Safety
A female client who’s at high risk for suicide needs close supervision. To best ensure the client’s safety, Nurse Mary 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 with suicidal clients
Check the client frequently at irregular intervals throughout the night
Primary level of prevention is exemplified by:
A. Helping the client resume self-care.
B. Ensuring the safety of a suicidal client in the institution.
C. Teaching the client stress management techniques
D. Case finding and surveillance in the community
C. Teaching the client stress management techniques
The therapeutic approach in the care of an autistic child includes 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
D. Rearrange the environment to activate the child
The nurse is aware that the 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
Accept responsibility for own behaviors
Nurse Fey is aware that the drug of choice for treating Tourette syndrome?
A. Fluoxetine (Prozac)
B. Fluvoxamine (Luvox)
C. Haloperidol (Haldol)
D. Paroxetine (Paxil)
C. Haloperidol (Haldol)
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
The injury isn’t consistent with the history or the child’s age
The primary nursing diagnosis for a female client with a medical diagnosis of major depression would be:
A. Situational low self-esteem related to altered role
B. Powerlessness related to the loss of idealized self
C. Spiritual distress related to depression
D. Impaired verbal communication related to depression
D. Impaired verbal communication related to depression
Danny who is diagnosed with bipolar disorder and acute mania, states the nurse, “Where is my daughter? I love Louis. Rain, rain go away. Dogs eat dirt.” The nurse interprets these statements as indicating which of the following?
A. Echolalia
B. Neologism
C. Clang associations
D. Flight of ideas
D. Flight of ideas
A male client is admitted to a psychiatric facility by court order for evaluation for antisocial personality disorder. This client has a long history of initiating fights and abusing animals and recently was arrested for setting a neighbor’s dog on fire. When evaluating this client for the potential for violence, nurse Perry should assess for which behavioral clues?
A. A rigid posture, restlessness, and glaring
B. Depression and physical withdrawal
C. Silence and noncompliance
D. Hypervigilance and talk of past violent acts
A rigid posture, restlessness, and glaring
According to Piaget, a 5-year-old is at what stage of development:
A. Sensorimotor stage
B. Concrete operations
C. Pre-operational
D. Formal operation
C. Pre-operational
You need to assess whether a patient who has a mood disorder is ready for discharge. Which statement would indicate readiness for discharge?
A. Right now, I can't bathe myself or dress myself, but I feel good about that.
B. Going home will be fun, but if it isn't fun, I can always make my mother help me or tell her to do so. She better help me.
C. I will take my medicines as I should and know to call the number you gave me if I have bad thoughts.
D. Taking care of myself is important, but it's okay if I don't want to do anything.
C. I will take my medicines as I should and know to call the number you gave me if I have bad thoughts.
Ricardo, an outpatient in psychiatric facility is diagnosed with dysthymic disorder. Which of the following statement about dysthymic disorder is true?
A. It involves a mood range from moderate depression to hypomania
B. It involves a single manic depression
C. It’s a form of depression that occurs in the fall and winter
D. It’s a mood disorder similar to major depression but of mild to moderate severity
D. It’s a mood disorder similar to major depression but of mild to moderate severity
When developing an initial nursing care plan for a male client with a Bipolar I disorder (manic episode) nurse Ron should plan to?
A. Isolate his gym time
B. Encourage his active participation in unit programs
C. Provide foods, fluids and rest
D. Encourage his participation in programs
C. Provide foods, fluids and rest
A client with paranoid personality disorder is admitted to a psychiatric facility. Which remark by the nurse would best establish rapport and encourage the client to confide in the nurse?
A. “I get upset once in a while, too.”
B. “I know just how you feel. I’d feel the same way in your situation.”
C. “I worry, too, when I think people are talking about me.”
D. “At times, it’s normal not to trust anyone.”
A. “I get upset once in a while, too.”
When developing the plan of care for a client receiving haloperidol, which of the following medications would nurse Monet anticipate administering if the client developed extrapyramidal side effects?
A. Olanzapine (Zyprexa)
B. Paroxetine (Paxil)
C. Benztropine (Cogentin)
D. Lorazepam (Ativan)
C. Benztropine (Cogentin)
A 22-year-old female is admitted to the unit following a suicide attempt. She has a 2-week history of depression as well as a history of abusing multiple substances and anorexia nervosa. What is your first nursing priority?
A. Socialization.
B. Contracting for eating behavior.
C. Safety.
D. Administering the Beck depression scale.
C. Safety.
Which of the following statements indicates that your patient, who has schizophrenia, is ready to manage a relapse?
A. I will think of a plan of action before I get these racing thoughts again.
B. I will not drink alcohol and will exercise daily. This will help me stay well.
C. If I start feeling badly and don't sleep very much, then I will tell my friend Sandy and talk to her. She or I will call my therapist.
D. When I feel stressed, I will sit near my bed and wait to feel better.
C. If I start feeling badly and don't sleep very much, then I will tell my friend Sandy and talk to her. She or I will call my therapist.
A client tells the nurse that people from Mars are going to invade the earth. Which response by the nurse would be most therapeutic?
A. “That must be frightening to you. Can you tell me how you feel about it?”
B. “There are no people living on Mars.”
C. “What do you mean when you say they’re going to invade the earth?”
D. “I know you believe the earth is going to be invaded, but I don’t believe that.”
A. “That must be frightening to you. Can you tell me how you feel about it?”
6. On review of the patients record, the nurse notes the admission was voluntary. Based on this information, the nurse anticipates which patient behavior?
A. Fearfulness regarding treatment measures.
B. Anger and aggressiveness directed toward others.
C. An understanding of the pathology and symptoms of the diagnosis
D. A willingness to participate in the planning of the care and treatment plan
D. A willingness to participate in the planning of the care and treatment plan
How soon after chlorpromazine (Thorazine) administration should the nurse expect to see a client’s delusional thoughts and hallucinations eliminated?
A. Several minutes
B. Several hours
C. Several days
D. Several weeks
D. Several weeks
Your patient has just been physically cleaned up after slicing his left arm 8 times. To show an appropriate evaluative response, which of the following would be your best statement?
A. I could care less if you cut yourself. It doesn't hurt me.
B. If you wouldn't cut yourself, you would have a much happier life.
C. You are lucky someone found you in time. Now you can help us make you better.
D. The behavior of cutting is not acceptable.
D. The behavior of cutting is not acceptable.
Your patient has a diagnosis of schizophrenia and believes that his thoughts are broadcast from his head. What is the most appropriate nursing diagnosis?
A. Risk for self-directed violence.
B. Disturbed sensory perception.
C. Impaired verbal communication.
D. Disturbed thought processes.
D. Disturbed thought processes.
As a nurse, you wish to reinforce functional behavior in your schizophrenic patient. Which intervention will accomplish reinforcement?
A. Praise the patient for reality-based perceptions and cessation of acting-out behaviors.
B. Educate the patient about the symptoms of schizophrenia.
C. Facilitate learning about the importance of medication compliance using written materials for reinforcing medication use.
D. Focus on the feelings of delusion to reinforce reality and decrease false beliefs by talking to the patient.
A. Praise the patient for reality-based perceptions and cessation of acting-out behaviors.
The nurse is preparing a patient for the termination phase of the nurse-patient relationship. The nurse prepares to implement which nursing task that is MOST APPROPRIATE for this phase?
A. Planning short-term goals
B. Making appropriate referrals
C. Developing realistic solutions
D. Identifying expected outcomes
B. Making appropriate referrals
What is the best drug of choice for treating obsessive-compulsive disorder?
A. Imipramine (Tofranil)
B. Lithium salts
C. Amitriptyline (Elavil)
D. Clomipramine (Anafranil)
D. Clomipramine (Anafranil)