Nle Pre Board June 2008 NPT 5 Questions and Rationale PDF

Situation 1 - Jimmy developed his goal for hospitalization. "To get a handle on my nervousness.
" The nurse is going to

collaborate with him to reach his goal. Jimmy was admitted to the hospital because he called his therapist that he planned to
asphyxiate himself with exhaust from his car but frightened instead. He realized he needed help.
1. The nurse recognized that Jimmy had conceptualized his problem and the next priority goal in the care plan is:
a. help the client find meaning in his experience
b. help the client to plan alternatives
c. help the client cope with present problem
d. help the client to communicate
CORRECT ANSWER: C
RATIONALE: Crisis Intervention is an active but temporary entry into the life situation of an individual, a family or a
group during a period of stress. It includes assessment, planning of therapeutic intervention, implementation of
therapeutic intervention and evaluation. Since the client has already conceptualized his own problem, there is no
need for assessment anymore. Helping him cope with present problem is already planning of therapeutic
intervention.
OPTION A- There is no need helping the client find meaning in his experience because as stated, he is already
aware of his own problem
OPTION B- Planning of alternatives is wrong because the client hasn’t cope with his problem yet. He hasn’t
developed any coping strategies yet.
OPTION D- There is no need to let the client verbalize and/or communicate because he has already verbalized that
he needs to handle his nervousness.
SOURCE: Shives, Psychiatric-Mental health Nursing, 5th ed, pp166-168
2. The nurse is guided that Jimmy is aware of his concerns of the "here and now" when he crossed out which item
from his "list of what to know"
a. anxiety laden unconscious conflicts
b. subjective idea of the range of mild to severe anxiety
c. early signs of anxiety
d. physiological indices of anxiety
CORRECT ANSWER: C
RATIONALE: Crisis Intervention deals with the “here and now”, Gestalt therapy. It emphasizes identifying the
person’s feelings and thoughts in the here and now. Therapist’s often use gestalt therapy to increase client’s self-
awareness, focusing on the present. Early signs of anxiety don’t deal with the here and now because the client is
already manifesting signs of anxiety. An early sign of anxiety is a part of assessment process.
SOURCE: Videbeck, Psychiatric Mental Health Nursing, 3rd ed, p 59
3. While Jimmy was discussing the signs and symptoms of anxiety with his nurse, he recognized that complete
disruption of the ability to perceive occurs in:
a. panic state of anxiety
b. severe anxiety
c. moderate anxiety
d. mild anxiety
CORRECT ANSWER: B
RATIONALE: A severely anxious person has trouble thinking and reasoning. They can’t complete a task. The range
of perception is reduced, anxiety interferes with effective functioning.
OPTION A- In panic the ability to concentrate is disrupted, the individual may experience terror or confusion or
unable to speak or move. They can’t communicate verbally and may be suicidal.
OPTION C-In Moderate Anxiety, the perception becomes narrower; concentration is increased and able to ignore
distractions in dealing with problems. Moderately anxious person has difficulty concentrating independently.
OPTION D- In Mild anxiety, the client is more alert, more aware of environment. It helps the person focus attention
to learn, solve problems, think, act, feel and protect himself.
SOURCE: Videbeck, Psychiatric Mental health Nursing, 3rd ed,
4. Jimmy initiates independence and takes an active part in his self care with the following EXCEPT:
a. agreeing to contact the staff when he is anxious
b. becoming aware of the conscious feeling
c. assessing need for medication and medicating himself
d. writing out a list of behaviors that he identifies as anxious
CORRECT ANSWER: A
RATIONALE: Contacting the staff every time he feels anxious is still being dependent to the staff nurses of his self-
care
OPTION B, C, and D—implies independence
5. The nurse notes effectiveness of Interventions in using subjective and objective data in the:
a. initial plans or order
b. database
c. problem list
d. progress notes
CORRECT ANSWER: D
RATIONALE: A progress note is a chart entry made by all health professionals involved in a client’s care. It is in the
progress notes that the nurse notes the effectiveness of interventions.
OPTION A-
OPTION B- includes the nursing assessment, the physician’s history, social and family data and the results of the
physical examination and baseline diagnostic tests.
OPTION C- derived from database. It is usually kept at the front of the chart and serves as an index to the
numbered entries in the progress notes.
SOURCE: Kozier, Fundamentals of Nursing, 7th ed, pp 331-332
Situation 2 - A research study was undertaken in order to identify and analyze a disabled boy's coping reaction pattern
during stress.
6. This study which is a depth study of one boy is a:

a. case study
b. longitudinal study
c. cross-sectional study
d. evaluative study
CORRECT ANSWER: A
RATIONALE: Case study involves an in-depth, longitudinal examination of a single instance or event: a case, rather
than using large samples and following a rigid protocol to examine a limited number of variables.
OPTION B- Longitudinal study is a correlational research that involves repeated studies observations of the same
items over a long period of time. It studies developmental ternds over a long period of time. OPTION C-Cross-
sectional study is a study design in which data are collected at one point in time; sometimes used to infer change
over time when data are collected from different age or developmental groups
OPTION D- Evaluative study is a research that investigates how well a program, practice or policy is working
SOURCE: Polit and Beck, Nursing Research, 7th ed, pp 712, 715 717, 723
7. The process recording was the principal tool for data collection. Which of the following is NOT a part of a process
recording?
a. Non verbal narrative account
b. Audio and interpretation
c. Audio-visual recording
d. Verbal narrative account
CORRECT ANSWER: C
RATIONALE: Process recordings are written records of segment from the nurse-client session that reflects closely
as possible the verbal and non-verbal behaviors of both client and nurse. It is usually best of the student can write
notes verbatim in a private area immediately after the interaction has taken place. Nurses record their words and
client’s words, identify whether the responses are therapeutic, and recall their emotions at that time.
OPTIONS A, B & D- all are part of process recording
SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4th ed, p 245
8. Which of these does NOT happen in a descriptive study?

a. Describing relationship among variables
b. Exploration of relationships between two or more phenomena
c. Manipulation of phenomenon in real life context
d. Manipulation of a variable
CORRECT ANSWER: D
RATIONALE: Descriptive research is a nonexperimental study. The purpose of it is to observe, describe, and
document aspects of a situation as it naturally occurs and sometimes to serve as a starting point for hypothesis
generation or theory development. The aim of this study is to describe relationship among variables. Neither of the
variables could be experimentally manipulated.
OPTIONS A, B, C- all happens in a descriptive study
SOURCE: Polit and Beck, Nursing Research, 7th ed, pp 192, 195
9. The investigator also provided the nursing care of the subject. The investigator is referred to as a/an.
a. Participant-observer
b. Observer researcher
c. Caregiver
d. Advocate
CORRECT ANSWER: C
RATIONALE: The primary role of caregiver is the primary role of the nurse. The provision of care to patients that
combines both the art and the science of nursing in meeting all the aspect of well being.
OPTION A- the researcher participates as a member of the group and observes the group at the same time in data
collection
OPTION B-the researcher observes a particular group and records behaviors or activities
OPTION D- in advocate role, the nurse informs the client and then supports him or her in whatever decision he or
she makes. Advocacy is the process of acting in the client’s behalf when he or she cannot do so.
SOURCE: Polit et al, Nursing Research, 7th ed, pp 726, 727 and Videbeck, Psychiatric Mental Health Nursing, 2nd
ed, p 104
10. To ensure reliability of the study, the investigator analysis and interpretations were:
a. subjected to statistical treatment
b. correlated with a list coping behaviors
c. subjected to an inter-observe agreement
d. scored and compared standard criteria
CORRECT ANSWER: A
RATIONALE: Statistical treatment is a process of using statistical tools such as mode of central tendency, mean,
median to test the reliability of the study. You need to quantify first the data obtained before you can say that the
study is reliable.
Situation 3 - During the morning endorsement, the outgoing nurse informed the nursing staff that Regina, 5 years old, was
given Flurazepam (Dalmane) 15 mg at 10:00pm because she had trouble going to sleep. Before approaching Regina, the
nurse read the observation of the night nurse.
11. Which of the following approaches of the nurse validates the data gathered?
a. "I learned that you were up till ten last night, tell me what happened before you were finally able to sleep
and how was your sleep?"
b. "Hmm...You look like you had a very sound sleep. That pill you were given last night is effective isn't
it?"
c. "Regina, did you sleep well?"
d. "Regina, how are you?"
CORRECT ANSWER: A
RATIONALE: Asking open-ended questions, leads or invite the client to explore (elaborate, clarify, describe,
compare or illustrate) thoughts or feelings. It enables the nurse to examine important ideas, experiences and
encourages communication
OPTIONS B & C-it is a closed ended question. It closes an interview rapidly.
SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2nd ed, p 116,118
12. Regina is a high school teacher. Which of these information LEAST communicate attention and care for her needs
for information about her medicine?
a. Guided by a medication teaching plan go over with her the purpose, indications and special instructions,
about the medication and provides her a checklist
b. Provide a drug literature and explain its contents
c. Have an informal conversation about the medication and its effects
d. Ask her what time she would like to watch the informative video about the medication
CORRECT ANSWER: D
RATIONALE: The main purpose is to provide health teaching to the client. Communicating helpful information to the
client about the drug she is taking. Asking her what time she would like to watch the informative video least
communicate attention to her needs about her medicine because you are giving the client the option to say no to the
activity. Although it is an informative video, yet as a nurse, health teaching is our primary responsibility. We must be
responsible for the learning of our clients.
OPTIONS A,B, C—Communicates attention and care for her needs about her medicine. It is part of health teaching.
13. The nurse engages Regina in the process of mutual inquiry to provide an opportunity for Regina to
a. face emerging problems realistically
b. conceptualize her problem
c. cope with her present problem
d. perceive her participation in an experience
CORRECT ANSWER: D
RATIONALE: In mutual inquiry, the nurse involves the patient in determining the facts of his/her situation wherein
the patient will be able to understand her involvement in a certain experience. Often just helping the client explore
his/her perceptions of a problem stimulates potential solutions in the client’s mind. Client’s participation is effective
in finding meaningful solutions to problems.
OPTIONS A, B, C- pertains to goals of crisis intervention
14. Which of these responses indicate that Regina needs further discussion regarding special instructions?
a. "I have to take this medicine judiciously."
b. "I know I will stop taking the medicine when there is an advice form the doctor for me to discontinue."
c. "I will inform you and the doctor any untoward reactions I have."
d. "I like taking this sleeping pill. It solves my problem of insomnia. I wish I can take it for life."
CORRECT ANSWER: D
RATIONALE: Sleeping pills are hypnotics. Hypnotics are effective in treating transient insomnia, but when used over
the long-term, patients run the risk of developing dependence on the drug itself. Hypnotics can worsen existing
sleep disturbances when they induce dug dependency insomnia, for once the drug is discontinued, the individual
then have rebound insomnia and nightmares.
OPTION A- taking the medicine with caution is a must

OPTION B and C- shows understanding of the special instructions given to her
SOURCE: Varcaloris, Foundations of Psychiatric Mental Health Nursing, 4th ed, p 892
15. Regina commits to herself that she understood and will observe all the medicine precautions by;
a. affixing her signature to the teaching plan that she has understood the nurse
b. committing what she learned to her memory
c. verbally agreeing with the nurse
d. relying on her husband to remember the precautions
CORRECT ANSWER: A
RATIONALE: The nurse should make an agreement or contract with the client. Teaching plans are signed by the
patient if she/he is able to understand fully the health teaching given to her. Any documents can also serve legal
purposes.
OPTION B- She may not able to recall everything
OPTION C- Written agreement is more formal compared to verbal agreement
OPTION D- The husband has nothing to do with the medications. The patient itself must understand the precautions
of her medications
Situation 4 - The nurse-patient relationship is a modality through which the nurse meets the client's needs.
16. The nurse's most unique tool in working with the emotionally ill client is his/her:
a. theoretical knowledge
b. personality make up
c. emotional reactions
d. communication skills
CORRECT ANSWER: D
RATIONALE: Therapist’s ability to convey an essential interest in the client has been found to be more important
than position, appearance, reputation, clinical experience, training and theoretical knowledge. Skilled use of
communication techniques helps the nurse understand and empathize with the client’s experience. It helps in
facilitating the client’s expression of emotions.
SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2nd ed, p112
17. The premise that an individual’s behavior and affect are largely determined by the attitudes and assumptions one
has developed about the world underlies:
a. modeling
b. milieu therapy
c. cognitive therapy
d. psychoanalytic psychotherapy
CORRECT ANSWER: C
RATIONALE: Cognitive theory uses cognitive therapy that is an active, directive, time-limited, structured approach
used to treat a variety of psychiatric disorders. Cognitive theory believes that individual’s affect and behavior are
largely determined by the way in which they are structure the world.
OPTION A- In modeling the therapist provides a role model for specific identified behaviors, and the client learns
through imitation.
OPTION B- Describe the use of the total environment to treat disturbed children. A comfortable, secure environment
is created in which psychotic children were helped to form a new world.
OPTION D- Uses many of the tools of psychoanalysis, such as free association, dream analysis, transference and
counter transference, but the therapist is much more involved and interacts with the client more freely.
SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4th ed, pp 38, 39, 42, 43
18. One way to increase objectivity in dealing with one's fears and anxieties is through the process of:
a. observation
b. intervention
c. validation
d. collaboration
CORRECT ANSWER: B
RATIONALE: Intervention is any act performed to prevent harming of a patient or to improve the mental, emotional
or physical function of a person
OPTION A- act of watching carefully and attentively
OPTION C- an agreement of the listener with certain elements of the patient’s communication
OPTION D- a structured, recursive process where two or more people work together toward a common goal—
typically an intellectual endeavor
SOURCE: Mosby, Mosby’s Pocket Dictionary, 4th ed, pp 671, 880, 1328
19. All of the following response are non therapeutic. Which is the MOST direct violation of the concept, congruence of
behavior?
a. Responding in a punitive manner to the client
b. Rejecting the client as a unique human being
c. Tolerating all behavior in the client
d. Communicating ambivalent messages to the client
CORRECT ANSWER: D
RATIONALE: Congruence signifies genuineness, or self-awareness of one’s feelings as they arise within the
relationship, and the ability to communicate them when appropriate. It is conveyed by actions such as not hiding
behind the role of nurse, listening to and communicating with others without distorting their message and being clear
and concrete in communications with clients. Congruence connotes the ability to use therapeutic communication
tools in an appropriately spontaneous manner, rather than rigidly or in a parrot-like fashion.
OPTION A- although it is also communicating with client’s, it is not the most direct violation of the concept of using
therapeutic communication in an appropriately spontaneous manner
OPTION B- not directly connected with communicating with the client
OPTION C- tolerating behavior is more on behavioral approach rather than communication
SOURCE: Varcaloris, Foundations of Psychiatric Mental Health Nursing, 4th ed, p 223
20. The mentally ill person demonstrating a child-like behavior responds positively to the nurse who is warm and caring.
This demonstration of the nurse's role as:
a. counselor
b. parent surrogate
c. therapist
d. socializing agent
CORRECT ANSWER: B
RATIONALE: When a client exhibits child-like behavior or when a nurse is required to provide personal care, the
nurse may be tempted to assume the parental role.
OPTION A- deals with human development concerns through support, consultation, evaluation, research
OPTION C- person with special skills. More on a professional level of a relationship between client and
nurse
OPTION D- people and groups that influence our self-concept, emotions, attitudes, and behavior
Situation 5 - The nurse engages the client in a nurse-patient interaction.
21. The best time to inform the client about terminating the nurse-patient relationship is
a. when the client asks, how long one relationship would be
b. during the working phase
c. towards the end of the relationship
d. at the start of the relationship
CORRECT ANSWER: D
RATIONALE: Termination begins in the orientation phase or at the start of the relationship. The date of the
termination phase should be clear from beginning to keep the client aware, less dependent on the nurse and avoid
developing a relationship more than that of a professional relationship. Also, to prevent separation anxiety.
OPTION A- you should not wait for the client to ask you how long your relationship would be. It is your obligation as
a nurse to inform him.
OPTION B- in the working phase, the nurse and client together identify and explore area’s in the client’s life that are
causing problems
OPTION C- Feelings are aroused in both the client and the nurse with regard to the experience they have had. If
you will tell the client that you will terminate your nurse-patient relationship towards the end of the relationship, it
would be difficult for the client to accept it and you might awaken the unresolved feelings of abandonment or
loneliness, or feelings of being rejected by others.
SOURCE: Varcaloris, Foundations of Psychiatric Mental Health Nursing, 4th ed, pp 232-235
22. The client says, "I want to tell you something but can you promise that you will keep this, a secret?" A therapeutic
response of the nurse is:
a. "Yes, our interaction is confidential provided the information you tell me is not detrimental to your safety."
b. "Of course yes, this is just between you and me. Promise!"
c. "Yes, it is my principle to uphold my client's rights."
d. "Yes, you have the right to invoke confidentiality of our interaction."
CORRECT ANSWER: A
RATIONALE: You are making your patient build a trusting relationship with you. Confidentiality means allowing only
those involved in the patient’s care to have access to any information that the patient divulges. The nurse must
define the boundaries of confidentiality to the patient. The nurse is clear that only members of the health care team
will have access to patient data. The team must have the data to care for the patient in the best manner possible.
OPTIONS B, C, D- it is non therapeutic to agree with the client. When the nurse agrees with the client, there is no
opportunity for the client to change his/her mind without being wrong
SOURCE: Videbeck, Psychiatric Mental Health Nursing 2nd ed, p 99
23. When the nurse respects the client's self-disclosure, this is a gauge for the nurse's:
a. trustworthiness
b. loyalty
c. integrity
d. professionalism
CORRECT ANSWER: A
RATIONALE: Nurse-client relationship requires trust. Trust builds when the client is confident in the nurse and the
nurse’s presence conveys integrity and reliability. Trust develops when the client believes that the nurse will be
consistent in his/her words and actions and respects the client’s self-disclosure, providing confidentiality.
OPTION B- it is a feeling of devotion, duty or attachment to somebody or something
OPTION C- the quality of possessing and steadfastly adhering to high moral principles or professional standards
OPTION D- character expected of a member of a highly trained profession
SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2nd ed, p 91
24. Building trust is important in:

a. orientation phase of the relationship
b. the problem identification subphase of the relationship
c. all phases of the relationship
d. the exploitation phase
CORRECT ANSWER: A
RATIONALE: It is during the orientation phase that the nurse begins to build trust with the client. It is the nurse’s
responsibility to establish a therapeutic environment that fosters trust and understanding. The nurse should share
appropriate information about himself/herself
OPTION B- part of the working phase, wherein client identifies the issues or concerns causing the
problem
OPTION D- during this phase the nurse guides the client to examine feelings and responses and develop
better coping skills and a more positive self-image; part of the working phase
SOURCE: Videbeck, Psychiatric Mental Health Nursing, 3rd ed, pp 93, 97
25. The client has not been visited by relatives for months. He gives a, telephone number and requests the nurse
to call. An appropriate action of the nurse would be:
a. Inform the attending psychiatric about the request of the client
b. Assist the client to bring his concern to the attention of the social worker
c. "Here (gives her mobile phone). You may call this number now."
d. Ask the client what is the purpose of contacting his relatives
CORRECT ANSWER: A
RATIONALE: Confidentiality is important during nurse-client interaction. No information will be discussed outside the
health care team. Only if information may be harmful for the client or others, information may be related to the other
nurses and the attending physician and only information that will be helpful in assisting the client toward recovery
will be provided to others. The attending psychiatrist or doctor will be informed regarding every concern of the
patient, for he will be the one who will decide about certain things pertaining to the concern of the client.
OPTION B- Social workers are secondary workers after the doctors.
OPTION C- Nurses must know that every decision is made by the attending physician. Before doing anything about
the concern of the patient, consult first.
OPTION D- Asking the client what is the purpose is not necessary because you already have the information that he
has not been visited by relatives for almost a month.
SOURCE: Shives, Basic concepts of Psychiatric Mental Health Nursing, 5th ed, p 133
Situation 6 - Camila, 25 years old, was reported to be gradually withdrawing and isolating herself from friends and family
members. She became neglectful of her personal hygiene. She was observed to be talking irrelevantly and incoherently.
She was diagnosed as schizophrenia
26. The past history of Camila would most probably reveal that her premorbid personality is:
a. schizoid
b. extrovert
c. ambivert
d. cycloid
CORRECT ANSWER: A
RATIONALE: A schizoid personality is characterized by a persistent pattern of detachment from social relationships
and a restricted range of emotional expression in interpersonal settings. They are aloof and indifferent, appearing
emotionally cold, uncaring or unfeeling (Videbeck, 352).
OPTION B- An extrovert is a person who is energized by being around other people. Extroverts tend to "fade" when
alone and can easily become bored without other people around. When given the chance, an extrovert will talk with
someone else rather than sit alone and think (about.com).
OPTION C- Ambiverts are the ones who fall between the two extremes of introversion and extroversion, possessing
some tendencies of each. They have a well-balanced personality (yahoo.com).
OPTION D- A cycloid personality is a person who tends to have periods of marked swings of mood, but within
normal limits.
27. Which of the following are considered the negative sign of schizophrenia?
a. Anhedonia, Restricted range of feelings, Catatonia
b. Delusions, hallucinations, disordered thinking
c. Ambivalence, Associative looseness, hallucinations
d. Alogia, Echopraxia, Ideas of reference
CORRECT ANSWER: A
RATIONALE: Schizophrenia has positive and negative symptoms. Positive or hard symptoms include ambivalence,
associative looseness, delusions, echopraxia, flight of ideas, hallucinations, ideas of reference and preservation.
Negative symptoms are alogia, anhedonia, apathy, blunted affect, catatonia, flat affect, lack of volition
OPTION B- positive symptoms
OPTION C- positive symptoms
OPTION D- alogia is a negative symptom, while the other two are positive symptoms
28. Which of the following disturbances in interpersonal relationships MOST often predispose, to the development of
schizophrenia?
a. Lack of participation in peer groups
b. Faulty family atmosphere and interaction
c. Extreme rebellion towards authority figures
d. Solo parenting
CORRECT ANSWER: B
RATIONALE: Interpersonal theorists suggested that schizophrenia resulted from dysfunctional relationships in early
life and adolescence. Therapists also believed that schizophrenia results from dysfunctional parenting or family
dynamics.
OPTION C- anti social personality disorder
SOURCE: Videbeck, Psychiatric Mental Health Nursing 3rd ed p 278
29. Schizophrenia is best described as a disorder characterized by:

a. Disturbed relationship related to an inability to communicate and think clearly
b. Severe mood swings and periods of low to high activity
c. Multiple personalities, one of which is more destructive than the others
d. Auditory and visual hallucinations
CORRECT ANSWER: A
RATIONALE: Schizophrenia can best be described as one of a group of psychotic reactions characterized by
disturbances in an individual’s relationship with people and an inability to communicate and think clearly
OPTION B- Severe mood swings and periods of low to high activity are typical of bipolar disorder
OPTION C- Multiple personality, which is sometimes confused with schizophrenia, is a dissociative disorder, not a
psychotic illness
OPTION D- Many schizophrenic patients have auditory, not visual hallucinations. Visual hallucinations are more
common in organic or toxic disorder
30. Schizophrenia is a/an:

a. anxiety disorder
b. neurosis
c. psychosis
d. personality disorder
CORRECT ANSWER: C
RATIONALE: Psychosis is a mental disorder of organic and emotional origin, and schizophrenia is an organic
disease with underlying physical brain pathology. Biologic theories of schizophrenia focus on genetic factors,
neuroanatomic and neurochemical factors
OPTION A- disorder in which anxiety is the most prominent feature
OPTION B- mental disorder in which the symptoms are distressing to the person, reality testing is intact
OPTION D- diagnosed when personality traits become inflexible and maladaptive and significantly interfere with how
a person functions in society or cause the person emotional distress
SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2nd ed, pp 299, 375 and Mosby, Mosby’s Pocket , 4th ed,
pp 93, 856
Situation 7 - Salome, 80 year old widow, has been observed to be irritable, demanding and speaking louder than usual.
She would prefer to be alone and take her meals by herself, minimized receiving visitors at home and no longer bothers to
answer telephone calls because of deterioration of her hearing. She was brought by her daughter to, the Geriatric clinic for
assessment and treatment.
31. The nurse counsels Salome's daughter that Salome's becoming very loud and tendency to become
aggressive is a/an:
a. beginning indifference to the world around her
b. attempt to maintain authoritative role
c. overcompensation for hearing loss
d. behavior indicative of unresolved repressed conflict of the part
CORRECT ANSWER: C
RATIONALE: It is not easy for older clients to experience a slowing of their mental and physical reactions and be
unable to do anything about it or to look on younger people perform their job and assume their role. Various
emotional and behavioral reactions occur as people undergo physiologic changes of the aging process. These
reactions include anxiety, frustration, fear depression, intolerance, loneliness, decreased independence, decreased
productivity and low self-esteem.
OPTION A- experienced by ages 60-65 during retirement stage
OPTION B- a defense mechanism used by elder people in trying to establish a comfortable routine after retirement
SOURCE: Shives, Psychiatric-Mental Health Nursing, 5th ed, pp 593-594
32. A nursing diagnosis for Salome is:

a. sensory deprivation
b. social isolation
c. cognitive impairment
d. ego despair
CORRECT ANSWER: A
RATIONALE: Salome is observed to be demanding and speaking louder than usual due to deterioration of her
hearing.
33. The nurse will assist Salome and her daughter to plan a goal which is:
a. adjust to the loss of sensory and perceptual function
b. participate in conversation and other social situations
c. accept the steady loss of hearing that occurs with aging
d. increase her self-esteem to maintain her authoritative role
CORRECT ANSWER: A
RATIONALE: aging necessitates adjustment to different roles, relationships, responsibilities, changes in self-image,
independence and changes in physical, emotional, mental and spiritual aspects of life.
OPTION B- let her adjust to the situation first before you make her participate in conversation and other social
situations
OPTION C- just a matter of acceptance, no action involved
SOURCE: Videbeck, Psychiatric Nursing Care Plans, 7th ed, p 18
34. The daughter understood the following ways to assist Salome meet her needs and avoiding which of the following:
a. Using short simple sentences
b. Speaking distinctly and slowly
c. Speaking at eye level and having the client's attention
d. Allowing her to take her meals alone
CORRECT ANSWER: D
RATIONALE: Allowing her to take her meals alone is like depriving her of care and treatment she deserves. It will
make her feel more sad and alone
OPTIONS A, B, C- Communicating with the hearing impaired includes: a.) when speaking, always face the person
directly as possible b.) make sure your face is as clear as possible. Locate yourself so that your face is well lighted
c.) speak slowly and distinctly and use short and simple sentences
SOURCE: Smeltzer, S.C. Medical-Surgical Nursing, 9th ed, p 1588
35. Salome was fitted a hearing aid. She understood the proper use and wear of this device when she ways that the
battery should be functional, the device is turned on and adjusted to a:
a. therapeutic level
b. comfortable level
c. prescribed level
d. audible level
CORRECT ANSWER: D
RATIONALE: Hearing aid programming software and real ear measurement equipment allow the hearing aids to be
individually customized to optimize the hearing aid fitting for the child and to assure the speech signal is delivered at
the most appropriate listening levels. The goal of digital hearing aids is to deliver soft sounds at an audible level.
Hearing aids should be turned on to a minimal level to avoid feedback.
Situation 8 - For more than a month now, Cecilia is persistently feeling restless, worried and feeling as if something
dreadful is going to happen. She fears being alone in places and situations where she thinks that no one might come to
rescue her just in case something happens to her.
36. Cecilia is demonstrating:

a. acrophobia
b. claustrophobia
c. agoraphobia
d. xenophobia
CORRECT ANSWER: C
RATIONALE: Agoraphobia involves intense, excessive anxiety or fear about being in places or situations from which
escape might be difficult or embarrassing, or in which help might not be available if a panic attack occurred.
OPTION A- Acrophobia is the fear of high places.
OPTION B- Claustrophobia is the fear of closed places.
OPTION D- Xenophobia is the fear of foreign places or strangers.
SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4th ed, pp 311& 313
37. Cecilia's problem is that she always sees and thinks negative hence she is always fearful. Phobia is a symptom
described as:
a. organic
b. psychosomatic
c. psychotic
d. neurotic
CORRECT ANSWER: D
RATIONALE: pertaining to neurosis, a category of mental disorder in which the symptoms are distressing to the
person, reality testing is intact, behavior does not violate gross social norms and there is no apparent organic cause.
The person who is neurotic is said to be emotionally unstable
OPTION A- organic disease or condition is any disease associated with detectable or observable changes in one or
more body organs
OPTION B- expression of an emotional conflict through physical symptoms
OPTION C- not in contact with reality
SOURCE: Mosby, Mosby’s Pocket Dictionary,4th ed, pp 856, 900, 1049, 1050
38. Cecilia has a lot of irrational thoughts: The goal of therapy is to modify her:
a. communication
b. cognition
c. observation
d. perception
CORRECT ANSWER: B
RATIONALE: Irrational thoughts refer to the impaired cognition of the person. It is the inability to think properly and
reasonably. Cognition is the mental process characterized by knowing, thinking, learning, understanding and
judging. Cognitive Therapy is a treatment of mental and emotional disorders that help a person change attitudes,
perceptions and patterns of thinking
OPTION A- has nothing to do with irrational thoughts
OPTION C- observation is an act of watching carefully and attentively, and it’s not related with treatments for
irrational thoughts
OPTION D- perception is the conscious recognition and interpretation of sensory stimuli that serve as a basis for
understanding, learning and knowing
SOURCE: Mosby, Mosby’s Pocket Dictionary, 4th ed, pp 258, 880, 959
39. Cognitive therapy is indicated for Cecilia when she is already able to handle anxiety reactions. Which of the
following should the nurse implement?
a. assist her in recognizing irrational beliefs and thoughts
b. help find meaning in her behavior
c. provide positive reinforcement for acceptable behavior
d. administer anxiolytic drug
CORRECT ANSWER: A
RATIONALE: Cognitive Behavior Therapy (CBT) helps improve a person’s moods and behavior by examining
confused or distorted patterns of thinking. During CBT the person learns that thoughts cause feelings and moods
which can influence behavior.
40. After discharge, which of these behaviors indicate a positive result of being able to overcome her phobia?
a. she read a book in the public library
b. she drives alone along the long expressway
c. she watches television with the family in the recreation room
d. she goes out with a friend
CORRECT ANSWER: A
RATIONALE: Reading a book in the public library indicates that the client has overcome her fear of being in an open
or public place, knowing that agoraphobics avoids being alone outside
OPTION B- driving alone doesn’t involve too much people
OPTION C- family is the comfort zone of the client
Situation 9 - it is the first day of clinical experience of nursing students at the Psychiatry Ward- During the orientation, the
nurse emphasizes that the team members including nursing students are legally responsible to safeguard patient's records
from loss or destruction or from people not authorized to read it.
41. It is unethical to tell one's friends and family member's data bout patients because doing so is violation of patients'
rights to:
a. Informed consent
b. Confidentiality
c. Least restrictive environment
d. Civil liberty
CORRECT ANSWER: B
RATIONALE: Confidentiality means respecting the client’s right to keep private information about his or her mental
and physical health and related care
OPTION A- obtained when a client is subjected to surgery, electroconvulsive treatment or the use of experimental
drugs or procedures
OPTION C- means that a client does not have to be hospitalized if he or she can be treated in an outpatient setting
or in a group home. It also means that the client must be free of restraint or seclusion unless it is necessary
OPTION D- curtails the client’s right to freedom-the ability to leave the hospital when he or she wishes.
SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4th ed, p170 and Videbeck, Psychiatric
Mental health Nursing, 3rd ed, p 169, 170 & 171
42. The nurse must see to it that the written consent of mentally ill patients must be taken from:
a. Doctor
b. Social worker
c. Parents or legal guardian
d. Law enforcement authorities
CORRECT ANSWER: C
RATIONALE: A mentally incompetent person cannot legally consent to medical or surgical treatment. The consent
must be taken from the parents or legal guardian.
SOURCE: Venzon, Professional Nursing in the Philippines, 10th ed. p175
43. In an extreme situation and when no other resident or intern is available, should a nurse receive, telephone orders,
the order has to be correctly written and signed by the physician within.
a. 24 hours
b. 36 hours
c. 48 hours
d. 12 hours
CORRECT ANSWER: A
RATIONALE: Once the order is transcribed on the physician’s order sheet, the order must be countersigned by the
physician within a time period described by agency policy, but many acute care hospitals require that this be done
within 24 hours.
SOURCE: Kozier, Fundamentals of Nursing, 7th ed, p 346
44. The following are SOAP (Subjective - Objective - Analysis -Plan) statements on a problem: Anxiety about diagnosis.
What is the objective data?
a. Relate patient's feelings to physician initiate and encourage her to verbalize her fears give emotional support
by spending more time with patient, continue to make necessary explanations regarding diagnostic test.
b. Has periods of crying, frequently verbalizes fear of what diagnostic tests will reveal
c. Anxiety due to the unknown
d. "I'm so worried about what else they'll find wrong with me"
CORRECT ANSWER: B
RATIONALE: Objective Data consist of information that is measured or observed by use of the senses
OPTION A- it is more of planning the care for the client
OPTION C- it is assessment or analysis drawn about the subjective and objective data
OPTION D- subjective data—information obtained from what the client says
SOURCE: Kozier, Fundamentals of Nursing, 7th ed, p 332
45. Nursing care plans provide very meaningful data for the patient profile and initial plan because the focus is on the:
a. Summary of chronological notations made by individual’s health team members
b. Identification of patient's responses to medical diagnosis and treatment
c. Patient's responses to health and illness as a total person in interaction with the environment
d. Step procedures for the management of common problems
CORRECT ANSWER: C
RATIONALE: Nursing Care Plan is a plan based on a nursing assessment and a nursing diagnosis carried out by a
nurse. It has four essential components: a.) identification of the nursing care problems b.) statement of the expected
benefit to the patient c.) statement of the specific actions by the nurse that reflect the nursing approach and achieve
the goals specified d.) evaluation of the patient’s response to nursing care and readjustment of that care as required
OPTION A- source-oriented record—each person or department makes notations in a separate section or section’s
in he client’s chart
OPTION B- progress notes—provides information about the progress a client is making toward achieving the
desired outcomes
OPTION D- nursing intervention—part of the nursing care plan
SOURCE: Kozier, Fundamentals of Nursing, 7th ed, 330, 339 and Mosby’s Pocket Dictionary, 4th ed, p 874
Situation 10 - Marie is 5 years old and described by the mother as bedwetting at night.
46. Which of the following is NOT a common cause of night bedwetting?

a. deep sleep factors
b. abnormal bladder development or structure problems
c. infections familial and genetic factors
d. drinking plenty of water before sleep
CORRECT ANSWER: D
RATIONALE: Bedwetting or enuresis is the involuntary urination during the day or at night into clothing or bed by a
child at least 5 years of age either chronologically or developmentally (Videbeck, 465). Bed-wetting isn't caused by
drinking too much before bedtime. Causes of bedwetting are, genetic factors (it tends to run in families), difficulties
waking up from sleep, slower than normal development of the central nervous system--this reduces the child's ability
to stop the bladder from emptying at night, hormonal factors (not enough antidiuretic hormone--this hormone
reduces the amount of urine made by the kidneys), urinary tract infections and inability to hold urine for a long time
because of small bladder (familydoctor.org).
47. All of the following, EXCEPT one comprise the concepts of behavior therapy program:
a. reward and punishment
b. extinction
c. learning
d. placebo as a form treatment
CORRECT ANSWER: D
RATIONALE: Behavior therapy is based on learning theory. It focuses on modifying observable and, at least in
principle, quantifiable behavior by means of systematic manipulation of the environment and variables thought to be
functionally related to behavior. Behaviorists believed that problem behaviors are learned, and therefore can be
eliminated or replaced by desirable behaviors through new learning experiences. Behavior therapy techniques
include behavior modification and systematic desensitization, aversion therapy, modeling, operant conditioning.
SOURCE: Shives, Psychiatric-Mental health Nursing, 5th ed, p 153
48. To help Marie who bed wets at night practice acceptable and appropriate behavior, it is important for the parents to
be consistent with the following approaches EXCEPT:
a. discipline with a king attitude
b. matter of fact in handling the behavior
c. sympathize for the child
d. be lowing yet firm
CORRECT ANSWER: A
RATIONALE: Bed wetting is modified and/or eliminated through behavior modification. Reinforcing positive
behaviors. Rewarding the desired behavior and withholding rewards for undesirable behaviors. Disciplining the child
in a king attitude will intimidate the child and make her feel that everything is her fault. The child might develop a low
self-esteem. Situation must be handled in a matter of fact attitude, sympathizing the child, be lowing yet firm and not
being too strict and demanding.
SOURCE: Shives, Basic concepts of Psychiatric-Mental Health Nursing, 5th ed, p153
49. Which of the following is used to treat enuresis?

a. Imipramine (Tofranil)
b. Methylphenidate (Ritalin)
c. Olanzapine (Zyprexa)
d. Resperidone (Risperdal)
CORRECT ANSWER: A
RATIONALE: Enuresis can be treated effectively with Imipramine (Tofranil), an antidepressant with a side effect of
urinary retention.
OPTION B- CNS stimulant use to treat patient’s with ADHD
OPTION C- Antipsychotic use to treat Schizophrenia
OPTION D- Antipsychotic, short-term treatment of schizophrenia
SOURCE: Lippincott Williams & Wilkins, Nursing Drug Handbook, 26th ed, pp 454, 495, 490, 509
50. During your conference, the parent inquires how to motivate Marie to be dry in the morning. Your response which is
an immediate intervention would be:
a. Give a star each time she wakes up dry and every set of five stars, give a prize
b. Tokens make her materialistic at an early age. Give praise and hugs occasionally
c. What does your child want that you can give every time he/she wakes up dry in the morning?
d. Promise him/her a long awaited vacation after school is over.
CORRECT ANSWER: B
RATIONALE: Behavior modification is based on the principle that behavior that is rewarded is more likely to be
repeated. Developmentally appropriate behaviors are normally rewarded with validation by a significant adult in the
child’s life, so modifying behavior in this manner is a standard parenting technique.
SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4th ed, pp 875-876
Situation 11 - The nurse is often met with the following situations when clients become angry and hostile.
51. To maintain a therapeutic eye contact and body posture while interacting with angry and aggressive individual, the
nurse should:
a. keep an eye contact while staring at the client
b. keep his/her hands behind his/her back or in one's pocket
c. fold his/her arms across his/her chest
d. keep an "open" posture, e.g. Hands by sides but palms turned outwards
CORRECT ANSWER: D
RATIONALE: The nurse should approach the client who is angry and hostile in a nonthreatening, calm manner and
non aggressive posture while maintaining personal safety
OPTION A- it’s like challenging the behavior of the client which is not therapeutic
OPTION B- it may be misinterpreted by the client that you will try to harm him/her, especially if the client is paranoid
OPTION C- shows a “close”, aggressive posture
52. During the pre-interaction phase of the N-P relationship the nurse recognizes this normal INITIAL reaction to an
assaultive or potentially assaultive person.
a. To remain and cope with the incident
b. Display empathy towards the patient
c. To call for help from the other members of the team
d. To stay and fight or run away
CORRECT ANSWER: B
RATIONALE: Approach should be nonthreatening and in a calm manner. Conveying empathy for the client’s anger
or frustration is important. The nurse can encourage the client to express his/her angry feelings verbally, suggesting
that the client is still in control and can maintain that control.
OPTION A- Respond as early as possible

OPTION C-Calling for help is not an initial reaction. It is necessary if the client becomes very physically aggressive
OPTION D- Always maintain control of yourself and the situation; remain calm. Your behavior provides a role model
for the client and communicates that you can and will provide control.
SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2nd ed, pp 197, 198, 203
53. Which of the following is an accurate way of reporting and recording an incident?
a. "When asked about his relationship with his father, client became anxious."
b. "When asked about his relationship with his father, client clenched his jaw/teeth made a fist and turned
away from the nurse."
c. "When asked about his relationship with his father, client was resistant to respond."
d. "When asked about his relationship with his father, his anger was suppressed."
CORRECT ANSWER: B
RATIONALE: Recording and reporting should be documented descriptively or completely. It should describe every
action and/or behavior undertaken by the client.
OPTION A, C and D—very vague descriptions. It doesn’t show the manifestations of each behavior.
54. To encourage thought. Which of the following approaches is NOT therapeutic?

a. "Why do you feel angry?"
b. "When do you usually feel angry?"
c. "How do you usually express anger?"
d. "What situations provoke you to be angry?"
CORRECT ANSWER: A
RATIONALE: It is non therapeutic because it requests an explanation from the client. There is a difference between
asking the client to describe what is occurring or has taken place and asking him to explain why. Usually, a “why”
question is intimidating. In addition, the client is unlikely to know “why” and may become defensive trying to explain
himself or herself.
OPTION B, C, D- Placing event in time or sequence—putting events in proper sequence helps both the nurse and
client to see them in perspective. The client may gain insight into cause-and-effect behaviour and consequences.
SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2nd ed, pp 117, 120
55. A patient grabs a chair and about to throw it. The nurse best responds saying.
a. "Stop. Put that chair down."
b. "Don't be silly."
c. "Stop, the security will be here in a minute."
d. "Calm down."
CORRECT ANSWER: A
RATIONALE: The client is about to loss control of himself. The nurse must take control of the situation and should
provide directions to the client in a calm, firm voice. The nurse should tell the client that aggressive behavior is not
acceptable and that the nurse is there to help the client regain control.
OPTION B- Ignoring the situation and belittling the client’s capabilities.
OPTION C- Threatening the client can lead to a more aggressive behavior
OPTION D- It is true if the client is still in the triggering phase of aggressive behavior.
Situation 12 - Nursing care for the elderly.
56. In planning care for a patient with Parkinson's disease, which of these nursing diagnoses should have priority?
a. potential for injury
b. altered nutritional state
c. ineffective coping
d. altered mood state
CORRECT ANSWER: A
RATIONALE: The client has neuromuscular impairment, such as muscle weakness, tremors, bradykinesia and
musculoskeletal impairment as manifested by joint rigidity; therefore the patient is potential for having an injury.
OPTION B- Secondary nursing diagnosis
OPTION C- not related to parkinson’s disease
OPTION D- not related to parkinson’s disease
SOURCE: Black et al, Medical-Surgical Nursing, 7th ed, vol. 2, p 2174
57. A healthy adaptation to aging is primarily related to an individual.

a. Number of accomplishments
b. Ability to avoid interpersonal conflict
c. Physical health throughout life
d. Personality development in his life span
CORRECT ANSWER: C
RATIONALE: Physical health also can influence how a person responds to psychosocial stress and illness. The
healthier a person is, the better he or she can cope with stress and illness.
OTHER OPTIONS—secondary reasons for healthy adaptation
SOURCE: Videbeck, Psychiatric Mental Health Nursing, 3rd ed, p132
58. The frequent use of the older client's name by the nurse is MOST effective in alleviating which of the following
responses to old age?
a. Loneliness
b. Suspicion
c. Grief
d. Confusion
CORRECT ANSWER: D
RATIONALE: Client’s with delirium cannot focus, sustain or shift attention effectively, and there is impaired recent
and immediate memory. To manage client’s confusion, the nurse provides orienting cues when talking with clients,
such as calling them by name and referring to the time of the day or expected activity.
OPTION A- a lot of things causes loneliness to an elderly person, such as death of a spouse or relative, pain,
certain times of the day or night. The role f the nurse is to let the client verbalize feelings and grow from the
experience
OPTION B- loss of sight or hearing, sensory deprivation and physical impairment often contribute to suspiciousness
in elderly persons. Aging persons may feel that others are talking about them or conspiring against them. Nursing
care focuses on establishing rapport; enhancing self-esteem; decreasing fears and suspicions; utilizing listening and
acceptance
OPTION C- loss of a spouse or loved one is the most stressful event across all ages. The role of the nurse as the
facilitator in grief work is to help the client accept the loss, express feelings about the loss and learn and grow from
the experience.
SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2nd ed, p517; Shives, Psychiatric Mental Health Nursing, 5th
ed, pp 288, 597, 598, 604
59. An elderly confused client gets out of bed at night to go to the bathroom and tries to go to another bed when she
returns. The MOST appropriate action the nurse would take is to:
a. Assign client to a single room
b. Leave a light on all night
c. Remind client to call the nurse when she wants to get up
d. put side rails on the bed
CORRECT ANSWER: A
RATIONALE: It may be difficult for client to be with other patients and engage them in a conversation because they
are easily distracted and display marked attention deficits. Memory is often impaired. Assigning the client to a single
room will help prevent the client from wandering; promote safety and decrease confusion.
OPTION B- comes after assigning the client into a single room. It also promotes safety
OPTION C- it fosters dependency to the nurse which is not therapeutic
OPTION D- client’s who are confused have errors in perception of sensory stimuli. They might mistake some objects
into something dreadful and although putting the side rails up can promote safety, patients need to be oriented first
about why there is a need for side rails because they might think that they are being held captive. It often becomes
the object of the client’s projected fear.
SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4th ed, p 578, 579
60. An elderly who has lots of regrets, unhappy and miserable is experiencing:
a. Crisis
b. Despair
c. Loss
d. Ambivalence
CORRECT ANSWER: B
RATIONALE: If an individual does not develop as sense of satisfaction with life and its meaning and believe that life
is not fulfilling and unsuccessful, that person is undergoing despair. They can’t adapt to the changing environment
and can’t overcome what has been referred to as “season of losses”.
OPTION A- Occurs when a person, family or group is inadequately prepared to handle the event or situation.
Normal coping methods fail, tension rises and feelings of anxiety, fear, guilt, anger, shame and helplessness may
occur.
OPTION C- A person experiences a feeling of loss when a spouse or relative dies
OPTION D- Presence of two opposing ideas, emotions, feelings at the same time.
SOURCE: Shives, Basic concepts of Psychiatric Mental Health Nursing, 5th ed, pp 161, 596
Situation 13 – Graciela, 1 year old is admitted in the hospital from the emergency room with a fracture of the left femur due
to a fall down a flight of stairs. Graciela is placed oh Bryant's traction.
61. While on Bryant's traction, which of these observations of Graciela and her traction apparatus would indicate a
decrease in the effectiveness of her traction?
a. Graciela's buttocks are resting on the bed
b. The traction weights are hanging 10 inches above the floor
c. Graciela's legs are suspended at a 90 degree angle to her trunk
d. The traction ropes move freely through the pulley
CORRECT ANSWER: A
RATIONALE: Bryant’s traction is a type of running traction in which the pull is only in one direction. Skin traction is
applied to the legs, which are flexed at a 90-degree angle at hips. The child’s trunk provides counter traction.
Buttocks are raised slightly off the bed. Traction weights are hanging 10 in above the floor and ropes move freely
through the pulley.
SOURCE: Hockenberry, Wong’s Essential of Pediatric Nursing, 7th ed, p 1161
62. The nurse notes that the fall might also cause a possible head injury- She will be observed for signs of increased
intracranial pressure which include:
a. Narrowing of the pulse pressure
b. Vomiting
c. Periorbital edema
d. A positive Kernig's sign
CORRECT ANSWER: B
RATIONALE: Manifestations of increased ICP are subtle and diligent observation for changes in the client’s
condition is necessary. Clinical manifestations include, any alteration in LOC, changes in speech, papillary reactivity
headache, nausea, vomiting, diplopia (blurred or double vision), papilledema,increased systolic blood pressure with
widened pulse pressure and bradycardia—late response and indicates severe increased ICP
OPTION A- Increased systolic blood pressure with widened pulse pressure not narrowed
OPTION C- There is papilledema instead of periorbital edema, due to increased tension in the skull that is
transmitted to the optic nerve
OPTION D- Kernig’s sign is a diagnostic sign for meningitis marked by loss of the ability of a supine patient to
completely straighten the leg when it is full flexed at the knee and hip
SOURCE: Black et al, Medical- Surgical Nursing, 7th ed, pp 2191-2192
63. Graciela is assessed to have no head injury. The Bryant's traction is removed. A plaster of paris is applied to his
spica. Which of these finding as a concern of immediate attention that must be reported to the physician
immediately?
a. Graciela is scratching the cast over her abdomen
b. The toes of Graciela's left foot blanch when the nurse applies pressure on them
c. Graciela's cast is still damp
d. The nurse is unable to insert a finger under the edge of Graciela's cast on her left foot
CORRECT ANSWER: D
RATIONALE: If the nurse is unable to insert a finger under the patient’s cast it means the client is suffering from
compartment syndrome, brought about by excessive swelling that constricts the enclosed soft tissue
OPTION A-
OPTION B- Normal capillary refill is about 2-3 seconds. Blanching of the foot when pressure is applied is normal.
OPTION C- As the water from newly applied cast eventually evaporates, a mature cast of full strength develops.
Plaster casts set quickly but take hours to days to dry completely
SOURCE: Black et al, Medical- Surgical Nursing, 7th ed, pp 631, 633-634
64. Part of discharge plan is for the nurse to give instructions about the care of Graciela's cast to the mother.
Which of statement by the mother indicates a need for further instructions?
a. “The cast may feel warm as the cast dries.”
b. “If the cast becomes wet, a blow drier set on the cool setting may be used to dry cast.”
c. “A small amount of white shoe polish can touch up a soiled white cast.”
d. “I can use lotion or powder around the cast edges to relieve itching.”
CORRECT ANSWER: D
RATIONALE: The mother must be instructed not to use lotion or powders on the skin around the cast edges or
inside the cast, since lotions and powders can become sticky, caked and cause skin irritation.
OPTION A- Feeling of warmth is normal when the cast is starting to dry up.
OPTION B- If the cast gets wet, it can be dried with a hair dryer set to a cool setting to prevent skin breakdown.
OPTION C- White shoe polish is used to touch up the soiled edges of a white cast.
SOURCE: Silvestri, Saunder’s Comprehensive Review for the NCLEX-RN, 3rd ed, p 1004
65. The nurse counsels Graciela's mother ways to safeguard safety while providing opportunities of Graciela to develop
a sense of:
a. Trust
b. Initiative
c. Industry
d. Autonomy
CORRECT ANSWER: D
RATIONALE:
STAGE POSITIVE EFFECT NEGATIVE EFECT
Infancy (0-1 ½ yrs) Sound basis for relating General difficulties
>Trust vs. Mistrust to other people relating to people effectively;
trust-fear conflict
Toddlerhood (1 ½-3 yrs) Sense of self-control and Independence-fear
>Autonomy vs. Shame & adequacy; free will conflict; sever feelings of self-
Doubt doubt
Preschool (3-6 yrs) Ability to initiate one’s Aggression-fear conflict;
>Initiative vs. Guilt own activities; sense of purpose sense of inadequacy or guilt
School Age (6-12 yrs) Competence; ability to Sense of inferiority;
>Industry v. Inferiority work difficulty learning and working
Situation 14 - Jolina is an 18 year old beginning college student. Her mother observed that she is having problems relating
with her friends. She is undecided about her future. She has lost insight, lost interest in anything and complained and
complained of constant tiredness.
66. Jolina is out on antidepressant drugs. These drugs act on the brain chemistry, therefore they would be useful in
which type of depression?
a. exogenous depression
b. neurotic depression
c. endogenous depression
d. psychotic depression
CORRECT ANSWER: B
RATIONALE: Neurotic depression is any state of depression that is not psychotic. Neurotic disorders are mental
disorders without any demonstrable organic basis in which the patient may have considerable insight and has
unimpaired reality testing, in that he usually does not confuse his morbid subjective experiences and fantasies with
external reality.
OPTION A- Exogenous depression is an inappropriate state of depression that is precipitated by events in the
person's life.
OPTION C- Endogenous depression is a severe form of depression usually characterized by insomnia, weight loss,
and inability to experience pleasure, thought to be of internal origin and not influenced by external events. Also
called melancholia.
OPTION D- Psychotic depression is a state of depression so severe that the person loses contact with reality and
suffers a variety of functional impairments.
67. This is a tricyclic antidepressant drug:

a. Venlafaxine (Effexor)
c. Setraline (Zoloft)
b. Flouxetine (Prozac)
d. Imipramine (Tofranil)
CORRECT ANSWER: D
RATIONALE: TCAs are thought to act primarily by blocking the reuptake of norepinephrine and to a lesser degree,
serotonin.
OPTION A- it is a novel antidepressant. Venlafaxine blocks the reuptake of both norepinephrine and serotonin
OPTION B- it is a SSRI that preferentially block the reuptake and thus the destruction of serotonin, with little or no
effect on the other monoamine transmitters
OPTION C- still a SSRI.
SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4th ed, pp 69, 72-73
68. After one week of antidepressant medication, Jolina still manifests depression. The nurse evaluates this as;
a. Unusual because action of antidepressant drug is immediate
b. Unexpected because therapeutic effectiveness takes within a few days
c. Expected because therapeutic effectiveness takes 2-4 weeks
d. Ineffective result because perhaps the drug's dosage is inadequate
CORRECT ANSWER: C
RATIONALE: One drawback to the use of antidepressant medication is that the client may have to take the
antidepressant agents for 1-3 weeks before improvement is noticed.
OPTION A- antidepressants doesn’t take effect immediately
OPTION B- it is expected because antidepressants take effect 2-3 weeks after ingestion
OPTION D- it is not ineffective
69. Jolina continues to verbalize feeling sad and hopeless. She is not mixing well with other clients. One of the nurse's
important consideration for Jolina initially is to:
a. Formulate a structured schedule so she is able to channel her energies externally
b. Let her alone until she feels like mingling with others
c. Encourage her to join socialization hour so she will start to relate with others
d. Encourage her to join group therapy with other patients
CORRECT ANSWER: C
RATIONALE: Often clients decline to engage in activities because they are too fatigued or have no interest. The
nurse can validate these feelings yet still promote participation. The nurse can let clients know they must become
more active to feel better rather than waiting passively for improvement.
OPTION A- Not applicable for depressed client
OPTION B- The first priority is to determine whether a client is suicidal. Depressed client are more likely to be
suicidal. Suicide precautions must be instituted. The client must not be left alone.
OPTION D- Group therapy is indicated for schizophrenic clients and personality disorder
SOURCE: Videbeck, Psychiatric Mental Health Nursing, 3rd ed, pp 319, 322
70. During the predischarge conference, the nurse suggests vocational guidance because it should help Jolina to:
a. Find a good job
b. Make some decision about her future
c. Realistically assess her assets and limitations
d. to solve her own problems
CORRECT ANSWER: C
RATIONALE: Vocational guidance aims to determine client’s interests and abilities and matching them with
vocational choices.
OPTION A- comes after the client has assess her assets and limitations
OPTION B- goal of psychotherapy
OPTION D- still with psychotherapy
Situation 15 - Group Approach in Nursing.
71. Membership drop out generally occurs in group therapy after a member:
a. Accomplishes his goal in joining the group
b. Discovers that his feelings are shared by the group members
c. Monopolizes the group
d. Discusses personal concerns with group members
CORRECT ANSWER: C
RATIONALE: A person who monopolizes the group uses his compulsive speech as an attempt to deal with anxiety.
As the client sees group tension grow, the client’s level of anxiety rises and the client’s tendency to speak increases
even more. Therefore no one else gets the chance to be heard, and other group members eventually lose interest
and begin to withdraw. Also client’s who experiences feelings of frustration in the group drops out from it.
OPTIONS A, B and D- shows that the client is interested in the group, happy to be in the group, fulfilled as a person
and has overcome her undesirable behaviors.
72. Which of the following questions illustrates the group role of encourager?
a. What were you saying?
b. Who wants to respond next?
c. Where do you go from here?
d. Why haven't we heard from you?
CORRECT ANSWER: B
RATIONALE: Asking who wants to respond next is encouraging client to express self with out forcing the client to do
it.
OPTION A- It’s like forcing the client to participate. Not therapeutic
OPTION C- Testing the client forces the client to respond
OPTION D- Why questions are intimidating and makes client defensive.
73. The goal of remotivation therapy is to facilitate:

a. Insight
b. Productivity
c. Socialization
d. Intimacy
CORRECT ANSWER: B
RATIONALE: Remotivation therapy resocializes regressed and apathetic clients, reawakens interest in their
environment, increases participants’ sense of reality and productivity and realizes more objective self image.
OPTION C- is true in reminiscing therapy
74. The treatment of the family as a unit is based on the belief that the family:
a.is a social system and all the members are interrelated components of that system
b.as a unit of society needs the opportunity to change its own destiny
c. who has therapy together will tend to remain together
d.is "contaminated" by the presence of deviant member and all members need treatment
CORRECT ANSWER: A
RATIONALE: Family is a group related by heredity, such as parents, children and siblings. It is a social unit and all
members are interrelated with each other. Although one family member usually is identified initially as the one who
has problems and needs help, it often becomes evident through the therapeutic process that other family members
also have emotional problems and difficulties.
75. The working phase in therapy group is usually characterized by which of the following?
a. Caution
b. Cohesiveness
c. Confusion
d. Competition
CORRECT ANSWER: B
RATIONALE: During the working phase, several group characteristics may be seen. Group cohesiveness is the
degree to which members work together cooperatively to accomplish the purpose. Cohesiveness is a desirable
group characteristic and is associated with positive group outcomes. Cohesiveness is evidenced when members
value one another’s contributions to the group.
OPTION D- Some groups exhibit competition, or rivalry, among members. This may positively affect the outcome of
the group if the competition leads to compromise, improved group performance. Many times, however, competition
can be destructive for the group.
Situation 16 – It is the nurse’s primary responsibility to ensure a safe environment for the patients at the Psychiatry Ward.
76. All of the following concepts are true, EXCEPT:

a. Hostility is destructive
b. Frustration develops in response to unmeet needs, wants and desires
c. Anger is incompatible with love
d. Aggression can be expressed in a constructive as well as destructive manner
CORRECT ANSWER: D
RATIONALE: Aggression is a threatening behavior or action. It is a behavior in which a person attacks or injures
another person or involves destruction of property. It is expressed in a destructive manner.
OPTION A- Hostility is an emotion expressed through verbal abuse or threatening behavior. It intends to intimidate
or cause emotional harm to another. It can lead to aggression.
OPTION B- When goals are thwarted or desires are unsatisfied, frustration develops.
OPTION C- Anger is the opposite of love. They can’t go together due to basic differences.
SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2nd ed, p193
77. Carlo is acting out hostile and aggressive feelings such as yelling, agitated, threatening, clenched fist, threatening
gestures, hostility. The MOST effective way to deal with Carlo’s behavior is initially to:
a. set limits on the behavior by verbal command
b. administer prn tranquilizer
c. remove the harmful objects from the room
d. restrain the patient and place him in the “Isolation Room”
CORRECT ANSWER: A
RATIONALE: Carlo is in the escalating phase of aggression. The nurse must take control of the situation. The nurse
should provide directions to the client in a calm, firm voice and tell the client that aggressive behavior is not
acceptable
OPTION B- prn tranquilizers should be offered if ordered by the physician in the triggering phase
OPTION C- removing of harmful objects is not necessary in the escalating phase
OPTION D- Restraining the patient is required in the crisis phase, wherein client loses control emotionally and
physically, throwing objects, kicking, hitting, screaming, etc. The staff must take charge of the situation for the safety
of the client, staff and other clients
78. Mrs. Dizon was visiting her son at the Psychiatry Ward. Which of the following items will the nurse not allow to be
brought inside the ward?
a. string rosary bracelet
b. box of cake
c. bottle of coke
d. rubber shoes
CORRECT ANSWER: C
RATIONALE: When the patient becomes physically aggressive, he/she can broke the bottle of coke and injure
him/her own self, the staff and even other patients. The environment must be free from potentially harmful objects.
Promote safety of patients, other clients and the staff.
OPTION A- A bracelet is too small to cause harm
OPTION B- No harm at all
OPTION D- Although it is painful being hit by a rubber shoes, but the damage is not fatal.
79. Which of the following will probably be most therapeutic for a patient on a behavioral modification ward?
a. if the client is agitated, discuss the feelings especially anger
b. insist to stop obscene language by verbal reprimand
c. give client support and positive feedback for controlling use of obscene language
d. provide a punching bag as an alternative to express upset emotions
CORRECT ANSWER: C
RATIONALE: Behavior Modification is a method of attempting to strengthen a desired behavior or response by
reinforcement, either positive or negative. The group leader provides positive reinforcement by giving the client
attention and positive feedback. Negative reinforcement involves removing a stimulus immediately after a behavior
occurs.
OPTION A- Although making the client verbalize his/her feelings is therapeutic, but the focus of behavior
modification is reinforcing the desired behavior.
OPTION B- Insisting the client to stop by verbal reprimand can stir up argument and promote more aggressive
behavior
OPTION D- Providing a punching bag can help to reduce upset emotions but you are not confronting the client
directly. Nurses must be firm and direct in modifying the aggressive behavior
80. Which of the following must be considered while planning activities for the depressed patient?
a. activities which require exertion of energy
b. challenging activities to get him out of his depression
c. reading materials to divert his thoughts
d. variety of unstructured activities
CORRECT ANSWER: A
RATIONALE: In dealing with depressed clients, one must consider the client’s energy level. Activities that require
exertion of energy is best for depressed clients because the more energy the task requires, the
less energy the client will have to engage in hostile, aggressive behavior and self inflicted harm
OPTIONS B & C—Depressed clients have impaired cognition and inability to concentrate. They will not be able to
comprehend or think well if you will engage them in challenging activities and make them read.
OPTION D- They should be involved in simple tasks to enhance their self-esteem and encourage concentration.
Unstructured activities could bring about more impaired cognition and decrease concentration
SOURCE: Shives, Basic concepts of Psychiatric-Mental Health Nursing, 5th ed, pp 302, 304, 305
Situation 17 - Nurse's in all practice areas are likely to come in contact with clients suffering from acute or chronic drug
abuse.
81. The psychodynamic therapy of substance abuse is based upon the premise that drug abuse is:
a. a common problem brought about by socioeconomic deprivation
b. caused by multiplicity of factors
c. predisposed by an inability to develop appropriate psychological resources to manage developmental stresses
d. due to biochemical factors
CORRECT ANSWER: B
RATIONALE: The exact cause of drug use, dependence and addiction are not known, but various factors are
thought to contribute to the development of substance-related disorders.
OPTION A- People risk addiction when they lack other capacities, choices, interests or sources of attachment to
something outside themselves.
OPTION C- Some people use prohibited drugs and even alcohol as a coping mechanism or to relieve stress and
tension, increase feelings of power and decrease psychological pain
OPTION D- All drugs of abuse have one thing in common—the stimulation of dopamine secretion. Dopamine is
responsible for integration of emotions and thoughts and involved in decision making
SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2nd ed p411; Shives, Basic concepts of Psychiatric-Mental
Health Nursing, 5th ed, pp 427-428
82. Being in contact with reality and the environment is a function of the:
a. conscience
b. ego
c. id
d. super ego
CORRECT ANSWER: B RATIONALE:
In Freud's theory, the ego mediates among the id, the super-ego and the external world. Its task is to find a balance
between primitive drives, morals, and reality while satisfying the id and superego. It is the part of the mind which
contains the consciousness.
OPTION A- Conscience is the awareness of a moral or ethical aspect of one’s conduct together with the urge to
prefer right over wrong.
OPTION C-The id stands in direct opposition to the super-ego. It is dominated by the pleasure principle. It is
responsible for our basic drives such as food, sex and aggressive impulses, and demands immediate satisfaction. It
is amoral and egocentric, ruled by the pleasure-pain principle. It does not take social norms into account when
'thinking' or 'acting'. The id is the primal, or beastlike, part of the brain.
OPTION D- The super-ego acts as the conscience, maintaining our sense of morality and the prohibition of taboos.
83. Substance abuse is different from substance dependence in the sense that substance dependence:
a. includes characteristics of adverse consequences and repeated use
b. requires long term treatment in a hospital based program
c. produces less severe symptoms than that of abuse
d. includes characteristics of tolerance and withdrawal
CORRECT ANSWER: D
RATIONALE: Toleranceincreasing amount of the substance is required to achieve the desired effect or there is a
markedly diminished effect with repeated use of the same dose. Withdrawalthe person following reduction or
cessation of intake of the substance experiences a substance-specific syndrome. Such withdrawal signs could be
physiologic or psychologic
SOURCE: Sia, Psychiatric Nursing, p361
84. During the detoxification stage, it is a priority for the nurse to:
a. teach skills to recognize and respond to health threatening situations
b. increase the client's awareness of unsatisfactory protective behaviors
c. implement behavior modification
d. promote homeostasis and minimize the client's withdrawal symptoms
CORRECT ANSWER: D
RATIONALE: The first and most critical purpose of alcohol treatment or removal of the harmful physical and
emotional effects of alcohol usage is to complete process of alcohol detoxification safely and with as few painful and
dangerous withdrawal symptoms as possible. There is a very high element of danger that can occur during the
process of detoxification when those alcohol dependents are made to stop using alcohol. It can result in dangerous
side effects during the alcohol withdrawal process. These side effects can be serious enough to cause even death.
For this reason, alcohol detoxification should never be attempted alone and be done by medical professionals.
SOURCE: www.detox.org.il/alcohol-detoxification.asp
85. Commonly known as "shabu" is:

a. Cannabis Sativa
b. Lysergic add diethylamide
c. Methylenedioxy methamphetamine
d. Methamphetamine hydrochloride
CORRECT ANSWER: D
RATIONALE: Methamphetamine hydrochloride is the scientific name of shabu.
OPTION A is commonly called marijuana.
OPTION B is the most widely used hallucinogenic drug. Hallucinogenic drugs cause a person to see vivid images,
hear sounds, and feel sensations that seem real but are not. LSD is also called acid, doses, hits, Microdot, sugar
cubes, tabs, and trips. It is odorless and colorless and has a slightly bitter taste. It can be obtained as a colored
tablet, clear liquid, or thin square of gelatin (window panes) or on blotter paper. Most often, LSD is licked off blotter
paper or taken by mouth. However, the gelatin and liquid forms can be put in the eyes.
OPTION C is most commonly known today by the street name ecstasy (often abbreviated to E, X, or XTC), is a
semisynthetic member of the phenethylamine class of psychoactive drugs. The drug is well known for its ability to
produce feelings of overwhelming euphoria, intimacy, and connectedness with others, and is commonly associated
with the rave culture and its related genres of music.
Situation 18 - It is common that client ask the nurse personal questions.
86. Anticipation of personal questions is given adequate attention during which phase of the nurse patient relationship?
a. Orientation phase
b. Working phase
c. Pre-interaction phase
d. Termination phase
CORRECT ANSWER: B
RATIONALE: Describing, and often re-experiencing in the working phase, old conflicts generally awakens high
levels of anxiety in the client. Clients may use various defenses against anxiety and displace their feelings onto the
nurse. Therefore during the working phase, intense emotions such as anxiety, anger, self-hate, and hopelessness
may surface. Behaviors such as acting out anger inappropriately withdrawing, intellectualizing, manipulating and
denying are to be expected. Nurses are often manipulated by client to change roles. This keeps the focus off the
client and prevents the building of a relationship. Testing and manipulating behaviors of clients during working
phase, challenges the nurse to stay focused and not to react or be distracted.
OPTION A- During the orientation phase, the nurse establishes roles, the purpose of meeting, and the parameters
of subsequent meetings; identifies client’s problems; and clarifies expectations
OPTION C- Pre interaction is where the nurse or nursing students together with their instructors, discusses the
common concerns regarding the exposure to a psychiatric unit. It usually revolves around planning the first
interaction with the client.
OPTION D- Final step of the therapeutic relationship. The nurse terminates the relationship when the mutually
agreed-on goals are reached, the client is transferred or discharged, or the nurse has finished the clinical rotation.
As separation occurs, it is common for the client to exhibit regressive behavior, demonstrate hostility or experience
sadness.
SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4th ed, pp 232, 235, 247 and Shives,
Psychiatric-Mental Health Nursing, 5th ed, p 139
87. The client asks for the nurse's telephone number, which of these responses is NOT appropriate?
a. "it is confidential I just don't give it to anyone."
b. "What would you do with my number if I give it to you?"
c. "If I say no to your request, what are your thoughts about it?"
d. "Are you asking for an official number of the hospital/clinic for your reference?"
CORRECT ANSWER: A
RATIONALE: Rejecting—this technique closes the possibility of exploration of the client’s feelings. In turn, the client
may feel personally rejected along with his/her ideas
OPTION B- Exploring—helps examine the issue more fully. Promotes further discussion
OPTION C- Encouraging expression—encourages the client to make his/her own appraisal rather than accepting
the opinion of others
OPTION D-Seeking Clarification—helps the nurse to avoid making assumptions. It helps client to express thoughts,
feelings and ideas more clearly
88. When the client asks about the family of the nurse the MOST appropriate response is:
a. Avoid the situation and redirect the client's attention
b. Give a brief and simple response and focus on the client
c. "Why don't we talk about your family instead?"
d. Introduce another topic like the client's interests
CORRECT ANSWER: B
RATIONALE: Answer directly and briefly and then go back to the topic you were discussing. Nurses should show
understanding and acceptance to the client and at the same time setting limits to the behavior. Therapeutic
relationship should be client-centered.
OPTION A- Rejecting—this technique closes the possibility of exploration of the client’s feelings. In turn, the client
may feel personally rejected along with his/her ideas
OPTION C- Requesting an explanation—this question is intimidating and client may become defensive
OPTION D- Introduction of unrelated topic—the nurse takes the initiative for the interaction away from the client
89. When the nurse is asked a personal question, which of these reactions indicates a need for her to introspect?
a. The client is simply curious
b. His/her right to privacy is being intruded
c. The client knows no other way to begin a conversation
d. Some patients are like children in seeking recognition from the nurse
CORRECT ANSWER: D
RATIONALE: The nurse must understand that some clients who are mentally ill feel rejected, seeks attention and
need to be loved and cared for. Sometimes they are like children who constantly seek attention and be recognized.
What they haven’t experienced from their own family, they try to get it from the nurse and other people. They need
to feel that somebody cares for them.
OPTION A- Mentally ill clients are not curious
OPTION B- The nurse has the option whether to answer or not answer the client’s question. If she chooses to
answer then it can’t be said that her right to privacy has been intruded.
OPTION C- It could be that clients know no other way to start a conversation with the nurse
90. It is 10 o'clock of your watch. The client asks, "What time is it?" The nurse's appropriate response is:
a. "Are you bored?"
b. "It is 10 o'clock."
c. "Why do you ask?"
d. "Guess, what time is it?"
CORRECT ANSWER: B
RATIONALE: Giving Information—informing the client of facts increases his or her knowledge about a topic. The
nurse is functioning as a resource person. Giving information also builds trust with the client.
OPTION A- Interpreting--the client’s thoughts and feelings are his or her own, not to be interpreted by the nurse or
for hidden meaning. Only the client can identify or confirm the presence of feelings
OPTION C- Requesting an explanation—“why” question is intimidating
OPTION D- Indicating the existence of an external source—implies that the client was made or compelled to think in
a certain way
SOURCE: Videbeck, Psychiatric Mental Health Nursing, 3rd ed, pp 112-115
Situation 19 – Jim, age 25, recalled that his problem began around age 15 or 16. He would count pencils in a mug over and
over with the thought that stopping could result in something bad happening.
91. There are many things Jim seems he has to do to keep him from getting:
a. confused
b. suspicious
c. excited
d. anxious
CORRECT ANSWER: D
RATIONALE: Jim has an obsessive-compulsive disorder. OCD can be manifested through many behaviors that are
repetitive, meaningless and difficult to conquer. The person understands that these rituals are unusual and
unreasonable but feels forced to perform them to alleviate anxiety or to prevent terrible thoughts.
OPTION A- defined as having impaired psychological capacity to the extent of being forgetful and no longer able to
carry out simple everyday task
OPTION B- believing that something is wrong. A characteristic of paranoid PD.
OPTION C- feeling or condition of lively enjoyment or pleasant anticipation
92. He has to change clothes 20 times before work, chew each bite he eats 24 times and go up and down the stairs four
to five times before it feels right. He is demonstrating:
a. ideas of reference
b. denial and projection
c. obsession and compulsion
d. rationalization and over reaction
CORRECT ANSWER: C
RATIONALE: Obsession is a recurrent, persistent, unpleasant and unwanted thoughts, images or impulses that
cause marked anxiety and interfere with interpersonal, social or occupational functions. Compulsion on the other
hand is a ritualistic or repetitive behavior or mental acts that a person carries out continuously in an attempt to
neutralize anxiety. 285
OPTION A- Ideas if reference is the client’s in accurate interpretation that general events are personally directed to
him/her 162
OPTION B- Denial is a defense mechanism that shows failure to admit reality of a situation; Projection is the
unconscious blaming of unacceptable thoughts or inclinations on an external object.
OPTION D- Rationalization is the act of excusing own behavior to avoid guilt, responsibility, conflict, anxiety or loss
of self-respect; Over reaction
93. The objective of nursing care for Jim is to develop or increase feelings of:
a. self-mastery
b. self actualization
c. self worth
d. self-determination
CORRECT ANSWER: C
RATIONALE: People with OCD have low self-esteem due to feelings of powerlessness to control the obsessions
and compulsions. It is important for the nurse to offer support and encouragement to the client by validating the
overwhelming feelings the client experiences while indicating the belief that the client can make needed changes
and regain a sense of self control.
OPTION A- More like self-actualization
OPTION B- Self-actualized are those persons who have achieved all the needs of the hierarchy and have
developed his/her fullest potential in life.
OPTION D- Self-determination is having a firm purpose, will or intention.
SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2nd ed, p 56, 267
94. All of these are therapeutic interventions, EXCEPT:

a. impose limits every time the behaviour becomes repetitive
b. establish a routine for him
c. assign task that can be done repetitively
d. facilitate self-expression
CORRECT ANSWER: C
RATIONALE: The goal of treatment for people with OCD is response prevention, which focuses on delaying or
avoiding performance of rituals. The person learns to tolerate the anxiety and to recognize that it will recede without
the disastrous imagined consequences. The client will spend less time performing rituals.
OPTION A- Imposing limits can help the client gain self-control and avoid spending time doing the rituals. Clients
are engage in a behavior therapy that targets response prevention, delaying or avoiding performance of rituals
OPTION B- To complete tasks efficiently, the client initially may need additional time to allow for rituals. It is
important for the nurse not to interrupt or attempt to stop the ritual because doing so will escalate the client’s
anxiety. The nurse and client can agree on a plan to limit the time spent performing rituals. When the client has
completed the ritual or the time allotted has passed, the client then must engage in the expected activity. At home,
the client can continue to follow a daily routine that helps him/her to stay on tasks and accomplish activities and
responsibilities.
OPTION D- The nurse encourages the client to talk about the feelings and to describe them in as much detail as the
client tolerate. Because many clients try to hide their rituals and to keep obsessions secret. Doing so can begin to
relieve some of the “burden” the client has been keeping to himself/herself.
SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2nd ed, p 265, 268
95. Jim is aware of his behavior, yet realizes that it is very disturbing to him. This is a pattern of:
a. personality disorder
b. psychosis
c. neurosis
d. habitual disorder
CORRECT ANSWER: A
RATIONALE: Personality disorder is described as a non psychotic illness characterized by maladaptive behavior,
which the person uses to fulfill his/her needs and brings satisfaction to self. The person with personality disorder is
in contact with reality but has difficulty dealing with it.
OPTION B- Psychosis displays symptoms of delusions, hallucinations and disordered thinking.
OPTION C- Neurosis is a mental disorder in which the symptoms are distressing to the person, reality testing is
intact.
OPTION D- No such thing as habitual disorder.
SOURCE: Shives, Basic concepts of Psychiatric Mental Health Disorder, 5th ed, p 362; Videbeck, Psychiatric Mental
Health Nursing, 2nd ed, p 298
Situation 20 - The abuse of dangerous drug is a serious public health concern that nurses need to address
96. The nurse should recognize that the unit primarily responsible for education and awareness of the members
of the family on the ill effects of dangerous drugs is the:
a. law enforcement agencies
b. school
c. church
d. family
CORRECT ANSWER: D
RATIONALE: A family is the primary unit of our society and health education takes place in the home. Learning
about health results from a wide variety of contacts between members of the family. Nurses educate the family, and
the family educates its own family members after learning some information from the health teaching of the nurse.
OPTION A- they are more concerned about the rules and regulations of our country. They are secondary unit
responsible for education
OPTION B- secondary
OPTION C- secondary
SOURCE: Reyala et al, Community Health Nursing Services in the Philippines, 9th ed, p 308
97. A drug dependent utilizes these defense mechanisms, EXCEPT:

a. sublimation
b. rationalization
c. projection
d. denial
CORRECT ANSWER: A
RATIONALE: Sublimation is the unconscious process of substituting constructive and socially acceptable activities
for strong impulses that are not acceptable in their original form.
OPTION B- Used to falsify an experience by giving a contrived socially acceptable and logical explanation to justify
an unpleasant experience or questionable behavior
OPTION C- Attributing an unconscious impulse, attitude or behavior to someone else
OPTION D- Escaping unpleasant realities by ignoring their existence
SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4th ed p 755
98. This drug produces mirthfulness, fantasies, flight of ideas, loss of train of thought, distortion of size, distance and
time, and "bloodshot eyes", due to dilated pupils.
a. Opiates
b. LSD
c. Marijuana
d. Heroin
CORRECT ANSWER: B
RATIONALE: LSD or lysergic acid diethylamide is a hallucinogen. It is quite unpredictable. One experience with
them may be good but the next may be disastrous. They are dangerous because they can lead to panic, paranoia,
flashbacks or death. Physiologic symptoms include increased pulse rate, blood pressure and temperature, dilated
pupils, tremors of hands and feet. Effects on the central nervous system include an increased distortion of senses,
loss of the ability to separate fact from fantasy, ambivalence and the inability to reason logically.
OPTION A- Opiates are narcotic drugs that induce sleep, suppress coughing and alleviate pain. User becomes
passive and listless as the opiates depress the respiratory center of the brain, causing shallow respirations. The
person also experiences reduced feelings of hunger, thirst, pain and sexual desire.
OPTION C- Known as Cannabis Sativa. It can act as a stimulant or depressant and is often considered to be a mild
hallucinogen with some sedative properties. General physiologic symptoms include increased appetite, lowered
body temperature, depression, drowsiness, unsteady gait, inability to think clearly, excitement, reduced coordination
and reflexes, and impaired judgment.
OPTION D- Heroin is an opiate. Physical symptoms include decreased respiration. It causes respiratory depression-
arrest
SOURCE: Shives, Psychiatric-Mental Health Nursing, 5th ed, pp 434-436 and Varcarolis, Foundations of Mental
Health Nursing, 4th ed, p 760
99. The nurse evaluates that-.her health teaching to a group of high school boys is effective if these students recognize
which of the following dangers of inhalant abuse.
a. Sudden death from cardiac or respiratory depression
b. Danger of acquiring hepatitis or AIDS
c. Experience of "blackout"
d. Psychological dependence after prolonged use
CORRECT ANSWER: A
RATIONALE: Inhalants are diverse group of drugs. Inhalant intoxication involves dizziness, nystagmus, lack of
coordination, slurred speech, unsteady gait, tremor, muscle weakness, and blurred vision. Acute toxicity causes
anoxia, respiratory depression, vagal stimulation and dysrythmias. Death may occur from bronchospasm, cardiac
arrest, suffocation or aspiration of the compound or vomitus.
OPTION B- Danger of acquiring hepatitis or AIDS is often associated with injectables
OPTION C- Alcohol is a central nervous system depressant. Initially the effects are relaxation and loss of inhibitions.
With intoxication, there is slurred speech, unsteady gait, impaired concentration, memory and judgment. The person
who is intoxicated may experience a blackout, which is an episode during which the person continues to function but
has no conscious awareness of his /her behavior at the time or any later memory of the behavior.
SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2nd ed, pp 412, 417
100. The mother of a drug dependent would never consider referring her son to a drug rehabilitation agency
because she fears her son might just becomes worse while relating with other drugs users. The mother's
behavior can be described as:
a. Unhelpful
b. Codependent
c. Caretaking
d. Supportive
CORRECT ANSWER: A
RATIONALE: Mother displays unwillingness in providing assistance and support to her son in getting well
OPTION B- a situation in which a person such as the partner of an alcoholic or parent of a drug-addicted
child needs to feel needed by the other person
OPTION C- giving care or emotional support to another
OPTION D- being understanding, giving moral or emotional support
SOURCE: Encarta Dictionaries

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Situation 1 - Jimmy developed his goal for hospitalization. "To get a handle on my nervousness.

" The nurse is going to

6. This study which is a depth study of one boy is a:

8. Which of these does NOT happen in a descriptive study?

OPTION A- taking the medicine with caution is a must

Situation 5 - The nurse engages the client in a nurse-patient interaction.

24. Building trust is important in:

29. Schizophrenia is best described as a disorder characterized by:

30. Schizophrenia is a/an:

32. A nursing diagnosis for Salome is:

36. Cecilia is demonstrating:

46. Which of the following is NOT a common cause of night bedwetting?

49. Which of the following is used to treat enuresis?

OPTION A- Respond as early as possible

54. To encourage thought. Which of the following approaches is NOT therapeutic?

Situation 12 - Nursing care for the elderly.

57. A healthy adaptation to aging is primarily related to an individual.

67. This is a tricyclic antidepressant drug:

Situation 15 - Group Approach in Nursing.

73. The goal of remotivation therapy is to facilitate:

76. All of the following concepts are true, EXCEPT:

85. Commonly known as "shabu" is:

Situation 18 - It is common that client ask the nurse personal questions.

94. All of these are therapeutic interventions, EXCEPT:

97. A drug dependent utilizes these defense mechanisms, EXCEPT:

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