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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.
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) “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: (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) 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
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
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) “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: (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
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: (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.
A. agoraphobia
B. social phobia
C. Claustrophobia
D. xenophobia
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
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. Nina 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.
The initial nursing diagnosis is dysfunctional grieving. The statement of the woman that supports this
diagnosis is:
Answer: (B) “I haven’t been able to open the door and go into my baby’s room “
This indicates denial. This defense is adaptive as an initial reaction to loss but an extended, unsuccessful
use of denial is dysfunctional. A. This indicates acknowledgement of the loss. Expressing feelings openly
is acceptable. C. This indicates the stage of depression in the grieving process. D. Remembering both
positive and negative aspects of the deceased love one signals successful mourning.
53. The client said “I can’t even take care of my baby. I’m good for nothing.” Which is the appropriate
nursing diagnosis?
A. Ineffective individual coping related to loss.
B. Impaired verbal communication related to inadequate social skills.
C. Low esteem related to failure in role performance
D. Impaired social interaction related to repressed anger.
Answer: (A) Agree on a consistent approach among the staff assigned to the client.
A consistent firm approach is appropriate. This is a therapeutic way of to handle attempts of exploiting
the weakness in others or create conflicts among the staff. Bargaining should not be allowed. B. This is
not therapeutic because the client tends to control and dominate others. C. Limits are set for interaction
time. D. Allowing the client to negotiate may reinforce manipulative behavior.
59. The nurse exemplifies awareness of the rights of a client whose anger is escalating by:
A. Taking a directive role in verbalizing feelings
B. Using an authoritarian, confrontational approach
C. Putting the client in a seclusion room
D. Applying mechanical restraints
Answer: (D) Hold the next dose and obtain an order for a stat serum lithium level
Diarrhea and vomiting are manifestations of Lithium toxicity. The next dose of lithium should be
withheld and test is done to validate the observation. A. The manifestations are not due to drug
interaction. B. Cogentin is used to manage the extra pyramidal symptom side effects of antipsychotics.
C. The common side effects of Lithium are fine hand tremors, nausea, polyuria and polydipsia.
61. Situation: A widow age 28, whose husband died one year ago due to AIDS, has just been told that
she has AIDS.
Pamela says to the nurse, “Why me? How could God do this to me?” This reaction is one of:
A. Depression
B. Denial
C. anger
D. bargaining
Answer: (D) ”It must really be frustrating for you. How can I best help you?”
This response reflects the pain due to loss. A helping relationship can be forged by showing empathy
and concern. A. This is not therapeutic since it passes the buck or responsibility to the clergy. B. This
response is not therapeutic because it gives the client the impression that she is right which prevents
the client from reconsidering her thoughts. C. This statement passes judgment on the client.
63. One morning the nurse sees the client in a depressed mood. The nurse asks her “What are you
thinking about?” This communication technique is:
A. focusing
B. validating
C. reflecting
D. giving broad opening
Answer: (A) Remove all potentially harmful items from the client’s room.
Accessibility of the means of suicide increases the lethality. Allowing patient to express feelings and
setting a no suicide contract are interventions for suicidal client but blocking the means of suicide is
priority. Increasing self esteem is an intervention for depressed clients bur not specifically for suicide.
66. Situation: A 14 year old male was admitted to a medical ward due to bronchial asthma after learning
that his mother was leaving soon for U.K. to work as nurse.
Answer: (A) Establishing relationship with the opposite sex and career planning.
The client belongs to the adolescent stage. The adolescent establishes his sense of identity by making
decisions regarding familial, occupational and social roles. The adolescent emancipates himself from the
family and decides what career to pursue, what set of friends to have and what value system to uphold.
B. This refers to the middle adulthood stage concerned with transmitting his values to the next
generation to ensure his immortality through the perpetuation of his culture. C. This reflects school age
which is concerned with the pursuit of knowledge and skills to deal with the environment both in the
present and in the future. D. The stage of young adulthood is concerned with development of intimate
relationship with the opposite sex, establishment of a safe and congenial family environment and
building of one’s lifework.
67. The personality type of Ryan is:
A. conforming
B. dependent
C. perfectionist
D. masochistic
The most basic factor in the intervention with clients in the area of sexuality is:
A. Knowledge about sexuality.
B. Experience in dealing with clients with sexual problems
C. Comfort with one’s sexuality
D. Ability to communicate effectively
Answer: (D) It is the desire to live or involve in reactions of the opposite sex
Gender identity disorder is a strong and persistent desire to be the other sex. A. This is fetishism. B. This
refers to masochism. C. This describes exhibitionism.
73. The sexual response cycle in which the sexual interest continues to build:
A. Sexual Desire
B. Sexual arousal
C. Orgasm
D. Resolution
Answer: (D) “I only need access to your arm. Putting up your sleeve is fine.”
The nurse needs to deal with the client with sexually connotative behavior in a casual, matter of fact
way. A and B. These responses are not therapeutic because they are challenging and rejecting. C.
Threatening the client is not therapeutic.
76. Situation: Knowledge and skills in the care of violent clients is vital in the psychiatric unit. A nurse
observes that a client with a potential for violence is agitated, pacing up and down the hallway and
making aggressive remarks.
Answer: (D) The staff carried out less restrictive measures but were unsuccessful.
This documentation indicates that the client has been placed on restraints after the least restrictive
measures failed in containing the client’s violent behavior.
81. Situation: Clients with personality disorders have difficulties in their social and occupational
functions.
Answer: (A) Lack of self esteem, strong dependency needs and impulsive behavior
These are the characteristics of client with borderline personality. B. This describes the avoidant
personality. C. These are the characteristics of a client with paranoid personality D. This describes the
obsessive compulsive personality
85. The plan of care for clients with borderline personality should include:
A. Limit setting and flexibility in schedule
B. Giving medications to prevent acting out
C. Restricting her from other clients
D. Ensuring she adheres to certain restrictions
A. deny reality
B. to deal with feelings and thoughts that are not acceptable
C. to show resentment towards others
D. manipulate others
Answer: (B) to deal with feelings and thoughts that are not acceptable
Projection is a defense mechanism where one attributes ones feelings and inadequacies to others to
reduce anxiety. A. This is not true in all instances of projection C and D. This focuses on the self rather
than others
88. The client says “ the NBI is out to get me.” The nurse’s best response is:
A. “The NBI is not out to catch you.”
B. “I don’t believe that.”
C. “I don’t know anything about that. You are afraid of being harmed.”
D. “ What made you think of that.”
Answer: (C) “I don’t know anything about that. You are afraid of being harmed.”
This presents reality and acknowledges the clients feeling A and B. are not therapeutic responses
because these disagree with the client’s false belief and makes the client feel challenged D. unnecessary
exploration of the false
89. The client on Haldol has pill rolling tremors and muscle rigidity. He is likely manifesting:
A. tardive dyskinesia
B. Pseudoparkinsonism
C. akinesia
D. dystonia
Answer: (C) She postpones the physical assessment until the client is calm
The nurse acts as a patient advocate as she protects the client from psychological harm A. The nurse
acts a a counselor B. The nurse acts as a technician D. This exemplifies the role of a teacher
94. Crisis intervention carried out to the client has this primary goal:
A. Assist the client to express her feelings
B. Help her identify her resources
C. Support her adaptive coping skills
D. Help her return to her pre-rape level of function
Answer: (D) Help her return to her pre-rape level of function
The goal of crisis intervention to help the client return to her level of function prior to the crisis. A,B and
C are interventions or strategies to attain the goal
95. Five months after the incident the client complains of difficulty to concentrate, poor appetite,
inability to sleep and guilt. She is likely suffering from:
A. Adjustment disorder
B. Somatoform Disorder
C. Generalized Anxiety Disorder
D. Post traumatic disorder
99. Which of the following medications will likely be ordered for the client?”
A. Prozac
B. Valium
C. Risperdal
D. Lithium
100. Which of the following is included in the health teachings among clients receiving Valium?:
A. Avoid foods rich in tyramine.
B. Take the medication after meals.
C. It is safe to stop it anytime after long term use.
D. Double up the dose if the client forgets her medication.