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Name: __________________________________ 6.

On a home visit to an older adult who has chronic heart

failure, the nurse observes that a 6-month-old grandchild
Evoke-ATII Nurse Review Center lies quietly in a crib, rarely smiles and babbles, and barely
CGFNS BOOT CAMP has basic needs attended. The client is the primary
MENTAL HEALTH caregiver for the infant The nurse should:
a. Advise purchasing appropriate toys designed for this
1. A nurse assesses a patient who has schizophrenia of the age level.
paranoid type. Which of the following behaviors should the b. Inform the client that the child will be retarded if not
nurse expect to observe? stimulated.
a. Elated affect and hyperactivity c. Explain the need for the family to hire a mother’s
b. Obsessive thoughts and rituals helper for the home.
c. Hallucinations and delusions d. Initiate a referral to an appropriate agency to assess the
d. Manipulation and narcissism need for a home health aide

2. A patient who has schizophrenia of the paranoid type says to a 7. A 55-year-old widow of 6 months is brought to a psychiatric
nurse, “The FBI is out to get me and you’re one of them.” hospital. During the assessment interview, the client avoids
Which of the following responses by the nurse would be most contact, responds in a low voice, and is tearful. The best
therapeutic? initial approach by the nurse would be:
a. You seem scared a. “You’ll find that you’ll get better faster if you try to
b. What makes you think the FBI is here help us to help you.”
c. You should go to your room and rest b. “I know that this is difficult, but as soon as we are
d. How could an FBI agent get in here finished, I’ll take you to your room.”
c. “Hold my hand. I know you are frightened, but I will
3. A patient who has schizophrenia of the paranoid type says to a not allow anyone to harm you.”
nurse, “That guy over there is staring at me and putting a spell d. “I am Ms Rose, your nurse. I’ll take you to the day
on me.” Which of the following nursing diagnoses should be room as soon as I get some information.”
given priority for this client?
a. High risk for violence related to delusional thinking 8. When teaching a patient who has a diagnosis of
b. Alteration in though processes related to mistrust schizophrenia about successful independent living in the
c. Anxiety related to misinterpretation of external stimuli community, a nurse should encourage the patient to
d. Defensive coping related to fear of other patients a. Establish a structured daily routine
b. Spend time alone
4. Which of the following statements, if made by a patient c. Plan a program of self-fulfillment
diagnosed with schizophrenia, indicates to a nurse that the d. Discontinue medication when symptoms disappear
patient needs additional instruction regarding haloperidol
(Haldol)? 9. A client who has recently been diagnosed with AIDS
a. I can stop my medicine when I don’t hear the voices comments to the nurse, “There are so many rotten people
anymore around. Why couldn’t one of them get AIDS instead of
b. I’ll take my Cogentin if my neck feels stiff me?” The nurse could best respond:
c. I’m going to eat bran cereal every morning a. “I can understand why you’re afraid of death.
d. I have to wear a hat when I go to the beach b. “It seems unfair that you should have this disease.”
c. “I’m sure you really don’t wish this on someone else.”
5. The most beneficial purpose of a group therapy is d. “Have you thought of speaking with a minister.”
a. Control anxiety
b. Teach social skills 10. When considering the nutritional needs of a patient on the
c. Deter deviant behavior psychiatric unit who has diagnosis of bipolar disorder,
d. Establish support systems manic type, a nurse should plan to
a. Offer finger foods
b. Serve food in sealed containers
c. Engage the patient in food preparation
d. Seat the patient with other lively patients in the dining

11. Which of the following patient outcomes would indicate 17. A nurse can validate that a patient understands safe,
that the manic phase of a bipolar disorder is subsiding? effective use of lithium carbonate (Eskalith) if the patient
a. The patient participates in group activity without makes which of the following statements?
disruption a. I should call the doctor if I have diarrhea or vomiting
b. The patient has an increased ability to verbalize b. What I eat or drink has no effect on this medication
c. The patient assumes leadership in social activities c. If I forget a pill, I should take two for my next dose.
d. The patient initiates multiple projects in the art therapy d. I can stop my medication when my symptoms disappear

12. A patient who is admitted to a medical unit for treatment of 18. A patient says to the nurse, “I want to tell you
congestive heart disease is tearful, forgetful and anxious. something, but you mustn’t tell anyone else.’ Which of the
Which of the following symptoms would indicate that the following responses by the nurse would be appropriate?
patient is developing dementia? a. I’m glad you can trust me.
a. Sundown phenomenon b. I have to reveal anything that would be essential to
b. Altered level of conscious your treatment
c. Sleep disturbance c. The nurse and the patient have a special relationship
d. Decreased appetite d. I am bound to keep it secret because of confidentiality

13. Which of the following patients should a nurse recognize as 19. When assessing a patient who has AIDS, which of the
being at greatest risk of suicide? following signs and symptoms would be most indicative of
a. A middle-aged divorced male who recently lost his job AIDS dementia complex?
b. An elderly married male in chronic pain a. Headaches
c. A young single female who had a miscarriage b. Bronchial infection
d. An adolescent female who just broke up with her c. Unsteady gait
boyfriend d. Diarrhea

14. Which of the following responses by the nurse would be 20. A hyperactive patient who is on the psychiatric unit is
most appropriate when a patient states during the admission changing his clothes in the day room. Which of the
interview on the psychiatric unit that she hears voices? following interventions by the nurse would most likely be
a. Try to focus on the questions that I’m asking you rather effective?
than on the voices. a. Ask him why he is doing this in front of other people
b. What are the voices telling you? b. Take him to his room to finish the activity
c. The voices will go away when you begin treatment c. Encourage the other patients to leave the area
d. Hearing voices must be upsetting to you. d. Lock up his clothes except those that he is wearing

15. A community mental health nurse is caring for an elderly 21. A five-year-old child displays hyperactive behavior after
home-bound patient who has a diagnosis of major receiving a dose of diphenhydramine hydrochloride
depression. Which of the following observations would be (Benadryl). The nurse would recognize that
typical of a patient who has received amitryptyline a. Allergic reactions to this drug are common
hydrochloride (Elavil) for a week? b. This behavior is indicative of inadequate dosing of the
a. Elevated mood drug
b. Increased social activity c. This is a typical adverse effect of the drug
c. Improve hygiene d. The blood brain barrier is sensitive to the drug.
d. Improved sleep pattern
22. Which of the following actions should a nurse take during
16. Which of the following foods, if chosen by a patient who is the pre-interaction phase of the nurse-patient relationship?
taking a monoamine oxidase inhibitor (MAOI), indicates a. Exploring personal feelings regarding care of the
that the patient is following the prescribed diet? mental health patient
a. Prunes b. Establishing boundaries for the patient and the nurse
b. Aged cheese c. Determining if the patient’s problems result from
c. Fresh vegetables stressors
d. Sausage d. Identifying goals and strategies

23. A 9-year-old boy has just been told he must stay in the 29. Which of the following patients would benefit most from
hospital in traction for at least two weeks. The nurse finds group therapy?
him crying and unwilling to talk. At this time, the nurse a. A patient in the second stage of dementia
should give the highest priority to: b. A patient in the manic phase of a bipolar disorder
a. Giving him privacy and allowing him to cry c. A patient who has positive signs of schizophrenia
b. Trying to distract him to avoid embarrassment d. A patient in the working phase of major depression
c. Telling him that his injury will not be permanent
d. Arranging for him to have a tutor begin immediately 30. A patient has a diagnosis of borderline personality disorder.
Which of the following nursing diagnoses would be basic to
24. A client calls out to every nursing staff member e\who planning nursing care for this patient?
passes by the door and asks them to do or get something. a. Hopelessness related to psychic injury
The nurse can best manage this behavior by: b. Powerlessness related to learned helplessness
a. Closing the door to the room so the client cannot see c. Impaired social interaction related to splitting
the staff members as they pass by d. Impaired adjustment related to loss of relationship
b. Assigning one staff member to approach the client
regularly and spend time talking with the client 31. Which of the following statements if made by a patient who
c. Informing the client that one staff member will come in has terminal cancer, demonstrates the stage of bargaining as
frequently to see whether the client has any requests described in the theory of death and dying?
d. Arranging for a variety of staff members to take turns a. I know I’m going to get better
going into the room to see whether the client has any b. I have to put my financial affairs in order
request c. I do not understand why this is happening to me
d. I plan to be around until my grandson’s graduation
25. The nurse is aware that a child’s emotional problems usually
occurs as a result of: 32. Which of the following activities, if performed by the nurse,
a. Rejection by the parents is an example of primary prevention?
b. Family pathologic factors a. Identification of problematic behavior in children
c. Authoritarian parenting style b. Screening for depression
d. Overbearing over protectiveness c. Assessment of family growth and development
d. Promoting independence in the elderly
26. A patient is receiving neuroleptic medication. The nurse
should assess the patient for symptoms of an acute dystonic 33. A client says he used amphetamines to be productive at
reaction, which include work. Which of the following symptoms commonly occurs
a. Intention tremors when the drug is abruptly discontinued?
b. Ataxic gait a. Severe anxiety
c. Difficulty swallowing b. Increased yawning
d. Psychomotor agitation c. Altered perceptions
d. Amotivational syndrome
27. Which of the following mental health problems is
commonly associated with severe, chronic medical 34. The nurse should teach a patient who is taking thioridazine
disorders? hydrochloride (Mellaril) to follow which of the following
a. Anxiety diets?
b. Depression a. Bland
c. Labile affect b. Low residue
d. Confusion c. Sodium restricted
d. High fiber
28. Which of the following comments if made by a patient who
has major depression, would indicate an increased risk for 35. A patient who has a borderline personality disorder praises
suicide? one nurse and asserts that all other staff members are
a. I think I’ll lie down. I feel like sleeping. terrible. The praised nurse should respond by
b. I won’t be a problem much longer a. Showing appreciation for the patient’s positive
c. I think the doctor should give me more medicine evaluation
d. I miss my family, especially my children. b. Provide reassuring information about the patient’s
psychosocial integrity
c. Maintaining objectivity regarding the patient’s remarks
d. Conveying acceptance of the patient’s need for a false
belief system

36. A 26 year old woman is brought to the psychiatric unit 42. An elderly man who has Alzheimer’s disease calls the nurse
because of suicidal thought. To determine if one to one by a different name. Which of the following measures by
observation is indicted for the woman, the nurse should the nurse would be the most appropriate?
determine if a. Responding to whatever name he calls the nurse
a. Anyone in the woman’s family has tempted suicide b. Asking him to remember the nurse’s name
b. The woman has a plan for suicide c. Stating the nurse’s name at each contact with him
c. The woman had had a recent loss d. Allowing him extra time in which to remember the
d. The woman has a social support system nurse’s name

37. In which of the following ways should the nurse intervene 43. A patient who has a borderline personality disorder asks the
when a patient repeatedly talks about the past? nurse on a psychiatric unit if she may stay up beyond the
a. Help the patient establish goals for the future designated bedtime. When the nurse says no, the patient
b. Give the patient a diversional activity says, “The nurse on duty last night let me stay up late.”
c. Ask the patient to think of recent pleasures Which of the following responses by the nurse would be
d. Encourage the patient to share memories therapeutic?
a. You should not have been given that privilege
38. A patient who has begun taking a tricyclic antidepressant is b. Everyone is required to go to bed now
given instructions regarding its use. Which of the following c. You can stay up from one more hour
comments would indicate that the patient understands the d. Why do you want to stay up?
a. I like active exercise, but I won’t be able to do it while 44. A 6 year old child who is admitted to a hospital for
I’m on this medicine. suspected sexual molestation tells a nurse, “I do not like it
b. This medicine will make my ears ring. when my step dad takes a bath with me.” Based on this
c. I won’t eat cheese if one of my visitors brings me some. information, which of the following actions should the nurse
d. I don’t feel any better, but I’ve only begun taking the take?
medicine for a week. a. Ask the child to explain to you what takes place during
bath time
39. When assessing disturbed children, the clue that the nurse b. Interview the child further by using anatomically
would find most indicative of severe emotional problems correct dolls
would be the child’s: c. Contact the facility’s designated child abuse interviewer
a. Physical complaints d. Approach the stepfather to clarify the child’s statement
b. Behavioral outburst
c. Poor school performance 45. Which of the following comments would a patient with an
d. Lack of response to the environment antisocial personality be most likely to make?
a. The police are always arresting me for nothing
40. When discussing methods of stress reduction with a patient, b. I’m feeling guilty because I’ve disappointed my family.
the nurse should use which of the following approaches c. I’m becoming very anxious
first? d. I’ve learned my lesson and I’ll never do that again

a. Explain to the patient the physiological effects of stress. 46. A 27 year old man is admitted to the psychiatric unit after
b. Teach the patient relaxation techniques that reduce striking his wife with a cooking utensil. He is hyperactive
stress and is in handcuffs. Which of the following behaviors would
c. Determine if the patient is able to identify sources of indicate that the patient needs continued restraints?
stress a. He pushes the attendant out of his way
d. Describe to the patient the benefits of active exercise in b. He shouts curses at the nurse
coping with stress. c. He tears up his chart
d. He makes obscene gestures
41. Which of the following plans is particularly important in the
care of a patient who has Alzheimer’s disease? 47. A patient is brought to the psychiatric unit. Which of
a. Using behavior modification techniques the following activities would be performed by the
b. Assessing the patient’s abilities on an on-going basis registered nurse rather than the licensed practical nurse?
c. Helping the patient explore emotional conflict a. Administering a stat dose of lorazepam (Ativan) 2 mg
d. Implementing a bowel-training program. (IM)
b. Admitting the patient to the psychiatric unit
c. Asking the patient whether he hears voices other
people do not hear

d. Drawing a blood sample for a lithium level.
54. A patient who has Alzheimer’s disease is told by the
48. A hospitalized patient has recovered from an acute nurse to brush his teeth. He shouts angrily, “Tomato soup”.
exacerbation of his chronic mental illness and is demanding Which of the following actions by the nurse would be
release. In planning the patient’s discharge, the nurse should correct?
take into consideration that the patient a. Focusing on the emotional reaction
a. Is used to being homeless and does not need much b. Clarifying the meaning of his statement
assistance c. Giving him step by step directions
b. Cannot be discharged until a suitable living d. Doing the procedure for him
arrangement is identified
c. will receive adequate aftercare at the community mental 55. Which of the following observations would be most
health center definitive when assessing a patient who has posttraumatic
d. has the right to be discharged stress disorder?
a. Substance abuse
49. The nursing staff on a psychiatric unit consists of registered b. Aggression
nurses, licensed practical nurses and unlicensed assistive c. Flashbacks
personnel. Which of the following activities can most safely d. Depression
be assigned to unlicensed assistive personnel?
a. Observing a patient after ECT 56. A patient is admitted to the ER following a sexual assault.
b. Monitoring a patient who is on suicide precautions Which of the following assessments should a nurse
c. Co-conducting an activity group recognize as most pertinent to crisis intervention?
d. Doing an intake interview of a new patient a. The patient’s past history
b. The patient’s perception of the event
50. The most common adverse effect of ECT for which the c. The patient’s behavior prior to the assault
nurse must plan intervention is? d. The patient’s understanding of STDs
a. Arrhythmia
b. Physical injury 57. Which of the following factors would best support a
c. Severe hypertension diagnosis of substance abuse?
d. Memory loss a. Daily substance abuse
b. Spending money on drugs
51. A nurse is leading a community meeting on an inpatient c. Interference with activities of daily living
psychiatric unit. One of the group members complains that d. Legal complications related to substance abuse
the hospital visiting hours are too short. The most
appropriate action for the nurse is to? 58. A nurse is counseling a parent whose 11 year old child has
a. Explain the reason for the visiting hours policy attention deficit hyperactivity disorder. The parent reports
b. Explore with the patient why he is so upset that the child is disruptive at home. Which of the following
c. Invite the nurse manager to the group to explain the approaches should the nurse suggest that the parent take?
policy a. Confine the child to the bedroom
d. Ask the other group members if they have similar b. Establish a specific schedule for activities
concerns c. Explain to the child why the behavior is disturbing
d. Vary the methods by which rewards are given
52. The best time to administer prn lorazepam (Ativan) to a
patient who is aggressive is when the patient 59. A patient who has autism demonstrates a high level of
a. Starts to pace in the hallway anxiety following the rearrangement of furniture in the
b. Stops pacing and starts making verbal threats room. A nurse should understand that the patient’s behavior
c. Stops threatening and actually performs a violent act is the result of a need for
d. Is placed in restraints a. Trust
b. Privacy
53. Although a patient expresses fear about having ECT c. Constancy
treatments, the patient’s significant other gives permission d. Independence
for the therapy. As a patient advocate, the nurse should
consider which of the following legal/ethical principles? 60. A nurse should teach a patient who is taking Thorazine
a. Negligence to avoid
b. Confidentiality a. Exposure to the sun
c. Informed consent b. Swimming in a chlorinated pool
d. Privileged communication c. Drinking fluids high in sodium

d. Eating foods such as chocolate and aged cheese 67. A nurse answering the telephone of a suicide hotline should
61. Which of the following action measures should a nurse assess which of the following patient comments as highest
include in the care plan of a patient who has a borderline priority?
personality disorder? a. “My husband has end stage cancer and I can’t stand the
a. Supporting the patient when arguments arise thought of losing him.”
b. Encouraging the patient to develop the care plan b. “I have a loaded gun and I’m thinking of using it.”
c. Channeling all patient requests through one nurse per c. “If things don’t get better, I’m going to drive my car
shift over a cliff.”
d. Administering psychotropic medication upon the d. “I’m so unhappy, I can’t go on.”
patient’s request
68. Which of the following nursing measures best illustrates the
62. Which of the following nursing interventions should a nurse primary concept of a therapeutic milieu?
include in the care plan for a patient who is taking a TCA a. Encouraging patient participating in competitive
medication? activities
a. Teach the patient to check for blood in the stool. b. Promoting social interactions between patients
b. Prepare the patient for excessive urinary output c. Planning daily therapy sessions with a psychiatrist
c. Offer the patient frequent sips of water for dry mouth d. Using containment as the primary method of
d. Instruct the patient to avoid tyramine-rich foods controlling patient behavior

63. A nurse places a patient in 4-point restraints following 69. A 76 year old patient repeatedly remarks that his life has
orders from a physician. Which of the following measures been wasted. According to growth and development as
should the nurse include in the patient’s care plan? defined by Erikson, which of the following stages does the
a. Socialize with other patients once a shift patient’s behavior exemplify?
b. Check circulation periodically a. Autonomy versus shame
c. Provide stimulating diversional activities b. Intimacy versus isolation
d. Assess rectal temperature frequently c. Identify versus role confusion
d. Integrity versus despair
64. A nurse should expect that a patient who consumes
excessive amounts of alcohol will be given a prescription 70. Which of the following comments by the nurse would be
for folic acid (Folate) supplements to used to encourage a patient who is schizophrenic and
a. Prevent stress ulcers withdrawn to participate in activity therapy?
b. Enhance gas exchange a. You must go to group right now.
c. Facilitate the immune response b. I’ll walk with you to activity therapy
d. Enhance mental acuity c. If you don’t go to group, you’ll be put in seclusion
d. If you go to activity therapy, I’ll increase your unit
65. A patient tells the nurse, “I’m too depressed to talk to you. privileges
Leave me alone.” Which of the following responses by the
nurse would be most therapeutic? 71. A patient who is manic has been monopolizing group
a. I’ll be back in 2 hours time and the nurse has been setting limits on this behavior.
b. Why are you so depressed? If the patient is benefiting from this intervention, the nurse
c. I’ll sit here for a moment. should expect the patient to
d. Call me when you feel like talking to me a. Arrive on time for group
b. Dress appropriately
66. Neuroleptic Malignant Syndrome (NMS) is a potentially c. Raise a hand before speaking
lethal complication of treatment with antipsychotic d. Remain seated throughout the session
medications. Which of the following manifestations should
the nurse recognize as an early sign of NMS? 72. A nurse teaches new coping skills to a patient who
a. Difficulty swallowing abused cocaine. Which of the following comments, if made
b. Unstable blood pressure by the patient, would indicate that the teaching was
c. Muscle stiffness effective?
d. Respiratory depression a. I’m staying off cocaine one day at a time.
b. I’m going to discourage my friends from using cocaine
c. I will try to sleep more so I don’t think of cocaine
d. I’m going to take a tranquilizer whenever I feel the urge
to use cocaine.

73. A nurse therapist uses systematic desensitization in the 78. A middle-aged patient says to the nurse, “I don’t
treatment of a patient who has a phobia about flying in deserve to live.” The most therapeutic initial response by
airplanes. Which of the following patient outcomes the nurse would be to
indicates a favorable response to the treatment? a. Continue to listen to the patient while maintaining
a. The patient visits an airport direct eye contact
b. The patient understands the reasons for his fear of b. Remain with the patient until she states she feels better
flying c. Say to the patient, “You sound depressed.” and lean
c. The patient uses methods of transportation other than toward her.
airplanes d. Ask the patient what she means by “I don’t deserve to
d. The patient cancels all travel plans live”.

74. A patient’s serum lithium carbonate (Eskalith) level is 1.9 79. A patient who made 12 calls to the police reporting that
Eq/L. The nurse should someone was trying to poison him is being admitted to the
a. Administer the lithium with an antacid psychiatric unit. Which of the following actions by the nurse
b. Administer the next dose of lithium at the prescribed would be most therapeutic?
time a. Explaining that fear is not reasonable
c. Ask the physician for an order to increase the lithium b. Delaying the admission interview until the patient is
dose medicated
d. Withhold the lithium and report the lithium level to the c. Helping the patient to identify the alleged poisoner
physician d. Acknowledging the patient’s fear
75. During the night shift report, the charge nurse learns
that an elderly patient has become very confused and is 80. A patient being treated for schizophrenia has his
shouting obscenities and is undressing himself. Which of the medication changed from fluphenazine (Clozaril) to
following actions is the most appropriate nursing response? clozapine (Clozaril), the nurse should be more vigilant in
a. Restrain the patient with a posey jacket assessing the patient for?
b. Medicate the patient with Haldol as ordered a. Dry mouth
c. Notify the physician b. Seizures
d. Complete the nursing assessment of the patient c. Orthostatic hypotension
d. Constipation
76. A patient was admitted to a psychiatric unit after she
assaulted her landlord, because she thought the landlord was 81. A patient receiving pharmacological treatment for a
putting bad ideas in her head. When determining if the psychotic disorder exhibits restlessness and only sits down
patient is ready for discharge, it would be most appropriate for a few minutes at a time. The nurse would recognize that
to ask the patient? this behavior.
a. What would you do if the same situation came up a. Needs to be further assessed to rule out a medication
again? side effect
b. Do you understand that these ideas about the landlord b. Is common in psychotic patients
are part of your stress? c. Results from internal conflicts the patient is
c. What do you see as the reason you were admitted to the experiencing
hospital? d. Will subside as the patient improves
d. Would you be willing to come back to the hospital for
further treatment if you needed it? 82. Which of the following behaviors is most indicative of
impairment due to substance abuse in a nurse?
77. A woman who has been identified as a victim of domestic a. Patients report that the nurse is always distracted and
violence is seen by the community mental health nurse. The tired during the shift
priority outcome is for the client to b. Patients report experiencing pain despite documented
a. Explore her relationship with her parents. administration of pain medication
b. Make a personal safety plan c. Patients report that valuables are missing
c. Accept responsibility for her role in the abusive d. Patients report rude treatment by the nurse.
d. Develop conflict-resolution skills

83. A patient is experiencing an acute dystonic reaction. All of d. Remain silent and wait for another group member to
the following prn medications are prescribed. Which speak
medications should the nurse administer?
a. Thorazine 89. While working on the adolescent psychiatric unit, the nurse
b. Ativan overhears a patient mentioning the name of another resident
c. Benadryl while he is talking on the telephone. The best response by
d. Xanas the nurse would be to?
a. Intervene immediately to remind the patient of
84. The outcome that would be most appropriate for a confidentiality
patient who has a diagnosis of agoraphobia would be that b. Ignore the incident but re-emphasize confidentiality at
the patient will? the next community meeting
a. Go shopping in town c. Talk with the patient after the phone call is finished.
b. Touch the neighbor’s dog d. Insist that the patient terminate the telephone call
c. Handle money without wearing gloves immediately
d. Bathe only once a day 90. An elderly postoperative patient is disoriented to time
and place. During rounds, the night charge nurse finds him
85. A schizophrenic patient says to the nurse, “You are wearing standing at the side of the bed. The patient says to the
a pretty red dress. Tomatoes are red. Vegetables make you nurses, “I’m waiting for the bus.” Which of the following
healthy. I am not healthy.” A nurse should recognize that interventions by the nurse would be most appropriate?”
these statements are an example of? a. Place the patient in a wheelchair and allow him to sit in
a. Echolalia (repetition of words) front of the nurse’s station
b. Confabulation (making up stories) b. Call the patient’s family to come and sit with him.
c. Neologisms (making up new words) c. Assist the patient back to bed and put on a posey jacket
d. Looseness of association d. Re-orient the patient, assist him back to bed and
observe him closely.
86. When providing anticipatory guidance to the parents of a 6
month old infant, a nurse would give priority to which of the 91. Which of the following nursing actions would be most
following issues? effective when encouraging a depressed patient to be less
a. Engaging the infant in interactive play socially isolated?
b. Placing potted plants out of the infant’s reach
c. Adding multivitamins supplements to the infant’s diet a. Move the patient to a room closer to the nurse’s station
d. Providing the infant with a cool water filed teething b. Ask a more stable patient to accompany the patient to
ring activities
c. Assign a psychiatric technician to monitor the patient’s
87. If child abuse is suspected in a family, which of the activity
following approaches would a nurse take when beginning to d. Explain to the patient that continued isolation may
interview the child? delay discharge
a. Speaking to the child by using specific, anatomically
correct terminology 92. The nurse should recognize that a patient who is unable to
b. Expressing concern to the child that something like this remember being raped by her brother when she was 10
could have happened years old is using which of the following ego defense
c. Assuring the child that any information given will be mechanism?
kept confidential a. compensation
d. Providing a private place to talk with the child about the b. repression
incident c. undoing
d. regression
88. A nurse is leading a community meeting at the partial-
hospitalization program. One group member talks constantly 93. Which of the following manifestations, in a woman who
and interrupts the other patients. The most appropriate delivered a newborn 36 hours ago, would lead a nurse to
action for the nurse to take is to suspect the woman may be experiencing postpartum
a. Explain to the member, after the meeting, that group depression?
time should be shared. a. Expressing concern about taking the infant home
b. Thank the group member for his contribution and ask b. delaying her morning shower
the other members for their ideas c. Exhibiting prolonged periods of fatigue
c. Ask the other group members if they are satisfied with d. asking repeated questions about infant care
the way the group is working

94. Which of the following actions by the nurse would be
a. Escorting a patient to a seclusion room following an
aggressive hostile attack
b. Confiscating a suicidal patient’s scissors
c. Telling the patient that he will get an IM injection if his
outburst continues
d. Inspecting a patient’s personal belongings upon

95. Which of the following comments by a patient should

indicate to a nurse that the patient has ideas of reference?
a. Those other nurses are talking about me
b. The nurse explained how my medication works.
c. Do all the nurses here have a college degree?
d. Will a nurse lead group therapy today?

96. Which of the following clinical conditions is frequently

seen among cocaine abusers?
a. Panic attacks
b. Bipolar cycling
c. Attention deficits
d. Expressive aphasia
97. Which of the following actions should a nurse take when
making the first contact with a paranoid patient?
a. Introduce self and avoid touching the patient
b. Avoid eye contact and shake hands with the patient
c. Close the door to the interview room and remain
d. Wait for the patient to initiate communication

98. Which of the following nursing intervention is a priority for

a client with borderline personality disorder?
a. maintain consistent and realistic limits
b. Give instructions for meeting basic self-care needs
c. Engage in daytime activities to stimulate wakefulness
d. Have the client attend group therapy on a daily basis

99. Which of the following emergencies is most likely to occur

when a client is using phencyclidine (PCP)?
a. Cardiac arrest
b. Seizure disorder
c. Violent behavior
d. Delirium reaction

100.Which of the following factors is associated with a client

with dissociative identity disorder (DID)?
a. an absent father
b. an inflated sense of self-esteem
c. very vivid memories of childhood trauma
d. A parent who was alternately loving and abusive