PSYCHIATRIC NURSING 1
 Part 1
 Part 10
 Part 2
1. Flumazenil (Romazicon) has been
ordered for a client who has overdosed on
oxazepam (Serax). Before administering the
medication, the nurse should be prepared
for which common adverse effect?
A. Seizures
B. Shivering
C. Anxiety
D. Chest pain
A. Seizures. Seizures are the most common
serious adverse effect of using flumazenil to
reverse benzodiazepine overdose. The
effect is magnified if the client has a
combined tricyclic antidepressant and
benzodiazepine overdose. Less common
adverse effects include shivering, anxiety,
and chest pain.
2. The nurse is caring for a client diagnosed
with bulimia. The most appropriate initial
goal for a client diagnosed with bulimia is to:
A. avoid shopping for large amounts of
food.
B. control eating impulses.
C. identify anxiety-causing situations.
D. eat only three meals per day
C. identify anxiety-causing situations.
Bulimic behavior is generally a maladaptive
coping response to stress and underlying
issues. The client must identify anxiety-
causing situations that stimulate the bulimic
behavior and then learn new ways of coping
with the anxiety. Controlling shopping for
large amounts of food isn’t a goal early in
treatment. Managing eating impulses and
replacing them with adaptive coping
mechanisms can be integrated into the plan
of care after initially addressing stress and
underlying issues. Eating three meals per
day isn’t a realistic goal early in treatment.
3. A client who’s at high risk for suicide
needs close supervision. To best ensure the
client’s safety, the nurse should:
A. check the client frequently at
irregular intervals throughout the
night.
B. assure the client that the nurse will
hold in confidence anything the
client says.
C. repeatedly discuss previous suicide
attempts with the client.
D. disregard decreased communication
by the client because this is common
in suicidal clients
A. check the client frequently at irregular
intervals throughout the night.
Rationale: Checking the client frequently but
at irregular intervals prevents the client from
predicting when observation will take place
and altering behavior in a misleading way at
these times. Option B may encourage the
client to try to manipulate the nurse or seek
attention for having a secret suicide plan.
Option C may reinforce suicidal ideas.
Decreased communication is a sign of
withdrawal that may indicate the client has
decided to commit suicide; the nurse
shouldn’t disregard it (option D
4. Which of the following drugs should the
nurse prepare to administer to a client with
a toxic acetaminophen (Tylenol) level?
 A. deferoxamine mesylate (Desferal)
B. succimer (Chemet)
C. flumazenil (Romazicon)
D. acetylcysteine (Mucomyst)
D. acetylcysteine (Mucomyst). The antidote
for acetaminophen toxicity is acetylcysteine.
It enhances conversion of toxic metabolites
to nontoxic metabolites. Deferoxamine
mesylate is the antidote for iron intoxication.
Succimer is an antidote for lead poisoning.
Flumazenil reverses the sedative effects of
benzodiazepines.
5. A client is admitted to the substance
abuse unit for alcohol detoxification. Which
of the following medications is the nurse
most likely to administer to reduce the
symptoms of alcohol withdrawal?
A. naloxone (Narcan)
B. haloperidol (Haldol)
C. magnesium sulfate
D. chlordiazepoxide (Librium)
D. chlordiazepoxide (Librium).
Chlordiazepoxide (Librium) and other
tranquilizers help reduce the symptoms of
alcohol withdrawal. Haloperidol (Haldol)
may be given to treat clients with psychosis,
severe agitation, or delirium. Naloxone
(Narcan) is administered for narcotic
overdose. Magnesium sulfate and other
anticonvulsant medications are only
administered to treat seizures if they occur
during withdrawal.
6. During postprandial monitoring, a client
with bulimia nervosa tells the nurse, “You
can sit with me, but you’re just wasting your
time. After you sat with me yesterday, I was
still able to purge. Today, my
goal is to do it twice.” What is the nurse’s
best response?
A. “I trust you not to purge.”
B. “How are you purging and when do
you do it?”
C. “Don’t worry. I won’t allow you to
purge today.”
D. “I know it’s important for you to feel
in control, but I’ll monitor you for 90
minutes after you eat.”
D. “I know it’s important for you to feel in
control, but I’ll monitor you for 90 minutes
after you eat.” This response acknowledges
that the client is testing limits and that the
nurse is setting them by performing
postprandial monitoring to prevent self-
induced emesis. Clients with bulimia
nervosa need to feel in control of the diet
because they feel they lack control over all
other aspects of their lives. Because their
therapeutic relationships with caregivers are
less important than their need to purge, they
don’t fear betraying the nurse’s trust by
engaging in the activity. They commonly
plot purging and rarely share their secrets
about it. An authoritarian or challenging
response may trigger a power struggle
between the nurse and client.
7. A client admitted to the psychiatric unit for
treatment of substance abuse says to the
nurse, “It felt so wonderful to get high.”
Which of the following is the most
appropriate response?
A. “If you continue to talk like that, I’m
going to stop speaking to you.”
B. “You told me you got fired from your
last job for missing too many days
after taking drugs all night.”
C. “Tell me more about how it felt to get
high.”
D. “Don’t you know it’s illegal to use
drugs?”
B. “You told me you got fired from your last
job for missing too many days after taking
drugs all night.” Confronting the client with
the consequences of substance abuse
helps to break through denial. Making
threats (option A) isn’t an effective way to
promote self-disclosure or establish a
rapport with the client. Although the nurse
should encourage the client to discuss
feelings, the discussion should focus on
how the client felt before, not during, an
episode of substance abuse (option C).
Encouraging elaboration about his
experience while getting high may reinforce
the abusive behavior. The client
undoubtedly is aware that drug use is
illegal; a reminder to this effect (option D) is
unlikely to alter behavior.
8. For a client with anorexia nervosa, which
goal takes the highest priority?
A. The client will establish adequate
daily nutritional intake.
B. The client will make a contract with
the nurse that sets a target weight.
C. The client will identify self-
perceptions about body size as
unrealistic.
D. The client will verbalize the possible
physiological consequences of self-
starvation
A. The client will establish adequate daily
nutritional intake. According to Maslow’s
hierarchy of needs, all humans need to
meet basic physiological needs first.
Because a client with anorexia nervosa eats
little or nothing, the nurse must first plan to
help the client meet this basic, immediate
physiological need. The nurse may give
lesser priority to goals that address long-
term plans (as in option B), self-perception
(as in option C), and potential complications
(as in option D).
9. When interviewing the parents of an
injured child, which of the following is the
strongest indicator that child abuse may be
a problem?
A. The injury isn’t consistent with the
history or the child’s age.
B. The mother and father tell different
stories regarding what happened.
C. The family is poor.
D. The parents are argumentative and
demanding with emergency
department personnel.
10. For a client with anorexia nervosa, the
nurse plans to include the parents in
therapy sessions along with the client. What
fact should the nurse remember to be
typical of parents of clients with anorexia
nervosa?
A. They tend to overprotect their
children.
B. They usually have a history of
substance abuse.
C. They maintain emotional distance
from their children.
D. They alternate between loving and
rejecting their children.
A. The injury isn’t consistent with the history
or the child’s age. When the child’s injuries
are inconsistent with the history given or
impossible because of the child’s age and
developmental stage, the emergency
department nurse should be suspicious that
child abuse is occurring. The parents may
tell different stories because their perception
may be different regarding what happened.
If they change their story when different
health care workers ask the same question,
this is a clue that child abuse may be a
problem. Child abuse occurs in all
socioeconomic groups. Parents may argue
and be demanding because of the stress of
having an injured child.
11. In the emergency department, a client
with facial lacerations states that her
husband beat her with a shoe. After the
health care team repairs her lacerations,
she waits to be seen by the crisis intake
nurse, who will evaluate the continued
threat of violence. Suddenly the client’s
husband arrives, shouting that he wants to
“finish the job.” What is the first priority of
the health care worker who witnesses this
scene?
A. Remaining with the client and
staying calm
B. Calling a security guard and another
staff member for assistance
C. Telling the client’s husband that he
must leave at once
D. Determining why the husband feels
so angry
B. Calling a security guard and another staff
member for assistance . The health care
worker who witnesses this scene must take
precautions to ensure personal as well as
client safety, but shouldn’t attempt to
manage a physically aggressive person
alone. Therefore, the first priority is to call a
security guard and another staff member.
After doing this, the health care worker
should inform the husband what is
expected, speaking in concise statements
and maintaining a firm but calm demeanor.
This approach makes it clear that the health
care worker is in control and may diffuse the
situation until the security guard arrives.
Telling the husband to leave would probably
be ineffective because of his agitated and
irrational state. Exploring his anger doesn’t
take precedence over safeguarding the
client and staff.
12. The nurse is caring for a client with
bulimia. Strict management of dietary intake
is necessary. Which intervention is also
important?
A. Fill out the client’s menu and make
sure she eats at least half of what is
on her tray.
B. Let the client eat her meals in
private. Then engage her in social
activities for at least 2 hours after
each meal.
C. Let the client choose her own food. If
she eats everything she orders, then
stay with her for 1 hour after each
meal.
D. Let the client eat food brought in by
the family if she chooses, but she
should keep a strict calorie count
C. Let the client choose her own food. If she
eats everything she orders, then stay with
her for 1 hour after each meal. Allowing the
client to select her own food from the menu
will help her feel some sense of control. She
must then eat 100% of what she selected.
Remaining with the client for at least 1 hour
after eating will prevent purging. Bulimic
clients should only be allowed to eat food
provided by the dietary department.
13. The nurse is assigned to care for a
suicidal client. Initially, which is the nurse’s
highest care priority?
A. Assessing the client’s home
environment and relationships
outside the hospital
B. Exploring the nurse’s own feelings
about suicide
C. Discussing the future with the client
D. Referring the client to a clergyperson
to discuss the moral implications of
suicide
B. Exploring the nurse’s own feelings about
suicide. The nurse’s values, beliefs, and
attitudes toward self-destructive behavior
influence responses to a suicidal client;
such responses set the overall mood for the
nurse-client relationship. Therefore, the
nurse initially must explore personal feelings
about suicide to avoid conveying negative
feelings to the client. Assessment of the
client’s home environment and relationships
may reveal the need for family therapy;
however, conducting such an assessment
isn’t a nursing priority. Discussing the future
and providing anticipatory guidance can
help the client prepare for future stress, but
this isn’t a priority. Referring the client to a
clergyperson may increase the client’s trust
or alleviate guilt; however, it isn’t the highest
priority.
14. A client with anorexia nervosa tells the
nurse, “When I look in the mirror, I hate
what I see. I look so fat and ugly.” Which
strategy should the nurse use to deal with
the client’s distorted perceptions and
feelings?
A. Avoid discussing the client’s
perceptions and feelings.
B. Focus discussions on food and
weight.
C. Avoid discussing unrealistic cultural
standards regarding weight.
D. Provide objective data and feedback
regarding the client’s weight and
attractiveness
D. Provide objective data and feedback
regarding the client’s weight and
attractiveness. By focusing on reality, this
strategy may help the client develop a more
realistic body image and gain self-esteem.
Option A is inappropriate because
discussing the client’s perceptions and
feeling wouldn’t help her to identify, accept,
and work through them. Focusing
discussions on food and weight would give
the client attention for not eating, making
option B incorrect. Option C is inappropriate
because recognizing unrealistic cultural
standards wouldn’t help the client establish
more realistic weight goals.
15. The nurse is caring for a client being
treated for alcoholism. Before initiating
therapy with disulfiram (Antabuse), the
nurse teaches the client that he must read
labels carefully on which of the following
products?
A. Carbonated beverages
B. Aftershave lotion
C. Toothpaste
D. Cheese
B. Aftershave lotion . Disulfiram may be
given to clients with chronic alcohol abuse
who wish to curb impulse drinking.
Disulfiram works by blocking the oxidation
of alcohol, inhibiting the conversion of
acetaldehyde to acetate. As acetaldehyde
builds up in the blood, the client
experiences noxious and uncomfortable
symptoms. Even alcohol rubbed onto the
skin can produce a reaction. The client
receiving disulfiram must be taught to read
ingredient labels carefully to avoid products
containing alcohol such as aftershave
lotions. Carbonated beverages, toothpaste,
and cheese don’t contain alcohol and don’t
need to be avoided by the client.
16. The nurse is developing a plan of care
for a client with anorexia nervosa. Which
action should the nurse include in the plan?
A. Restrict visits with the family until the
client begins to eat.
B. Provide privacy during meals.
C. Set up a strict eating plan for the
client.
D. Encourage the client to exercise,
which will reduce her anxiety.
C. Set up a strict eating plan for the client.
Establishing a consistent eating plan and
monitoring the client’s weight are important
for this disorder. The family should be
included in the client’s care. The client
should be monitored during meals — not
given privacy. Exercise must be limited and
supervised.
17. Victims of domestic violence should be
assessed for what important information?
A. Reasons they stay in the abusive
relationship (for example, lack of
financial autonomy and isolation)
B. Readiness to leave the perpetrator
and knowledge of resources
C. Use of drugs or alcohol
D. History of previous victimization
B. Readiness to leave the perpetrator and
knowledge of resources . Victims of
domestic violence must be assessed for
their readiness to leave the perpetrator and
their knowledge of the resources available
to them. Nurses can then provide the
victims with information and options to
enable them to leave when they are ready.
The reasons they stay in the relationship
are complex and can be explored at a later
time. The use of drugs or alcohol is
irrelevant. There is no evidence to suggest
that previous victimization results in a
person’s seeking or causing abusive
relationships.
18. A client is hospitalized with fractures of
the right femur and right humerus sustained
in a motorcycle accident. Police suspect the
client was intoxicated at the time of the
accident. Laboratory tests reveal a blood
alcohol level of 0.2% (200 mg/dl). The client
later admits to drinking heavily for years.
During hospitalization, the client periodically
complains of tingling and numbness in the
hands and feet. The nurse realizes that
these symptoms probably result from:
A. acetate accumulation.
B. thiamine deficiency.
C. triglyceride buildup.
D. a below-normal serum potassium
level
B. thiamine deficiency. Numbness and
tingling in the hands and feet are symptoms
of peripheral polyneuritis, which results from
inadequate intake of vitamin B1 (thiamine)
secondary to prolonged and excessive
alcohol intake. Treatment includes reducing
alcohol intake, correcting nutritional
deficiencies through diet and vitamin
supplements, and preventing such residual
disabilities as foot and wrist drop. Acetate
accumulation, triglyceride buildup, and a
below-normal serum potassium level are
unrelated to the client’s symptoms.
19. A parent brings a preschooler to the
emergency department for treatment of a
dislocated shoulder, which allegedly
happened when the child fell down the
stairs. Which action should make the nurse
suspect that the child was abused?
A. The child cries uncontrollably
throughout the examination.
B. The child pulls away from contact
with the physician.
C. The child doesn’t cry when the
shoulder is examined.
D. The child doesn’t make eye contact
with the nurse.
C. The child doesn’t cry when the shoulder
is examined. A characteristic behavior of
abused children is lack of crying when they
undergo a painful procedure or are
examined by a health care professional.
Therefore, the nurse should suspect child
abuse. Crying throughout the examination,
pulling away from the physician, and not
making eye contact with the nurse are
normal behaviors for preschoolers.
20. When planning care for a client who has
ingested phencyclidine (PCP), which of the
following is the highest priority?
A. Client’s physical needs
B. Client’s safety needs
 C. Client’s psychosocial needs
D. Client’s medical needs
B. Client’s safety needs . The highest
priority for a client who has ingested PCP is
meeting safety needs of the client as well as
the staff. Drug effects are unpredictable and
prolonged, and the client may lose control
easily. After safety needs have been met,
the client’s physical, psychosocial, and
medical needs can be met.
21. Which outcome criteria would be
appropriate for a child diagnosed with
oppositional defiant disorder?
A. Accept responsibility for own
behaviors.
B. Be able to verbalize own needs and
assert rights.
C. Set firm and consistent limits with
the client.
D. Allow the child to establish his own
limits and boundaries.
A. Accept responsibility for own behaviors.
Children with oppositional defiant disorder
frequently violate the rights of others. They
are defiant, disobedient, and blame others
for their actions. Accountability for their
actions would demonstrate progress for the
oppositional child. Options C and D aren’t
outcome criteria but interventions. Option B
is incorrect as the oppositional child usually
focuses on his own needs.
22. A client is found sitting on the floor of
the bathroom in the day treatment clinic with
moderate lacerations on both wrists.
Surrounded by broken glass, she sits
staring blankly at her bleeding wrists
while staff members call for an ambulance.
How should the nurse approach her
initially?
A. Enter the room quietly and move
beside her to assess her injuries.
B. Call for staff back-up before entering
the room and restraining her.
C. Move as much glass away from her
as possible and sit next to her
quietly.
D. Approach her slowly while speaking
in a calm voice, calling her name,
and telling her that the nurse is here
to help her.
D. Approach her slowly while speaking in a
calm voice, calling her name, and telling her
that the nurse is here to help her.Ensuring
the safety of the client and the nurse is the
priority at this time. Therefore, the nurse
should approach the client cautiously while
calling her name and talking to her in a
calm, confident manner. The nurse should
keep in mind that the client shouldn’t be
startled or overwhelmed. After explaining
that the nurse is there to help, the nurse
should observe the client’s response
carefully. If the client shows signs of
agitation or confusion or poses a threat, the
nurse should retreat and request
assistance. The nurse shouldn’t attempt to
sit next to the client or examine injuries
without first announcing the nurse’s
presence and assessing the dangers of the
situation.
23. A client with anorexia nervosa describes
herself as “a whale.” However, the nurse’s
assessment reveals that the client is 5′ 8″
(1.7 m) tall and weighs only 90 lb (40.8 kg).
Considering the client’s
unrealistic body image, which intervention
should be included in the plan of care?
A. Asking the client to compare her
figure with magazine photographs of
women her age
B. Assigning the client to group therapy
in which participants provide realistic
feedback about her weight
 C. Confronting the client about her
actual appearance during one-on-
one sessions, scheduled during
each shift
D. Telling the client of the nurse’s
concern for her health and desire to
help her make decisions to keep her
healthy
D. Telling the client of the nurse’s concern
for her health and desire to help her make
decisions to keep her healthy . A client with
anorexia nervosa has an unrealistic body
image that causes consumption of little or
no food. Therefore, the client needs
assistance with making decisions about
health. Instead of protecting the client’s
health, options A, B, and C may serve to
make the client defensive and more
entrenched in her unrealistic body image.
24. Eighteen hours after undergoing an
emergency appendectomy, a client with a
reported history of social drinking displays
these vital signs: temperature, 101.6° F
(38.7° C); heart rate, 126 beats/minute;
respiratory rate, 24 breaths/minute; and
blood pressure, 140/96 mm Hg. The client
exhibits gross hand tremors and is
screaming for someone to kill the bugs in
the bed. The nurse should suspect:
A. a postoperative infection.
B. alcohol withdrawal.
C. acute sepsis.
D. Pneumonia
B. alcohol withdrawal. The client’s vital
signs and hallucinations suggest delirium
tremens or alcohol withdrawal syndrome.
Although infection, acute sepsis, and
pneumonia may arise as postoperative
complications, they wouldn’t cause this
client’s signs and symptoms and typically
would occur later in the postoperative
course.
25. Clonidine (Catapres) can be used to
treat conditions other than hypertension. For
which of the following conditions might the
drug be administered?
A. Phencyclidine (PCP) intoxication
B. Alcohol withdrawal
C. Opiate withdrawal
D. Cocaine withdrawal
C. Opiate withdrawal. Clonidine is used as
adjunctive therapy in opiate withdrawal.
Benzodiazepines, such as chlordiazepoxide
(Librium), and neuropleptic agents, such as
haloperidol, are used to treat alcohol
withdrawal. Benzodiazepines and
neuropleptic agents are typically used to
treat PCP intoxication. Antidepressants and
medications with dopaminergic activity in
the brain, such as fluoxotine (Prozac), are
used to treat cocaine withdrawal.
26. One of the goals for a client with
anorexia nervosa is that the client will
demonstrate increased individual coping by
responding to stress in constructive ways.
Which of the following actions is the best
indicator that the client is working toward
meeting the goal?
A. The client drinks 4 L of fluid per day.
B. The client paces around the unit
most of the day.
C. The client keeps a journal and
discusses it with the nurse.
D. The client talks almost constantly
with friends by telephone
C. The client keeps a journal and discusses
it with the nurse. The client is moving
toward meeting the goal because recording
and discussing feelings is a constructive
way to manage stress. Although physical
activity can reduce stress, the anorexic
client is more likely to use pacing to burn
calories and lose weight. Although talks with
friends can decrease stress, constant
talking is more likely a way of avoiding
dealing with problems. Increased fluid
intake may be an attempt by the client to
curb her appetite and artificially increase her
weight.
27. The nurse in the substance abuse unit is
trying to encourage a client to attend
Alcoholics Anonymous meetings. When the
client asks the nurse what he must do to
become a member, the nurse should
respond:
A. “You must first stop drinking.”
B. “Your physician must refer you to
this program.”
C. “Admit you’re powerless over alcohol
and that you need help.”
D. “You must bring along a friend who
will support you.”
C. “Admit you’re powerless over alcohol and
that you need help.” The first of the “Twelve
Steps of Alcoholics Anonymous” is
admitting that an individual is powerless
over alcohol and that life has become
unmanageable. Although Alcoholics
Anonymous promotes total abstinence, a
client will still be accepted if he drinks. A
physician referral isn’t necessary to join.
New members are assigned a support
person who may be called upon when the
client has the urge to drink.
28. An attorney who throws books and
furniture around the office after losing a
case is referred to the psychiatric nurse in
the law firm’s employee assistance
program. The nurse knows that the client’s
behavior most likely represents the use of
which defense mechanism?
A. Regression
B. Projection
C. Reaction-formation
D. Intellectualization
A. Regression . An adult who throws temper
tantrums, such as this one, is displaying
regressive behavior, or behavior that is
appropriate at a younger age. In projection,
the client blames someone or something
other than the source. In reaction formation,
the client acts in opposition to his feelings.
In intellectualization, the client overuses
rational explanations or abstract thinking to
decrease the significance of a feeling or
event.
29. After completing chemical detoxification
and a 12-step program to treat crack
addiction, a client is being prepared for
discharge. Which remark by the client
indicates a realistic view of the future?
A. “I’m never going to use crack again.”
B. “I know what I have to do. I have to
limit my crack use.”
C. “I’m going to take 1 day at a time.
I’m not making any promises.”
D. “I will substitue crack for something
else”
C. “I’m going to take 1 day at a time. I’m not
making any promises.” Twelve-step
programs focus on recovery 1 day at a time.
Such programs discourage people from
claiming that they will never again use a
substance, because relapse is common.
The belief that one may use a limited
amount of an abused substance indicates
denial. Substituting one abused substance
for another predisposes the client to cross-
addiction.
30. The nurse is assessing a client on
admission to the chemical dependency unit
for alcohol detoxification. When the nurse
asks about alcohol use, this client is most
likely to:
A. accurately describe the amount
consumed.
 B. underestimate the amount
consumed.
C. overestimate the amount consumed.
D. deny any consumption of alcohol
B. underestimate the amount consumed.
Most people who abuse substances
underestimate their consumption in an
attempt to conform to social norms or
protect themselves. Few accurately
describe or overestimate consumption;
some may deny it. Therefore, on admission,
quantitative and qualitative toxicology
screens are done to validate information
obtained from the client.
31. The nurse is assessing a 15-year-old
female who’s being admitted for treatment
of anorexia nervosa. Which clinical
manifestation is the nurse most likely to
find?
A. Tachycardia
B. Warm, flushed extremities
C. Parotid gland tenderness
D. Coarse hair growth
C. Parotid gland tenderness. Frequent
vomiting causes tenderness and swelling of
the parotid glands. The reduced metabolism
that occurs with severe weight loss
produces bradycardia and cold extremities.
Soft, downlike hair (called lanugo) may
cover the extremities, shoulders, and face of
an anorexic client.
32. A 38-year-old client is admitted for
alcohol withdrawal. The most common early
sign or symptom that this client is likely to
experience is:
A. impending coma.
B. manipulating behavior.
C. suppression.
D. perceptual disorders
D. perceptual disorders. Perceptual
disorders, especially frightening visual
hallucinations, are very common with
alcohol withdrawal. Coma isn’t an
immediate consequence. Manipulative
behaviors are part of the alcoholic client’s
personality but aren’t signs of alcohol
withdrawal. Suppression is a conscious
effort to conceal unacceptable thoughts,
feelings, impulses, or acts and serves as a
coping mechanism for most alcoholics.
33. The nurse is caring for an adolescent
female who reports amenorrhea, weight
loss, and depression. Which additional
assessment finding would suggest that the
woman has an eating disorder?
A. Wearing tight-fitting clothing
B. Increased blood pressure
C. Oily skin
D. Excessive and ritualized exercise
D. Excessive and ritualized exercise . A
client with an eating disorder will normally
exercise to excess in an effort to burn as
many calories as possible. The client will
usually wear loose-fitting clothing to hide
what she considers to be a fat body. Skin
and nails become dry and brittle and blood
pressure and body temperature drop from
excessive weight loss.
34. A client with a history of polysubstance
abuse is admitted to the facility. She
complains of nausea and vomiting 24 hours
after admission. The nurse assesses the
client and notes piloerection, pupillary
dilation, and lacrimation. The nurse
suspects that the client is going through
which of the following withdrawals?
A. Alcohol withdrawal
B. Cannabis withdrawal
C. Cocaine withdrawal
D. Opioid withdrawal
D. Opioid withdrawal. The symptoms listed
are specific to opioid withdrawal. Alcohol
withdrawal would show elevated vital signs.
There is no real withdrawal from cannabis.
Symptoms of cocaine withdrawal include
depression, anxiety, and agitation.
35. A client is admitted to the psychiatric
unit with a diagnosis of anorexia nervosa.
Although she is 5′ 8″ (1.7 m) tall and weighs
only 103 lb (46.7 kg), she talks incessantly
about how fat she is. Which measure should
the nurse take first when caring for this
client?
A. Teach the client about nutrition,
calories, and a balanced diet.
B. Establish a trusting relationship with
the client.
C. Discuss cultural stereotypes
regarding thinness and
attractiveness.
D. Explore the reasons why the client
doesn’t eat
B. Establish a trusting relationship with the
client. A client with an eating disorder may
be secretive and unwilling to admit that a
problem exists. Therefore, the nurse first
must establish a trusting relationship to elicit
the client’s feelings and thoughts. The
anorexic client may spend long hours
discussing nutrition or handling and
preparing food in an effort to stall or avoid
eating food; the nurse shouldn’t reinforce
her preoccupation with food, as in option A.
Although cultural stereotypes may play a
prominent role in anorexia nervosa,
discussing these factors isn’t the first action
the nurse should take. Exploring the
reasons why the client doesn’t eat would
increase her emotional investment in food
and eating.
36. A client is admitted for an overdose of
amphetamines. When assessing this client,
the nurse should expect to see:
A. tension and irritability.
B. slow pulse.
C. hypotension.
D. constipation.
A. tension and irritability. An amphetamine
is a nervous system stimulant that is subject
to abuse because of its ability to produce
wakefulness and euphoria. An overdose
increases tension and irritability. Options B
and C are incorrect because amphetamines
stimulate norepinephrine, which increases
the heart rate and blood flow. Diarrhea is a
common adverse effect, so option D is
incorrect.
37. Which of the following drugs may be
abused because of tolerance and
physiologic dependence.
A. lithium (Lithobid) and divalproex
(Depakote).
B. verapamil (Calan) and
chlorpromazine (Thorazine)
C. alprazolam (Xanax) and
phenobarbital (Luminal)
D. clozapine (Clozaril) and amitriptyline
(Elavil)
C. alprazolam (Xanax) and phenobarbital
(Luminal) . Both benzodiazepines, such as
alprazolam, and barbiturates, such as
phenobarbital, are addictive, controlled
substances. All the other drugs listed aren’t
addictive substances.
38. Which of the following groups are
considered to be at highest risk for suicide?
A. Adolescents, men over age 45, and
persons who have made previous
suicide attempts
B. Teachers, divorced persons, and
substance abusers
 C. Alcohol abusers, widows, and young
married men
D. Depressed persons, physicians, and
persons living in rural areas
A. Adolescents, men over age 45, and
persons who have made previous suicide
attempts . Studies of those who commit
suicide reveal the following high-risk groups:
adolescents; men over age 45; persons who
have made previous suicide attempts;
divorced, widowed, and separated persons;
professionals, such as physicians, dentists,
and attorneys; students; unemployed
persons; persons who are depressed,
delusional, or hallucinating; alcohol or
substance abusers; and persons who live in
urban areas. Although more women attempt
suicide than men, they typically choose less
lethal means and therefore are less likely to
succeed in their attempts.
39. Tourette syndrome is characterized by
the presence of multiple motor and vocal
tics. A vocal tic that involves repeating one’s
own sounds or words is known as:
A. echolalia.
B. palilalia.
C. apraxia.
D. aphonia.
B. palilalia. Palilalia is defined as the
repetition of sounds and words. Echolalia is
the act of repeating the words of others.
Apraxia is the inability to carry out motor
activities, and aphonia is the inability to
speak
40. A client is admitted to the psychiatric
unit with a diagnosis of borderline
personality disorder. The nurse expects the
assessment to reveal:
A. unpredictable behavior and intense
interpersonal relationships.
B. inability to function as a responsible
parent.
C. somatic symptoms.
D. coldness, detachment, and lack of
tender feelings.
A. unpredictable behavior and intense
interpersonal relationships. A client with
borderline personality disorder displays a
pervasive pattern of unpredictable behavior,
mood, and self-image. Interpersonal
relationships may be intense and unstable
and behavior may be inappropriate and
impulsive. Although the client’s impaired
ability to form relationships may affect
parenting skills, inability to function as a
responsible parent is more typical of
antisocial personality disorder. Somatic
symptoms characterize avoidant personality
disorder. Coldness, detachment, and lack of
tender feelings typify schizoid and
schizotypal personality disorders.
41. A client with disorganized type
schizophrenia has been hospitalized for the
past 2 years on a unit for chronic mentally ill
clients. The client’s behavior is labile and
fluctuates from childishness and
incoherence to loud yelling to slow but
appropriate interaction. The client needs
assistance with all activities of daily living.
Which behavior is characteristic of
disorganized type schizophrenia?
A. Extreme social impairment
B. Suspicious delusions
C. Waxy flexibility
D. Elevated affect
A. Extreme social impairment .
Disorganized type schizophrenia (formerly
called hebephrenia) is characterized by
extreme social impairment, marked
inappropriate affect, silliness, grimacing,
posturing, and fragmented delusions and
hallucinations. A client with a paranoid
disorder typically exhibits suspicious D. administer as needed dose of
delusions, such as a belief that evil forces haloperidol (Haldol) by mouth.
are after him. Waxy flexibility, a condition in
B. administer as needed dose of
which the client’s limbs remain fixed in
benztropine (Cogentin) I.M. as ordered.
uncomfortable positions for long periods,
The client is most likely suffering from
characterizes catatonic schizophrenia.
muscle rigidity due to haloperidol. I.M.
Elevated affect is associated
benztropine should be administered to
withschizoaffective disorder.
prevent asphyxia or aspiration. Lorazepam
42. The nurse is providing care for a female treats anxiety, not extrapyramidal effects.
client with a history of schizophrenia who’s Another dose of haloperidol would increase
experiencing hallucinations. The physician the severity of the reaction.
orders 200 mg of haloperidol (Haldol) orally
44. A 24-year-old client is experiencing an
or I.M. every 4 hours as needed. What is
acute schizophrenic episode. He has vivid
the nurse’s best action?
hallucinations that are making him agitated.
A. Administer the haloperidol orally if The nurse’s best response at this time
the client agrees to take it. would be to:
B. Call the physician to clarify whether A. take the client’s vital signs.
the haloperidol should be given
B. explore the content of the
orally or I.M.
hallucinations.
C. Call the physician to clarify the order
C. tell him his fear is unrealistic.
because the dosage is too high.
D. engage the client in reality-oriented
D. Withhold haloperidol because it may
activities.
worsen hallucinations.
B. explore the content of the hallucinations.
C. Call the physician to clarify the order
Exploring the content of the hallucinations
because the dosage is too high. The
will help the nurse understand the client’s
dosage is too high (normal dosage ranges
perspective on the situation. The client
from 5 to 10 mg daily). Options A and B
shouldn’t be touched, such as in taking vital
may lead to an overdose. Option D is
signs, without telling him exactly what is
incorrect because haloperidol helps with
going to happen. Debating with the client
symptoms of hallucinations.
about his emotions isn’t therapeutic. When
43. A client receiving haloperidol (Haldol) the client is calm, engage him in reality-
complains of a stiff jaw and difficulty based activities.
swallowing. The nurse’s first action is to:
45. Which medication can control the
A. reassure the client and administer as extrapyramidal effects associated with
needed lorazepam (Ativan) I.M. antipsychotic agents?
B. administer as needed dose of A. perphenazine (Trilafon)
benztropine (Cogentin) I.M. as
B. doxepin (Sinequan)
ordered.
C. amantadine (Symmetrel)
C. administer as needed dose of
benztropine (Cogentin) by mouth as D. clorazepate (Tranxene)
ordered.
C. amantadine (Symmetrel) . Amantadine is
an anticholinergic drug used to relieve drug-
induced extrapyramidal adverse effects,
such as muscle weakness, involuntary
muscle movement, pseudoparkinsonism,
and tardive dyskinesia. Other anticholinergic
agents used to control extrapyramidal
reactions include benztropine mesylate
(Cogentin), trihexyphenidyl (Artane),
biperiden (Akineton), and diphenhydramine
(Benadryl). Perphenazine is an
antipsychotic agent; doxepin, an
antidepressant; and chlorazepate, an
antianxiety agent. Because these
medications have no anticholinergic or
neurotransmitter effects, they don’t alleviate
extrapyramidal
46. A client with paranoid schizophrenia has
been experiencing auditory hallucinations
for many years. One approach that has
proven to be effective for hallucinating
clients is to:
A. take an as-needed dose of
psychotropic medication whenever
they hear voices.
B. practice saying “Go away” or “Stop”
when they hear voices.
C. sing loudly to drown out the voices
and provide a distraction.
D. go to their room until the voices go
away.
B. practice saying “Go away” or “Stop” when
they hear voices. Researchers have found
that some clients can learn to control
bothersome hallucinations by telling the
voices to go away or stop. Taking an as
needed dose of psychotropic medication
whenever the voices arise may lead to
overmedication and put the client at risk for
adverse effects. Because the voices aren’t
likely to go away permanently, the client
must learn to deal with the hallucinations
without relying on drugs. Although
distraction is helpful, singing loudly may
upset other clients and would be socially
unacceptable after the client is discharged.
Hallucinations are most bothersome in a
quiet environment when the client is alone,
so sending the client to his room would
increase, rather than decrease, the
hallucinations.
47. A dystonic reaction can be caused by
which of the following medications?
A. diazepam (Valium)
B. haloperidol (Haldol)
C. amitriptyline (Elavil)
D. clonazepam (Klonopin)
B. haloperidol (Haldol) . Haloperidol is a
phenothiazine and is capable of causing
dystonic reactions. Diazepam and
clonazepam are benzodiazepines, and
amitriptyline is a tricyclic antidepressant.
Benzodiazepines don’t cause dystonic
reactions; however, they can cause
drowsiness, lethargy, and hypotension.
Tricyclic antidepressants rarely cause
severe dystonic reactions; however, they
can cause a decreased level of
consciousness, tachycardia, dry mouth, and
dilated pupils.
48. While pacing in the hall, a client with
paranoid schizophrenia runs to the nurse
and says, “Why are you poisoning me? I
know you work for central thought control!
You can keep my thoughts. Give me back
my soul!” How should the nurse respond
during the early stage of the therapeutic
process?
A. “I’m a nurse. I’m not poisoning you.
It’s against the nursing code of
ethics.”
B. “I’m a nurse, and you’re a client in
the hospital. I’m not going to harm
you.”
 C. “I’m not poisoning you. And how
could I possibly steal your soul?”
D. “I sense anger. Are you feeling
angry today?”
B. “I’m a nurse, and you’re a client in the
hospital. I’m not going to harm you.” The
nurse should directly orient a delusional
client to reality, especially to place and
person. Options A and C may encourage
further delusions by denying poisoning and
offering information related to the delusion.
Validating the client’s feelings, as in option
D, occurs during a later stage in the
therapeutic process.
49. A client is admitted to the inpatient unit
of the mental health center with a diagnosis
of paranoid schizophrenia. He’s shouting
that the government of France is trying to
assassinate him. Which of the following
responses is most appropriate?
A. “I think you’re wrong. France is a
friendly country and an ally of the
United States. Their government
wouldn’t try to kill you.”
B. “I find it hard to believe that a foreign
government or anyone else is trying
to hurt you. You must feel frightened
by this.”
C. “You’re wrong. Nobody is trying to
kill you.”
D. “A foreign government is trying to kill
you? Please tell me more about it.”
B. “I find it hard to believe that a foreign
government or anyone else is trying to hurt
you. You must feel frightened by this.”
Responses should focus on reality while
acknowledging the client’s feelings. Arguing
with the client or denying his belief isn’t
therapeutic. Arguing can also inhibit
development of a trusting relationship.
Continuing to talk about delusions may
aggravate the psychosis. Asking the client if
a foreign government is trying to kill him
may increase his anxiety level and can
reinforce his delusions.
50. Mental health is defined as:
A. The ability to distinguish what is real
from what is not.
B. A state of well-being where a person
can realize his own abilities can cope with
normal stresses of life and work
productively.
C. Is the promotion of mental health,
prevention of mental disorders, nursing care
of patients during illness and rehabilitation
D. Absence of mental illness
Answer: (B) A state of well-being where a
person can realize his own abilities can
cope with normal stresses of life and work
productively. Mental health is a state of
emotional and psychosocial well being. A
mentally healthy individual is self aware and
self directive, has the ability to solve
problems, can cope with crisis without
assistance beyond the support of family and
friends fulfill the capacity to love and work
and sets goals and realistic limits. A. This
describes the ego function reality testing. C.
This is the definition of Mental Health and
Psychiatric Nursing. D. Mental health is not
just the absence of mental illness.
51. Another client is brought to the
emergency room by friends who state that
he took something an hour ago. He is
actively hallucinating, agitated, with irritated
nasal septum.
A. Heroin
B. Cocaine
C. LSD
D. marijuana
Answer: (B) cocaine
The manifestations indicate intoxication with
cocaine, a CNS stimulant. A. Intoxication
with heroine is manifested by euphoria then
impairment in judgment, attention and the
presence of papillary constriction. C.
Intoxication with hallucinogen like LSD is
manifested by grandiosity, hallucinations,
synesthesia and increase in vital signs D.
Intoxication with Marijuana, a cannabinoid is
manifested by sensation of slowed time,
conjunctival redness, social withdrawal,
impaired judgment and hallucinations.
52. Which of the following describes the role
of a technician?
A. Administers medications to a
schizophrenic patient.
B. The nurse feeds and bathes a catatonic
client
C. Coordinates diverse aspects of care
rendered to the patient
D. Disseminates information about alcohol
and its effects.
Answer: (A) Administers medications to a
schizophrenic patient. Administration of
medications and treatments, assessment,
documentation are the activities of the nurse
as a technician. B. Activities as a parent
surrogate. C. Refers to the ward manager
role. D. Role as a teacher.
53. Liza says, “Give me 10 minutes to recall
the name of our college professor who
failed many students in our anatomy class.”
She is operating on her:
A. Subconscious
B. Conscious
C. Unconscious
D. Ego
Answer: (A) Subconscious. Subconscious
refers to the materials that are partly
remembered partly forgotten but these can
be recalled spontaneously and voluntarily.
B. This functions when one is awake. One is
aware of his thoughts, feelings actions and
what is going on in the environment. C. The
largest portion of the mind that contains the
memories of one’s past particularly the
unpleasant. It is difficult to recall the
unconscious content. D. The conscious self
that deals and tests reality.
54. The superego is that part of the psyche
that:
A. Uses defensive function for
protection.
B. Is impulsive and without morals.
C. Determines the circumstances before
making decisions.
D. The censoring portion of the mind.
Answer: (D) The censoring portion of the
mind. The critical censoring portion of one’s
personality; the conscience. A. This refers
to the ego function that protects itself from
anything that threatens it.. B. The Id is
composed of the untamed, primitive drives
and impulses. C. This refers to the ego that
acts as the moderator of the struggle
between the id and the superego.
55. Primary level of prevention is 57. The wife admits that she is a victim of
exemplified by: abuse and opens up about her persistent
distaste for sex. This sexual disorder is:
A. Helping the client resume self care.
A. Sexual desire disorder
B. Ensuring the safety of a suicidal
client in the institution. B. Sexual arousal Disorder
C. Teaching the client stress C. Orgasm Disorder
management techniques
D. Sexual Pain Disorder
D. Case finding and surveillance in the
community
Answer: (A) Sexual desire disorder . Has
Answer: (C) Teaching the client stress
little or no sexual desire or has distaste for
management techniques .Primary level of
sex. B. Failure to maintain the physiologic
prevention refers to the promotion of mental
requirements for sexual intercourse. C.
health and prevention of mental illness. This
Persistent and recurrent inability to achieve
can be achieved by rendering health
an orgasm. D. Also called dyspareunia.
teachings such as modifying ones
Individuals with this disorder suffer genital
responses to stress. A. This is tertiary level
pain before, during and after sexual
of prevention that deals with rehabilitation. B
intercourse.
and D. Secondary level of prevention which
involves reduction of actual illness through
early detection and treatment of illness.

58. What would be the best approach for a

56. Situation: In a home visit done by the
nurse, she suspects that the wife and her
child are victims of abuse. Which of the
following is the most appropriate for the
nurse to ask?
wife who is still living with her abusive
husband?
A. “Here’s the number of a crisis center
that you can call for help .”

A. “Are you being threatened or hurt by B. “Its best to leave your husband.”
your partner? C. “Did you discuss this with your
B. “Are you frightened of you partner” family?”

C. “Is something bothering you?” D. “ Why do you allow yourself to be

treated this way”
D. “What happens when you and your
partner argue?”
Answer: (A) “Are you being threatened or
hurt by your partner? The nurse validates
her observation by asking simple, direct
question. This also shows empathy. B, C,
and D are indirect questions which may not
lead to the discussion of abuse.
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.
59. 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.
60. The primary nursing intervention for a
victim of child abuse is:
A. Assess the scope of the problem
B. Analyze the family dynamics
C. Ensure the safety of the victim
D. Teach the victim coping skills
Answer: (C) Ensure the safety of the victim.
The priority consideration is the safety of the
victim. Attend to the physical injuries to
ensure the physiologic safety and integrity
of the child. Reporting suspected case of
abuse may deter recurrence of abuse. A,B
and D may be addressed later.
61. Situation: A 30 year old male employee
frequently complains of low back pain that
leads to frequent absences from work.
Consultation and tests reveal negative
results. The client has which somatoform
disorder?
A. Somatization Disorder
B. Hypochondriasis
C. Conversion Disorder
D. Somatoform Pain Disorder
Answer: (D) Somatoform Pain Disorder .
This is characterized by severe and
prolonged pain that causes significant
distress. A. This is a chronic syndrome of
somatic symptoms that cannot be explained
medically and is associated with
psychosocial distress. B. This is an
unrealistic preoccupation with a fear of
having a serious illness. C. Characterized
by alteration or loss in sensory or motor
function resulting from a psychological
conflict.
62. Freud explains anxiety as:
A. Strives to gratify the needs for
satisfaction and security
B. Conflict between id and superego
C. A hypothalamic-pituitary-adrenal
reaction to stress
D. A conditioned response to stressors
Answer: (B) Conflict between id and
superego. Freud explains anxiety as due to
opposing action drives between the id and
the superego. A. Sullivan identified 2 types
of needs, satisfaction and security. Failure
to gratify these needs may result in anxiety.
C. Biomedical perspective of anxiety. D.
Explanation of anxiety using the behavioral
model.
63. The following are appropriate nursing
diagnosis for the client EXCEPT:
A. Ineffective individual coping
B. Alteration in comfort, pain
C. Altered role performance
D. Impaired social interaction
Answer: (D) Impaired social interaction .
The client may not have difficulty in social
exchange. The cues do not support this
diagnosis. A. The client maladaptively uses
body symptoms to manage anxiety. B. The
client will have discomfort due to pain. C.
The client may fail to meet environmental
expectations due to pain.
64. The following statements describe
somatoform disorders:
A. Physical symptoms are explained by
organic causes
B. It is a voluntary expression of
psychological conflicts
C. Expression of conflicts through
bodily symptoms
D. Management entails a specific
medical treatment
Answer: (C) Expression of conflicts through
bodily symptoms . Bodily symptoms are
used to handle conflicts. A. Manifestations
do not have an organic basis. B. This
occurs unconsciously. D. Medical treatment
is not used because the disorder does not
have a structural or organic basis.
65. What would be the best response to the
client’s repeated complaints of pain:
A. “I know the feeling is real tests
revealed negative results.”
B. “I think you’re exaggerating things a
little bit.”
C. “Try to forget this feeling and have
activities to take it off your mind”
D. “So tell me more about the pain”
Answer: (A) “I know the feeling is real tests
revealed negative results.” . Shows
empathy and offers information. B. This is a
demeaning statement. C. This belittles the
client’s feelings. D. Giving undue attention
to the physical symptom reinforces the
complaint.
66. Situation: A nurse may encounter
children with mental disorders. Her
knowledge of these various disorders is
vital. When planning school interventions for
a child with a diagnosis of attention deficit
hyperactivity disorder, a guide to remember
is to:
A. provide as much structure as
possible for the child
B. Ignore the child’s overactivity.
C. encourage the child to engage in
any play activity to dissipate energy
D. remove the child from the classroom
when disruptive behavior occurs
Answer: (A) provide as much structure as
possible for the child. Decrease stimuli for
behavior control thru an environment that is
free of distractions, a calm non –
confrontational approach and setting limit to
time allotted for activities. B. The child will
not benefit from a lenient approach. C.
Dissipate energy through safe activities. D.
This indicates that the classroom
environment lacks structure.
67. The child with conduct disorder will likely
demonstrate:
A. Easy distractibility to external stimuli.
B. Ritualistic behaviors
C. Preference for inanimate objects.
D. Serious violations of age related
norms.
Answer: (D) Serious violations of age
related norms. . This is a disruptive disorder
among children characterized by more
serious violations of social standards such
as aggression, vandalism, stealing, lying
and truancy. A. This is characteristic of
attention deficit disorder. B and C. These
are noted among children with autistic
disorder.
68. Ritalin is the drug of choice for chidren
with ADHD. The side effects of the following
may be noted:
A. increased attention span and
concentration
B. increase in appetite
C. sleepiness and lethargy
D. bradycardia and diarrhea
Answer: (A) increased attention span and
concentration. The medication has a
paradoxic effect that decrease hyperactivity
and impulsivity among children with ADHD.
B, C, D. Side effects of Ritalin include
anorexia, insomnia, diarrhea and irritability.
69. School phobia is usually treated by:
A. Returning the child to the school
immediately with family support.
B. Calmly explaining why attendance in
school is necessary
C. Allowing the child to enter the school
before the other children
D. Allowing the parent to accompany
the child in the classroom
Answer: (A) Returning the child to the
school immediately with family support.
Exposure to the feared situation can help in
overcoming anxiety. A. This will not help in
relieving the anxiety due separation from a
significant other. C. and C. Anxiety in school
phobia is not due to being in school but due
to separation from parents/caregivers so
these interventions are not applicable. D.
Thiswill not help the child overcome the fear
70. A 10 year old child has very limited
vocabulary and interaction skills. She has
an I.Q. of 45. She is diagnosed to have
Mental retardation of this classification:
A. Profound
B. Mild
C. Moderate
D. Severe
Answer: (C) Moderate. The child with
moderate mental retardation has an I.Q. of
35-50 Profound Mental retardation has an
I.Q. of below 20; Mild mental retardation 50-
70 and Severe mental retardation has an
I.Q. of 20-35.
71. The nurse teaches the parents of a
mentally retarded child regarding her care.
The following guidelines may be taught
except:
A. overprotection of the child
B. patience, routine and repetition
C. assisting the parents set realistic
goals
D. giving reasonable compliments
72. The parents express apprehensions on
their ability to care for their maladaptive
child. The nurse identifies what nursing
diagnosis:
A. hopelessness
B. altered parenting role
C. altered family process
D. ineffective coping
Answer: (A) overprotection of the child . The
child with mental retardation should not be
overprotected but need protection from
injury and the teasing of other children. B,C,
and D Children with mental retardation have
learning difficulty. They should be taught
with patience and repetition, start from
simple to complex, use visuals and
compliment them for motivation. Realistic
expectations should be set and optimize
their capability.
73. A 5 year old boy is diagnosed to have
autistic disorder. Which of the following
manifestations may be noted in a client with
autistic disorder?
A. argumentativeness, disobedience,
angry outburst
B. intolerance to change, disturbed
relatedness, stereotypes
C. distractibility, impulsiveness and
overactivity
D. aggression, truancy, stealing, lying
Answer: (B) altered parenting role . Altered
parenting role refers to the inability to create
an environment that promotes optimum
growth and development of the child. This is
reflected in the parent’s inability to care for
the child. A. This refers to lack of choices or
inability to mobilize one’s resources. C.
Refers to change in family relationship and
function. D. Ineffective coping is the inability
to form valid appraisal of the stressor or
inability to use available resources
74. The therapeutic approach in the care of
an autistic child include the following
EXCEPT:
A. Engage in diversionary activities
when acting -out
B. Provide an atmosphere of
acceptance
C. Provide safety measures
D. Rearrange the environment to
activate the child
Answer: (B) intolerance to change,
disturbed relatedness, stereotypes. These
are manifestations of autistic disorder. A.
These manifestations are noted in
Oppositional Defiant Disorder, a disruptive
disorder among children. C. These are
manifestations of Attention Deficit Disorder
D. These are the manifestations of Conduct
Disorder
Answer: (D) Rearrange the environment to
activate the child. The child with autistic
disorder does not want change. Maintaining
a consistent environment is therapeutic. A.
Angry outburst can be rechanneled through
safe activities. B. Acceptance enhances a
trusting relationship. C. Ensure safety from
self-destructive behaviors like head banging
and hair pulling.

75. According to Piaget a 5 year old is in
what stage of development:
A. Sensory motor stage
B. Concrete operations
C. Pre-operational
D. Formal operation
Answer: (C) Pre-operational. Pre-
operational stage (2-7 years) is the stage
when the use of language, the use of
symbols and the concept of time occur. A.
Sensory-motor stage (0-2 years) is the
stage when the child uses the senses in
learning about the self and the environment
through exploration. B. Concrete operations
(7-12 years) when inductive reasoning
develops. D. Formal operations (2 till
adulthood) is when abstract thinking and
deductive reasoning develop.
76. Situation : The nurse assigned in the
detoxification unit attends to various
patients with substance-related disorders. A
45 years old male revealed that he
experienced a marked increase in his intake
of alcohol to achieve the desired effect This
indicates:
A. withdrawal
B. tolerance
C. intoxication
D. psychological dependence
Answer: (B) tolerance
tolerance refers to the increase in the
amount of the substance to achieve the
same effects. A. Withdrawal refers to the
physical signs and symptoms that occur
when the addictive substance is reduced or
withheld. B. Intoxication refers to the
behavioral changes that occur upon recent
ingestion of a substance. D. Psychological
dependence refers to the intake of the
substance to prevent the onset of
withdrawal symptoms.
77. The care for the client places priority to
which of the following:
A. Monitoring his vital signs every hour
B. Providing a quiet, dim room
C. Encouraging adequate fluids and
nutritious foods
D. Administering Librium as ordered
Answer: (A) Monitoring his vital signs every
hour
Pulse and blood pressure are usually
elevated during withdrawal, Elevation may
indicate impending delirium tremens B.
Client needs quiet, well lighted, consistent
and secure environment. Excessive
stimulation can aggravate anxiety and
cause illusions and hallucinations. C.
Adequate nutrition with sulpplement of Vit. B
should be ensured. D. Sedatives are used
to relieve anxiety.
78. Another client is brought to the
emergency room by friends who state that
he took something an hour ago. He is
actively hallucinating, agitated, with irritated
nasal septum.
A. Heroin
B. cocaine
C. LSD
D. Marijuana
Answer: (B) cocaine
The manifestations indicate intoxication with
cocaine, a CNS stimulant. A. Intoxication
with heroine is manifested by euphoria then
impairment in judgment, attention and the
presence of papillary constriction. C.
Intoxication with hallucinogen like LSD is
manifested by grandiosity, hallucinations,
synesthesia and increase in vital signs D.
Intoxication with Marijuana, a cannabinoid is
manifested by sensation of slowed time,
conjunctival redness, social withdrawal,
impaired judgment and hallucinations.
79. The client admitted for alcohol
detoxification develops increased tremors,
irritability, hypertension and fever. The
nurse should be alert for impending:
A. delirium tremens
B. Korsakoff’s syndrome
C. esophageal varices
D. Wernicke’s syndrome
Answer: (A) delirium tremens
Delirium Tremens is the most extreme
central nervous system irritability due to
withdrawal from alcohol B. This refers to an
amnestic syndrome associated with chronic
alcoholism due to a deficiency in Vit. B C.
This is a complication of liver cirrhosis which
may be secondary to alcoholism . D. This is
a complication of alcoholism characterized
by irregularities of eye movements and lack
of coordination.
80. Situation: An old woman was brought for
evaluation due to the hospital for evaluation
due to increasing forgetfulness and
limitations in daily function. The daughter
revealed that the client used her toothbrush
to comb her hair. She is manifesting:
A. apraxia
B. aphasia
C. agnosia
D. amnesia
Answer: (C) agnosia
This is the inability to recognize objects. A.
Apraxia is the inability to execute motor
activities despite intact comprehension. B.
Aphasia is the loss of ability to use or
understand words. D. Amnesia is loss of
memory.
81. She tearfully tells the nurse “I can’t take
it when she accuses me of stealing her
things.” Which response by the nurse will be
most therapeutic?
A. ”Don’t take it personally. Your
mother does not mean it.”
B. “Have you tried discussing this with
your mother?”
C. “This must be difficult for you and
your mother.”
D. “Next time ask your mother where
her things were last seen.”
Answer: (C) “This must be difficult for you
and your mother.”
This reflecting the feeling of the daughter
that shows empathy. A and D. Giving advise
does not encourage verbalization. B. This
response does not encourage verbalization
of feelings.
82. The primary nursing intervention in
working with a client with moderate stage
dementia is ensuring that the client:
A. receives adequate nutrition and
hydration
B. will reminisce to decrease isolation
C. remains in a safe and secure
environment
D. independently performs self-care
Answer: (C) remains in a safe and secure
environment
Safety is a priority consideration as the
client’s cognitive ability deteriorates.. A is
appropriate interventions because the
client’s cognitive impairment can affect the
client’s ability to attend to his nutritional
needs, but it is not the priority B. Patient is
allowed to reminisce but it is not the priority.
D. The client in the moderate stage of
Alzheimer’s disease will have difficulty in
performing activities independently
83. She says to the nurse who offers her
breakfast, “Oh no, I will wait for my
husband. We will eat together” The
therapeutic response by the nurse is:
A. “Your husband is dead. Let me
serve you your breakfast.”
B. “I’ve told you several times that he is
dead. It’s time to eat.”
C. “You’re going to have to wait a long
time.”
D. “What made you say that your
husband is alive?
Answer: (A) “Your husband is dead. Let me
serve you your breakfast.”
The client should be reoriented to reality
and be focused on the here and now.. B.
This is not a helpful approach because of
the short term memory of the client. C. This
indicates a pompous response. D. The
cognitive limitation of the client makes the
client incapable of giving explanation.
84. Dementia unlike delirium is
characterized by:
A. slurred speech
B. insidious onset
C. clouding of consciousness
D. sensory perceptual change
Answer: (B) insidious onset
Dementia has a gradual onset and
progressive deterioration. It causes
pronounced memory and cognitive
disturbances. A,C and D are all
characteristics of delirium.
85. Situation: A 17 year old gymnast is
admitted to the hospital due to weight loss
and dehydration secondary to starvation.
Which of the following nursing diagnoses
will be given priority for the client?
A. altered self-image
B. fluid volume deficit
C. altered nutrition less than body
requirements
D. altered family process
Answer: (B) fluid volume deficit
Fluid volume deficit is the priority over
altered nutrition (A) since the situation
indicates that the client is dehydrated. A and
D are psychosocial needs of a client with
anorexia nervosa but they are not the
priority.
86. What is the best intervention to teach
the client when she feels the need to
starve?
A. Allow her to starve to relieve her
anxiety
B. Do a short term exercise until the
urge passes
C. Approach the nurse and talk out her
feelings
D. Call her mother on the phone and
tell her how she feels
Answer: (C) Approach the nurse and talk
out her feelings
The client with anorexia nervosa uses
starvation as a way of managing anxiety.
Talking out feelings with the nurse is an
adaptive coping. A. Starvation should not be
encouraged. Physical safety is a priority.
Without adequate nutrition, a life threatening
situation exists. B. The client with anorexia
nervosa is preoccupied with losing weight
due to disturbed body image. Limits should
be set on attempts to lose more weight. D.
The client may have a domineering mother
which causes the client to feel ambivalent. control of eating habits. The goal for this
The client will not discuss her feelings with problem is:
her mother.
A. Patient will learn problem solving
87. The client with anorexia nervosa is skills
improving if:
B. Patient will have decreased
A. She eats meals in the dining room. symptoms of anxiety.
B. Weight gain C. Patient will perform self care
activities daily.
C. She attends ward activities.
D. Patient will verbalize how to set
D. She has a more realistic self-
limits on others.
concept.
Answer: (A) Patient will learn problem
Answer: (B) Weight gain
solving skills
Weight gain is the best indication of the
if the client learns problem solving skills she
client’s improvement. The goal is for the
will gain a sense of control over her life. (B)
client to gain 1-2 pounds per week. (A)The
Anxiety is caused by powerlessness. (C)
client may purge after eating. (C) Attending
Performing self care activities will not
an activity does not indicate improvement in
decrease ones powerlessness (D) Setting
nutritional state. (D) Body image is a factor
limits to control imposed by others is a
in anorexia nervosa but it is not an indicator
necessary skill but problem solving skill is
for improvement.
the priority.
88. The characteristic manifestation that will
90. In the management of bulimic patients,
differentiate bulimia nervosa from anorexia
the following nursing interventions will
nervosa is that bulimic individuals
promote a therapeutic relationship
A. have episodic binge eating and EXCEPT:
purging
A. Establish an atmosphere of trust
B. have repeated attempts to stabilize
B. Discuss their eating behavior.
their weight
C. Help patients identify feelings
C. have peculiar food handling patterns
associated with binge-purge
D. have threatened self-esteem behavior

Answer: (A) have episodic binge eating and D. Teach patient about bulimia nervosa
purging
Answer: (B) Discuss their eating behavior.
Bulimia is characterized by binge eating
The client is often ashamed of her eating
which is characterized by taking in a large
behavior. Discussion should focus on
amount of food over a short period of time.
feelings. A,C and D promote a therapeutic
B and C are characteristics of a client with
relationship
anorexia nervosa D. Low esteem is noted in
both eating disorders 91. Situation: A 35 year old male has
intense fear of riding an elevator. He claims
89. A nursing diagnosis for bulimia nervosa
“ As if I will die inside.” This has affected his
is powerlessness related to feeling not in
studies The client is suffering from:
 A. agoraphobia
B. social phobia
C. Claustrophobia
D. Xenophobia
Answer: (C) Claustrophobia
Claustrophobia is fear of closed space. A.
Agoraphobia is fear of open space or being
a situation where escape is difficult. B.
Social phobia is fear of performing in the
presence of others in a way that will be
humiliating or embarrassing. D. Xenophobia
is fear of strangers.
92. Initial intervention for the client should
be to:
A. Encourage to verbalize his fears as
much as he wants.
B. Assist him to find meaning to his
feelings in relation to his past.
C. Establish trust through a consistent
approach.
D. Accept her fears without criticizing.
Answer: (D) Accept her fears without
criticizing.
The client cannot control her fears although
the client knows its silly and can joke about
it. A. Allow expression of the client’s fears
but he should focus on other productive
activities as well. B and C. These are not
the initial interventions.
93. The nurse develops a
countertransference reaction. This is
evidenced by:
A. Revealing personal information to
the client
B. Focusing on the feelings of the
client.
C. Confronting the client about
discrepancies in verbal or non-verbal
behavior
D. The client feels angry towards the
nurse who resembles his mother.
Answer: (A) Revealing personal information
to the client
A. Countertransference is an emotional
reaction of the nurse on the client based on
her unconscious needs and conflicts. B and
C. These are therapeutic approaches. D.
This is transference reaction where a client
has an emotional reaction towards the
nurse based on her past.
94. Which is the desired outcome in
conducting desensitization:
A. The client verbalize his fears about
the situation
B. The client will voluntarily attend
group therapy in the social hall.
C. The client will socialize with others
willingly
D. The client will be able to overcome
his disabling fear.
Answer: (D) The client will be able to
overcome his disabling fear.
The client will overcome his disabling fear
by gradual exposure to the feared object.
A,B and C are not the desired outcome of
desensitization.
95. Which of the following should be
included in the health teachings among
clients receiving Valium:
A. Avoid taking CNS depressant like
alcohol.
B. There are no restrictions in activities.
C. Limit fluid intake.
 D. Any beverage like coffee may be
taken
Answer: (A) Avoid taking CNS depressant
like alcohol.
Valium is a CNS depressant. Taking it with
other CNS depressants like alcohol;
potentiates its effect. B. The client should be
taught to avoid activities that require
alertness. C. Valium causes dry mouth so
the client must increase her fluid intake. D.
Stimulants must not be taken by the client
because it can decrease the effect of
Valium.
96. Situation: A 20 year old college student
is admitted to the medical ward because of
sudden onset of paralysis of both legs.
Extensive examination revealed no physical
basis for the complaint. The nurse plans
intervention based on which correct
statement about conversion disorder?
A. The symptoms are conscious effort
to control anxiety
B. The client will experience high level
of anxiety in response to the
paralysis.
C. The conversion symptom has
symbolic meaning to the client
D. A confrontational approach will be
beneficial for the client.
Answer: (C) The conversion symptom has
symbolic meaning to the client
the client uses body symptoms to relieve
anxiety. A. The condition occurs
unconsciously. B. The client is not
distressed by the lost or altered body
function. D. The client should not be
confronted by the underlying cause of his
condition because this can aggravate the
client’s anxiety.
97. 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.
98. Malingering is different from somatoform
disorder because the former:
A. Has evidence of an organic basis.
B. It is a deliberate effort to handle
upsetting events
C. Gratification from the environment
are obtained.
D. Stress is expressed through physical
symptoms.
Answer: (B) It is a deliberate effort to handle
upsetting events
Malingering is a conscious simulation of an
illness while somatoform disorder occurs
unconscious. A. Both disorders do not have
an organic or structural basis. C. Both have
primary gains. D. This is a characteristic of
somatoform disorder.
99. Unlike psychophysiologic disorder Linda
may be best managed with:
A. medical regimen
B. milieu therapy
C. stress management techniques
D. psychotherapy
Answer: (C) stress management techniques
Stress management techniques is the best
management of somatoform disorder
because the disorder is related to stress
and it does not have a medical basis. A.
This disorder is not supported by organic
pathology so no medical regimen is
required. B and D. Milieu therapy and
psychotherapy may be used a therapeutic
modality but these are not the best.
100. A client is admitted with needle tracts
on his arm, stuporous and with pin point
pupil will likely be managed with:
A. Naltrexone (Revia)
B. Narcan (Naloxone)
C. Disulfiram (Antabuse)
D. Methadone (Dolophine)
Answer: (B) Narcan (Naloxone)
Narcan is a narcotic antagonist used to
manage the CNS depression due to
overdose with heroin. A. This is an opiate
receptor blocker used to relieve the craving
for heroine C. Disulfiram is used as a
deterrent in the use of alcohol. D.
Methadone is used as a substitute in the
withdrawal from heroine