1. All of the following describe a mentally healthy person EXCEPT?

a. He has the capacity to invest in others

b. He lacks emotional conflicts
c. He is spontaneous in work and social relations
d. He has high energy level
2. According to Erikson, the central conflict of the young adult is:
a. Identity vs. Role
b. Generativity vs. Stagnation
c. Intimacy vs Isolation
d. Ego Integrity vs Despair
3. The concept of generativity as described by Erikson is illustrated by
a. The concern of a parent for a child's livelihood
b. The concern of a teacher for a student's learning.
c. The concern of a nurse for a client's health
d. All of the above
4. Which nursing intervention is best for facilitating communication with a psychiatric client who
speaks a foreign language?
a. Rely on nonverbal communication.
b. Speak in universal phrases.
c. Select symbolic pictures as aids.
d. Use the services of an interpreter.
5. The nurse explains to a mental health care technician that a client's obsessive-compulsive
behaviors are related to unconscious conflict between id impulses and the superego (or
conscience). On which of the following theories does the nurse base this statement?
a. Behavioral theory
b. Interpersonal theory
c. Cognitive theory
d. Psychoanalytic theory
6. Which age group has the greatest potential to demonstrate regression when they are sick?
a. Adolescent
b. Young Adult
c. Toddler
d. Infant
7. A 16 year old child is hospitalized, according to Erik Erikson, what is an appropriate
intervention?
a. tell the friends to visit the child
b. encourage patient to help child learn lessons missed
c. call the priest to intervene
d. tell the child's girlfriend to visit the child.
8. A maternity nurse is providing instruction to a new mother regarding the psychosocial
development of the newborn infant. Using Erikson's psychosocial development theory, the nurse
would instruct the mother to
a. Allow the newborn infant to signal a need
b. Anticipate all of the needs of the newborn infant
C. Avoid the newborn infant during the first 10 minutes of crying
d. Attend to the newborn infant immediately when crying
9. While giving nursing care to a hospitalized adolescent, the nurse should be aware that the
MAJOR threat felt by the hospitalized adolescent is
a. Pain management
b. Altered body image
c. Separation from family
d. Restricted physical activity
10. Pick the correct order of the stages in development.
a. repression, denial, projection, isolation, regression
b. oral, anal, phallic, latency, genital
c. latency, oral, denial, anal, genital
d. phallic, oral, latency, genital, anal
11. When caring for a 2-year-old child, the nurse should offer choices, when appropriate, about
some aspects of care. According to Erikson, this helps the child to achieve which of the
following?
a. Trust and honesty
b. Autonomy and responsibility
c. Industry and competence
d. Initiative and authority
12. A mother of a 6-year-old child is concerned about her child's compulsion for collecting
things. The nurse explains that this behavior is related to the cognitive ability to perform:
a. Concrete operations.
b. Formal operations.
c. Coordination of secondary schemas
d. Tertiary circular reactions
13. According to Freud's psychosexual theory, the ego has several functions. The primary
function of the ego is w of the following?
a. To serve as the source of instinctual drives
b. To stimulate psychic energy
c. To operate as a conscience that controls unacceptable drives
d. To test reality and direct behavior
14. In a therapeutic relationship, what component is shown when the nurse builds rapport with
the patient?
a. Trust and Respect
b. Empathy
c. Genuine Interest
d. Self-Awareness
15. A patient is pacing the floor after learning that her cancer has spread, a nurse might say,
'Jane, I see you're tense. How can I help you?' The nurse is demonstration what component of a
therapeutic relationship?
a. Trust and Respect
b. Empathy
c. Genuine Interest
d. Self-Awareness
16. The nurse makes it a point to maintain eye contact with the patient as their interaction
progresses. The nurse is demonstration what component of a therapeutic relationship?
a. Trust and Respect
b. Empathy
c. Genuine Interest
d. Self-Awareness
17. The process of developing an understanding of the nurse's own values, beliefs, thoughts,
feelings, attitudes, motivations, prejudices, strengths, and limitations and how these qualities
affect others.
a. Trust and Respect
b. Empathy
c. Genuine Interest
d. Self-Awareness
18. Patient Elsa wanted to understand a specific answer to a question and Nurse PJ obliged by
explaining it within a larger context. The nurse portrays what role?
a. Teacher
b. Leader
c. Surrogate
d. Resource Person
19. Nurse Jess began the discussion of the harmful effects of tobacco using slides and
presenting facts to his patient Griffins who does not admit that he has nicotine addiction. The
nurse portrays what role?
a. Teacher
b. Leader
c. Surrogate
d. Resource Person
20. Judy Ann shares all her fears to nurse Tyrone and asks for his advises the same way that
she does with her older brother Robert.. The nurse portrays what role?
a. Teacher
b. Leader
c. Surrogate
d. Resource Person
21. What is a defense mechanism?
a. Any form of martial arts
b. A mechanism designed to reduce stress and conflict caused by specific experiences
c. A method for negotiating a stage of development
d. A mechanism designed to remove psychological barriers
22. A client who abuses alcohol and cocaine tells a nurse that he only uses substances
because of his stressful marriage and difficult job. Which defense mechanisms is this client
using?
a. Displacement
b. Projection
c. Rationalization
d. Sublimation
23. "I'm so angry! I missed my bus, forgot my homework, and then I was late for work again
which got me a warning. When I got home I punched a wall, screamed at my mom for burning
the beans, (how can you burn beans?!). Then I kicked the cat."
a. Repression
b. Denial
c. Displacement
d. Rationalization
24. "Bad things happened to me in my past, but I've unconsciously buried them deep in my
mind."
a. Repression
b. Denial
c. Displacement
d. Rationalization
25. "Everyone around me thinks they're big, funny and clever. They're all telling me my goldfish
Swimmy has died. They even thought I'd be fooled by flushing a pretend one down the toilet.
She's only hiding because she's cold. But it's ok... I put boiling water in there so she could warm
up."
a. Repression
b. Denial
c. Displacement
d. Rationalization
26. "I failed my math exam, but I'm not that bothered. It wasn't my fault; it was Mr Glin who can't
teach. If he can't be bothered then why should I revise? I won't need math in the future anyway."
a. Repression
b. Denial
c. Displacement
d. Rationalization
27. "There is this girl at work who I hate so much. She's intimidating, disrespectful and offensive.
Strangely, she's now one of my best friends and we get on really well. Now I can't remember
what I thought of her in the first place."
a. Rationalization
b. Sublimation
c. Reaction Formation
d. Identification
28. "Argh, my mother-in-law has come to stay for the weekend and she's driving me crazy. I'm
just staying out of the way by doing the housework and washing up so that I'm not dragged into
an argument about how much of a bad wife and mother I am." What defense mechanism does
this illustrate?
a. Rationalization
b. Sublimation
c. Identification
d. Reaction Formation
29. "The way she spoke to me was completely unacceptable, but she's going through a tough
time at the moment. I'd react the same way if my mother had just died." What defense
mechanism am I expressing?
a. Rationalization
b. Sublimation
c. Identification
d. Reaction Formation
30. "I'm sure my boyfriend has been cheating on me. When I find out he'll be sorry. Oh yeah and
I need to buy my husband a birthday present..."
a. Projection
d. Reaction Formation
b. Identification
c. Rationalization
31. "It's so unfair! My mom doesn't care how much I cry and scream, she won't get me a car.
She doesn't even care about me! She hates me!"
a. Repression
b. Regression
c. Denial
d. Withdrawal
32. "I split up with my boyfriend and everything reminds me of him. So I quit my job, dropped out
of college and I don't go out anymore. Drugs and drink are the only way I can escape these
thoughts."
a. Repression
b. Regression
c. Denial
d. Withdrawal
33. Forcing thoughts to remain unconscious in order to avoid the anxiety that would result if they
were conscious is the definition of which Freudian defense mechanism?
a. Denial
b. Isolation
c. Regression
d. Repression
34. Bill has been having family problems lately. He has started drinking heavily the past few
months. Whenever his friends approach him and accuse him of having a drinking problem, he
acts like he doesn't know what they're talking about and denies the whole thing. Bill is illustrating
which of the following:
a. Projection
b. Repression
c. Regression
d. Denial
35. A husband and wife are fighting, and the husband becomes so angry he hits a door instead
of his wife. Which defense mechanism is he using?
a. Denial
b. Displacement
c. Identification
d, Intellectualization
36. The pain over a parent's sudden death is reduced by saying, "He wouldn't have wanted to
live with a disability." Which defense mechanism is he using?
a. Displacement
b. Identification
c. Intellectualization
d. Introjection
37. A mother is told her child must repeat a grade in school, and she blames this on the
teacher's poor instruction. Which defense mechanism is she using?
a. Intellectualization
b. Introjection
c. Minimization
d. Projection
38. Patricia has learned that she is dying. Patricia starts to cry. The nurse understands
therapeutic communication when the nurse:
a. Asks clarifying question to encourage the patient to explain why she is crying
b. Asks the patient exactly what is making her sad
c. The nurse leaves the room to give Patricia some privacy and alone time
d. The nurse allows pat to cry on her shoulder
39. Eric is a new nurse. He is very concerned about getting his tasks done. He walks in in his
patient who is looking at the window. Eric asks, "What's wrong?" The patient answers, "I'm old
and my body is wearing out. Eric replies, "Nonsense, you aren't that old and you just have a
kidney infection. What has Stan done?
a. False reassurance
b. Value judgment
c. Minimizing feelings
d. Non verbal blocker
40. Kelsey is a 17 year-old who has decided to have an abortion. The nurse does not agree with
abortion. Kelsey is afraid of the procedure. The nurse who is angry by the patient's behavior
does not make eye contact with Kelsey. The nurse goes in and out of the room and looks
annoyed and only answers questions with a simple yes or no. The nurse has done what?
a. False reassurance
b. Value judgment
c. Minimizing feelings
d. Non verbal blocker
41. A client who completed inpatient treatment for addiction to heroin is prescribed to take daily
doses of methadone during outpatient treatment. The nurse concludes that the primary rationale
for the client's outpatient treatment with methadone is to:
a. block the effects of opiates to prevent a "high" if the dient uses heroin while in treatment.
b. treat any residual withdrawal symptoms during the outpatient phase of treatment.
c. reduce heroin craving by binding to the brain receptor sites usually occupied by heroin.
d. reduce mania and the potential for self-injury through a legal and safe alternative to heroin
use during treatment.
42. Which of the following is included in the goals for therapeutic communication?
1. Establish a therapeutic nurse-dient relationship
2. Identify the most important client concern at that moment
3. Guide the client toward identifying a plan of action to a satisfying and socially acceptable
resolution.
a. None of the choices
b. 1, 2, and 3
c. 1 and 2 only
d. 2 and 3 only
43. A severely depressed client tells a nurse, "I don't need these antidepressants, they're too
expensive! I'm going to use St. John's wort instead." Which is the most appropriate response by
the nurse?
a. "I have some information showing the effective use of St. John's wort. Let's review it."
b. "Although St. John's wort may be less expensive, it has not been shown to improve severe
depression."
c. "What would you think about taking the St. John's wort and the antidepressant to maximize
the effectiveness?"
d. "That would be a safe alternative, especially if you need to consider your financial resources."
44. A nurse is working with a family whose 9-year-old child is taking atomoxetine (StratteraR®)
for attention den hyperactivity disorder (ADHD). Which instructions should a nurse include when
teaching the parents? SELECT ALL THAT APPLY.
1. Provide ample stimulation for the child as the medication will cause sedation.
2. Administer the child's medication immediately after meals.
3. Administer the medication at least 6 hours before bedtime.
4. Do not skip doses at any time in order to maintain therapeutic levels.
5. Weigh the child weekly to monitor for untoward weight loss.
6. Consult with the health-care provider if the child needs any cold or allergy medication.
a. 1, 3, 5 and 6
b. 2, 4, and 6 only
c. 2, 3, 5 and 6
d. All of the above
45. A client taking an antipsychotic medication begins to exhibit severe parkinsonian muscle
rigidity, a temperature of 105°F (40.6°C), tachycardia, and diaphoresis. Prioritize the steps that a
nurse should take to respond to this situation.
Notify the health-care provider (HCP) of the symptoms.
Withhold all doses of the antipsychotic medication.
Assess level of consciousness.
Administer bromocriptine (ParlodelR) as prescribed by the HCP stat.
Assess degree of muscle rigidity.
Take vital signs.
a. 2, 3, 6, 1, 5, 4
b. 5, 1, 3, 6, 4, 2
C. 3, 2, 1, 4, 5, 6 d. 1, 2, 3, 4, 5, 6
e. 6, 5, 4, 3, 2, 1
46. The nurse is caring for a client with schizophrenia who is taking haloperidol (Haldol). The
client complains of restlessness, cannot sit still, and has muscle stiffness. Of the following prn
medications, which will the nurse administer?
a. Haloperidol (Haldol) 5 mg p.o.
b. Benztropine (Cogentin) 2 mg p.o.
c. Propranolol (Inderal) 20 mg p.o. d. Trazodone 50 mg p.o.
47. Client teaching for lamotrigine (Lamictal) should include which of the following?
a. Eat a well-balanced diet to avoid weight gain.
b. Report any rashes to your doctor immediately.
c. Take each dose with food to avoid nausea.
d. This drug may cause psychological dependence.
48. Clients taking which of the following types of psychotropic medications need close
monitoring of their cardiac status?
a. Antidepressants
b. Antipsychotics
c. Mood stabilizers
d. Stimulants
49. What is the major side effect of Selective Serotonin Reuptake Inhibitor (Prozac)?
a. Loss of sexual desire
b. Weight loss
c. Loss of hair
d. Weight gain
50. The nurse is teaching a client taking an MAOI about foods with Tyramine that he or she
should avoid. Which of the following statements indicates that the client needs further teaching?
a. "I'm so glad I can have pizza as long as I don't order pepperoni."
b. "I will be able to eat cottage cheese without worrying."
c. "I will have to avoid drinking nonalcoholic beer."
d. "I can eat green beans on this diet."
51. A client taking sertraline (Zoloft®) for treatment of depression for the past 11 months reports
feeling much better and wishes to discontinue the medication. Which is the most appropriate
response by a nurse?
a. "The medication will have to be reduced gradually to prevent undesirable symptoms."
b. "It appears that the medication has worked very well. It should be safe to discontinue its use."
c. "You should not stop the medication without talking to your health-care provider first."
d. "You should take this medication indefinitely to prevent recurrence of depressive symptoms."
52. A client is to be started on citalopram (Celexa®) for treatment of depression. Which
information should be most important for a nurse to include when planning teaching for the
client?
a. Activity levels should be increased to include a daily exercise routine.
b. If sexual side effects become unbearable, consult your health-care provider.
c. Avoid processed meats, red wine, and Swiss cheese.
d. Monitor blood pressure regularly, and report any significant changes.
53. A client, who switched to paroxetine (Paxil®) several days ago after taking imipramine
(Tofranil®) for several years, presents with tachycardia, hyper-tension, fever, sweating, and
confusion. A nurse notifies the health-care provider, suspecting the client is experiencing:
a. neuroleptic malignant syndrome.
b. discontinuation syndrome.
c. serotonin syndrome.
d. extrapyramidal symptoms.
54. A nurse is developing a teaching plan for a client prescribed nortriptyline (Pamelor®). Which
self-care aspects should be included to minimize medication side effects and prevent injury?
SELECT ALL THAT APPLY.
1. Avoid driving until vision is completely clear to prevent injury.
2. Suck on candy or ice chips to keep your mouth moist.
3. Try running water in the bathroom to stimulate urination.
4. Avoid eating processed meats, cheeses, and wine.
5. Increase fluid and fiber in the diet to prevent constipation.
6. Increase exposure to sunlight to facilitate vitamin D absorption.
a. 1, 2, 3 and 5 only
b. 1, 2, 3 and 4 only
c. 2, 3 and 5 only
d. 1, 3 and 5 only
55. Since taking the antidepressant doxepin (Sinequan®), a female client has been reporting a
decrease in sexual desire. She says she "just isn't that interested" because she "just doesn't
enjoy sex anymore." She and her partner agree that they miss the excitement they used to
share. Which is the most helpful response by a nurse?
a. "This often happens when couples are together for a longer period of time. Tell me how you
would feel about a referral for counseling."
b. "Try to wait for awhile. This is a temporary effect of your therapy, and as your depression gets
better your interest in sexual activity should increase."
c. "Perhaps you could try some alternatives to your normal sexual routines to enhance your
sexual relationship."
d. "This may be due to your medication, How would you feel about talking to your doctor about
changing to a different type of antidepressant?"
56. Which aspect is most appropriate for a nurse to include in a teaching plan for a client taking
amitriptyline (Elavil®)?
a. Establish a calorie-controlled diet plan suitable to the client's preferences.
b. Provide support for concerns of sexual dysfunction.
c. Instruct to discontinue the medication immediately if experiencing a sudden elevation in blood
pressure.
d. Encourage to take the medication upon awakening to manage the side effect of insomnia.
57. A dient taking tranylcypromine (Pamate®) develops a list of possible meal plans. Which
meal plans should a nurse determine comprise safe food and beverage selections? SELECT
ALL THAT APPLY.
1. Baked chicken, mashed potatoes and gravy, 8 oz 2% milk
2. Grilled salmon, steamed broccoli, 12 oz lemon- lime soda
3. Pepperoni pizza, Caesar salad, 16 oz iced tea
4. Beef burritos with sour cream and guacamole topping, corn chips, 12 oz beer
5. Granola with raisins and almonds, low-fat yogurt, and 8 oz coffee
6. Grilled pork loin, rice, green beans, 12 oz diet clear soda
a. 1, 3 and 5
b. 1, 2 and 6
c. 1, 3, 4 and 5
d. 2, 3 and 4
58. A nurse is assessing a client for adverse effects of trazodone (DesyrelR). Which
assessment finding should the nurse determine is an adverse effect unique to the use of
trazodone?
a. Hepatic failure
b. Priapism
c. Weight gain
d. Cardiac dysrhythmias
59. After a recreational game of basketball with peers, a client taking lithium for bipolar disorder
complains of feeing nauseous and shaky, having blurred vision, and finding it hard to stand.
Considering this information, which action should be taken by a nurse?
a. Instruct the client to sit and rest in a cool place.
b. Call the health-care provider (HCP) to request that a stat lithium level be prescribed.
c. Give the client an antiemetic with a large glass of some cool water.
d. Prepare the emergency team for the client's impending cardiac arrest.
60. At discharge, a nurse documents that a client taking lithium has an accurate understanding
of self-care. On which client statement should the nurse base this judgment?
a. "I know I need to restrict foods high in sugar while I'm taking lithium."
b. "I need to come back and have my blood lithium level checked every 2 weeks."
c. "I should take my lithium on an empty stomach for best absorption."
d. "I need to eat enough foods containing sodium and drink at least 2 to 3 liters of fluid daily."
61. A nurse is providing instructions to a client. Which substances should a client who is taking
alprazolam (Xanax®) be cautioned to avoid? SELECT ALL THAT APPLY.
1. Alcohol
2. Caffeine
3, Antihistamines
4. Narcotics
5. Antidepressants
6. Antioxidants
a. 1, 2, and 5
b. 1, 3, 4 and 5
c. 1, 3, and 5
d. 2, 3,5 and 5
62. A hospitalized dient is exhibiting occasional anxiety. A nurse notifies a health-care provider
to re- quest that a pm anxiolytic medication be prescribed. Which medication, if prescribed,
should the nurse question regarding its
effectiveness for pm use?
a. Alprazolam (Ativan®)
b. Clonazepam (Klonopin®)
c. Clorazepate (Tranxene®)
d. Buspirone (Buspar®)
63. A nurse is reviewing the medications for all as- signed clients on an inpatient psychiatric
unit. The nurse anticipates assessing for extrapyramidal symptoms (EPS) in clients taking:
a. risperidone (Risperdal®)
b. haloperidol (Haldol®)
c. clozapine (Clozaril)
d. ziprasidone (Geodon®)
64. Which of the following types of delusion believes that gestures and words of others are
specifically directed at them.
a. Sexual delusions
b. Unspecified delusions
c. Referential delusions
d. Religious delusions
65. This cognitive evaluation wherein the client has the ability to recall about the holiday or
world event within the past few months.
a. Short term memory
b. Long term memory
c. Recent memory
d. Insight
66. Which of the following refers to the interpersonal interaction between the nurse and client
during which the nurse focuses on the client's specific needs to promote an effective exchange
of information?
a. Short term memory
b. Therapeutic communication
c. Recent memory
d. Insight
67. A nurse is performing a health history on a child who is being evaluated for attention deficit
hyperactivity disorder (ADHD). Regarding the likelihood of management with psychostimulants,
which area is critical to document in the review of systems?
a. Musculoskeletal history
b. Genitourinary history
c. Immunization history
d. Cardiovascular history
68. A client is taking methylphenidate sustained release tablets (Ritalin SR) once daily for
attention deficit disorder. The medication peaks in 4 to 7 hours and has a duration of 12 hours.
At which time should a nurse instruct the client to take the prescribed dose of methylphenidate?
a. At bedtime
b. Six hours before bedtime
c. With the midday meal
d. As soon as the client awakens in the morning
69. A client is beginning treatment with bupropion (Wellbutrin@) for depression. After meeting
with the health-care provider (HCP), the client tells a nurse, "I'm also taking ZybanR to help me
stop smoking." Which is the most appropriate action for the nurse to take?
a. Inform the HCP that the client is already taking bupropion, but for smoking cessation.
b. Instruct the client to report any allergic-type reactions after beginning the ZybanR.
c. Provide the client with the telephone number for a smoking cessation support group.
d. Encourage and support the client in following the smoking cessation regimen.
70. A client, being discharged from treatment for alcoholism, is receiving teaching on taking
daily doses of disulfiram (Antabuse®). Which client statement indicates to a nurse that the client
correctly under- stands the safe use of disulfiram?
a. "If I take disulfiram and then drink alcohol, I will become intoxicated much more quickly."
b. "I should take disulfiram at the same time each day to maintain therapeutic effectiveness."
c. "If I do ingest alcohol, I should skip the daily dose of disulfiram to avoid being ill."
d. "I should avoid products such as vanilla extract or certain cough preparations containing
alcohol while taking disulfiram."
71. Unresolved feelings related to loss may be the most likely recognized during which phase of
the therapeutic nurse-client relationship?
a. Orientation
b. Working
c. Termination
d. Trusting
72. A client with a diagnosis of major depression who attempted suicide says to the nurse, "I
should have died. I've always been a failure. Nothing ever goes right for me." The most
therapeutic response to the dient is:
a. "I don't see you as a failure"
b. "Feeling like this is all part of being ill"
c. "You've been feeling like a failure for a while?"
d. "You have everything to live for"
73. A community health nurse visits a dient at home. The client states, "I haven't slept at all the
last couple of nights." Which response by the nurse illustrates the most therapeutic
communication technique for this client?
a. "Go on.."
b. "Sleeping..?"
c. "The last couple of nights?"
d. "You're having difficulty sleeping?"
74. A nurse is performing an admission assessment on a client and is attempting obtain
subjective data about the dient's sexual and reproductive status. The client states, "I don't want
to discuss this; it's private and personal." Which statement, if made by the nurse, indicates that
the nurse is therapeutic?
a. "I hate being asked these sorts of questions too"
b. "I am a professional nurse and as such I'll have you know that all information is kept
confidential
c. "I know that some of these questions are difficult for you but, as a professional nurse, I must
legally respect your confidentiality."
d. "This is difficult for you to speak about, but I am trying to perform a complete assessment and
I need this information."
75. A dient admitted to the mental health unit is experiencing Altered Though Process. The
client believes that the food is being poisoned. Which communication technique does the nurse
plan to use to encourage the dient to express feelings?
a. Using open ended questions and silence
b. Offering opinions about the necessity of adequate nutrition
c. Identifying the reasons that the dient may not want to eat
d. Focusing on self-disclosure about food preferences.
76. A nurse is working with a client who has sought counseling after trying to rescue a neighbor
involved in a house fire. In spite of the client's efforts, the neighbor died. Which action does the
nurse engage in with the client during the working phase of the nurse-client relationship?
a. Exploring the dient's potential for self-harm
b. Exploring the dient's ability to function
C. Inquiring about the client's perception or appraisal of the neighbor's death
d. Inquiring about and examining the client's feelings that may block adaptive coping
77. A client who has just been sexually assaulted is very quiet and calm. The nurse analyzes
this behavior as indicative of which defense mechanism?
a. Denial
b. Projection
c. Rationalization
d. Intellectualization
78. A nurse completes the initial assessment of a client admitted to the mental health unit. The
nurse analyzes the data obtained on assessment and determines that which of the following
presents a priority concern?
a. The presence of bruises on client's body
b. The client's report of not eating or sleeping
c. The client's report of suicidal thoughts
d. The significant other's disapproving of the treatment
79. Laboratory work is prescribed for a dient who has been experiencing delusions. When the
nurse approaches the dient to obtain a specimen of the client's blood, the dient begins to shout,
"You're all vampires!! Let me out of here!", The most appropriate nursing response is which of
the following?
a. "I am not going to hurt you, I am going to help you!"
b. "What makes you think that I am a vampire?"
c. "I'll leave and come back later for your blood."
d. "It must be fearful to think others want to hurt you."
80. An inebriated client is brought to the emergency department by the local police. The client is
told that the physician will be in to see the dient in about 30 min. The dient becomes very loud
and offensive and wants to be seen by the physician immediately. The most appropriate nursing
intervention is which of the following?
a. Attempt to talk with the client to deescalate behavior
b. Watch the behavior escalate before intervening
c. Inform the dient that he or she will be asked to leave if the behavior continues
d. Offer to take the dient to an examination room until he or she can be treated
81. A client is admitted to a mental health unit for treatment of psychotic behavior. The client is
at locked exit door is shouting. "Let me out, there's nothing wrong with me, I don't belong here."
The nurse analyzes this behavior as:
a. Projection
b. Denial
c. Regression
d. Rationalization
82. A supervisor reprimands the nurse in charge of a nursing unit because the charge nurse has
not adhered to the unit budget. Later that afternoon the charge nurse accuses the nursing staff
of wasting the supplies. This behavior is an example of:
a. Denial
b. Regression
c. Suppression
d. Displacement
83. A client says to the nurse. "I am going to die, and I wish my family would stop hoping for a
cure! I get so angry when they carry on like this! After all, I'm the one who's dying." The most
therapeutic response by the nurse is"
a. "You're feeling angry that your family continues to hope for you to be cured?"
b. "I think we should talk more about your anger with your family."
c." Well, it sounds like you're being pretty pessimistic. After all, years ago people died of
pneumonia."
d. "Have you shared your feelings with your family."
84. A nurse employed in a mental health unit is assigned to care for a client admitted to the unit
2 days ago. On review of the client's record, the nurse notes that the admission was a voluntary
admission. Based on this admission, the nurse anticipates which of the following?
a. The client will be very resistant to treatment measures
b. The client's family will be very resistant to treatment measures
c. The client will be angry and will refuse care
d. The client will participate in the planning of the care and treatment plan
85. A nurse enters a client's room and the client is demanding release from the hospital. The
nurse reviews the client's record and notes that the client was admitted 2 days ago for treatment
of an anxiety disorder and that the admission was voluntary. Which of the following actions will
the nurse take?
a. Tell the client that discharge is not possible at this time
b. Call the dient's family
c. Contact the physician
d. Persuade the dient to stay a few more days.
86. A dient is admitted to the mental health unit. On admission assessment, the nurse notes that
the dients as admitted by involuntary status. Based on this type of admission, the nurse would
most likely expect the client:
a. Presents a harm to self
b. Requested the admission
c. Consented to the admission
d. Provided written application to the facility for admission
87. After a group therapy session, a client approaches a nurse and verbalizes a need for
seclusion because of uncontrollable feelings. The most appropriate nursing action would be to:
a. Inform the client that seclusion has not been prescribed
b. Obtain an informed consent
c. Call the client's family
d. Place the client in seclusion immediately
88. A nurse is providing care to a client admitted to the hospital with a diagnosis of acute anxiety
disorder. The nurse is conversing with the client. The client says to the nurse" I have a secret
that I want to tell you. You won't tell anyone about it, will you?" The most appropriate response
is which of the following?
a." No, I won't tell anyone."
b. "I cannot promise to keep a secret."
c. "If you tell me the secret, I will tell it to your doctor."
d. "If you tell me the secret, I will need to document it in your record."
89. A nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store.
The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your
clinic every week." The most appropriate nursing response is which of the following?
a. "I am not supposed to discuss this, but since you are my neighbor, I can tell you she is doing
great."
b. "I am not supposed to discuss this, but since you are my neighbor, I can tell you that she
really has some problems!"
c. "If you want to know about Carol, you need to ask her yourself."
d. "I cannot discuss any client situation with you."
90. A nurse is preparing a client for the termination phase of the nurse-client relationship. The
nurse prepares to implement which nursing task that is most appropriate for this phase?
a. Identifying expected outcomes
b. Planning short-term goals
c. Making appropriate referrals
d. Developing realistic solutions
91. A client who abuses alcohol and illegal drugs tells a nurse that he only uses substances
because of his stressful marriage and difficult job. Which defense mechanisms is this client
using?
a. Sublimation
b. Displacement
c. Projection
d. Rationalization
92. Mr. Cruz, an attorney who throws books and furniture around the office after losing a case is
referred to the psychiatric nurse for assistance. Nurse Alvin knows that the client's behavior
most likely represents the use of which defense mechanism?
a. Projection
b. Regression
c. Intellectualization
d. Reaction-formation
93. Nurse Lucas is aware that the defense mechanism commonly used by clients who are
alcoholics is:
a. Displacement
b. Compensation
c. Denial
d. Projection
94. A rape victim testifying in court suddenly loses her voice when asked to recount to event is
displaying which defense mechanism:
a. Conversion
b. Repression
c. Displacement
d. Suppression
95. Forcing thoughts to remain unconscious in order to avoid the anxiety that would result if they
were conscious is the definition of which defense mechanism?
a. Denial
b. Isolation
c. Regression
d. Repression
96. A client who has become more open and warmer when communicating with the nurse is
now in which phase:
a. Orientation Phase
b. Termination Phase
c. Working - Exploitation
d. Working - Problem Identification
97. The nurse who is reviewing the dient's medical history and list of medications is performing
tasks in which phase:
a. Working - Exploitation
b. Orientation Phase
c. Termination Phase
d. Working - Problem Identification
98. When Nurse Jrenzo outlines to his client his specific responsibilities during the initial phases
of therapeutic relationship, he is performing:
a. Nurse - Client Contract
b. Self-disclosure
c. Establishing Rapport
d. Observing Confidentiality
99. During the course of the interaction, Nurse Ezra shares to the client that they have the same
favorite color and food to establish a doser working relationship between the two of them. This
is an example of the use of: a. Nurse - Client Contracts
b. Establishing Rapport
c. Self-disclosure
d. Maintaining the relationship
100. Nurse Kevin has started working on building a therapeutic relationship with an identified
client. During the course of the initial interaction, the client states that he is not comfortable
talking about his line of work. Nurse Angelo replies that he will not force the client to talk about
things he does not want to talk about. This is an example of:
a. Nurse Client Contracts
c. Establishing Rapport
b. Confidentiality
d. Self-disclosure