities despite intact comprehension. B. Aphasia is the loss of ability to use or understand words. D. Amnesia is loss of memory.
32. She tearfully tells the nurse “I can’t take it when she accuses me of stealing her things.” Which response by the nurse will be most therapeutic?
A. ”Don’t take it personally. Your mother does not mean it.”
B. “Have you tried discussing this with your mother?”
C. “This must be difficult for you and your mother.”
D. “Next time ask your mother where her things were last seen.”
Answer: C. “This must be difficult for you and your mother.”
This reflecting the feeling of the daughter that shows empathy. A and D. Giving advise does not encourage verbalization. B. This response does not encourage verbalization of feelings.
33. The primary nursing intervention in working with a client with moderate stage dementia is ensuring that the client:
A. receives adequate nutrition and hydration
B. will reminisce to decrease isolation
C. remains in a safe and secure environment
D. independently performs self care
Answer: C. remains in a safe and secure environment
Safety is a priority consideration as the client’s cognitive ability deteriorates.. A is appropriate interventions because the client’s cognitive impairment can affect the client’s ability to attend to his nutritional needs, but it is not the priority B. Patient is allowed to reminisce but it is not the priority. D. The client in the moderate stage of Alzheimer’s disease will have difficulty in performing activities independently
34. She says to the nurse who offers her breakfast, “Oh no, I will wait for my husband. We will eat together” The therapeutic response by the nurse is:
A. “Your husband is dead. Let me serve you your breakfast.”
B. “I’ve told you several times that he is dead. It’s time to eat.”
C. “You’re going to have to wait a long time.”
D. “What made you say that your husband is alive?
Answer: A. “Your husband is dead. Let me serve you your breakfast.”
The client should be reoriented to reality and be focused on the here and now.. B. This is not a helpful approach because of the short term memory of the client. C. This indicates a pompous response. D. The cognitive limitation of the client makes the client incapable of giving explanation.
35. Dementia unlike delirium is characterized by:
A. slurred speech
B. insidious onset
C. clouding of consciousness
D. sensory perceptual change
Answer: B. insidious onset
Dementia has a gradual onset and progressive deterioration. It causes pronounced memory and cognitive disturbances. A,C and D are all characteristics of delirium.
36. Situation: A 17-year-old gymnast is admitted to the hospital due to weight loss and dehydration secondary to starvation. Which of the following nursing diagnoses will be given priority for the client?
A. altered self-image
B. fluid volume deficit
C. altered nutrition less than body requirements
D. altered family process
Answer: B. fluid volume deficit
Fluid volume deficit is the priority over altered nutrition A. since the situation indicates that the client is dehydrated. A and D are psychosocial needs of a client with anorexia nervosa but they are not the priority.
37. What is the best intervention to teach the client when she feels the need to starve?
A. Allow her to starve to relieve her anxiety
B. Do a short term exercise until the urge passes
C. Approach the nurse and talk out her feelings
D. Call her mother on the phone and tell her how she feels
Answer: C. Approach the nurse and talk out her feelings
The client with anorexia nervosa uses starvation as a way of managing anxiety. Talking out feelings with the nurse is an adaptive coping. A. Starvation should not be encouraged. Physical safety is a priority. Without adequate nutrition, a life threatening situation exists. B. The client with anorexia nervosa is preoccupied with losing weight due to disturbed body image. Limits should be set on attempts to lose more weight. D. The client may have a domineering mother which causes the client to feel ambivalent. The client will not discuss her feelings with her mother.
38. The client with anorexia nervosa is improving if:
A. She eats meals in the dining room.
B. Weight gain
C. She attends ward activities.
D. She has a more realistic self concept.
Answer: B. Weight gain
Weight gain is the best indication of the client’s improvement. The goal is for the client to gain 1-2 pounds per week. (A)The client may purge after eating. C. Attending an activity does not indicate improvement in nutritional state. D. Body image is a factor in anorexia nervosa but it is not an indicator for improvement.
39. The characteristic manifestation that will differentiate bulimia nervosa from anorexia nervosa is that bulimic individuals
A. have episodic binge eating and purging
B. have repeated attempts to stabilize their weight
C. have peculiar food handling patterns
D. have threatened self-esteem
Answer: A. have episodic binge eating and purging
Bulimia is characterized by binge eating which is characterized by taking in a large amount of food over a short period of time. B and C are characteristics of a client with anorexia nervosa D. Low esteem is noted in both eating disorders
40. A nursing diagnosis for bulimia nervosa is powerlessness related to feeling not in control of eating habits. The goal for this problem is:
A. Patient will learn problem solving skills
B. Patient will have decreased symptoms of anxiety.
C. Patient will perform self care activities daily.
D. Patient will verbalize how to set limits on others.
Answer: A. Patient will learn problem solving skills
If the client learns problem solving skills she will gain a sense of control over her life. B. Anxiety is caused by powerlessness. C. Performing self care activities will not decrease ones powerlessness D. Setting limits to control imposed by others is a necessary skill but problem solving skill is the priority.
41. In the man agement of bulimic patients, the following nursing interventions will promote a therapeutic relationship EXCEPT:
A. Establish an atmosphere of trust
B. Discuss their eating behavior.
C. Help patients identify feelings associated with binge-purge behavior
D. Teach patient about bulimia nervosa
Answer: B. Discuss their eating behavior.
The client is often ashamed of her eating behavior. Discussion should focus on feelings. A,C and D promote a therapeutic relationship
42. Situation: A 35 year old male has intense fear of riding an elevator. He claims “ As if I will die inside.” This has affected his studies The client is suffering from:
A. agoraphobia
B. social phobia
C. Claustrophobia
D. xenophobia
. Answer: C. Claustrophobia
Claustrophobia is fear of closed space. A. Agoraphobia is fear of open space or being a situation where escape is difficult. B. Social phobia is fear of performing in the presence of others in a way that will be humiliating or embarrassing. D. Xenophobia is fear of strangers.
43. Initial intervention for the client should be to:
A. Encourage to verbalize his fears as much as he wants.
B. Assist him to find meaning to his feelings in relation to his past.
C. Establish trust through a consistent approach.
D. Accept her fears without criticizing.
. Answer: D. Accept her fears without criticizing.
The client cannot control her fears although the client knows it’s silly and can joke about it. A. Allow expression of the client’s fears but he should focus on other productive activities as well. B and C. These are not the initial interventions
44. The nurse develops a countertransference reaction. This is evidenced by:
A. Revealing personal information to the client
B. Focusing on the feelings of the client.
C. Confronting the client about discrepancies in verbal or non-verbal behavior
D. The client feels angry towards the nurse who resembles his mother.
Answer: A. Revealing personal information to the client
A. Countertransference is an emotional reaction of the nurse on the client based on her unconscious needs and conflicts. B and C. These are therapeutic approaches. D. This is transference reaction where a client has an emotional reaction towards the nurse based on her past.
45. Which is the desired outcome in conducting desensitization:
A. The client verbalize his fears about the situation
B. The client will voluntarily attend group therapy in the social hall.
C. The client will socialize with others willingly
D. The client will be able to overcome his disabling fear.
Answer: D. The client will be able to overcome his disabling fear.
The client will overcome his disabling fear by gradual exposure to the feared object. A,B and C are not the desired outcome of desensitization
46. Which of the following should be included in the health teachings among clients receiving Valium:
A. Avoid taking CNS depressant like alcohol.
B. There are no restrictions in activities.
C. Limit fluid intake.
D. Any beverage like coffee may be taken
. Answer: A. Avoid taking CNS depressant like alcohol.
Valium is a CNS depressant. Taking it with other CNS depressants like alcohol; potentiates its effect. B. The client should be taught to avoid activities that require alertness. C. Valium causes dry mouth so the client must increase her fluid intake. D. Stimulants must not be taken by the client because it can decrease the effect of Valium
47. Situation: A 20 year old college student is admitted to the medical ward because of sudden onset of paralysis of both legs. Extensive examination revealed no physical basis for the complaint. The nurse plans intervention based on which correct statement about conversion disorder?
A. The symptoms are conscious effort to control anxiety
B. The client will experience high level of anxiety in response to the paralysis.
C. The conversion symptom has symbolic meaning to the client
D. A confrontational approach will be beneficial for the client.
Answer: C. The conversion symptom has symbolic meaning to the client
the client uses body symptoms to relieve anxiety. A. The condition occurs unconsciously. B. The client is not distressed by the lost or altered body function. D. The client should not be confronted by the underlying cause of his condition because this can aggravate the client’s anxiety
48. Nikki reveals that the boyfriend has been pressuring her to engage in premarital sex. The most therapeutic response by the nurse is:
A. “I can refer you to a spiritual counselor if you like.”
B. “You shouldn’t allow anyone to pressure you into sex.”
C. “It sounds like this problem is related to your paralysis.”
D. “How do you feel about being pressured into sex by your boyfriend?”
Answer: D. “How do you feel about being pressured into sex by your boyfriend?”
Focusing on expression of feelings is therapeutic. The central force of the client’s condition is anxiety. A. This is not therapeutic because the nurse passes the responsibility to the counselor. B. Giving advice is not therapeutic. C. This is not therapeutic because it confronts the underlying cause.
49. Malingering is different from somatoform disorder because the former:
A. Has evidence of an organic basis.
B. It is a deliberate effort to handle upsetting events
C. Gratification from the environment are obtained.
D. Stress is expressed through physical symptoms.
Answer: B. It is a deliberate effort to handle upsetting events
Malingering is a conscious simulation of an illness while somatoform disorder occurs unconscious. A. Both disorders do not have an organic or structural basis. C. Both have primary gains. D. This is a characteristic of somatoform disorder
50. Unlike psychophysiologic disorder Linda may be best managed with:
A. medical regimen
B. milieu therapy
C. stress management techniques
D. psychotherapy
Answer: C. stress management techniques
Stress management techniques is the best management of somatoform disorder because the disorder is related to stress and it does not have a medical basis. A. This disorder is not supported by organic pathology so no medical regimen is required. B and D. Milieu therapy and psychotherapy may be used a therapeutic modality but these are not the best
51. A man is admitted to the nursing care unit with a diagnosis of cirrhosis. He has a long history of alcohol dependence. During the late evening following his admission, he becomes increasingly disoriented and agitated. Which of the following would the client be least likely to experience?
A. Diaphoresis and tremors.
B. Increased blood pressure and heart rate.
C. Illusions.
D. Delusions of grandeur.
Answer D. Delusions of grandeur
Diaphoresis and tremors occur in the first phase of alcohol withdrawal. The blood pressure and heart rate increase in the first phase of alcohol withdrawal. Illusions are common in persons withdrawing from alcohol. Illusions occur most often in dim artificial lighting where the environment is not perceived accurately. Delusions of grandeur are symptomatic of manic clients, not clients withdrawing from alcohol. The symptoms and history of alcohol abuse suggest this client is in alcohol withdrawal
52. Mr. Peterson, 35, is admitted for bipolar illness, manic phase, after assaulting his landlord in an argument over Mr. Peterson is staying up all night playing loud music. Mr. Peterson is hyperactive, intrusive, and has rapid, pressured speech. He has not slept in three days and appears thin and disheveled. Which of the following is the most essential nursing action at this time?
A. Providing a meal and beverage for Mr. Peterson to eat in the dining room.
B. Providing linens and toiletries for Mr. Peterson to attend to his hygiene.
C. Consulting with the psychiatrist to order a hypnotic to promote sleep.
D. Providing for client safety by limiting his privileges.
Answer D. Providing for client safety by limiting his privileges.
Food and fluids are necessary. However, Mr. Peterson’s hyperactivity does not allow him to sit quietly to eat. Finger foods “on the run” will provide needed nourishment. When hyperactivity decreases, then approach Mr. Peterson’s. regarding hygiene and grooming needs. Medications will be ordered. However, a thorough evaluation must be done first. Mr. Peterson has been assaultive with the landlord and it is reasonable to expect that he may be with peers and staff. His mental illness produces a hyperactive state and poor judgment and impulse control. External controls such as limiting of unit privileges will assist in feelings of security and safety.
53. Which of the following would best indicate to the nurse that a depressed client is improving?
A. Reduced levels of anxiety.
B. Changes in vegetative signs.
C. Compliance with medications.
D. Requests to talk to the nurse.
Answer B. Changes in vegetative signs.
Reduced levels of anxiety do not indicate an improvement in depressive symptoms. Vegetative signs such as insomnia, anorexia, psychomotor retardation, constipation, diminished libido, and poor concentration are biological responses to depression. Improvement in these signs indicates a lifting of the depression. Compliance with medications does not indicate improvement in depression. Requests to talk to the nurse vary. Requests may show trust in the nurse but are not a sign that depression has diminished.
54. An elderly man is admitted to the hospital. He was alert and oriented during the admission interview. However, his family states that he becomes disruptive and disoriented around dinnertime. One night he was shouting furiously and didn’t know where he was. He was sedated and the next morning he was fine. At dinnertime the disruptive behavior returned. The client is diagnosed as having sundown syndrome. The client’s son asks the nurse what causes sundown syndrome. The nurse’s best response is that it is attributed to
A. an underlying depression.
B. inadequate cerebral flow.
C. changes in the sensory environment.
D. fluctuating levels of oxygen exchange.
. Answer C. changes in the sensory environment.
An underlying depression does not cause sundown syndrome. There is not sufficient evidence to suggest he has inadequate cerebral blood flow. Because the confusion occurs at sundown, the cause is probably changes in the sensory environment. Sundown syndrome is related to environmental and sensory abnormalities that lead to acute confusion. Fluctuating levels of oxygen exchange do not cause sundown syndrome.
55. The nurse is discussing electroconvulsive therapy (ECT) with a client who asks how long it will be before she feels better. The nurse explains that the beneficial effects of ECT usually occur within
A. one week.
B. three weeks.
C. four weeks.
D. six weeks.
Answer A. one week.
Beneficial effects of ECT usually are evident after the first several treatments. Since treatments are administered at intervals of 48 hours, these effects are apparent after one week of therapy. Beneficial effects of ECT therapy are usually seen before three weeks. It takes three to four weeks for tricyclic antidepressants to take effect. Beneficial effects of ECT therapy are usually seen before four weeks. It takes three to four weeks for tricyclic antidepressants to take effect. Beneficial effects of ECT therapy are usually seen after the first few treatments.
56. The nurse is assessing a 17-year-old female who is admitted to the eating disorders unit with a history of weight fluctuation, abdominal pain, teeth erosion, receding gums, and bad breath. She states that her health has been a problem but there are no other concerns in her life. Which of the following assessments will be the least useful as the nurse develops the care plan?
A. Information regarding recent mood changes.
B. Family functioning using a genogram.
C. Ability to socialize with peers.
D. Whether she has a sexual relationship with a boyfriend.
Answer D. Whether she has a sexual relationship with a boyfriend.
Information about mood changes is important to assess, as bulimia is often associated with affective disorders. Family functioning is the most essential point to assess, as it reveals if binge eating is triggered by conflict within the family. Information about ability to socialize with peers is important to assess, as it is possible the problem initiated with peer relationships. It is inappropriate to ask about her sexual relationships.
57. A 34-year-old woman is admitted for treatment of depression. Which of these symptoms would the nurse be least likely to find in the initial assessment?
A. inability to make decisions.
B. feelings of hopelessness.
C. family history of depression.
D. increased interest in sex.
Answer D. increased interest in sex.
Indecisiveness and fear of being wrong are common in depression. Depression creates feelings that nothing will ever improve. The risk of depression is increased when there is a family history. Interest in sex is markedly decreased in depression.
58. The nurse is planning care for a client who has a phobic disorder manifested by a fear of elevators. Which goal would need to be accomplished first? The client
A. demonstrates the relaxation response when asked.
B. verbalizes the underlying cause of the disorder.
C. rides the elevator in the company of the nurse.
D. role plays the use of an elevator.
Answer A. demonstrates the relaxation response when asked.
The ability to use relaxation is basic to treatment of phobia. Clients with phobias are resistant to insight therapy. Riding the elevator accompanied by the nurse is an appropriate long-term goal. Role playing may be appropriate after the client has learned relaxation.
59. A teenage female is admitted with the diagnosis of anorexia nervosa. Upon admission, the nurse finds a bottle of assorted pills in the client’s drawer. The client tells the nurse that they are antacids for stomach pains. The best response by the nurse would be
a. “These pills aren’t antacids since they are all different.”
b. “Some teenagers use pills to lose weight.”
c. “Tell me about your week prior to being admitted.”
d. “Are you taking pills to change your weight?”
Answer C. “Tell me about your week prior to being admitted.”
This is an open-ended question which is non-judgemental and allows for further discussion. The topic is also non threatening yet will give the nurse insight into the client’s view of events leading up to admission. It is the only option that is client centered. The other options focus on the pills.
60. A mother with a Roman Catholic belief has given birth in an ambulance on the way to the hospital. The neonate is in very critical condition with little expectation of surviving the trip to the hospital. Which of these requests should the nurse in the ambulance anticipate and be prepared to do?
A. The refusal of any treatment for self and the neonate until she talks to a reader
B. The placement of a rosary necklace around the neonate’s neck and not to remove it unless absolutely necessary
C. Arrange for a church elder to be at the emergency department when the ambulance arrives so a “laying on hands” can be done
D. Pour fluid over the forehead backwards towards the back of the head and say “I baptize you in the name of the father, the son and the holy spirit. Amen.”
Answer D. Pour fluid over the forehead backwards towards the back of the head and say “I baptize you in the name of the father, the son and the holy spirit. Amen.”
Infant baptism is mandatory in the Roman Catholic belief especially if a neonate is not expected to live. Anyone may perform this if an infant or child is gravely ill. Option A refers to the Christian Science belief. Option B is a belief of Russian Orthodoxy. Mormons believe of divine healing with the laying on of hands, as represented in option C.
61. Which statement by the client during the initial assessment in the the emergency department is most indicative for suspected domestic violence?
a. “I am determined to leave my house in a week.”
b. “No one else in the family has been treated like this.”
c. “I have only been married for 2 months.”
d. “I have tried leaving, but have always gone back.”
Answer D. “I have tried leaving, but have always gone back.”
Victims develop a high tolerance for abuse. They blame themselves for being victimized. All members in the family suffer from the effects of abuse, even if they are not the actual victims. For these reasons, victims often have an extensive history of abuse and struggle for a long time before they can leave permanently.
62. Which of these statements by the nurse reflects the best use of therapeutic interaction techniques?
a. “You look upset. Would you like to talk about it?”
b. “I’d like to know more about your family. Tell me about them.”
c. “I understand that you lost your partner. I don’t think I could go on if that happened to me.”
d. “You look very sad. How long have you been this way?”
Answer A. “You look upset. Would you like to talk about it?”
Giving broad opening statements and making observations are examples of therapeutic communication. The other options are too specific or focused to be therapeutic.
63. When planning the therapeutic milieu, it is MOST important to select group activities which
A. Match the clients’ preferences
B. Are consistent with clients’ skills
C. Achieve clients’ therapeutic goals
D. Build skills of group participation
Answer C. Achieve clients’ therapeutic goals
Activity groups are used to enhance the therapeutic milieu and to meet the clinical and social needs of clients, e.g., to minimize withdrawal and regression, to develop self care skills, etc.
64. A client was admitted to the psychiatric unit for severe depression. After several days, the client continues to withdraw from other clients. Which of the following would be the MOST appropriate statement by the nurse to promote interaction with other clients?
a. “Your doctor thinks its good for you to spend time with others.”
b. “It is important for you to participate in group activities.”
c. “Painting this picture will help you feel better.”
d. “Come play Chinese Checkers with Gerry and me.”
Answer D. “Come play Chinese Checkers with Gerry and me.”
This gradually engages the client in interactions with others and uses positive behavioral expectation.
65. The nurse can BEST ensure the safety of a demented client who wanders from the room by
A. Repeatedly reminding the client of time and place
B. Explaining the risks of becoming lost
C. Using soft restraints
D. Attaching a wander-guard sensor band to the client’s
Wrist
Answer D. Attaching a wander-guard sensor band to the client’s wrist
This type of identification band easily tracks the client’s movements and ensures safety while wandering on the unit.
66. A client with paranoid thoughts refuses to eat because he believes the food is poisoned. The MOST appropriate initial action is to
A. Taste the food in the client’s presence
B. Suggest that food be brought from home
C. Simply state the food is not poisoned
D. Inform the client he will be tube fed if he does not eat
Answer C. Simply state the food is not poisoned
This actions presents reality.
67. The nurse is caring for a severely depressed client who has just been admitted to the in-client psychiatric unit. Which of the following is a PRIORITY of care?
A. Nutrition
B. Elimination
C. Rest
D. Safety
Answer D. Safety
Safety is a priority of care for the depressed client. Precautions to prevent suicide must be a part of the plan.
68. A nurse is teaching a stress-management program for client. Which of the following beliefs will the nurse advocate as a method of coping with stressful life events?
A. Avoidance of stress is an important goal for living.
B. Control over one’s response to stress is possible.
C. Most people have no control over their level of stress.
D. Significant others are important to provide care and concern.
Answer B. Control over one’s response to stress is possible.
When learning to manage stress, it is helpful to believe that one has the ability to control one’s response to stress. It is impossible to avoid stress, which is a normal experience. Stress can be positive and growth enhancing as well as harmful. The belief that one has some control can minimize the stress response.
69. A student nurse is caring for a 75-year-old client who is very confused. The student’s communication tools should include:
A. written directions for bathing.
B. speaking very loudly.
C. gentle touch while guiding ADLs (activities of daily living).
D. flat facial expression.
Answer C. gentle touch while guiding ADLs (activities of daily living).
Nonverbal, gentle touch is an important tool here. Providing appropriate forms of touch to reinforce caring feelings. Because tactile contacts vary considerably among individuals, families, and cultures, the nurse must be sensitive to the differences in attitudes and practices of clients and self.
70. When a husband takes out his work frustrations and anger by abusing his wife at home, the nurse would identify this crisis as which type?
A. psychiatric emergency crisis
B. developmental crisis
C. anticipated life transition
D. dispositional crisis
Answer D. dispositional crisis
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