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. 1. When a nurse establishes a therapeutic relationship with a client, which of the following is the primary focus of the client’s care? a. The medical diagnosis c. The nursing diagnosis b. The client’s needs and problems d. The client’s social interaction Answer: B- The nurse establishes the therapeutic relationship, which is a helping relationship, to assist the client in working in his needs and problems. Both medical and nursing diagnosis would be important in understanding the client. However, the nurse provides care for person, not the diagnosis. Improving social interaction, but it is not the purpose of the relationship 2. Which of the following is the overall purpose of therapeutic communication? a. To analyze client’s problems b. To elicit cooperation c. To facilitate a helping relationship d. To provide emotional support Answer: C- The purpose of the therapeutic communication is to foster a helping relationship, so that the client can more effectively cope with problems. The other tasks described are part of the helping relationship but are not the over-all purpose 3. In which of the following situations would communications be LEAST likely hindered? a. Mrs.L, 30 years old is admitted to the hospital for the first time for acute appendicitis b. Mrs. R, 50 years old, diabetic, is admitted to the hospital after a stroke. She has right hemiplegia c. Mrs. D, 45 years old, is admitted to the hospital for cervical cancer d. Mr. T, 70 years old, is admitted for fractured tibia. He speaks Spanish only Answer: C. the rest can hinder communication except C... unless if the patient with cervical cancer is in severe pain (but not present in situation) 4. Which of the following communication technique is MOST effective in dealing with covert communication? a. Listening c. Clarification b. Evaluation d. Validation Answer: A- Clarification and validation is just the result of listening. Evaluation doesn’t have to do with covert communication 5. Which of the following is MOST important in fostering a positive relationship? a. The nurse recognizes that some patient regress when confronted with illness b. The nurse functions as a positive role model to encourage health oriented patient behavior c. Needs to understand that patients may test her before he can accept and trust her d. The nurse must fully share the patient’s feelings before she can develop her goal for her nursing care Answer: D- The nurse should accept the role of the patient SITUATION 2: Stress can bring about various human reactions that may result to illness or enhance one’s coping mechanism. Stress also triggers local and general adaptation syndrome. 6. Which of the following BEST describes the general adaptation syndrome. It is a: a. Psychological response to stress c. Behavioral response to stress b. Physiologic response to stress d. Sociocultural response to stress Answer: B- General adaptation syndrome refers to the physiologic response to stress 7. Which of the following levels of anxiety is BEST for client’s learning? a. Moderate c. Severe b. Mild d. No anxiety Answer: B- In mild level of anxiety, it produces a slight arousal state that enhances perception, learning and productive abilities. Moderate anxiety increases client’s arousal state to a point where the person expresses feelings of tension, nervousness and concerns but perceptual ability is narrowed. Sever anxiety consumes most of person’s energies and requires intervention, perception is further decreased 8. Which of the following defense mechanism is consciously used in coping mechanism with stress?
a. Regression c. Repression b. Suppression d. Projection Answer: B- Suppression refers to consciously forgetting of painful events while repression refers to unconsciously forgetting of painful events 9. Which of the following models identifies ability to cope with stress, practice and norms of the peer group, effect of social environment and the resources used to deal with stress as determinants to stress and stress reactions? a. Stimulus based model c. Response based model b. Adaptation based model d. Transaction based model Answer: D- Transaction based model was created by Lazarus which is a Stimulus Theory and Response theory in which do not consider individual differences 10. The purpose of the first stage of the General Adaptation Syndrome is which of the following? a. Determine the causes of the danger b. Present the individual from having an unpleasant experience c. Mobilize energy needed for adaptation d. Alert the individual to danger Answer: C- this is the purpose of the first stage of GAS in order to prevent crisis SITUATION 3: Paul, 16 year old was committed to a mental health facility with diagnosis of personality disorder. He has a history of promiscuity and running away. He tells the staff “I can’t stand this place, I want to go away.” 11. How would the nurse deal effectively with Paul’s threat to run away? a. Tell him to stay in her room b. Lock him in her room c. Tell him firmly that if he does not control herself, the staff will help him control herself d. Ignore the threat Answer: C. global 12. The early experiences of Paul may indicate a history of: a. Severe parental rejection c. Severe temper tantrums b. Failure in interpersonal relationship d. Failure to identify positively with father Answer: A 13. How would you describe parental rejection? a. Failure to identify positively with father c. Lack of recognition as a person b. Lack of parental love and discipline d. Lack of the capacity to trust others Answer: B- Clients with antisocial disorder lacks trust for others 14. What should the nurse do to prevent Paul from manipulating and dominating others? a. Ignore him demands c. Observe him closely b. Isolate Paul d. Protect others from being manipulated Answer: D- Safety precautions must be posed to protect others, provide endorsement to other nurses 15. In dealing with manipulative behavior, the nurse should convey an attitude of: a. Active friendliness c. Love and understanding b. Permissiveness d. Consistency Answer: D- Firmness, matter of fact and consistency is used to approach clients with antisocial personality SITUATION 4: Mark was brought to the National Center for Mental Health for substance abuse. 16. Which of the following behaviors would indicate stimulant intoxication? a. Slurred speech, unsteady gait, impaired concentration b. Hyperactivity, talkativeness, euphoria c. Relaxed inhibitions, increased appetite, distorted perceptions d. Depersonalization, dilated pupils, visual hallucinations Answer: B- Choice a are manifestations of depressants, choice b and c are manifestations of hallucinogen while hyperactivity, talkativeness, euphoria are signs of stimulant intoxication 17. Which of the following statements would indicate the teaching about Naltrexone (Revia) had been effective? a. “I’ll get sick if I use heroine on this medication.”
b. “This medication will block the effects of any opioid substance I take.” c. “If I use opioid while taking naltrexone, I’ll become extremely ill.” d. “Using naltrexone may make me dizzy.” Answer: B- Naltrexone (Revia) is a narcotic antagonist 18. Clonidine (Catapres) is prescribed for symptoms of opioid withdrawal. Which of the following nursing assessments is essential before giving a dose of this medication? a. Assessing the client’s blood pressure b. Determining when the client last use an opiate c. Monitoring the client for tremors d. Completing a thorough physical assessment Answer: A- Clonidine (Catapres) is an antihypertensive which is given to patients with opioid withdrawal because these patients are hyperactive which results to increase in their vital signs. 19. The nurse has provided an in-service program on impaired professionals. She knows that teaching has been effective when staff identify the following as the greatest risk for substance abuse among professionals: a. Most nurses are codependent in their personal and professional relationships b. Most nurses come from dysfunctional families and are risk for developing addiction c. Most nurses are exposed to various substances and believe they are not risk to develop the disease d. Most nurses have preconceived ideas about what kind of people become addicted Answer: C- It is due to availability of drugs 20. The client tells the nurse that she takes a drink every morning to calm her nerves and stops her tremors. The nurse realizes the client is at risk for: a. An anxiety disorder c. Physical dependence b. A neurological disorder d. Psychological addiction Answer: C- Physical dependence is a physical effect of drug SITUATION 5: A nurse must be aware of the latest issues on Child Abuse and Family Violence. 21. Marinel, a 16 years old young lady was left with her stepfather and with a mother who is working in the office the whole day. As a nurse, what would be your advice? a. Tell the mother to keep watching her daughter b. Tell the child get to her regular activities c. Ask the child to get away from her stepfather d. Let the child stay with the relatives Answer: D- Other than her stepfather let the child stay with the relatives 22. Marinel’s high school friend made a visit and talked to her father. Marinel feels fidgety and continuously smoked while her friend is talking to her mother. Beth is experiencing: a. Worries b. Anger c. Nervousness d. Stress Answer: C- Nervousness is a physiological symptom to relieve anxiety 23. The best way a nurse can advise an abused child is to call the: a. Police station b. School c. Parish d. Bantay Bata 163 Answer: D- Bantay Bata 163 is a non-government organization 24. When planning the care for a client who is abused, which of the following measures would be most important to include? a. Being compassionate and empathetic b. Teaching the client about abuse and the cycle of violence c. Explaining to the client his or her personal and legal rights d. Helping the client develop a safety plan Answer: D- So that the client can escape the abuse for safety reason 25. During the session with the nurse, a client who is being abused states, “I don’t know what to do anymore. He doesn’t want me to go anywhere while he’s at work, not even to visit my friends.”
Which of the following nursing diagnoses would the nurse formulate in respect to this information? a. Risk for violence related to abusive husband, as evidenced by victim’s statement of being battered b. Low Self-Esteem related to victimization, as evidenced by not being able to leave the house c. Powerlessness related to abusive husband, as evidenced by inability to make decisions d. Ineffective Coping related to victimization, as evidenced by crying Answer: C- Powerlessness related to abusive husband, as evidenced by inability to make decisions refers to marital status SITUATION 6: The following questions pertains to Musculoskeletal System of aging persons 26. Which of the following behaviors contribute to osteoporosis: a. Smoking, and lack of exercise c. Drinking tea, deep breathing, and losing weight b. Physical activity, dancing, and swimming d. Knee bends, shopping, and weight lifting Answer: A 27. As people gets older, they lose height (become shorter). This is due to: a. The fact that they don’t stand up straight c. Loss of bone mass in the vertebral discs b. The rest of the population has grown taller d. Inaccurate measurement Answer: C 28. As one ages, muscle mass (that is muscle size): a. Decreases c. Stays about the same b. Increases d. Can go either way Answer: A 29. As a result of changes in long bones and the spinal column, the gait of older people: a. Becomes like a dancer c. Is more steady b. Is less stable and balanced when walking d. Hardly changes at all Answer: B 30. Changes in the bone of older people make which of the following a major danger? a. Infection c. Allergy b. Contagion d. Fractures Answer: D SITUATION 7: Sensory deprivation is experienced by most people in any setting whether they are patients confined in hospitals, workers assigned in mining industries or a family member assigned in far places. 31. Which of the following will LEAST likely result to sensory deprivation? a. Increased sensory input brought about by unlimited visitors from families and friends b. Restriction of the environment in patients who are on absolute bed rest c. Reduced sensory input in the case of patients who have just been operated on glaucoma d. Elimination of order or “meaning” from input in the case of ICU patients or was in reverse isolation Ans.A.. the rest can lead to sensory deprivation.. A is the least 32. Which of the following are observed in sensorially deprived adult and elderly people because of deafness? a. They prefer interaction with hearing adults b. They show greater interdependence than hearing adult c. They become more flexible in daily routine d. They show poor social judgment Ans.A.. they show poor social judgment becoz of the deprived hearing loss 33. Which nursing intervention would be appropriate for client with hyperthesia? a. Firm pressure when touching body parts c. Minimal use of direct touch b. Vigorous hair brushing d. Frequent back rubs Ans. C.. becoz the rest can aggravate sensitivity to stimuli of any senses 34. A post-operative blind patient needs to be assisted for ambulation. Which of the following should
the nurse do in ambulating a client with visual impairment? a. Stand on the client’s nondominant side, approximately one step behind the client, grasping the client’s arm b. Stand on the client’s dominant side and grasp the client’s arm c. Stand on the client’s dominant aside slightly in front of the client, allowing the client to grasp the nurse’s arm d. Stand slightly in front of the client’s nondominant side allowing the client to grasp the nurse’s arm Ans. D.. The nurse should stand slightly infront so you can better guide the patient with visual impairment 35. Which of the following is an appropriate communication method for client’s with hearing impairment? a. Talk side by side with the client b. Use visual aide and gestures to enhance the spoken word c. Restrict use of the client’s hands d. Speak loud enough or shout if you may so that client will be able to hear you Ans. B. Gesture and visual aids can enhance better understanding for people with hearing impairment SITUATION 8: Sexuality is one problem area that is often neglected by nurses in the care of elderly clients. The nurse however must be able to identify and address the sexual changes to provide nursing care. 36. Menopause is considered complete when: a. Hot flashes cease c. A woman has been without periods for a year b. Emotional stability ends d. Irritability goes away Answer: C 37. Hormonal decline in women causes: a. Increased risk for atherosclerotic plaques c. No changes in risk for atherosclerotic plaques b. Decreased risk for atherosclerotic plaques d. None of the above Answer: A 38. Benefits of hormone replacement therapy (HRT) include: a. Protection against constipation b. Protection against osteoporosis and elimination of the unpleasant symptoms of menopause c. Protection against the flu d. Protection against fever Answer: B 39. Which of the following is NOT a known risk of hormone replacement therapy: a. Formation of blood clots and hypertension b. Development of noncancerous fibroid tumors in the uterus c. Breast and endometrial cancers d. Lung cancer Answer: D SITUATION 9: The nurse is caring for an adult admitted with a diagnosis of brain tumor. He was scheduled for craniotomy. 40. A client has a supratentorial craniotomy for a tumor in the right frontal lobe of the cerebral cortex. Post operatively, the position that would be most appropriate for this client would be: a. High fowler’s with knee gatch raised b. Flat with small pillow under the nape of the neck c. Head of the bed elevated 20 degrees with the head turned to the operative side d. Head of the bed elevated 45 degrees with a large pillow under the head and shoulders Answer: D- This lessens the possibility of hemorrhage, provides for better circulation of CSF, and promotes venous return 41. A client is regaining consciousness after a craniotomy becomes restless and attempts to pull out her intravenous line. Which nursing intervention protects the client without increasing her ICP? a. Place her in a jacket restraint
b. Wrap her hands in soft “mitten” restraints c. Tuck her arms and hands under the draw sheet d. Apply a wrist restraint to each arm Answer: B- It is best for the client to wear mitts, because restraining her movements will cause agitation and lead to an increase of the ICP 42. Following 3 months of rehabilitation after craniotomy, a female client is still having some motor speech difficulty. To promote the client’s use of speech the nurse should: a. Correct her mistakes immediately b. Respond to her crude efforts of speaking c. Re-explain why she is having difficulty of speaking d. Speak to her in simple words and short sentences Answer: B- Recognition of effort is motivating 43. A client undergoes a craniotomy for removal of her brain tumor. The nurse notes that her dressing is saturated with blood. Which of the following interventions is most appropriate? a. Replacing the dressing b. Marking the area of drainage on the dressing c. Reinforcing the dressing and notifying the doctor immediately d. Doing nothing because this is normal occurrence Answer: C- If the dressing becomes saturated with blood, it should be reinforced and the doctor notified immediately. The patient may need to return to the operating room to stop the bleeding. The dressing shouldn’t be removed because removing it might disturb clot formation. When there is a small amount of drainage on the dressing, the drainage area can be marked to easily identify an increase in drainage 44. After craniotomy, what is your primary goal? a. Prevent increased ICP b. Prevent infection c. Prevent secondary surgery d. Prevent hemorrhage SITUATION 10: Dementing illness and changes in the brain 45. As one gets older, there is a loss of brain cells. The significance of this is: a. A cell transplant is indicated b. The lost cells will regenerate on their own c. The remaining cells are more than enough for learning and remembering d. The significance is not known Answer: C 46. ACUTE dementia is due to causes which can be reversed. A frequent cause of this type of dementia is: a. Cerebrovascular accident b. Alzheimer’s disease c. Multiple Infarcts d. Electrolyte imbalance, especially hyponatremia (loss of sodium) Answer: D 47. When assessing a client with dementia, which of the following behaviors would the nurse interpret as a manifestation of disinhibition? a. Wandering and getting lost b. Auditory and/or visual hallucinations c. Decreased interest in bathing and hygiene d. Inappropriate language and sexual behaviors Answer: D- Loss of judgment decreases the ability to control impulses and behaviors in social situations. Therefore, the client typically exhibits inappropriate language and sexual behaviors. Wandering and getting lost involve cognitive changes, not disinhibition 48. The brains of persons with Alzheimer’s disease are characterized by the presence of: a. Fatty deposits c. Calcium deposits b. Senile plaques and neurofibrillary tangles d. Lack of gray matter Answer: B SITUATION 11: A 23 year-old man was voluntarily admitted to the inpatient unit with a diagnosis of
paranoid schizophrenia. 49. As the nurse approaches the client, he says, “If you come any closer, I’ll die.” This is an example of: a. Hallucination b. Delusion c. Illusion d. Idea of reference Answer: B- A delusion is a fixed false belief 50. Delusion is: a. Psychomotor disturbance b. Mood disturbance c. Disturbance of thought d. Disturbance of perception 51. When communicating with a paranoid client, the main principle is to: a. Use logic and be persistent b. Provide an anxiety-free environment c. Express doubt and do not argue d. Encourage ventilation of anger Answer: C- Paranoid clients develop a delusional system to defend against anxiety. Arguing with the client would increase his anxiety 52. The client tells his primary nurse that he’s scheduled to meet the President of the Philippines a special time, making it impossible for the client to leave his room for dinner. Which of the following responses by the nurse is most appropriate? a. “It’s meal time. Let’s go so you can eat.” b. “The President of the Philippines told me to take you to dinner.” c. “Your physician expects you to follow the unit’s schedule.” d. “People who don’t eat on this unit aren’t being cooperative.” Answer: A- A delusional client is wrapped up in his false beliefs that he tends to disregard activities of daily living, such as nutrition and hydration. He needs clear, concise, firm directions from a caring nurse to meet his needs. The second option belittles and tricks the client, possibly evoking mistrust on the part of the client. The third option evades the issue of meeting his basic needs. The last option is demeaning and doesn’t address the delusion 53. A schizophrenic patient who began taking haloperidol (Haloperidol) 1 week ago now exhibits jerking movements of the neck and mouth. These are signs of: a. Dystonia b. Psychosis c. Akathisia d. Parkinsonism Answer: A- Haloperidol and other high-potency conventional antipsychotics cause a high incidence of dystonia and other extrapyramidal adverse effects. Dystonia is marked by prolonged, repetitive muscle contractions that cause twisting or jerking movements – especially of the neck, mouth, and tongue SITUATION 12: Nico, 27 yrs. old, is admitted for treatment of a major depression. 54. He is withdrawn, appears disheveled, and states, “No one could ever love me.” The nurse can expect the client to be placed on a. Antiparkinsonism medication b. Suicide precautions c. A low-salt diet d. Phototherapy Answer: B- Maintaining safety for the client is a priority because she may have suicidal ideation and/or plan 55. Which of the following behaviors indicates to the nurse that a client’s major depression is improving? The client: a. Displays a blunted effect b. Has lost an additional 2 pounds c. States one “good” thing about himself d. Sleeps about 16 hours per day
Answer: C- This behavior may indicate an increase in self-esteem that accompanies an improvement in depression. A depressed person often cannot problem solve or acknowledge any positive aspects of their lives 56. Nico is scheduled for electroconvulsive therapy (ECT) tomorrow. The nurse would plan for which of the following activities? a. Force fluids 6 to 8 hours before treatment b. Administer succinylcholine (Inestine, Anectine) during pretreatment care c. Encourage the client’s spouse to accompany him d. Reorient the client frequently during posttreatment care Answer: D- Common side effects of bilateral treatment include confusion, disorientation, and shortterm memory loss. The nurse should provide frequent orientation statements that are brief, distinct, and simple 57. Nico is recovering from a severe depression. Which of the following behaviors alerts the nurse to a risk for suicide? a. The client sleeps most of the day b. The client has a plan to kill himself c. The client loses 5 pounds d. The client does not attend unit activities Answer: B- Having a suicide plan is a risk factor. The lethality needs to be assessed. When a depression is “lifting,” the client may have the energy and resources to carry out a plan. Behavioral, somatic, and emotional cues may be overt or covert 58. Nico has been depressed severely depressed for 2 weeks. He had mentioned “ending it all” prior to admission. Which of the following questions should the nurse ask during the prescreen assessment? a. “How long have you thought about harming yourself?” b. “What is it that makes you think about harming yourself?” c. “How has your concentration been?” d. “What specifically have you thought about doing to harm yourself?” Answer: D- This question assists in determining suicidal intent and lethality SITUATION 13: A client is admitted with a diagnosis of Alzheimer’s Disease. 59. When developing the plan of care for a client with Alzheimer’s disease who is experiencing moderate impairment, which of the following types of care would the nurse expect to include? a. Considerable assistance with activities of daily living b. Managing complex medication schedule c. Constant supervision and total care d. Supervision of risky activities, such as shaving Answer: D- Considerable assistance is associated with moderate impairment when the client is unable to make decisions but can follow directions. Supervision of shaving is appropriate with mild impairment – that is, when the client still has motor function but lacks judgment about safety issues. Managing medications is needed even in mild impairment. Constant care is unable to follow directions 60. Which of the following would be priority to include in the plan of care for a client with Alzheimer’s disease who is experiencing difficulty processing and completing complex tasks? a. Repeating the directions until the client follows them b. Asking the client to do one step of the task at a time c. Demonstrating for the client how to do the task d. Maintaining routine and structure for the client Answer: B- Because the client is experiencing difficulty processing and completing complex tasks, the priority is to provide the client with only one step at a time, thereby breaking the task up into simple step, ones that the client is able to process. Repeating the directions until the client follows them or demonstrating how to do the task is still too overwhelming to the client because of the multiple steps involved. However, demonstrating one step would be helpful. Although maintaining structure and routine is important, it is unrelated to task completion 61. Clients with Alzheimer’s disease may have delusions about being harmed by staff and others. When the client expresses fear of being killed by staff, which of the following responses would be most appropriate? a. “What makes you think we want to kill you?” b. “We like you too much to want to kill you.”
c. “You are in the hospital. We are nurses trying to help you.” d. “Oh, don’t be so silly. No one wants to kill you here.” Answer: C- The nurse needs to present reality without arguing with the delusions. Therefore, stating that the client is in the hospital and the nurses are trying to help is most appropriate. The client doesn’t recognize the delusion or why it exists. Telling the client that the staff likes him too much to want to kill him is inappropriate because the client believes the delusions and doesn’t know that they are false beliefs. It also restates the word, “kill,” which may reinforce the client’s delusions. Telling the client not to be silly is condescending and disparaging and therefore inappropriate 62. When helping the families of clients with Alzheimer’s disease to cope with vulgar or sexual behaviors, which of the following suggestions would be most helpful? a. Ignore the behaviors, but try to identify the purposes b. Give feedback on the inappropriateness of the behaviors c. Employ anger management strategies d. Administer the prescribed risperidone (Risperdal) Answer: A- The vulgar or sexual behaviors are often expressions of anger or more sensual needs that can be addressed directly. Therefore, the families should be encouraged to ignore the behaviors but attempt to identify their purpose. Then the purpose can be addressed, possibly leading to decrease in the behaviors. Because of impaired cognitive function, the client is not likely to be able to process the inappropriateness of the behaviors if given feedback. Likewise, anger management strategies would be ineffective because the client would probably be unable to process the inappropriateness of the behaviors. Risperidone (Risperdal) may decrease agitation, but it does not improve social behaviors 63. The nurse determines that the son of the client with Alzheimer’s disease needs further education about the disease when he makes which of the following statements? a. “I didn’t realize the deterioration would be so incapacitating.” b. “The Alzheimer’s support group has so much good information.” c. “I get tired of the same old stories, but I know it’s important for Dad.” d. “I woke up this morning hoping that my old Dad would be back.” Answer: D- The statement about hoping that the Dad would be back conveys a lack of acceptance of the irreversible nature of the disease. The statement about not realizing that the deterioration would be so incapacitating is based in reality. The statement about Alzheimer’s group is based in reality and demonstrates the son’s involvement with managing the disease. Stating that reminiscing is important reflects a realistic interpretation on the son’s part SITUATION 14: A 34-year old is hospitalized with bipolar disorder. 64. The nurse knows that the major factor that distinguishes a bipolar from a unipolar disorder is the a. Higher incidence in women b. Severity of the depression c. Genetic etiology d. Presence of mania Answer: D- Both unipolar and bipolar disorders include episodes of depression. The diagnosis of bipolar disorder is given to persons who also experience manic episodes 65. At 2 a.m. the nurse the nurse finds him phoning friends all across the country to discuss his new plan for eradicating world hunger. His excited explanations are keeping the entire unit awake, but he won’t quiet down. The nurse caring for him knows the drug most likely to be prescribed for this client is: a. A tricyclic depressant b. An MAOI-inhibitor antidepressant c. Lithium carbonate (Eskalith) d. An antianxiety drug Answer: C- A drug frequently used to treat manic clients is lithium carbonate (Eskalith) 66. Supportive therapy for a client who is exhibiting manic behavior may include all of the following EXCEPT: a. Psychoanalysis b. Cognitive therapy c. Interpersonal therapy d. Problem-solving therapy Answer: A- Psychoanalysis is an in-depth, insight-oriented psychotherapy, not appropriate in treatment of bipolar disorders
67. The client is creating considerable chaos in a day treatment program with dominating and manipulative behavior. Which of the following nursing intervention is most appropriate? a. Allow the peer group to intervene b. Describe acceptable behavior and set realistic limits with the client c. Recommend the client to be hospitalized for treatment d. Tell client that his behavior is not appropriate Answer: B- The nurse’s response is an alternative behavior for unacceptable ones in order to assist the client in self-control. It is not the responsibility of the peer group to monitor the client’s behavior. The client’s behavior does not warrant hospitalization. The intervention in answer choice (D) is inappropriate because the client is told only what is unacceptable and is not given any alternatives 68. The client is skipping up and down the hallway practically running into other clients. Which of the following activities would the nurse expect to include in the client’s plan of care? a. Leading a group activity b. Watching television c. Reading the newspaper d. Cleaning the dayroom tables Answer: D- The client with mania is very active and needs to have this energy channeled in a constructive task such as cleaning or tidying the dayroom. Because the client is distracted easily and can concentrate only for short periods, the successful completion of a helpful task would give the nurse the opportunity to thank the client for the help, thereby enhancing the client’s selfesteem. Leading a group activity is too stimulating for the client. Participating in this type of activity also would be probably causes the client to be disruptive. Watching television or reading the newspaper would be inappropriate for the client who is unable to sit for a period of time. SITUATION 15: A client is admitted to outpatient surgery for cataract extraction on the right eye. 69. The client asks, “What does the lens of my eye do?” The nurse should explain that the lens of the eye: a. Produces aqueous humor b. Holds the rods and cones c. Focuses light rays onto the retina d. Regulates the amount of light entering the eye Answer: C- The lens of the eye is suspended on the suspensory ligaments. The ligaments influence the tension on the lens and thereby focus light rays onto the retina. Accommodation is the ability of the lens to adjust to near and far objects. The ciliary bodies secrete aqueous humor. The retina contains the rods and cones. The iris regulates the amount of light entering the eye 70. The client would most likely to complain of which symptoms? a. Halos and rainbows around lights b. Eye pain and irritation that worsens at night c. Blurred and hazy vision d. Eye strain and headache when doing close work Answer: C- A client with a cataract usually complains of dimness, blurring, and/or hazy vision. Typically, light scattering occurs and is related to the degree of opacity of the lens. Opacity of the lens blocks light rays from reaching the retina. Eye pain and irritation are not associated with glaucoma. Eye strain and headache when doing close work is associated with refractive errors 71. The nurse is to instill drops of phenylephrine hydrochloride (Neo-Synephrine) into a client’s right eye before cataract removal surgery. This preparation acts in the eye produce a. Dilatation of the pupil and blood vessels b. Dilatation of the pupil and constriction of blood vessels c. Constriction of the pupil and constriction of blood vessels d. Constriction of the pupil and dilatation of blood Answer: B- Instilled in the eye, phenylephrine hydrochloride asks as a mydriatic, causing the pupil to dilate. It also constricts small blood vessels in the eye 72. A short time after cataract surgery, the client complains of nausea. Which of the following represents the nurse’s best course of action? a. Instruct the client to take a few deep breaths until the nausea subsides b. Explain that this is a common feeling that will pass quickly c. Tell the client to call the nurse promptly if vomiting occurs d. Medicate the client with an antiemetic, as ordered Answer: D- A prescribed antiemetic should be administered as soon as the client who has undergone
cataract extraction complains of nausea. Vomiting can increase intraocular pressure, which should be avoided after eye surgery because it can cause complications. Deep breathing is unlikely to relieve nausea. Postoperative nausea may be common; however, it doesn’t necessarily pass quickly and can lead to vomiting. Telling the client to call only if vomiting occurs ignores the client’s need for comfort and intervention to prevent complications 73. Discharge planning would include: a. Wearing eye patches for the first 72 hours b. Lifting light objects is acceptable c. Bending with the knees and keep the head straight d. Bending with the waist is acceptable if slowly done SITUATION 16: A client is admitted with a diagnosis of Parkinson’s disease. 74. Which of the following is an initial sign of Parkinson’s disease? a. Rigidity b. Tremor c. Bradykinesia d. Akinesia Answer: B- The first sign of Parkinson’s disease is usually tremors. The client often is the first to notice this sign, because the tremors may be minimal at first. Rigidity is the second sign, and bradykinesia is the third sign. Akinesia is a later stage of bradykinesia 75. The nurse develops a teaching plan for a client newly diagnosed with Parkinson’s disease. Which of the following topics that the nurse plans to discuss is the most important? a. Maintaining a balanced nutritional diet b. Enhancing the immune system c. Maintaining a safe environment d. Engaging in diversional activity Answer: C- The primary focus is on maintaining a safe environment, because the client with Parkinson’s disease often has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking. This type of gait often causes the client to fall or to have trouble stopping 76. When does the nurse encourage a client with Parkinson’s disease to schedule the most demanding physical activities to minimize the effects of hypokinesia? a. Early in the morning, when the client’s energy level is high b. To coincide with the peak action of drug therapy c. Immediately after a rest period d. When family members will be available Answer: B- Demanding physical activity should be performed during the peak action of drug therapy. Clients should be encouraged to maintain independence in self-care activities to the greatest extent possible 77. Which goal is the most realistic and appropriate for a client diagnosed with Parkinson’s disease? a. To cure the disease b. To stop the progression of the disease c. To begin preparations for terminal care d. To maintain optimal body function Answer: D- The most appropriate and realistic goal is to help the client function at his best. There is no known cure for Parkinson’s disease. Parkinson’s disease progresses in severity, and there is no known way to stop its progression. Many clients live for years with the disease, however, and it would not be appropriate to start planning terminal care at this time 78. The client needs a long time to complete her morning hygiene, but she becomes annoyed when the nurse offers assistance and refuses all help. Which statement is the nurse’s best initial response in this situation? a. Tell the client firmly that she needs assistance and help her with her care b. Praise the client for her desire to be independent and give her extra time and encouragement c. Tell the client that she is being unrealistic about her abilities and accept that she needs help d. Suggest to the client that if she insists on self care, she should at least modify her routine Answer: B- Ongoing self-care is a major goal for clients with Parkinson’s disease. The client should be given additional time as needed and praised for her efforts to remain independent. Firmly telling the client that she needs assistance will undermine her self-esteem and defeat her efforts to be independent. Telling the client that her perception is unrealistic does not foster hope in her ability to
care for herself. Suggesting that the client modify her routine seems to put the hospital or the nurse’s time schedule before the patient’s needs. This will only decrease the client’s self-esteem and her desire to try to continue self-care, which is obviously important to her SITUATION 17: A client is admitted to the hospital with Bell’s Palsy. 79. A client with Bell’s Palsy asks the nurse why artificial tears were ordered by the physician. Select the best reply by the nurse. a. “When your affected eye fails to make tears, the eye can become irritated and ulcerated.” b. “ Because your eye remains closed, foreign matter can be trapped beneath the lid.” c. “Artificial tears will remove the purulent drainage from your eye, which speeds healing.” d. “Because you cannot blink the affected eye, it can become dry and irritated.” Answer: D- Bell’s palsy may cause paralysis of the eyelid and loss of the blink reflex on the affected side. The eye may not close completely. These problems render the eye susceptible to drying and irritation from dust or other debris 80. Which nursing diagnosis takes priority for the patient with Bell’s palsy? a. Risk for dysfunctional grieving b. Risk for injury related to corneal laceration c. Risk for chronic low self-esteem d. Risk for impaired physical mobility Answer: B- The patient with Bell’s palsy will be unable to close his eyelid on the affected side; therefore, he’ll be at risk for injury to the cornea 81. The nurse observes that the client’s right eye does not close completely. Based on this, which of the following nursing interventions would be most appropriate? a. Making sure the client wears her eyeglasses at all times b. Placing an eye patch over her eye c. Instilling artificial tears once every shift d. Cleansing the eye with a clean washcloth every shift Answer: B- When the blink reflex is absent or the eyes do not close completely, the cornea may be dry and irritated. Placing a patch over the eye is the most appropriate intervention to prevent eye injury. Making sure the client wears her eyeglasses at all times will not help protect the eye from injury. A once-per-shift intervention will not adequately relieve the potential for injury from a dry and irritating ocular environment. A normal saline solution should be used to moisten the eye, not tap water 82. The client has a feeling of stiffness and a drawing sensation of the face. What would be an important teaching to the patient? a. Eye is susceptible to injury when eyelid does not close b. Drooling from an increased saliva on the affected area may occur c. Cleaning the eye will prevent ulceration d. All of the above SITUATION 18: A 46-year old is admitted to the hospital because her family is unable to manage her constant hand washing rituals. 83. Her family reports she washes her hands at least 30 times each day. The nurse noticed the client’s hands are reddened, scaly, and cracked. The main nursing goal is to: a. Remind the client several times of her appointment b. Limit the number of hand washings c. Tell her it is her responsibility to be there on time d. Provide ample time for her to complete her rituals Answer: B- Obsessive-compulsive behavior represents displacement of anxiety. A concrete measurable goal is to decrease the number of hand washings 84. Which of the following is an appropriate treatment for this client? a. An unstructured schedule of activities b. A structured schedule of activities c. Intense counseling d. Negative reinforcement every time she performs her rituals Answer: B- Planning a structured schedule of activities provides the client with ways other than hand washing to reduce anxiety 85. The most effective way for the nurse to intervene with her hand and face washing is to:
a. Allow her a certain amount of time each shift to engage in this behavior b. Interrupt the activity briefly and frequently c. Lock the door to her room and restrict access to the bathroom d. Tell her to stop each time she is observed doing it Answer: A- Allowing the client a certain amount of time to engage in the activity alleviates some of the client’s anxiety 86. The client is also constipated and dehydrated. Which nursing intervention would the client be most likely to comply with? a. Drinking Ensure between meals b. Drinking extra fluids with meals c. Drinking 8 oz water every hour between meals d. Drinking adequate amounts of fluid during the day Answer: C- Building the intake of a specified amount of liquid into a daily schedule of activities is very consistent with the obsessive-compulsive client’s need to control as many aspects of her life as possible 87. Upon admission she was also dehydrated and underweight. The nurse and the client will know That discharge planning is appropriate when the client: a. Regains her normal body weight b. Expresses a desire to leave the hospital c. Is able to start talking about her guilt and anxiety d. Limits her hand and face washing to a few times a day Answer: D- The major issue is control of behavior and thoughts. When the client is able to control her compulsive behavior, ie., limit her hand and face washing to a few times a day, she will then be able to resume normal activities of daily living SITUATION 19: The nurse is caring for a client who is experiencing panic attack. 88. Which intervention would be most appropriate? a. Tell the client he’s all right, and there is no need to panic b. Speak to the client in short, simple sentences c. Explain to the client that there’s no need to worry because he’s safe d. Give the client a detailed explanation of his panic reaction Answer: B- The client experiencing a panic attack is unable to focus and his ability to relate to others is diminished; therefore, short, simple sentences are the most effective means of communication. Options A, B and C minimize the patient’s anxiety 89. The client reports that she often feels a choking sensation in her throat, a racing heart, dizziness and fearfulness. All of these symptoms have occurred almost daily for the past 3 months. Suspecting a psychological component to these symptoms, what would the nurse anticipate administering? a. Benzodiazepines b. Proton pump inhibitors c. Nitropusside d. Lithium carbonate Answer: A- Pharmacologic management would consist of either tricyclic antidepressants or benzodiazepines. Proton pump inhibitors are used for GI disorders. Nitroprusside is a potent vasodilator, used for hypertensive emergencies. Lithium carbonate is an antimanic agent 90. The client has a generalized anxiety disorder. Which statement is true about this client? a. The client has regular obsessions b. Relaxation techniques and psychotherapy are necessary for care c. Nightmares and flashbacks are common in individuals who suffer from generalized anxiety disorder d. Generalized anxiety disorder is characterized by anxiety that lasts longer than 6 months Answer: D- Constant patterns of anxiety that affect the client for more than 6 months and interfere with normal activities are characteristic of generalized anxiety disorder. Frequently, pharmaceutical therapy with benzodiazepines can help. Clients having regular obsessions are probably suffering from obsessive-compulsive disorder. Nightmares and flashbacks are typical symptoms of posttraumatic stress disorder 91. The client is pacing and complains of racing thoughts. The nurse asks the client if something upsetting happens, and the client response is vague and not focused on nurse’s question. The nurse assesses the client’s level of anxiety as: a. Mild
b. Moderate c. Severe d. Panic Answer: C- When the client has difficulty focusing and exhibits excessive motor activity, the level of anxiety is severe. Mild anxiety is characterized by increased alertness and problem-solving ability; the client described is unable to do this. Moderate anxiety is characterized by the ability to focus on central concerns, but the inability to solve problem without assistance; the client described is unable to do this. Panic level of anxiety is characterized by complete inability to focus and reduced perceptions; the client described is not at this point 92. Which of the following is a behavior manifestation of anxiety, except: a. Panic b. Tachycardia c. Hyperventilation d. Tachypnea SITUATION 20: Defense Mechanisms 93. Sam is diagnosed with cancer does not talk about or acknowledge the diagnosis. Which of the following defense mechanism is Sam using? a. Denial b. Identification c. Projection d. Rationalization Answer: A- The failure to acknowledge the reality of the diagnosis is an example of defense mechanism of denial. The other choices do not apply to this situation 94. Nathaniel, released from prison for selling narcotics has been rehabilitated and now works for a youth drug prevention agency. Darwin is reflecting which of the following defense mechanism? a. Denial b. Displacement c. Identification d. Sublimation Answer: D- Sublimation is the defense mechanism whereby an individual substitutes constructive, socially acceptable behavior for strong impulses that are unacceptable. The other answer choice options are not applicable to this situation 95. Nina is admitted to the ICU with chest pain, an abnormal ECG, and elevated enzymes. When the significance of this is explained to her, she says, “I can’t be having a heart attack. No way. You must be mistaken.” The nurse suspects the client is using which defense mechanism? a. Sublimation b. Regression c. Dissociation d. Denial Answer: D- Denial helps the person escape unpleasant or intolerable reality by refusing to perceive the facts. It can serve as a normal protection in the early stages of crisis, but if the denial persists it will prevent the client from coping 96. In patients with dissociative disorders, the defense mechanism most often used to block traumatic experiences is: a. Passive-aggression b. Reaction formation c. Denial d. Repression Answer: D- Repression is the defense mechanism used most often to block traumatic experiences. Neither reaction formation nor denial is relevant in these disorders 97. The defense mechanism utilized by manic patients to cover up depression is: a. Displacement b. Denial c. Compensation d. Reaction formation SITUATION 21: Psychosomatic disorders
98. A man’s family brought him onto the hospital because of his many somatic complaints. He has been seen by many medical specialists in the past without discovery of organic pathology. The nurse assesses that the client is probably experiencing which of the following problems? a. Conversion disorder b. Body dysmorphic disorder c. Malingering d. Hypochondriasis Answer: D- Hypochondriasis is excessive preoccupation with one’s physical health, without organic pathology 99. Amie is hospitalized for treatment of conversion disorder. She complained of paralysis of her right side after her husband threatened to leave her and their children. She seems unconcerned about her paralysis. An appropriate long term goal for the nurse to formulate is that client will: a. Cope effectively with stress without using conversion b. Identify stressors c. Express feelings about conflict d. Develop an increased sense of relatedness to others Answer: A- This is an appropriate long term goal related to the client’s ineffective coping (use of conversion symptom, paralysis) related to unresolved conflicts and anxiety 100. A patient who reports paralysis with no specific cause but has a history of a recent stressful event has a probable diagnosis of: a. Hypochondriasis b. Somatic illness c. Conversion disorder d. Pain disorder Answer: C- In conversion disorder, symptoms suggest a physical disorder, but physical examination and diagnostic tests find no physiological cause
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