PSYCIATRIC NURSING WORKBOOK D. Monitoring vital signs before, during, and after the 11.
re, during, and after the 11. A client diagnosed with major depressive disorder has the
1. A client reports becoming involved with legislation that
promotes gun safety after the death of a child by accidental
shooting. Which defense mechanism is the client exhibiting?  lithium carbonate to a patient with acute mania? *
A. Identification
B. Denial
C. Sublimation
D. Intellectualization
2. A client who had a suicidal attempt is being discharged
from the hospital. Which question asked by the nurse
assesses the learned prevention and future coping strategies
of the client?
A. “Do you have the phone number of the suicide prevention
center?”
B. “What skills can you utilize if you experience problems
again?”
C. “How did you try to kill yourself?”
D. “Why did you think life wasn’t worth living?”
3. To which nursing diagnosis should nurse give the highest
priority when caring for a client with major depressive
disorder?
A. Disturbed sleep patterns
B. Risk for self-directed behavior
C. Powerlessness
D. Potential for spiritual distress
4. Which care setting is the most appropriate for a client who
recently attempted suicide and continues to report suicidal
ideation?  A. “That’s not appropriate and I’m offended.”
A. A nursing home
B. An outpatient clinic
C. An inpatient mental health unit
D. A community mental health center
5. A new nurse is establishing a plan of care for a client
scheduled for electroconvulsive therapy (ECT).Which action by
the new nurse requires intervention from the nurse supervisor? *
A. Administering succinylcholine after the procedure to
decrease recovery time
B. Educating the client that experiencing confusion, tiredness,
headache, muscle pain, or back pain after the procedure is
normal
C. Administering a short-acting barbiturate prior to the
procedure
procedure
6. What situation must occur prior to initiating treatment with
A. Administration of benzodiazepine has been terminated.
B. Room seclusion has proven ineffective in controlling the
client’s behavior.
C. The client has been fasting for 12 hours.
D. The client’s history and physical results, including
laboratory results, are reviewed.
7. A nurse is teaching a client about prescription antidepressant
medications and the appropriate expectations when taking these.
Which statement by the nurse is correct? *
A. “Your symptoms will subside about 72 hours after starting
the antidepressant medication.”
B. “Some common side effects of SSRIs are dry mouth, blurred
vision, and urinary retention.”
C. “It is important to continue taking antidepressant medication
even after you feel better.”
D. “The most potent antidepressant is fluoxetine.”
8. A nurse is reviewing diet restrictions with a client taking a
monoamine oxidase inhibitor (MAOI). Which of the following
will occur if the client does not adhere to the dietary
restriction? *
A. Severe hypotension
B. Agranulocytosis
C. Explosive occipital headache
D. Akathisia
9. Which intervention would establish a therapeutic relationship
with a client diagnosed with major depressive disorder? *
A. Invite the client to attend an exercise class.
B. Ask the client to join others to watch a 2-hour movie.
C. Sit with the client in silence.
D. Ask the client how his or her day should be scheduled.
10. A pregnant client diagnosed with depression asks the nurse
what other treatment options are available, besides taking
antidepressant medications. Which type of therapy should a
nurse recommend as an alternate treatment for depression? *
A. Cognitive behavioral therapy
B. Client-centered therapy
C. Gestalt therapy
D. Therapeutic touch therapy
nursing diagnosis of Disturbed sleep pattern.When developing a
plan of care for this client, the following actions are appropriate
except for one. Choose the exception. *
A. Reinforce reality thinking.
B. Determine sleep patterns prior to hospitalization.
C. Discourage sleeping during the day.
D. Record and limit caffeinated drinks.
E. Encourage measures that aid in relaxation.
12. A nurse is assessing a client with dysthymia who reports
symptoms of depressed mood. Which of the following is an
essential feature of dysthymia? *
A. Chronically depressed mood for most of the day for at least
2 years
B. Recurrent thoughts of death
C. Diminished ability to think or concentrate
D. Significant weight loss
13. A nurse is developing a care plan for a client diagnosed with
bipolar disorder and includes the nursing diagnosis: Risk for
imbalanced nutrition. This demonstrates that the nurse
understands that clients diagnosed with bipolar disorder: *
A. have a greater risk for obesity.
B. are compulsive eaters.
C. often suffer from poor nutrition.
D. take medications that can cause weight losss
14. A client diagnosed with mania tells a nurse, “I think you’re
very pretty. Maybe we could go to my room.” What would be
the most therapeutic response by the nurse? *
B. “I don’t have that kind of relationship with clients.”
C. “It’s time for occupational therapy.”
D. “Let’s walk down to the seclusion room.”
15. Which action should a nurse perform when caring for a
client experiencing agitation related to acute mania? *
A. Leave the client alone
B. Maintain a low level of stimuli in the client’s environment
C. Apply restraints to prevent the client from harming self or
others
D. Involve the client in group activities to provide structure
16. A female client who is in a manic state emerges from her
room topless while making sexual remarks and lewd gestures
toward the staff and her peers. Which intervention should the
nurse initiate first? *
A. Confront the client on the inappropriateness of her behavior
and offer her a time out.
B. Ask the other clients to ignore her behavior; eventually she
will return to her own room.
C. Approach the client in the hallway and insist that she go to
her own room immediately.
D. Quietly approach the client, escort her to her room, and
offer help to get dressed.
17. Which nursing action should the nurse plan when caring for
a client admitted and diagnosed with acute mania? *
A. Sustain conversations to improve the client’s concentration.
B. Teach the client and family about available community
resources.
C. Help the family understand that anger directed at them is
likely to escalate unless they confront the client’s behavior.
D. Provide finger foods that the client can carry while moving
around the unit.
18. A nurse observes presence coarse hand tremors in a patient
with acute mania. Upon reviewing the patient’s laboratory
results, it shows that the client’s serum lithium level is 1.8
mEq/L. Which action should be taken by the nurse? *
A. Advise the client to limit fluids.
B. Acknowledge that the side effects are unpleasant.
C. Continue to administer lithium as ordered.
D. Withhold the medication and notify the physician.
19. A nurse appropriately address a manic behavior by doing
the following, except? *
A. Follow through about the consequences of behavior in a
nonpunitive manner.
B. Communicate expected behaviors to the client.
C. Ensure that the client knows that they are not in charge of
the nursing unit.
D. Assist the client in identifying ways of setting limits on
personal behaviors.
20. A manic client begins to make sexual advance towards
visitors in the dayroom. When the nurse firmly states that this is
inappropriate and will not be allowed, the client becomes
verbally abusive and threatens physical violence to the nurse.
Based on the analysis of this situation, which intervention
should the nurse implement? *
A. Place the client in seclusion for 30 minutes.
B. Tell the client that the behavior is inappropriate.
C. Escort the client to their room, with the assistance of other
staff.
D. Tell the client that their telephone privileges are revoked for
24 hours.
21. A manic client is placed in a seclusion room after an
outburst of violent behavior and physical assault on another
client. Which intervention should the nurse include in her plan
of care before seclusion? *
A. Remain silent because verbal interaction would be too
stimulating.
B. Tell the client that she will be allowed to come out when she
can behave.
C. Inform the client that she is being secluded to help her
regain her self-control.
D. Ask the client if she understands why the seclusion is
necessary.
22. During a group therapy session, a client diagnosed with
mania consistently disrupts the group’s interactions. Which
intervention should the nurse implement first? *
A. Setting limits on the client’s behavior
B. Asking the client to leave the group session
C. Asking another nurse to escort the client out of the group
session
D. Telling the client that they will not be able to attend any
future group sessions
23. The nurse determines that which menu choice would be best
for a bipolar client in a manic state? *
A. Beef stew, fruit salad, tea
B. Cheeseburger, banana, milk
C. Macaroni and cheese, apple, milk
D. Scrambled eggs, orange juice, coffee with cream and sugar
24. A client is taking lithium carbonate for the treatment of
bipolar disorder. Which assessment question should the nurse
ask the client to determine signs of early lithium toxicity?  5. Which of these illicit drugs are commonly taken by client’s
A. “Have you noted excessive urination?”
B. “Do you have frequent headaches?”
C. “Have you been experiencing any nausea, vomiting, or
diarrhea?”
D. “Have you been experiencing leg aches over the past few
days?”
SOMATOFORM DISORDERS, SEXUALITY, EATING
DISORDERS
1. Which of the following interventions would help stop a
client’s binge eating due to her bulimia nervosa *
A. Focus on dysfunctional family and peer relationships and
teach positive self-talk.
B. Address the defense mechanism of projection and talk about
underlying conflicts.
C. Provide anger management counseling and later involve the
client’s family in the treatment.
D. Discuss the binge-purge cycle and identify where the cycle
could be interrupted.
2. A client who confesses to binge eating was assessed by the
nurse. Which assessment should the nurse elicit from the
client? *
A. Extreme restlessness
B. Adolescent turmoil
C. Disorganized behavior
D. Emotional hunger
3. When admitting a patient with bulimia nervosa, the nurse
should be expects the client to have a history of? *
A. Is accepting of body size
B. Overeats for the enjoyment of eating food
C. Overeats in response to losing control of diet
D. Binge eats, then purges
4. The nurse is taking care of a female client who was admitted
for anorexia nervosa. When attending to her needs, she
suddenly engages in rigorous push-ups. What should the nurse
do? *
A. Interrupt the client and offer to take the client for a walk.
B. Interrupt the client and weigh the client immediately.
C. Allow the client to complete the exercise program.
D. Tell the client that she is not allowed to exercise rigorously.
who have bulimia nervosa? *
A. Sedatives
B. Cannabis
C. Amphetamines
D. Hallucinogens
6. The nurse is planning an eating disorder protocol for
hospitalized clients experiencing bulimia and anorexia. Which
should be included in the protocol? Select all that apply. i .
Clients are not allowed to discuss food or eating in groups or
informal conversation with peers. ii. Clients must rest within
view of a staff member and not go to the bathroom for one-half
hour to an hour after eating. iii. Clients are not told their weight
and cannot see their weight while being weighed. iv. lients must
eat within view of a staff member. v. Clients cannot participate
in any groups after admission until they gain 1 lb. *
A. I, III, V
B. I, II, IV
C. II, III, IV
D. I, IV V
7. An adolescent exhibiting signs of anorexia nervosa refuses to
comply with her daily weigh in saying that she had just drank a
glass of water, which in turn would have greatly increased her
weight. What would be the best response to give the client? *
A. “You are here to gain weight so that will work in your
favor.”
B. “You must weigh in every day at this time. Please step on
the scale.”
C. “Don't drink or eat for 2 hours and then I'll weigh you.”
D. “If you don't get on the scale, I will be forced to call your
doctor.”
8. While doing rounds, the nurse notices that a client with
anorexia nervosa has been taking diet pills instead of complying
with her diet regimen. What should the nurse do first? *
A. Talk with the client about how weight loss and emaciation
worry the health care providers.
B. Explain to the client how diet pills can jeopardize health.
C. Listen to the client about fears of losing control of eating
while being treated.
D. Inquire about worries of the client's family concerning the
client's physical and emotional health
9. When teaching a group of adolescents about anorexia
nervosa, the nurse should describe this disorder as being
characterized by which of the following? *
A. Extreme concern about dieting, calorie counting, and an
unrealistic body image.
B. Intense fear of becoming obese, emaciation, and a disturbed
body image.
C. Excessive fear of becoming obese, near-normal weight, and
a self-critical body image.
D. Obsession with the weight of others, chronic dieting, and an
altered body image.
10. The nurse is developing a teaching plan about anorexia
nervosa and its signs and symptoms which would be taught to
high school health class. Which of the following would the
nurse include as the primary group of people who are affected
by this condition? *
A. Women, onset typically after 30 years.
B. Women, age at onset between 12 and 20 years.
C. Men, onset during the college years.
D. Men, onset after 20 years.
11. A family approaches the nurse complaining of their
daughter. With further investigation, the client exhibits signs
and symptoms of anorexia nervosa. Which of the following
subjective data is a typical response for a client with this
ailment? *
A. “She's been a model child. We've never had any problems
with her.”
B. “We have five children, all normal kids with some problems
at times.”
C. “We've given her everything, and look how she repays us!”
D. “She's had behavior problems for the past year both at home
and at school.”
12. A 20 year old male client and his roommate go the
emergency department complaining of an upset stomach. The
client reveals that he attends college and works at a fast food
joint each evening. a further look into the client’s diet reveals
that his menu consist mainly of carbonated drinks and junk
food. His roommate then adds that the client would always
complain of uneasiness on his stomach and would always go to
the bathroom. The nurse should refer the client to:  bulimic.”
A. A weight loss program
B. An overeating support group
C. A mental health clinic
D. The client’s family doctor
13. A nurse is working with a client with bulimia. Which of the
following goals should be excluded in the care plan? *
A. The client will maintain normal weight.
B. The client will comply with medication therapy.
C. The client will achieve a positive self-concept.
D. The client will acknowledge the disorder.
E. The client will never have the desire to purge again.
14. Considering a client with bulimia, what is an appropriate
long-term client goal for this client? *
A. Being able to eat out without binging or purging.
B. Being able to attend college in another state without binging
or purging
C. Eating meals at home without binging or purging.
D. Managing stresses in life without binging or purging.
15. While coaching a youth basketball team, the nurse notices
that one of the students have been binging and purging on
multiple occasions. The nurse calls the mother of the child to
discuss the situation. How would the nurse initiate the
conversation? 
A. “Let me get right to the point. Your daughter is very sick
and needs to see a mental health therapist right away.”
B. “Thank you for letting your daughter play on the team. She's
a very good player and is also pleasant and easy to coach.”
C. “I have some very bad news for you. Your daughter has a
serious problem that is diagnosed as an eating disorder.”
D. “I am a nurse. I have seen your daughter doing things that
are considered to be part of an eating disorder.”
16. A client who was newly diagnosed with bulimia tells the
nurse who was leading a group discussion that the only reason
she was attending the class was her husband. She elaborates that
her husband said that he would get angry with her if she did not
get help. What is the best response of the nurse? *
A. “You sound angry with your husband. Is that correct?”
B. “You will find that you like coming to group. These people
are a lot of fun.”
C. “Tell me more about why you are here and how you feel
about that.”
D. “Tell me something about what has caused you to be
17. A client with bulimia explains to the nurse that she only
binge when she fights with her best friend and purges in fear of
gaining weight. The nurse should next: *
A. Enroll client in a coping skills group.
B. Schedule daily family therapy sessions.
C. Work with the client to limit her purging.
D. Have client take lorazepam (Ativan) 1 mg as needed
whenever she feels the urge to binge.
18. While interviewing a client with an eating disorder, the
client exclaims “I hate how my body looks!” Which of the
following statements by the nurse is most therapeutic? *
A. “Don't worry, you'll soon be back in shape.”
B. “I don't think you look bad at all.”
C. “Tell me more about your feelings.”
D. “Everyone who has the same problem feels like you do.”
19. A community health nurse working with a group of fourth-
grade girls is planning a primary prevention strategy to teach
the girls how to avoid developing eating disorders during their
teen years. The nurse should focus on which of the following? *
A. Limiting the girls' access to media images of very thin
models and celebrities.
B. Telling the girls' parents to monitor their daughter's weight
and media access.
C. Working with the school nurse to closely monitor the girls'
weight during middle school.
D. Helping the girls accept and appreciate their bodies and feel
good about themselves.
20. Which of the following nursing interventions is appropriate
for a client who has anorexia nervosa? *
A. Instruct the client to get plenty of exercise.
B. Encourage the client to go for a walk to get some exercise.
C. Tell the client to lie down for 2 hours after eating.
D. Prevent the client from using the bathroom for 90 minutes
after eating.
21. A nurse who is assigned din the mental health ward is taking
care of several patients who have eating disorders. Based on the
physical appearance, which parameters differentiates bulimic
patients from anorectic patients? *
A. By looking for Mallory-Weiss tears
B. By their teeth
C. By body size and weight
D. The clients are indistinguishable upon physical examination
22. What treatment best suits a bulimic client? *
A. Antidepressants
B. Cognitive-behavioral therapy
C. Total parenteral nutrition (TPN) and antidepressants
D. Antidepressants and cognitive behavioral therapy
23. A nurse is caring for a client who has a depersonalization
disorder. Which of the following would be the most favorable
outcomes would the nurse want to obtain? *
A. Focusing on past accomplishments, rather than the current
condition
B. Increasing confidence and active participation in planning
and implementation of the treatment
C. Emphasizing strengths, rather than the pathologic condition
D. Eliciting empathetic responses from the client
24. When assessing a client, he verbalizes that he feels
“estranged and separated from himself.” This is typically
associated with which illness?  A. “Tell me about your sexual preference. Are you attracted to
A. Intoxication
B. Anti-motivational syndrome
C. Depersonalization
D. Existentialism
25. A client is complaining of amnesia. The nurse later on
discovers the client to have dissociative disorder.What could
have triggered the client’s amnesia? *
A. Conscious sedation
B. Short-acting sedation
C. Severe psychosocial stress
D. Syndrome of inappropriate antidiuretic hormone (SIADH)
26. A client who has dissociative amnesia has just experienced
her divorce recently. What interventions would the nurse
include in her plan of care? *
A. Tell the client that everything will be all right.
B. Encourage the client to verbalize feelings of distress.
C. Discourage the client from verbalizing feelings because they
will be too traumatic.
D. Force the client to confront her memories about the divorce
in a direct, confrontational manner.
27. A client verbalizes that he is experiencing a notable
decrease in sexual desire. The nurse notes this to be hypoactive
sexual desire. What is its classification?
A. Sexual desire disorder
B. Sexual pain disorder
C. Sexual arousal disorder
D. Orgasmic disorder
28. A nurse is caring for a client who is said to have episodes of
voyeurism as noted by his neighbors.Which term most
appropriately describes such behavior? *
A. Depersonalization disorder
B. Gender identity disorder
C. Dissociative fugue
D. Paraphilia
29. A female client who is about to undergo thrombolytic
therapy was asked by her physician about her last menstrual
period. The client then becomes flushed and asks the physician
if she could talk to her nurse in private. The client then tells the
nurse that she underwent sex-reassignment surgery. What is the
best response of the nurse? *
men or women?”
B. “I understand your reluctance to tell the physician, but it
may have an impact on your treatment.”
C. “Your sex change and your hormones have nothing to do
with your heart attack.”
D. “Based on client confidentiality, I won’t tell the physician if
you wish.”
30. Which of the following responses would be best when a
client with problems on his sexual arousal asks if attending
educational sessions on sexual disorders bring about change to
his condition? *
A. “If you have a substance abuse problem, the class won’t be
helpful.”
B. “I’m not sure if the class is appropriate for you; please ask
your doctor what he thinks.”
C. “I’ll be talking about how certain medications can enhance
sexual functioning.”
D. “I think that everyone can benefit from an educational class
on sexual functioning.”
31. A male adolescent client is brought into the psychiatric
crisis room by his mother. The mother reports that the client
prefers to wear woman’s clothing and asks if there is anything
that could help alleviate said peculiarities. The best response
would be? *
A. “Your son will be evaluated shortly.”
B. “I see you’re upset. Would you like to talk?”
C. “You’re being judgmental. There’s nothing wrong with a
boy wearing female clothing.”
D. “I will explain to your son that his behavior isn’t
appropriate.”
32. A nurse who is caring for a client notes symptoms such as
gait disturbances, paralysis, pseudoseizures, and tremors. These
symptoms may be manifestations of what psychiatric
disorder? *
A. Conversion disorder
B. Pain disorder
C. Adjustment disorder
D. Delirium
33. A client diagnosed with pain disorder is talking with the
nurse about bowling when he suddenly reverts to talking about
the pain in his arm. Which of the following should the nurse do
next? *
A. Ask the client if he needs more pain medication.
B. Get up and leave the client.
C. Allow the client to talk about his pain.
D. Redirect the interaction back to bowling.
34. The unlicensed assistive personnel (UAP) verbalizes that the
client with somatoform disorder is sick and decided that he
can’t come for lunch. The nurse should direct the UAP to do
which of the following? *
A. Tell the client he'll need to wait until supper to eat if he
misses lunch.
B. Take the client a lunch tray and let him eat in his room.
C. Inform the client that he has 10 minutes to get to the dining
room for lunch.
D. Invite the client to lunch and accompany him to the dining
room.
35. At 9 am, a client with an Axis I diagnosis of pain disorder
orders that the nurse call the primary health care provider for
more pain medication because she's still in pain after the 8 am
analgesic. Which of the following should the nurse do next? *
A. Tell the client that the primary health care provider will be
in later to talk to her about it.
B. Inform the client that the nurse cannot give her additional
medication at this time.
C. Call the primary health care provider as the client requests.
D. Suggest the client lie down while she is waiting for her next
dose.
36. A nurse who was taking care of a client with conversion
disorder with presenting symptoms of a paralyzed arm reports, I
would tell the client that the reason her arm is paralyzed is
because she neglected the care her infant needed to the extent
that the said infant was hospitalized for severe dehydration.”
What is the best response by the senior nurse? *
A. “Pushing insight will increase the client's anxiety and the
need for physical symptoms.”
B. “Pushing awareness will be helpful and further the client's
recovery.”
C. “Ignore the client's behaviors and treat her with respect.”
D. “We'll meet with the client and confront her with her
behavior.”
37. Which of these statements made by the client would indicate
that he is progressing positively to his treatment for somatoform
disorder? *
A. “My stomach pain will go away once I get properly
diagnosed.”
B. “My headache feels better when I time my medication
dose.”
C. “I understand my pain will feel worse when I'm worried
about my divorce.”
D. “I need to find a doctor who understands what my pain is
like.”
SCHIZOPHRENIA/PSYCHOSIS
1. A nurse includes the nursing diagnosis of Disturbed thought
processes secondary to paranoia in the care plan for a newly
admitted client diagnosed with schizophrenia. Which approach
is most appropriate for this client? *
A. Have the client sign a written release of information form.
B. Begin to identify social supports in the community.
C. Avoid laughing or whispering in front of the client.
D. Encourage the client to interact with others on the unit.
2. A nurse is assessing a client with a history of aggressive
behavior toward others. Which client behavior requires
immediate nursing intervention? *
A. Refusing to attend a mandatory group session on the unit
B. Petitioning the staff to extend recreation time by 30 minutes
C. Stating, “The guy over there needs to sit down and shut up.”
D. Crying while talking on the telephone with family
3. A nurse observes a client who has a history of aggressive
behavior toward others swearing and kicking the furniture in the
dayroom. Based on the client’s behavior, what should be the
nurse’s immediate priority of care? *
A. Eliminate the source of agitation.
B. De-escalate the client’s agitation.
C. Assess the client’s agitation level.
D. Provide for a safe, therapeutic milieu.
4. A nurse is reviewing with the client’s father the discharge
plan of a client recently diagnosed with paranoid schizophrenia.
Which of the father’s statements indicates to the nurse that he
understands the diagnoses and prognosis of paranoid
schizophrenia? *
A. “There is a good chance that this will be his only
hospitalization.”
B. “He won’t get worse if he continues to take his medication.”
C. “We will need to keep him at home so we can monitor his
illness closely.”
D. “We will need to watch for signs of depression.”
5. The nurse is planning care for a hallucinating and delusional
client who has been rescued from a suicide attempt. Which
intervention should the nurse incorporate into the nursing care
plan? *
A. Initiate one-to-one suicide precautions immediately.
B. Ask the client to report suicidal thoughts immediately
C. Begin suicide precautions with 30-minute checks.
D. Check the client’s location every 15 minutes.
6. A client experiencing paranoid delusions tells a nurse that
“The foreigner who lives next to me wants to kill me.” Which
nursing response is most therapeutic to assist the client
experiencing paranoid delusions? *
A. “What makes you think your neighbor wants to kill you?”
B. “That’s not true. I’m sure your neighbor is a nice person.”
C. “Do you feel afraid that people are trying to hurt you?”
D. “You believe that your foreign neighbor really wants to kill
you?”
7. A nurse is evaluating a client who threatens suicide. The
nurse’s primary responsibility to the client is to provide a safe,
therapeutic environment. Which nursing intervention is most
effective in establishing a safe environment for the client? *
A. Assign a staff member to stay with the client and provide
constant observation.
B. Place the client in a seclusion room designed to minimize
stimulation.
C. Keep the client involved in structured activities with other
clients as directed by the staff.
D. Remove all potential items that could assist the client in
committing suicide.
8. A nurse observes a client with a history of violent command
hallucinations mumbling erratically while making threatening
gestures directed toward a particular staff member. Which
nursing intervention is most appropriate when working with a
client with violent command hallucinations? *
A. Observe the client for signs of escalating agitation.
B. Place the client in seclusion to help de-escalate anger.
C. Inform the client of pending restraint if behavior does not
subside.
D. Ask the client to explain the cause of anger.
9. A nurse is evaluating a client experiencing paranoid
delusions. The client states, “Two men wearing gray shirts keep
coming into the dayroom and watching me.” Which of the
nurse’s responses is most therapeutic when communicating to a
client with paranoid delusions? *
A. “Ignore them, and let’s select a movie to watch after
dinner.”
B. “What makes you think they are interested in you?”
C. “Those are maintenance personnel discussing the room
remodeling.”
D. “I don’t believe you have anything to worry about.”
10. A nurse is assessing the mood and cognitive state of mind of
a client diagnosed with schizophrenia.Which signs and
symptoms is the nurse most likely to observe? SELECT ALL
THAT APPLY.iI. Involuntary muscle movementII. Compulsive
behaviorIII. Poor appetiteIV. Disrupted sleepV. Poor
concentrationVI. Incongruous affect *
A. III, IV, V, VI
B. I, III, V, VI
C. I, II, III, IV, VI
D. I, II, III, IV, V, VI
11. A client is admitted to the inpatient mental health unit.
When asked her name, she responds, “I am Elizabeth, the
Queen of England.” What should the nurse recognize this client
statement as indicating? *
A. Auditory hallucination
B. Visual illusion
C. Grandiose delusion
D. Loose association
12. A client, who is experiencing both positive and negative
symptoms of schizophrenia, is prescribed an atypical
antipsychotic, risperidone. The client asks the nurse to explain
the common side effects of this medication. Which side effects
should the nurse state to the client? SELECT ALL THAT
APPLY.I. DizzinessII. DystoniaIII.DrowsinessIV. weight
gainV. ConstipationVI. Hypotension *
A. I, III, IV, Vi
B. II, IV, V, VI
C. I, II, III, IV, VI
D. I, II, III, IV, V, VI
13. A client admitted to a behavioral medicine unit with a
diagnosis of catatonic schizophrenia is constantly rearranging
furniture and appears to be responding to internal stimuli. In
addition to being free of physical injury during phases of
hyperactivity, which short-term goal is appropriate for this
client? *
A. The client will show decreased activity within 24 hours of
onset of hyperactivity.
B. The client will sleep at least 6 hours per night.
C. The client will engage in at least one client-to client
interaction daily.
D. The client will consume adequate food and fluid per day.
14. The mother of a client newly diagnosed with paranoid
schizophrenia visits her son for the first time 2 days after the
client was admitted to the psychiatric unit. Bewildered, she
approaches a nurse and states, “He is still talking about how the
government is controlling his thoughts.” What is the most
accurate nursing appraisal of the mother’s statement? *
A. The mother’s expectations of her son are realistic.
B. The mother’s concern is reasonable.
C. The mother should request a medication adjustment.
D. The mother requires further education regarding the client’s
diagnosis
15. A client who was recently prescribed with haloperidol
complains of severe muscle pain. Upon assessment, the nurse
noted the following: HR 104 beats per minute, BP 175/52 mm
Hg, and temperature 38.4°C. Based on the assessment findings,
what is the most appropriate nursing action? *
A. Assure the client that the symptoms are unrelated to the new
medication.
B. Gather information concerning the client’s possible
exposure to a bacterial infection.
C. Question the client concerning known cardiovascular health
status.
D. Immediately notify the client’s health-care provider of the
assessment findings and complaints.
16. A nurse is evaluating a client diagnosed with paranoid
schizophrenia who reports hearing a voice that says, “Do not
remove your hat because they will be able to read your mind.”
Which response by the nurse is the most therapeutic? *
A. “It must be very frightening to believe that someone can
read your mind.”
B. “I do not believe that anyone can read another’s mind.”
C. “Who are ‘they’?”
D. “Why would someone want to read your mind?”
17. A nurse engages an older adult client by describing the
weather as “raining cats and dogs.” The client looks bewildered
and shows concern for the “animals.” The nurse determines that
the client is exhibiting concrete thinking. Which response by the
nurse is most therapeutic? *
A. Assure the client that the animals are not being hurt in any
way.
B. Alert the staff to the client’s inability to understand abstract
concepts.
C. Explain to the client that it is a way of saying it is raining
heavily.
D. Document the client’s response to the conversation as
concrete thinking.
18. A nurse is assessing a client recently admitted into a
psychiatric unit for observation. Which client behavior is
indicative of impaired cognition? *
A. Asking repeatedly, “How did I get here?”
B. Spending hours staring out the window
C. Discussing “the voices” with another client
D. Mumbling
19. A nurse is discussing discharge plans with a homeless client
diagnosed with paranoid schizophrenia.What is the primary
factor that will affect the formulation of the discharge plan for
this client?
A. The nurse’s ability to work effectively with the homeless
client
B. The existence of community resources such as homeless
shelters
C. The formulation of a support system for the homeless client
D. The homeless client’s ability to comply with the discharge
plan
20. A nurse is developing a plan of care for a client prescribed
the traditional antipsychotic drug haloperidol for the treatment
of schizophrenia. Which medication should the nurse expect to
administer if extrapyramidal side effects develop? *
A. Benztropine
B. Olanzapine
C. Escitalopram oxalate
D. Chlorpromazine
21. A client who is taking an antipsychotic is preparing for
discharge. To facilitate health promotion for this client, what
instruction should the nurse provide? *
A. Recognize the signs and symptoms of a relapse of
depression.
B. Have therapeutic blood levels drawn because the medication
has a narrow therapeutic range.
C. Avoid prolonged exposure to the sun.
D. Adhere to a strict tyramine-restricted diet.
22. The nurse notes that a client with schizophrenia and
receiving an antipsychotic medication is moving her mouth,
protruding her tongue, and grimacing as she watches television.
The nurse determines that the client is experiencing which
medication complication? (955) *
A. Parkinsonism
B. Tardive dyskinesia
C. Hypertensive crisis
D. Neuroleptic malignant syndrome
DEFENSE MECHANISMS AND THERAPEUTIC
COMMUNICATION
1. The spouse of a dying client says to the nurse, “I don’t think I
can come anymore and watch her die.It’s chewing me up too
much!” Which therapeutic response should the nurse make to
the spouse? *
A. “Focus on your wife’s pain rather than yours. I know it’s
hard, but this isn’t about what’s happening to you, you know.”
B. “I know it’s hard for you, but she would know if you’re not
there, and you would feel so very guilty all of the rest of your
days.”
C. “It’s hard to watch someone you love die. You’ve been here
with your wife every day. Are you taking any time for
yourself?”
D. “I think you’re making the right decision. Your wife knows
you love her. You don’t have to come every day. I’ll take care
of her.”
2. An older adult client at the retirement center spits her food
out and throws it on the floor. She yells, “This turkey is dry and
cold! I can’t stand the food here!” How should the nurse
respond to the client? *
A. “Let me get you another serving that is more to your liking.
Would you like to see the chef and select your own serving?”
B. “I think you had better return to your apartment now. I’ll
make arrangements for a new meal to be served to you there.”
C. “Now look what you’ve done! You’re ruining this meal for
the whole community. Aren’t you ashamed of yourself?”
D. “One of the things that was agreed upon was that anyone
who did not use appropriate behavior would be asked to leave
the dining room. Please leave now.”
3. A client with a diagnosis of major depression says to the
nurse, “I should have died. I’ve always been a failure.” The
nurse should make which therapeutic response to the client? *
A. “I see a lot of positive things in you.”
B. “You’ve been feeling like a failure for some time now?”
C. “You still have a great deal to live for.”
D. “Feeling like a failure is part of your illness.”
4. A health care provider prescribes a follow-up home care visit
for an older adult client with emphysema.When the home care
nurse arrives, the client is smoking. Which statement by the
nurse would be therapeutic? *
A. “I’m glad I caught you smoking! Now that your secret is
out, let’s decide what you are going to do.”
B. “Well, I can see you never got to the stop smoking clinic!”
C. “I notice that you are smoking. Did you explore the stop
smoking program at the senior citizens center?”
D. “I wonder if you realize that you are slowly killing yourself.
Why prolong the agony? You can just jump off the bridge!”
5. A client says to the nurse, “I can’t get any help with my care!
I call and call, but the nurses never answer my light. Last night
one of them told me she had other clients besides me! I’m very
sick, but the nurses don’t care!” Which statement from the nurse
is therapeutic? *
A. “You poor thing! I’m so sorry this happened to you. That
nurse should be fired immediately.”
B. “I think you are being very impatient. The nurses come as
quickly as they can.”
C. “It’s hard to be in bed and to have to ask for help. You feel
that the nurses do not seem to care?”
D. “I can hear your anger. That nurse had no right to speak to
you that way. I will report her.”
6. The nurse is caring for a dying client who says, “Will you be
the executor of my will?” How should the nurse best respond to
this client? *
A. “I must decline your offer because I am your nurse.”
B. “I will carry out your will according to your wishes.”
C. “It is an honor to be named the executor of your will.”
D. “Tell me more so that I can understand your thinking.”
7. While assessing a 14-year-old child, the nurse notes bruises
and cigarette burns on the child’s chest and rope burns on the
buttocks. The child states, “I’m afraid to go home because my
stepfather will be angry with me for telling on him!” The nurse
should make which therapeutic response to the child? *
A. “You must know that your presence in the house will only
tease your stepfather more.”
B. “You can’t go back there with that man. How do you think
your mother will react?”
C. “I am sorry that this has happened to you, but you will be
safe here until plans can be made.”
D. “Let’s keep this between you, me, and the health care
provider until we formulate further plans to assist you.”
8. The nurse is caring for a 12-year-old client who has been
physically and sexually abused by her father. The father angrily
approaches the nurse and says, “I’m taking my daughter home.
She’s told me what you people are up to, and we’re out of
here!” Which therapeutic response should the nurse make? *
A. “Your daughter will remain here until the doctor discharges
her. I’ll call hospital security and the police if you attempt to
take her.”
B. “You seem very upset. Let’s talk at the nurse’s station. I
know you’re very concerned and that you want to help your
daughter. It will be best if you agree to let your daughter stay
here for now.”
C. “Try to listen to me, please. If you are insistent and do take
your daughter from this unit, the police will most certainly
order you to bring her back again.”
D. “Your daughter is ill and needs to be here. I know you want
to help her to recover and that you will work to help everyone
straighten out the circumstances that caused this.”.
9. A female victim of a sexual assault is being seen in the crisis
center for a third visit. She states that although the rape
occurred nearly 2 months ago, she still feels “as though the rape
just happened yesterday.” How should the nurse respond? *
A. “What can you do to alleviate some of your fears about
being assaulted again?”
B. “Tell me more about those aspects of the rape that cause you
to feel like the rape just occurred.”
C. “In reality, the rape did not just occur. It has been over 2
months now.”
D. “In time, our goal will be to help you move on from these
strong feelings about your rape.”
10. The nurse is caring for a client who says, “I don’t want to
talk with you because you’re only the nurse.I’ll wait for my
doctor.” What should the nurse say in response to the client? *
A. “I understand. So should I call your health care provider?”
B. “I’m angry with the way you dismissed me.”
C. “So then, you would prefer to speak with your health care
provider?”
D. “Your health care provider directs me in your nursing care.”
11. The client angrily tells the nurse that the health care
provider (HCP) purposefully provided incorrect information.
Which response to the client would hinder therapeutic
communication? *
A. “I’m not sure what information you are referring to.”
B. “Can you describe the information that you are referring
to?”
C. “I’m certain that the HCP would not lie to you.”
D. “Do you think it would be helpful to talk to your doctor
about this?”
12. A charge nurse is supervising a nursing student who is
providing care to a client with end-stage heart failure. The client
is withdrawn and reluctant to talk, and she shows little interest
in participating in hygienic care or activities. Which statement,
if made by the student to the client, indicates that the student
requires teaching regarding the use of therapeutic
communication techniques? *
A. “What are your feelings right now?”
B. “Why don’t you feel like getting up for your bath?”
C. “These dreams you mentioned, what are they like?”
D. “Many clients with end-stage heart failure fear death.”
13. The nurse is caring for a client diagnosed with depression
who appears anxious and withdrawn. Which statement is
appropriate for the nurse to make when initially initiating
conversation? *
A. “Can you tell me how you are feeling today?”
B. “You are wearing your new shoes.”
C. “It appears that talking makes you anxious.”
D. “Do you feel like talking today?”
14. The nurse is caring for a client diagnosed with delirium who
states, “Look at the spiders on the wall.” How should the nurse
respond? *
A. “I know that you are frightened, but I do not see any spiders
on the wall.”
B. “While there may be spiders on the wall, they are not going interprets these behaviors as indicative of the client's use of
to hurt you.” which of the following defense mechanisms? 
C. “You are having a hallucination; I’m sure there are no
spiders in this room.” A. Denial
D. “Would you like me to kill the spiders for you?” B. Displacement
C. Rationalization
15. A mother comes to the pediatric clinic because her D. Reaction formation
previously continent 6-yearold son has resumed bedwetting.
The nurse assesses the home environment and discovers there is
a new baby at home. Which explanation by the nurse describes
for the mother the defense mechanism the son is using? *
A. Identification
B. Rationalization
C. Regression
D. Repression
16. A client reports becoming involved with legislation that
promotes gun safety after the death of a child by accidental
shooting. Which defense mechanism is the client exhibiting? *
A. Sublimation
B. Denial
C. Intellectualization
D. Identification
17. Anna’s dog Lucky got away from her while they were
taking a walk. He ran into the street and was hit by a car. Anna
cannot remember any of these circumstances of his death. This
is an example of what defense mechanism? *
A. Suppression
B. Denial
C. Rationalization
D. Repression
18. Lucky sometimes refused to obey Anna and, indeed, did not
come back to her when she called to him on the day he was
killed. But Anna continues to insist, “he was the very best dog.
He always minded me. He always did everything I told him to
do.” This represents the defense mechanism of? *
A. compensation.
B. reaction formation.
C. undoing.
D. sublimation.
19. The client sees no connection between her liver disorder and
her alcohol intake. She believes that she drinks very little and
that her family is making something out of nothing. The nurse