Psychiatric Bank

QID: 7233 C 19(280-285 h 320) A 21-year-old secretary with a history of anxiety reactions is admitted to the emergency
room. The nurse should know that the most common symptoms of an anxiety reaction are:
1. Hypotension, pain
2. Lethargy flat affect
3. Confusion, hunger
4. Increased pulse, tightness in the chest
Correct; 4 chapter 19 text pg 280-285 meds 89 hesi 320
Category: physiologic integrity adaptation
Rationale
(4) Integrated process: nursing process data collection; client need: physiological integrity; physiological adaptation;
content area: psychiatric-mental health.
RATIONALE
(1) Hypotension and pain may be possible symptoms of anxiety but are not typical of a generalized anxiety reaction. (2)
Lethargy and flat affect are not typical symptoms of anxiety (3) Confusion and hunger are possible symptoms but not
common features of an anxiety reaction. (4) Increased heart rate and tightness in the chest are common characteristics of
anxiety
QID: 7234 C19 (287-288 h 320-321) An initial care plan for a client with a diagnosis of anxiety would include which of
the following interventions?
1. Monitoring vital signs, offering reassurance
2. Monitoring l&O, obtaining weight
3. Observation of nailbed color
4. History of drug use, offering high-carbohydrate food
Correct; 1 chapter 19 text pg 287-288 meds 80 hesi 320-321
Category: physiologic integrity
Rationale
(1) Integrated processes: nursing process — implementation; client need: physiological integrity; reduction of risk
potential; content area: psychiatric-mental health.
RATIONALE
(1) The initial care plan would include monitoring vital signs and providing support and reassurance. The initial priority
is to deal with the current anxiety reaction. (2) There is no reason to measure l&O or obtain weight for an anxiety
reaction. (3) Nail bed color would not change during an anxiety reaction. (4) The nurse might later explore a history of
drug use and offer high- carbohydrate foods, but not as an initial plan.
QID: 7235 C 19(280-284 h 320) To help a client modify an anxiety reaction, the nurse should speak slowly and softly
asking the client if there is anything in his or her life that is upsetting. The client responds, “Nothing is wrong;
everything is perfect.”
This may be an example of:
1. Introjection
2. Sublimation
3. Denial
4. Displacement
Rationale
(3) Integrated processes: nursing process — data collection; caring; client need: psychosocial integrity; content area:
psychiatric-mental health.
RATIONALE
(1) Introjection is identifying with another. (2) Sublimation is replacing an unacceptable need with one more acceptable.
(3) The client is using denial. (4) Displacement is transferring feelings about one person onto another
QID: 7236 C19 (287-288 h 320-321) Which of the following pharmacological agents is prescribed to reduce anxiety?
1
1. Imipramine (Tofranil)
2. Lorazepam (Ativan)
3. Lithium (Lithane)
4. Amitriptyline (Elavil)
Category: physiologic integrity pharmacology and parenteral therapies
Rationale
(2) Integrated processes: nursing process.—. Implementation; client need: physiological integrity; pharmacological
therapies; content area: psychiatric-mental health.
RATIONALE
(1) Imipramine is an antidepressant. (2) Lorazepam is an anxiolytic. (3) Lithium is a mood stabilizer. (4) Amirnptyline is
an antidepressant
QID: 7237 C 19(287-288 h 320-321) After administering an anxiolytic to an emergency room client, the nurse checks to
see if the siderails are secure. The nurse realizes that one of the common side effects of anxiolytics is:
1. Drowsiness
2. Convulsions
3. Blurred vision
4. Fear of falling
Rationale
(1) Integrated processes: nursing process — data collection; client need: physiological integrity; pharmacological
RATIONALE
(1) Anxiolytics often have the side effect of drowsiness. (2) Some clients could experience convulsions; however, it is a
more common side effect of an antipsychotic drug. (3) Although blurred vision may be experienced by some clients, it is
not a common side effect of anxiolytics. (4) Fear of falling is not a common side effect of medications
QID: 7238 C19 (287-288 h 320-321) A client is given a prescription for lorazepam. It is the nurse’s responsibility to
inform the client that anyone taking lorazepam should not:
1. Work
2. Consume herring
3. Consume alcohol
4. Spend prolonged time in the sun
Category: physiological integrity; reduction and risk potential
Rationale
(3) Integrated processes: nursing process —implementation; teaching/learning; client need: physiological integrity;
reduction of risk potential; Content area: psychiatric-mental health
RATIONALE
(1) Many persons work while taking psychiatric medications. (2) Persons taking antidepressants such as MAOIs should
not consume herring. (3) A person taking lorazepam, an anxiolytic, should not consume alcohol. (4) Persons taking some
antipsychotics such as phenothiazine should be cautionic in the sun because of the possibility of sunburn.
QID: 7239 C 19(287-288 h 320-321) After a client suffering from an anxiety reaction was safely discharged from the
emergency room, the nurse documented that the client experienced a rapid pulse, tightness of the chest, discomfort, and
an inability to focus on anything but obtaining relief. The nursing diagnosis may conclude:
1 Panic-level anxiety
2. Mild anxiety
3. Moderate anxiety
4. Severe anxiety
2
Category: physiologic integrity; physiology adaptation
Rationale
(4) Integrated processes: nursing process — data collection; communication and documentation; client need:
physiological integrity; physiological adaptation; content area: psychiatric-mental health.
RATIONALE
(1) In panic-level anxiety, the person has dilated pupils, a feeling of terror, and loss of rational thought. (2) Mild anxiety
is associated with day-to-day living. (3) Moderate anxiety manifests as tension in neck, headaches, hypercriticism, and
inability to concentrate. (4) Severe anxiety is associated with the stated symptoms
QID: 7240 C 21(325 h 332) A 59-year-old man is admitted to a medical unit with symptoms of lethargy and withdrawal.
He was forced into early retirement because of his company’s merger with a larger sister company. On admission, the
nurse observes that the client will not make eye contact with any member of the staff. Poor eye contact is an example of:
1. Verbal communication
2. Therapeutic communication
3. Nonverbal communication
4. Mass communication
Correct; 3 chapter 21 text pg 325 meds 95-98 hesi 332
Rationale
psychosocial integrity; content area: psychiatric-mental health.
RATIONALE
(1) The medium of verbal communication is speech. (2) Therapeutic communication is a process of using specific
techniques. (3) Poor eye contact is an example of nonverbal communication. (4) Mass communication is a component of
journalism or marketing.
QID: 7241 C 7(76-78 h 332) A nurse observes that a client has poor eye contact, complains of nausea and diarrhea, and
is crying about the death of his wife. The nurse realizes that this cluster of symptoms is common in:
1. Anxiety disorders
2. Grief reactions
3. Panic attacks
4. Eating disorders
Correct; 2 chapter 7 text pg 76-78 meds 95-98 hesi 332
Category: physiologic integrity; physiologic adaptation;
Rationale
(2) Integrated processes: nursing process data collection; client need: physiological integrity; physiological adaptation;
RATIONALE
(1) Anxiety disorders manifest themselves with a different cluster of symptoms. (2) The cluster of symptoms is common
in grief reactions, specifically the stage of developing awareness. (3) Panic attacks typically are characterized by a
sudden onset of intense discomfort and often resemble symptoms of a heart attack. (4) The stated symptoms are not
typical of eating disorders.
QID: 7242 C 7(76-78 h 332) In planning initial care for a newly admitted client, the nurse realizes that one establishes a
therapeutic relationship by:
1. Assessing the client, remaining subjective
2. Judging the client, offering advice
3. Respecting the client, offering presence
4. Confronting the client, displaying sympathy
Rationale
3
(3) Integrated processes: nursing process — implementation; caring; client need: psychosocial integrity; content area:
RATIONALE
(1) The nurse does not want to remain subjective, but rather objective. (2) The nurse does not want to judge the client or
offer advice. (3) Therapeutic communication requires that the nurse respect the client and offer presence. (4) Empathy,
rather than sympathy, is a therapeutic technique.
QID: 7243 C 7(76-78 h 332) A client informs the nurse that his wife died 2 days ago. The nurse replies, ‘Tell me more
about that.” This is an example of the therapeutic communication technique of:
1. Restating
2. Providing feedback
3. Identifying themes
4. Open-ended statement
Rationale
(4) Integrated processes: nursing process — implementation; communication and documentation; client need:
RATIONALE
(1) Restating is repeating the client’s message using different words. (2) Providing feedback is making observations
about the client’s behavior. (3) Identifying a theme is helping the client see a pattern of thought. (4) The nurse is giving
the client an opportunity to verbalize by using an open-ended statement.
QID: 7244 C 9(76-78 h 332) During a conversation between a client and the nurse, the physician enters the room
accompanied by seven medical students. The nurse and the client end their discussion because:
1. Physicians are important in status.
2. The physician’s entry changed the context and psychosocial setting.
3. The content of the communication between the nurse and the client should remain private.
4. The type, quality, and purpose of nurses’ and physicians’ communication are totally different.
Rationale
(2) Integrated processes: nursing process implementation; communication and documentation; client need: psychosocial
integrity; content area: psychiatric-mental health.
RATIONALE
(1) Obviously, the nurse does not stop communicating simply because physicians have status. (2) A one-to-one
communication is altered when physical (e.g., noise) or psychosocial (eg, visitors, physicians) factors change. (3) There
is no overriding reason that the communication between nurse and client should be private. Usually, the content of the
communication is charted and shared with the team. (4) The purpose of other health team members’ communication with
the client is generally similar. All health-care disciplines are concerned with caring and communicating with the client.
QID: 7245 C7 (76-78 h 332) A student nurse says to a client who has been grieving over the death of a spouse, “I think
you should get on with life and stop mourning over the death.” This is an example of communication called:
1. Omission of content
2. Offering personal opinion
3. Rejection
4. Faulty reassurance
Rationale
RATIONALE
4
(1) Omission of content means failing to consider the entire conversation between the student and client. (2) The student
offered personal advice, which stops open, effective communication. (3) The student is not rejecting the client; she is
offering personal advice. (4) There is no indication that the student is offering faulty reassurances by offering a personal
opinion.
QID: 7246 C 24(406-407 h 332) In assessing a 61-year-old client, the nurse should know that the developmental stage
is:
1. Industry versus inferiority
2. Intimacy versus isolation
3 Ego integrity versus despair
4. Generativity versus stagnation
Category: health promotion and maintenance
Rationale
(3) Integrated processes: nursing process — data collection; client need: health promotion and maintenance; content
area: psychiatric-mental health.
RATIONALE
(1) According to Erikson theory industry versus inferiority occurs between 6 and 11 years. (2) Intimacy versus isolation
occurs between 19 and 34 years. (3) The developmental stage of a 61-year-old is ego integrity versus despair. (4) The
generativity versus stagnation developmental stage occurs between 35 and 60 years.
QID: 7247 C 11(143-147 h 315-316) A 60-year-old client becomes very upset after his sister visits. He throws a tray at
the wall. The nurse’s most effective response would be:
1. Maintain a calm and supportive manner.
2. Administer neuroleptic drugs.
3. Encourage the client to call his sister.
4. Report the incident to the hospital administrator.
Correct; 1 chapter 11 text pg 143-147 meds 88-89 hesi 315-316
Rationale
RATIONALE
(1) The nurse must offer calm support to maintain a relationship with the client and assess the situation. (2) Neuroleptic
drugs are used to treat acute and chronic psychosis. (3) It is more important to help the client develop self-direction than
to give advice. (4) Notifying the hospital administrator is inappropriate until more data are collected.
QID: 7248 C 7(76-78 h 332) A 75-year-old client tells the nurse that he wishes to see a priest because “it will help.” The
nurse realizes that this would be an example of:
1. A coping mechanism
2. A defense mechanism
3. Reaction formation
4. Intellectualization
Correct; 1 chapter 7 text pg 76-78 meds 95, 98 hesi 332
Rationale
(1) Integrated processes: nursing process — data collection: client need: psychosocial integrity; content area: psychiatric-
mental health.
(1) Coping mechanisms are task-oriented behaviors to increase one’s ability to cope. (2) Defense mechanisms are
unconscious ego-oriented reactions for self-protection. (3) Reaction formation is a defense mechanism. (4)
Intellectualization is also a defense mechanism.
5
QID: 7249 C 17(252-258 h 332) A 39-year-old client has a diagnosis of depression. The physician prescribes ECT. The
nurse must know that ECT:
1. Requires preoperative nursing care
2. Causes excessive weight gain
3. Is administered in conjunction with neuroleptics
4. Will result in mood suppression
Category: physiologic integrity; reduction and risk potential
Rationale
(1) Integrated processes: nursing process planning; client need: physiological integrity; reduction of risk potential;
RATIONALE
(1) ECT is administered to depressed clients and requires all the nursing care that an operative procedure requires (e.g.,
NPO, preoperative permit, denture removal). (2) ECT does not cause weight gain. (3) ECT is not usually given in
conjunction with neuroleptics. (4) ECT usually increases rather than decreases health.
QID: 7250 C 23(375 h 330) A 14-year-old girl who displays symptoms of anorexia nervosa was brought to the clinic for
an evaluation. She has a 15-year-old sister and lives with her parents, who are physicians. The client achieves well in
school and is very active in sports activities. During the initial interview with the nurse, the client states that she is “just
normal.” Which of the following would suggest to the nurse that the client displays symptoms of anorexia nervosa?
1. She expresses a desire to gain weight.
2. She has episodes of overeating.
3. She has had severe weight loss due to dieting.
4. She uses large amounts of food to relax.
Correct; 3 chapter 23 text pg 375 meds 111 hesi 330
Rationale
(2) Integrated processes: nursing process .—. data collection; client need: health promotion and maintenance; content
RATIONALE
(1) Clients with a diagnosis of anorexia are frightened of being fat. (2) Clients with a diagnosis of anorexia do not eat
large amounts of food. (3) Clients with anorexia are very thin because of starvation. (4) Clients with a diagnosis of
anorexia do not perceive food as comforting or relaxing.
QID: 7251 C 24(406-407 h 330) The nurse would know that the development stage of a 14-year-old adolescent is:
1. Trust versus mistrust
2. Autonomy versus shame and doubt
3. Initiative versus guilt
4. Identity versus role diffusion
Rationale
(1) The trust versus mistrust stage of development occurs in infancy, according to Erikson. (2) The autonomy versus
shame and doubt stage of development occurs in a 2-year-old child, according to Erikson. (3) The initiative versus guilt
stage of development occurs during the preschool years, according to Erikson. (4) A 14-year-old struggles with identity
versus role diffusion, according to Erikson.
QID: 7252 C 23(375 h 330) The nurse should know that it is important to assess for which one of the following
characteristics of anorexia nervosa?
1. Vigorous exercise
2. Increased libido
6
3. Average intelligence
4. Tachycardia
Category: Health promotion and maintenance
Rationale
RATIONALE
(1) Individuals with anorexia nervosa often exercise 3-4 hours daily (2) Individuals with anorexia nervosa have
decreased libido. (3) Individuals with anorexia nervosa usually are of above-average intelligence. (4) Individuals with
anorexia nervosa suffer from bradycardia.
QID: 7253 C 19(288-289 h 322-323) A 21-year-old client denies that she ever feels anxious, but the nurse observes her
biting her fingernails. One component of nursing care for the client would be for the nurse to:
1. Administer neuroleptic medication.
2. Assess the client’s coping mechanisms.
3. Encourage vigorous exercise.
4. Make arrangements for sculptured nails.
Rationale
(2) Integrated processes: nursing process — planning; client need: psychosocial integrity; content area: psychiatric-
mental
RATIONALE
(1) Neuroleptic drugs are used to treat thought disorders. (2) Coping mechanisms should be assessed to determine the
client’s pattern of coping with anxiety (3) Vigorous exercise should be discouraged. (4) Nurses do not “prescribe”
fingernail treatment.
QID: 7254 C 24(408-409 h 322-323) A client tells the nurse that when she gets upset, she kicks the cat. This is an
example of which one of the following defense mechanisms?
1. Rationalization
2. Projection
3. Displacement
4. Regression
Rationale
(3) integrated processes: nursing process — data collection; client need: psychosocial integrity; content area: psychiatric-
mental health.
RATIONALE
(1) Rationalization is an attempt to make unacceptable feelings acceptable (2) Projection is attributing one’s own
thoughts to another. (3) This is a classic case of displacement. (4) Regression is retreating to an earlier stage of life.
Correct; 3
QID: 7255 C23 (375-401 h 330) While interacting with a client with a diagnosis of anorexia nervosa, the client changes
the conversation from talking about self to talking about the weather. The nurse must use which of the following
communication techniques?
1. Refocusing
2. Restating
3. Silence
4. Summarizing
7
Rationale
(1) Integrated processes: nursing process — implementation; client need: psychosocial integrity; content area:
psychiatric- mental health.
RATIONALE
(1) The nurse must help the client stick to a theme of therapeutic value. (2) Restating talk about self when the topic is
weather is less than useful (3) Silence would be inappropriate in this case. (4) Summarizing may be used to link themes
and feelings and to review important points in the interaction. Summarizing would be an inappropriate communication
technique in this case.
QID: 7256 C25 (375 h 330) A 15-year-old female client with a diagnosis of anorexia is scheduled for an
electrocardiogram (ECG). The nurse will:
1. Teach the client about the procedure
2. Tell the client that she has a heart problem
3. Explain that persons with anorexia nervosa suffer from tachycardia
4. Ask a male aide to accompany the client
Rationale
(1) Integrated processes: nursing process — planning; teaching/learning; client need: physiological integrity; reduction
of risk potential; content area: psychiatric-mental health.
RATIONALE
(1) Clients should receive information regarding procedures. (2) The implications of the procedure should not be
exaggerated or overexplained. (3) This response does not meet the client at her level of understanding. (4) A male aide
should not accompany a teenage girl suffering from anorexia nervosa for an ECG because of the client’s development
stages
QID: 7257 C25 (437-459 h 345-347) An 18-year-old male client has serious problems with substance abuse. He has
had difficulty with his school work and with school authority figures. He has come to the clinic for help. The nurse
observes that the client is restless and pacing. Other physical characteristics of substance abusers that the nurse should
pay special attention to include:
1. Dilated pupils
2. Increased concentration
3. Euphoria
4. Pale nailbeds
Category: physiologic adaptation; physiology adaptation
Rationale
(1) Integrated processes: nursing process — data collection; client need: physiological integrity; physiological
adaptation; content area: psychiatric-mental health.
RATIONALE
(1) Clients suffering from substance abuse often have dilated pupils. (2) Substance abusers have poor concentration and
low tolerance for frustration. (3) Euphoria is a psychological characteristic. (4) The color of nail beds is not generally
affected by substance abuse.
QID: 7258 C 25(436-443 h 346) A 22-year-old client admitted to the emergency room stated that 1 month previously he
had been brought to the emergency room for an overdose of cocaine. What nursing actions in the emergency room would
be most important in treating a client who has overdosed?
1. Monitoring vital signs and output
2. Obtaining weight and temperature
3. Inducing client to vomit
4. Obtaining a psychiatric evaluation
8
Rationale
RATIONALE
(1) Drug overdose can lead to unstable vital signs and diminished urine output. (2) Obtaining weight and temperature is
not an immediate concern. (3) Some drug overdoses would preclude inducing vomiting. (4) A psychiatric consultation
may be obtained after the threatening situation is resolved
QID: 7259 C 25 (445-459 h 346) A client is admitted to an inpatient detoxification unit. During the acute phase of
detoxification from drug abuse, which of the following would be the most important nursing action?
1. Monitoring manipulative behavior
2. Monitoring family dynamics
3. Evaluating vocational abilities
4. Monitoring vital signs frequently
Category:
Rationale
RATIONALE
(1) The nurse may consider monitoring manipulative behavior but not during the acute phase of detoxification. (2)
Intervening in family dynamics is not an important issue during the acute phase of detoxification. (3) Evaluating
vocational skills during the acute phase of detoxification is not an appropriate nursing action. (4) Monitoring a client’s
vital signs is an important nursing task during the acute phase of withdrawal.
QID: 7260 C 25 (437-459 h 345-347) A client in a substance abuse program tells the nurse during the first week of
treatment that he has no drug problem. The nurse identifies this behavior as an example of the defense mechanism:
1. Denial
2. Projection
3. Displacement
4. Sublimation
Rationale
(1) Integrated processes: nursing process — data collection; client need: psychosocial integrity; content area: psychiatric
mental health.
RATIONALE
(1) Denial is consciously disowning intolerable compulsions and thoughts. Denial is extremely common in substance
abuse clients. (2) Projection is attributing one’s own thoughts to another. (3) Displacement is shifting your emotions to
another person or object. (4) Sublimation is substituting a socially acceptable goal for an unwanted drive.
QID: 7261 C 25(437-459 h 345-347) When a client explains to the nurse that he does not have a drug abuse problem,
the nurse replies, “What do you mean when you say you have no drug problem?” This communication technique is an
example of:
1. Focusing
2. Clarifying
3. Providing feedback
4. Making an observation
9
Rationale
RATIONALE
(1) Focusing provides statements that help the client expand on the topic, (2) Clarifying is a communication technique
that is effective in seeking consensual validation of the client’s perception of reality and its significance and meaning to
his or her life. (3) Providing feedback promotes exchange with the sender and the receiver. (4) Making an observation is
the receiver telling the sender what he or she sees and thinks.
QID: 7263 C 25(445-459 h 346) Which of the following behaviors would the nurse expect to observe from a client who
has successfully completed a substance abuse treatment program?
1. Identifying positive ways to cope with anxiety
2. Identifying ways to decrease but not discontinue drug use
3. Identifying the family members responsible for the drug abuse
4. Identifying methods of social isolation
Rationale
(1) Integrated processes: nursing process — evaluation; client need: psychosocial integrity; content area: psychiatric-
mental health.
RATIONALE
(1) At the termination of therapy the client will identify new modes of coping. (2) Clients must discontinue all drug use.
(3) Clients must accept responsibility for their lives and actions. (4) Clients must find new ways of social interaction.
QID: 7263 C 25(454 h 338) A 48-year-old man is admitted to a surgical unit with the diagnosis of chronic cholecystitis.
The client’s chart reveals that he is scheduled for surgery the following morning and that he has lived in a sheltered
residence home for 10 years and suffers from schizophrenia. As a nurse reads the chart, he or she should know that
schizophrenia is:
1. A thought disorder
2. An affective disorder
3. A personality disorder
4. An adjustment disorder
Correct; 1 chapter 25 text 454 meds 93 hesi 338
Rationale
(1) Integrated processes: nursing process — data collection; client need: psychosocial integrity; content area: psychiatric-
mental health.
RATIONALE
(1) Schizophrenia is a thought disorder characterized by disturbances of thought content, form, affect, and relationship.
(2) Affective disorders are disorders of feeling or mood. (3) Personality disorders are disorders of personality traits that
are inflexible and maladaptive. (4) An adjustment disorder is one in which psychological factors affect physical
conditions; it is usually short lived and related to stress
QID: 7264 C22 (357-358 h 338) With the diagnosis of schizophrenia, the nurse may anticipate which of the following
cluster of symptoms?
1. Stuttering, cluttering, passive behavior
2. Delusions, tangential thought, hallucinations
3. Hyperactivity, crying, violence
4. Inexhaustible energy absence of mood, altered sleep pattern
Rationale
10
(2) Integrated processes: nursing process data collection; client need: psychosocial integrity; content area: psychiatric-
mental health.
RATIONALE
(1) Stuttering, cluttering, and passive behavior are not symptoms characteristic of schizophrenia. (2) Schizophrenia is
characterized by delusions, hallucinations, grandiosity, suspiciousness, disorganized behavior, tangential thought,
negativism, diminished self-care, and inappropriate emotional responses. (3) Hyperactivity, crying, and violence are
symptoms of mood disorders. (4) These symptoms are characteristic of other mood disorders or thought disorders but not
of schizophrenia.
QID: 7265 C 22(364-368 h 341-343) Clients who suffer from schizophrenia are most likely to be given a prescription
for which of the following?
1. Anxiolytic medications
2. Antidepressant medications
3. Antipsychotic medications
4. Antiseizure medications
Category: physiologic integrity pharmacology and parenteral therapis
Rationale
(3) Integrated processes: nursing process planning; client need: physiological integrity; pharmacological therapies;
RATIONALE
(1) Anxiolytic medications are used for anxiety disorders. (2) Antidepressant medications are used for mood disorders.
(3) Schizophrenia is a thought disorder that generally responds to antipsychotic medications such as haloperidol,
trifluoperazine (Stelazine), or fluphenazine. (4) Antiseizure medications are used for various types of seizures (e.g.,
epilepsy).
QID: 7266 C 22(364-368 h 341-343) The nurse who cares for clients taking antipsychotic medication knows that:
1. The nurse must monitor temperature closely
2. The nurse must monitor vital signs
3. The nurse must monitor diet closely
4. The nurse must monitor blood levels
Rationale
(2) Integrated processes: nursing process planning; client need: physiological integrity; reduction of risk potential;
RATIONALE
(1) Less frequently antipsychotic medications may cause neuroleptic malignant syndrome (NMS) in which the client
experiences high temperatures (105°F [40.5°Cl). (2) Antipsychotic medications frequently result in orthostatic
hypotension, and therefore blood pressure measurements are taken lying and standing before the medication is
administered. Although NMS is less common than orthostatic hypotension, it is important to monitor vital signs such as
blood pressure and temperature. (3) There is no indication that antipsychotic medications have complex interactions with
various foods in a client is diet. (4) Blood samples should be ordered by the physician at frequent intervals to determine
the therapeutic level of the medication. The nurse should notify the physician of abnormal laboratory results.
QID: 7267 C22 (354 h 330) A hospitalized client recovering from surgery tells the nurse that “men from Mars are fixing
get-well food to be put in my veins.” The nurse knows that this is an example of:
1. A delusion
2. A hallucination
3. Anxiety
4. Tangential thought
11
Rationale
mental health.
RATIONALE
(1) This is an example of a delusion or a faulty thought process or belief. (2) A hallucination is a sensory response to
something or someone not present. (3) Anxiety is a feeling of vague uneasiness that may cause physiological arousal. (4)
Tangential thought is skipping from one topic to another.
QID: 7268 C 22(354 h 330) As a 25-year-old male client suffering from schizophrenia recovers from surgery he
becomes more disorganized in his thinking, and his behavior becomes more inappropriate. The nurse’s best nursing
action is to:
1. Tell the client he is psychotic
2. Alter medications as needed
3. Tolerate the client’s behavior
4. Document the client behavior
Category: safe effective care environment
Rationale
(4) Integrated processes: nursing process — implementation; communication and documentation; client need: safe,
effective care environment; coordinated care; content area: psychiatric-mental health.
RATIONALE
(1) Telling the client that he is psychotic is not an acceptable nursing action. (2) Medications are altered by physician’s
orders, not by the nurse. (3) Tolerating the behavioral change is not an accountable action. (4) When a client’s behavior
changes, the nurse must document the assessment.
QID: 7269 C 22(354 h 330) A 40-year-old woman is admitted to the emergency room. Her husband states that she has
not slept in 48 hours, is irritable and uncooperative, and has made comments about ending her life. When the nurse
attempts to take the client’s vital signs, she strikes the nurse’s hand. The thermometer breaks and the client bursts into
tears. The nurse’s first response is to:
1. Comfort the client and hold her hand
2. Tell the client to act appropriately
3. Call for assistance
4. Obtain vital signs
Rationale
(3) Integrated processes: nursing process — implementation; client need: safe, effective care environment; coordinated
care; content area: psychiatric-mental health.
RATIONALE
(1) The nurse must demonstrate respect for the client’s personal space. An invasion of the client’s space will likely
escalate the agitated behavior. (2) Telling the client to act appropriately may lead to a communication barrier between
nurse and client. Avoid giving advice. (3) When a client strikes a nurse, the client is displaying poor impulse control.
Safety of self, the client, and the staff is a priority Impulsive clients should not be managed alone. The nurse should call
for assistance before any other nursing actions are planned. (4) Obtaining vital signs is important information but
inappropriate at this time.
QID: 7270 C 23(383 h 332-338) A client is given a diagnosis of bipolar disorder. Bipolar disorder is:
1. A disorder of mood, affect, and thought
2. A disorder of personality and self-care
3. A disorder of interpersonal deficits
4. A disorder of intelligence and ideation
Correct; 1 chapter 23 text pg 383 meds 98-99 hesi 332-338
12
Rationale
mental health.
RATIONALE
(1) In bipolar disorder, client behavior ranges from excitability to depression. Bipolar disorder is an alteration of mood,
affect, and thought. (2) Many clients have personality problems and self-care deficits, but the central issue of the disorder
is altered mood. (3) Interpersonal functioning may contribute to altered mood episodes. (4) Intelligence and ideation are
not relevant.
QID: 7271 C 21(343 h 337) Clients with the medical diagnosis of bipolar disorder are often placed on lithium. Before
administering this medication, the nurse is aware of:
1. The diet of the client
2. The sleep pattern of the client
3. The lithium blood level of the client
4. The activity level of the client
Correct; 3 chapter 21 text 343 meds 99, 102-103 hesi 337
Rationale
(3) integrated processes: nursing process — planning; client need: physiological integrity; pharmacological therapies;
content area: psychiatric-mental health
RATIONALE
(1) The nurse might monitor the diet but not specifically for administration of lithium. (2) The sleep pattern may also be
monitored but not specifically for administration of lithium. (3) Lithium is a salt; its blood level must be monitored. The
range of normal blood levels is 1.0-4.2 mEq/L. If the lithium blood level is >1.2, the nurse will hold the medication and
notify the physician. (4) The nurse might monitor the activity level as part of overall care but not specifically for
administration of lithium
QID: 7272 C 21(343 h 37) A client who has been taking lithium for a number of months and has a lithium blood level
meq/L >1.2 may experience lithium toxicity. Lithium toxicity is characterized by:
1. Painful eyes, nausea, vomiting
2, Diarrhea, nausea, vomiting, tremors
3. Hypertension, swollen joints, fever
4. Hypotension, thirst, nausea, vomiting
Correct; 2 chapter 21 text pg 343 meds 99, 102-103 hesi 37
Category:
Rationale
RATIONALE
(1) Lithium toxicity usually does not cause painful eyes, nausea, or vomiting. (2) Lithium toxicity is a serious disorder
characterized by diarrhea, tremors, nausea, and vomiting. Generally, toxicity is reversed by intravenous infusion. (3)
These symptoms are not typical of lithium toxicity (4) Hypotension, thirst, nausea, and vomiting usually are not common
symptoms of lithium toxicity.
QID: 7273 C 27(499 h 352) A 90-year-old man who resides in a nursing home has been given a diagnosis of
Alzheimer’s disease. The nurse caring for this client would anticipate which of the following behaviors?
1. Overeating, overspending
2. Mood stability
3. Self-care deficits, impaired memory
4. Limb pain
Category: physiologic integrity physiology adaptation
Rationale
13
RATIONALE
(1) Overeating and overspending are not characteristics of Alzheimer disease. (2) Labile mood rather than mood stability
is characteristic of Alzheimer disease. (3) Alzheimer’s disease is characterized by impaired memory; self-care deficits,
anxiety, impaired judgment, rage reactions, and weakness of limbs. (4) Limb pain is not a characteristic of Alzheimer’s
disease.
QID: 7274 C 27(499 h 352) In caring for clients with ALzheimer’s disease, the nurse should:
1. Provide external signs of orientation.
2. Provide increased environmental stimulation.
3. Encourage frequent change.
4. Encourage group therapy
Rationale
mental health.
RATIONALE
(1) Clients with Alzheimer’s disease are frequently confused and disoriented. Clocks, calendars, and open drapes help
the client to know time, place, and person. (2) These clients need a stable environment and decreased environmental
stimuli when they no longer can tolerate the sensory level. (3) Clients with Alzheimer’s disease need a consistent care
routine. (4) Because of the narrowed communication ability, these clients usually are unable to work in group situations.
QID: 7275 C 27(499 h 352) A 75-year-old male client diagnosed with Alzheimer’s disease becomes very agitated at
night and begins tearing off the bed sheets. He tells the nurse that his suitcase is in the bedroom and he must catch a train
to the office. The nurse’s most appropriate response is to:
1. Restrain the client.
2. Reorient and reassure the client.
3. Provide a well-lighted environment.
4. Observe the client.
Rationale
RATIONALE
1. Restraints and medication may be necessary but these are not the first line of intervention. (2) Clients with
Alzheimer’s disease often become confused at night. This is called “sundowning.” The nurse should first reorient the
client and offer reassurance. (3) Controlling the light is an important environmental factor and may enhance the client’s
ability to maintain orientation, but reassurance is most important. (4) Safety issues are the responsibility of the caregiver,
and observation of all clients serves to eliminate unsafe conditions.
QID: 7276 C 24(406-407 h 352) The nurse knows that a person in his 90th year is in the developmental stage of:
1. Trust versus mistrust
2. Ego integrity versus despair
3. Identity versus identity diffusion
Rationale
14
RATIONALE
(1) The development stage of trust versus mistrust occurs between 0 and 12 months of age. (2) The aged client’s
developmental stage is ego integrity versus despair. The wisdom, experience, and purpose of one’s life should synthesize
in old age to create an integration of the self or ego. (3) Identity viruses identity confusion occurs in the teen years. (4)
Generativity versus stagnation occurs in the middle years.
QID: 7277 C 27(499 h 352) In caring for clients with Alzheimer’s disease, the nurses priority is:
1. Physiological care
2. Psychological care
3. Safety
4. Spiritual care
Rationale
(3) Integrated processes: nursing process — planning; client need: safe, effective care environment; safety and infection
control; content area: psychiatric-mental health.
RATIONALE
(1) Nursing care must be planned to meet the physiological needs of the person if the client is unable to meet these
needs. Impaired cognition usually involves sensory and perceptual disorders that may endanger the client’s safety
Meeting the client’s safety need is the number one priority (2) Alzheimer’s disease is a progressive deterioration that
robs the person of intellectual functioning with possible emotional changes. Falls become a safety concern in clients with
Alzheimer disease. (3) A safe environment allows for both simple activities and security; Attention span and the ability
to concentrate may be impaired as a result of neurological brain disease. To promote and maintain optimal health, the
nurse must attend to the client’s safety. If priorities must be set, safety is of extreme importance to the care of the client
with Alzheimer’s disease. (4) Spiritual care must be appropriate for the client and should be included as part of holistic
nursing interventions but safety is the number one priority
QID: 7278 C29 (536-539 h 110) A 7-year-old girl is admitted to the pediatric unit. She is severely mentally retarded and
is admitted for cellulitis. When admitting a retarded child, the nurse first assesses for:
1. Communication ability
2. Reading ability
3. Hobbies
4. Moral development
Category: physiologic adaptation
Rationale
physiological integrity; physiological adaptation; content area: psychiatric-mental health.
RATIONALE
(1) Although severely retarded children usually have an IQ between 20 and 40, it is important to assess for
communication abilities so that their needs can be understood. (2) Severely retarded children usually do not read. (3)
Children who are severely retarded do not usually participate in hobbies. (4) These children may not know right from
wrong.
QID: 7279 C29 (536-539 h 352) In caring for mentally retarded children, the nurse must:
1. Be aware of his or her own feelings.
2. Minimize family contact.
3. Interview the child extensively
4. Teach the child to cope with anxiety
Rationale
15
(1) Integrated processes: nursing process — planning; client need: safe, effective care environment; coordinated care;
RATIONALE
(1) Mentally retarded children are exceptional and need a great deal of care. Their handicaps often elicit feelings within
nurses that should be recognized and processed. (2) It is important to have family contact. (3) The child’s mental
development precludes extensive interviewing. (4) Teaching coping skills may be attempted but may prove to be futile.
QID: 7280 C19 (280-284 h 320) The mother of a 10-year-old girl reports to the clinic nurse that her daughter has been
acting “jumpy” lately. If the client is experiencing anxiety, the most important symptom that the nurse would likely
observe is:
1. Withdrawal
2. Lethargy
3. Hunger
4. An increased heart rate
Rationale
RATIONALE
(1) Withdrawal is not typical of anxiety reactions. (2) Lethargy may exist without anxiety (3) Hunger is not related to an
anxiety reaction. (4) The nurse may see an increased heart rate, hypervigilance, a startled response, or irritability in
children with anxiety
QID: 7281 C 19(288-289 h 322-323) A 32-year-old client is receiving treatment for obsessive-compulsive disorder
(OCD). Obsessive-compulsive behaviors manifest themselves as:
1. Reality orientation
2. Rigid perfectionism
3. A wide range of emotions
4. Ritualistic thoughts
Rationale
mental health.
RATIONALE
(1) Reality orientation is not associated with OCD. (2) Persons with a diagnosis of obsessive-compulsive behavior
disorder exhibit a preoccupation with rules, lack spontaneity and are perfectionistic. (3) A wide range of emotions is not
associated with OCD. (4) Ritualistic thought is the obsessive part of the disorder. Compulsion describes the action.
QID: 7282 C 19(288-289 h 322-323) A hospitalized client misses breakfast in the cafeteria three times in 1 week
because of his ritualistic handwashing. His handwashing ritual may go on for 30 minutes. Which of the following
nursing actions would be most appropriate for the client with an OCD?
1. Document the behavior, and work with the treatment team to design a treatment program to extinguish the behavior.
2. Tell the client to stop washing his hands and design a care plan to decrease anxiety.
3. Ask the client why he feels he must wash his hands and ask the physician for an order for an antianxiety agent.
4. Plan to bring a breakfast to the client’s room and schedule three periods a day for handwashing activity
Rationale
RATIONALE
16
(1) The most appropriate nursing intervention would be to document the behavior and work with the treatment team to
design a consistent treatment program. The treatment of OCD requires an interdisciplinary approach that addresses the
anxiety, dread, and guilt of the client; extinguishes the behavior; allows a safe environment; and assists the client to
understand his or her feelings and actions. Rituals are extinguished in a systematic time- step fashion over a period of
weeks. (2) Asking the client to stop the ritualistic behavior may produce anxiety that the client is unable to manage. (3)
Asking a “why” question is unrealistic and may cause the client to become defensive. (4) Reinforcing the behavior is
ineffective.
QID: 7283 C 29(559 h 353) A 14-year-old girl has been hospitalized by the court for psychiatric evaluation after
running away from home repeatedly. The nurse finds the client in her room during school hours and asks why she is not
in class. The client responds by stating that another nurse said she could miss class if she did not feel like going. The
nurse knows the client’s response is an example of:
1. Avoidance behavior
2. Manipulation
3. Rebellion
4. Projection
Rationale
(2) Integrated processes; nursing process — data collection; client need: psychosocial integrity; content area: psychiatric-
mental health.
RATIONALE
(1) Avoidance is a conscious or unconscious defense mechanism used to manage anxiety-laden experiences through
evasive behaviors. There is no indication that the client is exhibiting avoidance behavior. (2) The client is trying to
manipulate the nurse by playing one staff member against the other (commonly called “splitting”). Manipulation is
characterized by (a) having a conflict of goals, (b) consciously and intentionally trying to influence others, (c) practicing
deception, and (d) feeling good about the act of manipulation. (3) The client is not opposing or resisting authority She is
playing one staff member against the other. (4) The client is not using the unconscious defense mechanism of projection.
Projection is attributing one’s own thoughts to another
QID: 7284 C 29(559 h 353) A 16-year-old girl who is hospitalized for running away from home refuses to attend class,
stating that yesterday the other nurse told her she did not have to go to class if she did not want to. The nurse best
response would be:
1. “I know that you are lying.”
2. “Missing class is against the rules.”
3. “Why do you fight the system?”
4. “Fine, but you’re confined to your room.”
Rationale
RATIONALE
(1) Accusatory statements do not facilitate constructive communication. (2) Missing class is against the rules.
Reinforcing the rule avoids a power struggle with the client. The client needs to understand rules and limitations, and
that these rules and limitations will be reinforced consistently (3) The question is inappropriate at this stage of the illness.
(4) Closed-ended comments inhibit communication between the nurse and the client.
QID: 7285 C 29(559 h 253) Acting-out behavior is exemplified by which one of the following?
1. Discussing sexual feelings
2. Attempting suicide
3. Attending treatment activities
4. Contracting for safety
17
Rationale
(2) Integrated processes: nursing process — data collection; client need; psychosocial integrity; content area; psychiatric
mental health.
RATIONALE
(1) A discussion of sexual feelings can increase knowledge and may decrease anxiety and facilitate problem solving. (2)
Attempted suicide is an extreme form of acting Out. Acting-out behavior is limit testing. Limits are challenged in an
attempt to communicate feelings of fear or anger, which the client is unable to communicate directly (3) Attending
activities is not a form of acting-out behavior. (4) Contracting for safety suggests that the client is seeking security in the
environment.
QID: 7286 C 29(559 h 253) Two 15-year-old boys are being treated on the psychiatric unit. During a card game in the
recreation room, they begin fist-fighting. Nursing interventions for this incident would include: (Select all that apply.)
1. Remove the boys to separate areas and set limits.
2. Obtain an order for seclusion.
3. Share observations with the boys.
4. Restrain each boy as punishment for fighting.
5. Call juvenile detention to have children detained
6. Punish each boy with phone call restrictions.
Correct; 1, 3 chapter 29 text pg 559 meds 91 hesi 353
Rationale
(1, 3) Nursing process phase: Implementation; client need: psychosocial integrity
RATIONALE
(1) To defuse the situation, the nurse should provide a safe, nonthreatening environment and remove the stimulus
reinforcement. Limits are clearly reinforced in conversation. (2) Seclusion is viewed as control over personal freedom.
(3) Sharing observations assists the client to problem solve (e.g., “Fighting is against the rules. It doesn’t solve the
conflict. What happened to start the fight? How could it be handled differently?”). (4) Restraints should not be used as
punishment. Clients are restrained if they are possibly harmful to themselves or others. (5) Behavior modification works
better than calling in the legal authorities. (6) To defuse the situation, the nurse should provide a safe, nonthreatening
environment and remove the stimulus reinforcement.
QID: 7287 C29 (533-560 h 353-354) A 17-year-old male client is readmitted to the hospital for leukemia. He is angry
and refuses to talk with staff. The nurse should know that:
1. Adolescents may find it difficult to talk about death
2. Adolescents see death as temporary
3. Adolescents feel that death is a punishment
4. Adolescents think of the here and now not the future
Rationale
(1) Integrated processes; nursing process — data collection; client need; health promotion and maintenance; content
area; psychiatric-mental health.
RATIONALE
(1) Adolescents find it difficult to engage in a discussion related to death. (2) It is the child who sees death as temporary
(3) School-age children feel that death is a punishment. (4) Adolescents are thinking about the future and realize that
they might not participate.
QID: 7288 C 7(76-78 h 353-354) A client is being discharged from the hospital after a below-the-knee amputation.
Which statement by the client would indicate that the client is getting in touch with the loss?
1. “What is the use of going home with one leg?”
18
2. “Why me, God? If only I had changed my ways!”
3. “Are there support groups that help people like me?”
4 “Please leave me alone until my friend comes to take me home.”
Rationale
mental health.
RATIONALE
(1) The client is angry and feels helpless and hopeless. (2) The client is in the bargaining stage of the grief process. (3)
The client indicates that she is willing to move on with her life. (4) The client sounds depressed and continues to mourn
over the loss.
QID: 7289 C 29(533-569 h 353-354) A 13-year-old client’s history reveals that his cultural orientation discourages him
from verbalizing his spiritual issues. Which one of the following is the best nursing intervention?
1. Reassure the client that it is all right to verbalize spiritual issues.
2. Question the client about his religious orientation needs.
3. Refer the client to a nondenominational group.
4. Discuss immortality with the client.
Correct; 1 chapter 29 text pg 533-569 meds 95, 98 hesi 353-354
Rationale
(1) Integrated processes: Nursing process planning; client need: psychosocial integrity; content area: psychiatric-mental
health.
RATIONALE
(1) Spiritual development is an important aspect of the personality A holistic approach to nursing care is provided within
the framework of the nurse-client relationship and includes spiritual health. (2) Questioning may sort out the religious
preoccupation, but the client may use it as a barrier for any further communication. (3) Because it is impossible to be
informed about all religious traditions, it is important to discuss the client’s spiritual issues with informed members of
the health-care team before referring him to any group. (4) A discussion about immortality would be inappropriate.
QID: 7290 C 7(76-78 h 353-354) Which of the following concepts should the nurse be aware of when interacting with
survivors of victims of sudden death?
1. Survivors have time to engage in anticipatory grief.
2. Survivors may feel guilty for not engaging in special activities with the deceased.
3. Survivors feel immediate detachment.
4. Survivors may experience an uncomplicated grief response.
Correct; 2 chapter 7 text pg 76-78 hesi 353-354
Rationale
mental health.
RATIONALE
(1) Survivors do not have time to engage in anticipatory grief, the progression through the phases of grief before the
death. (2) Many survivors feel guilty for not having given something special or extra to the deceased. (3) Survivors’
immediate responses to a sudden death are feelings of shock, disbelief, guilt, despair, desertion, or betrayal. Detachment
takes place over time and is the process of “letting go.” (4) An uncomplicated grief reaction is an essential emotional
process that is a normal response to a loss. Survivors of victims of sudden death do not have time to prepare for the loss.
QID: 7291 C 7(76-78 h 353-354) During an Interview, an 83-year-old male client confides in the nurse that his spiritual
needs are not being met. Which one of the following is most important for the nurse to explore?
19
1. Source of strength and hope
2. Purpose and meaning in living
3. Spiritual orientation
4. Religious affiliation
Rationale
(2) Integrated processes: nursing process — data collection; caring; client need: psychosocial integrity; content area:
RATIONALE
(1) Significant others and religious beliefs may serve as a source of help and strength, but often do not. Clients need to
experience hope and support for the beliefs that give them strength.
(2) Spirituality concerns, especially among elderly persons, cause them to question the meaning and purpose in living.
Persons experiencing spiritual distress question their own existence and the reasons for suffering. (3) Information about
the client’s spiritual component is hard to obtain because it does not always lend itself to direct observation. (4)
Religious affiliation may be most meaningful for the client, and it is an outlet for the expression of spirituality, but it is
not the issue here.
QID: 7292 C 25(437 h 345-347) A 55-year-old male client who has been a heavy drinker for 20 years presents at the
emergency room in a state of agitation, delirium, and diaphoresis. It is reported that the client has not consumed any
alcohol during the past 72 hours. The nurse should know that the client is suffering from:
1. Delirium tremens
2. Korsakoff syndrome
3. Alcoholic hepatitis
4. Alcoholic hallucinosis
Correct; 1 text pg 437 chapter 25 meds 105 hesi 345-347
Rationale
RATIONALE
(1) The symptoms indicated are associated with delirium tremens and usually develop 72 hours after the last drink. (2)
Korsakoff’s syndrome is a disturbance of short-term memory possibly related to thiamine deficiency. (3) Alcoholic
hepatitis is a physical effect of chronic alcoholism. There is no observable evidence of hepatitis at this time. (4)
Alcoholic hallucinosis refers to auditory hallucinations. The client did not present with hallucinations.
QID: 7293 C 25(428-462 h 344-347) A 16-year-old boy was brought to the emergency room by his parents because he
was abusing cocaine and out of control. The nurse should know that one of the signs of cocaine intoxication is:
1. Dry cool skin
2. Hypotension
3. Bradycardia
4. Psychomotor agitation
Rationale
RATIONALE
(1) A sign of cocaine intoxication is diaphoresis, not dry, cool skin. (2) Clients suffering from cocaine intoxication
experience elevated blood pressure. (3) A common effect of cocaine detoxification on the body is a demand for oxygen
and an increase in the heart rate. (4) A common sign of cocaine intoxication is psychomotor agitation
QID: 7294 C 25(428-462 h 344-347) Which one of the following drugs is used to inhibit impulsive abuse of alcohol?
20
1. Chlordiazepoxide (Librium)
2. Disulfiram (Antabuse)
3. Diazepam (Valium)
4. Lithium
Category: physiologic adaptation; pharmacology and parenteral therapies
Rationale
(2) Integrated processes: nursing process planning; client need: physiological integrity; pharmacological therapies;
RATIONALE
(1) Librium is commonly used in the treatment of alcohol withdrawal. (2) Disulfiram is used as a deterrent to drinking if
the client wishes to stop drinking alcohol. Ingestion of alcohol while Antabuse is in the body results in an unpleasant
physical reaction. (3) Valium is used to reduce the symptoms of alcohol withdrawal. (4) Lithium is the drug of choice for
clients suffering from mood disorders.
QID: 7295 C 24(406-407 h 345-347) Which one of the following is a contributing factor in the development of
codependency?
1. Effective family dynamics
2. Difficulty in negotiating boundaries
3. Balanced internal ego states
4. Positive aspects of self
Rationale
mental health.
RATIONALE
(1) The harboring of family secrets and the inability to express true feelings are dysfunctional behaviors that may
contribute to ineffective family dynamics rather than effective family dynamics. (2) A person who is codependent has
difficulty with establishing a separate identity Ego boundaries are weak and the diffuseness of boundaries inhibits the
development of autonomy (3) Codependency involves an imbalance in internal ego states. (4) Codependency involves
negative messages about self that came from childhood experiences.
QID: 7296 C (436-437 h 345-3457) What is the nurse’s greatest responsibility when intervening with an alcoholic
family?
1. Instill hope in the family’s future.
2. Maintain homeostatic balance.
3. Encourage cross-generational clinging.
4. Promote the use of defense mechanisms.
Correct; 1 chapter 25 text 436-437 meds 105 hesi 345-347
Rationale
RATIONALE
(1) Instilling hope in the family’s future is one of the nurse’s greatest responsibilities. (2) Alcoholic families are
dysfunctional and lack homeostatic balance. (3) Cross-generational clinging is dysfunctional and should be discouraged.
(4) Promoting defense mechanisms such as rationalization or blaming others for behaviors associated with alcohol abuse
serves only to prolong the denial.
QID: 7297 C 21(352-372 h 338-343) A woman is admitted to a psychiatric unit for evaluation after displaying recurring
bizarre behavior. The nurse explains to the client’s family that:
21
1. The mentally ill person has often learned inappropriate behaviors that must be unlearned or replaced with acceptable
behaviors
2. Treatment is aimed at complete recovery which can occur at any time during the therapy
3. Part of the mental illness is insensitivity of the person to how others react to him or her
4. Evaluation is based on known criteria from which the mentally ill rarely deviate
Rationale
(1) Integrated processes: nursing process —. Implementation; teaching/learning; client need: psychosocial integrity;
RATIONALE
(1) Behavior modification therapy can be effective in facilitating coping skills and adaptive behaviors in certain mental
illnesses. (2) Although complete recovery may be possible, the aim of treatment is to facilitate the client’s ability to
function more effectively (3) Mentally ill persons are sensitive about how others will react to them. (4) Evaluation is
based on observation of the individual’s behavior. Diagnostic criteria are delineated in the Diagnostic and Statistical
Manual of Mental Disorders, 4th edition (DSM-IV). This may not be significant to the family
QID: 7298 C5 (59-60 h 338-342) The family of a newly admitted client is concerned about the client’s rights should
commitment be necessary It is important to remember that:
1. Initially commitment implies custodial care and therefore a client’s rights are not compromised
2. A client has the right to therapeutic treatment, informed consent, and to refuse treatment
3. Although a client retains all right to participate in his treatment, the facility cannot be held liable if treatment is not
provided
4. Treatment will not be initiated until the client and the legal guardian consent
Rationale:
RATIONALE
(1) Clients have a right to therapeutic, not custodial, care. (2) A client’s Bill of Rights ensures that a client has the right
to therapeutic treatment, informed consent, and to refuse treatment.
(3) Court cases have found in behalf of clients who did not receive therapeutic treatment and/or who were not treated
humanely. The facility was held liable, and the client was released. (4) The courts can look at competency versus
incompetency of the person. Competency is defined as the capability of making a decision. At times, the courts have
appointed a guardian, but not always. Therefore, a client may not even have a guardian.
QID: 7299 C 24(406-407 h 338-342) A mother received a call from her daughter’s teacher. The 7-year-old child seems
withdrawn, does not interact with other children, and does not participate in class. The concern of the mother and the
teacher is based on the fact that:
1. Children progress through the stages of development at a similar rate and react to school with predictable behaviors
2. This developmental period is psychologically stormy and changes in behaviors are considered significant.
3. Seven-year-old children rely on peer approval rather than positive reinforcement from parents,
4. This is usually a period during which the child makes great social and intellectual strides.
Rationale:
RATIONALE
(1) Individuals develop at their own rate, although, in any stage, most individuals accomplish certain tasks within that
stage. (2) This school-age period (6.—16 years) is psychologically the quiet years. (3) During this developmental period,
22
children usually get a sense of approval from positive reinforcement from the parent. (4) Sexual curiosity is replaced by
intellectual curiosity; great social and intellectual strides are accomplished; group activities become more important
QID: 7300 C 24(406-407 h 338-342) An individual’s personality and perception of self are key factors in determining
behavior. The nurse recognizes that:
1. Events occurring throughout life affect emotional adjustment
2. It is not necessary to complete one developmental stage before the individual can progress to the next stage
3. Withdrawn behavior illustrates a person’s inability to move from one developmental stage to the next
4. The most psychologically significant stage of development is birth to 12 months
Rationale:
RATIONALE
(1) Events occurring throughout life may affect emotional adjustment; most experts believe that events which occur in
the first 20 years have the greatest impact; some believe the first 6 years are the most significant. (2) Every
developmental stage is the foundation for the next. If a stage is completed successfully, the foundation is firm; if not, the
personality structure may be weakened. (3) Inability to progress through a developmental stage does not always result in
withdrawn behavior, and it is not the primary cause of withdrawn behavior. (4) Events occurring during the first 12
months of life primarily affect the development of trust versus mistrust, but this period is not the most psychologically
significant.
QID: 7301C 21(334 h 332-338) A 70-year-old severely dehydrated woman was admitted to a medical unit. Her husband
died a month ago and she lives alone. Her only child lives 200 miles away with his wife and son. The nurse notes that the
client always gazes downward and does not respond to questions. This behavior is an example of:
1. Conversion reaction
2. Suppression
3. Depression
Correct; 3 chapter 21 text pg 334 meds 98 hesi 332-338
Rationale:
mental health.
TIONALE
(1) Conversion reaction occurs when unacceptable feelings disguised by repression manifest as physical symptoms. (2)
Suppression is consciously keeping unacceptable feelings and thoughts out of awareness. (3) Symptoms of depression
can include withdrawal, poor eye contact, and failure to perform ADLs such as eating and hygiene. (4) Reaction
formation occurs when unacceptable feelings are disguised by repression of the true feelings and reinforcement of the
opposite feelings.
QID: 7302 C 24(406-407 h 332-338) The developmental stage for a 70-year-old client is:
3. Integrity versus despair
Rationale:
RATIONALE
23
(1)This is the developmental stage for ages 6—12 years. (2) This is the developmental stage for ages 18—25 years. (3)
This is the developmental stage for ages 65 years to death. (4) This is the developmental stage for ages 30—45 years
QID: 7303 C 21(336-348 h 332-338) In trying to reassure a recently widowed client, the nurse says, “Don’t worry,
everything is going to be fine.” According to the principles of therapeutic communication, this statement communicates:
1. Empathy and understanding
2. Clarification of a client’s feelings
3. Devaluation of a client’s own perception
4. Caring and concern
Rationale:
RATIONALE
(1) Empathy is the ability to feel the feelings of others so that one can relate to the situation in their terms. (2) The client
is aware that everything will not be fine; she is alone and her spouse is deceased. (3) This communication block does not
acknowledge the clients own perception of her situation. (4) Superficial reassurance denies the client’s feelings and her
grief.
QID: 7304 C 24(406-407 h 332-338) During his monthly therapy session, a 48-year-old father of an adolescent son tells
you that his son is “impossible” and cannot make decisions. On the basis of your knowledge of adolescent behavior, you
know that:
1. All adolescents are difficult to control and cannot make sound decisions.
2. A hallmark of adolescence is ambivalence related to dependence and independence.
3. Adolescents want to be dependent and rely on others to make decisions.
4. At this developmental stage, the adolescent is primarily seeking parental approval.
Rationale:
RATIONALE
(1) This statement is all-inclusive; therefore, “all-or-none” cannot be correct. (2) Adolescents want independence without
responsibility, and this accounts for ambivalent feelings. (3) The dependence versus independence conflict accounts for
much of adolescents’ irritable and erratic behavior; they long to be independent and self-sufficient. (4) Peer approval is
very important to adolescents they are deeply involved in their own feelings of self-worth and self-identity
QID: 7305 C 24(406-407 h 332-338) Sex education during adolescence is important because:
1 Adolescents are unaware of the physical and emotional changes that are occurring.
2. The love object of an adolescent is primarily the parent of the same sex.
3. Adolescents are more concerned about self than others, and this is the focus of their attention.
4. As bodily changes occur, the adolescent has to feel comfortable discussing these changes.
Category: health promotion an maintenance
Rationale:
(4) Integrated processes: nursing process — planning; client need: health promotion and maintenance; content area:
RATIONALE
(1) Adolescents are aware of physical and emotional changes as well as of the sexual changes equated with maturity and
the need to belong. (2) “Love” relationships are likely to be based on what the “loved” person does to strengthen the
adolescent own self-esteem; these love objects are found among peers and others outside the home setting. (3)
Adolescents have a need to be accepted by others, as is evident by the development of language or cues unique to the
24
group and the creation of inclusive situations that readily make the members identifiable. (4) The adolescent is keenly
aware of body changes and maturation and shows a readiness to learn about them. Sex education during this period is
important to prevent pregnancy and sexually transmitted diseases.
QID: 7306 C 24(406-407 h 332-338) In response to failing courses in school, an adolescent boy says, “Well, if I were all
brains and nothing else, I would make As in all of my courses.” This is an example of which defense mechanism?
1. Repression
2. Compensation
3. Denial of reality
4. Rationalization
Rationale:
mental health.
RATIONALE
(1) Repression is unconsciously keeping unacceptable feelings out of awareness. (2) Compensation is overachievement
in one area because of feeling of inadequacy in another. (3) Denial of reality involves the repression of a reality as
though it does not exist (e.g., an alcoholic who says he does not have a drinking problem). (4) Rationalization is the
falsification of experience through the creation of a logical or socially acceptable explanation of the behavior.
QID: 7307 C 11(143-147 h 315-317) At the conclusion of a therapy session, a client says to the therapist, “I’m really
grateful for your time; you’re a great listener. You know, you remind me of my wife.” An appropriate response by the
therapist would be:
1. “She must be a great listener too.”
2. “That’s because she and I are both concerned about you and your son.”
3. “What about me reminds you of your wife?”
4. “Do you want to talk about this some time?”
Rationale:
(3) Integrated processes: nursing process implementation; communication and documentation; client need: psychosocial
integrity; content area: psychiatric-mental health.
RATIONALE
(1) This response makes assumptions about characteristics that may or may not be true or contribute to the client’s
perceptions. (2) This response makes inappropriate generalizations of emotions about family and/or significant others.
(3) This response is an open-ended question that does not cue the client as to an expected response. (4) This response
does not maintain the focus of the session or the direction of the interaction. In addition, the therapist is setting himself or
herself up for a boundary violation
QID: 7308 C 22(364-368 h 341-343) The major clinical use of antipsychotics (or neuroleptics) is in the treatment of
psychoses. When used in the treatment of schizophrenia, neuroleptics:
1. Eliminate the need for psychotherapy by effectively curing social withdrawal and apathy.
2. Provide symptomatic control by blocking the activity of dopamine.
3. Heighten the sex drive and require weekly titers to assess peak and trough.
4. Alter the client’s response to reality and decrease paranoia.
Category: physiologic integrity; pharmacology adaptation
Rationale:
(2) Integrated processes: nursing process — evaluation; client need: physiological integrity; pharmacological therapies;
RA11ONALE
25
(1) Neuroleptics do not cure social withdrawal and apathy; they treat brain chemistry to aid in the reintegration and
reorganization of thoughts. (2) Increased levels of dopamine increase the neurotransmitter activity in the brain and result
in erratic behavior associated with schizophrenia. (3) Neuroleptics do not increase sex drive; in men, they cause
ejaculation dysfunction. (4) Alteration of reality is unclear in terms of how the client’s perception of reality changes.
Paranoia does not occur in all schizophrenia; it is a component or symptom of some mental illnesses
QID: 7309 C 22(364-368 h 341-343) The nurse plan of care for the client taking neuroleptics must include observing for
side effects, which include:
1. Nausea, vomiting, diarrhea, weight loss
2. Heartburn, hypoglycemia, edema
3 Nasal congestion, seizures, urinary retention
4. Insomnia, drooling, agranulocytopenia
Category: physiological integrity; pharmacology adaptation
Rationale:
RATIONALE
(1) Neuroleptics cause weight gain secondary to decreased metabolism and gastric motility. (2) Neuroleptics may
precipitate a hyperglycemic response in individuals who are predisposed but are not associated with precipitating
diabetes. (3) Nasal congestion, seizures, and urinary retention are serious side effects that are believed to occur because
of the additive anticholinergic properties of phenothiazine. (4) A common side effect of neuroleptics is hypersonmia.
QID: 7310 C 24(406-407 h 341-343) A 3- to 4-month-old infant who is allowed to cry for hours or who is neglected:
1. Will instinctively continue to cry until his or her needs are met and he or she no longer feels neglected
2. Begins to mistrust people and surroundings even though the infant is too young to distinguish himself or herself from
others
3. Will withdraw from the world of reality to the world of fantasy, which feels less threatening
4. Will develop alternate ways to feel good about him self or herself and about the world
Rationale:
mental health.
RATIONALE
(1) Infants will withdraw and no longer cue their needs through crying. (2) The developmental stage for this age group is
trust versus mistrust. The unrelenting frustration of not having needs met can result in the negative outcome of mistrust.
(3) Infants do not possess the cognitive ability to create an alternate or fantasy world. (4) Infants lack the cognitive
ability to accomplish this.
QID: 7311 C24 (405-406 h 341-343) A nurse is teaching parenting classes. When teaching growth and development, the
nurse states, “The gradual realization in a child that neither the child nor his or her parent is omnipotent leads to….
1. Sadness and withdrawal.”
2. Anger and displacement.”
3. Mastery of more skills.”
4. Developmental regression.”
Rationale:
(3) Integrated processes: nursing process — implementation; teaching/learning; client need: health promotion and
maintenance; content area: psychiatric-mental health.
RATIONALE
26
(1) This realization is a turning point in the infant’s development of self and self-sufficiency (2) The infant does not have
the emotional ability to displace anger or frustration on others. (3) Gradually, the child begins to master more skills that
allow him or her to feel more in control of the environment and more secure. (4) As skills are developed and mastered,
the infant progresses developmentally
QID: 7312 C 24(406-407 h 341-343) When the nurse is teaching the growth and development of a 2-year-old child, the
nurse identifies that the child:
1. Begins to develop a sense of autonomy
2. Becomes dependent and less self-reliant
3. Generally cannot master new challenges
4. Cannot socialize and demonstrates fear of the environment
Rationale:
RATIONALE
(1) A 2-year-old’s exploration of the environment leads to conquests and feelings of autonomy (2) The 2-year-old child
is independent and self-reliant. (3) New challenges, for example, toilet training, are mastered. (4) Social skills are
increased, usually secondary to a curiosity about the environment.
QID: 7313 C 24(406-407 h 341-343) When teaching the growth and development of 3- to 5-year-old children, the nurse
identifies:
1. Little or no need for discipline
2. Lack of concern for parental approval
3. Increasing motor and intellectual skills
4. Lack of social skills
Rationale:
(3) lntegrated processes: nursing process data collection; eaching/1earning; client need: health promotion and
maintenance; content area: psychiatric-mental health.
RATIONALE
(1) Discipline is needed to provide the 3- to 5-year-old with structure and a sense of security (2) Parental approval is
important in the development of good self-esteem. (3) Motor and intellectual skills are increasing, and in 3- to 5-year-
olds, accomplishments such as the ability to ride a tricycle, run with only a few falls, and dress themselves boost their
self-esteem. (4) This age group is becoming more aware of peers and group activities; socialization skills improve
QID: 7314 C33 (648-656 h 341-343) A client who was raped 10 years ago is now unable to have a satisfying sexual
relationship with her husband. The nurse identifies that the client may be exhibiting which defense mechanism?
2. Displacement
3. Repression
4. Suppression
Rationale:
mental health.
RATIONALE
(1) Reaction formation is denial of unacceptable feelings and the adoption of the opposite behavior. If this were the case,
the client would be promiscuous. (2) Displacement occurs when the client transfers hostile or unacceptable behavior
from one object to another. (3) Repression is unconsciously keeping unacceptable feelings out of awareness. This client
27
has repressed her feelings about the catastrophic sexual experience earlier in life. (4) Suppression is the conscious
keeping of unacceptable feelings out of awareness.
QID: 7315 C 24(404-426 h 327-329) A man who was paralyzed from his waist down after an accident is asked what
effect his paralysis will have on his previously active life. His response is, “no effect.” The nurse identifies this as an
example of:
1. Denial of reality
2. Compensation
3. Fantasy
4. Introjection
Rationale:
mental health.
RATIONALE
(1) The reality in this situation is the paralysis. To deny that paralysis will change his previously active life is to deny its
reality (2) Compensation allows the individual to cover up a perceived area of inadequacy or weakness by overexcelling
in another area. (3) Fantasy allows the temporary escape from a painful environment; it can also help the individual
arrive at solutions to problems that he otherwise may not be able to solve. (4) Introjection occurs when the person
incorporates into his own personality attributes of others, thus protecting him from threatening circumstances
QID: 7316 C 24(404-426 h 327-329) A 3- or 4-year-old child who has been toilet trained begins to have incontinent
episodes and “talk baby talk” when her newborn sister is brought home from the hospital. This behavior demonstrates
which defense mechanism?
1. Displacement
2. Regression
3. Sublimation
Rationale:
(2) Integrated processes: nursing process — data collection; client need psychosocial integrity; content area: psychiatric-
mental health.
RATIONALE
(1) Displacement occurs when a person transfers hostile and aggressive feelings from one object to another object or
person. For example, a man who gets “chewed out” at work comes home and kicks the dog or yells at his wife and
children. (2) Regression, displayed by this child, is a reaction against anxiety that allows the person to go back in
development to a time when he or she felt more at ease and better able to cope with his environment. (3) Sublimation
allows the person to divert unacceptable impulses and motives into socially acceptable ones. For example, persons with
strong aggressive impulses participate in physically violent sports or other socially accepted activities. (4) Reaction
formation occurs when one denies unacceptable feelings and impulses by adopting conscious behavior that appears (at
least on the surface) to be contradictory to the feelings being denied.
QID: 7317 C 21(342-343 h 333-334) A client experiences free-floating anxiety that has worsened since his recent
divorce. He is taking a non- barbiturate benzodiazepine agent. The nurse recognizes that this classification of drug:
1. Is recommended because of its low potential for abuse, toxicity, and lethal overdose
2. Works selectively on the limbic system of the brain, which is responsible for emotions such as rage and anxiety
3. Has a tranquilizing effect without numbing emotions and produces reversible amnesia in the treatment of post-
traumatic stress disorder (PTSD)
4. Acts primarily by enhancing normal coping mechanisms, is well tolerated, and is nonaddictive
Correct; 2 chapter 21 text pg 342-343 meds 99-101 hes 333-334
Category: physiologic integrity pharmacology adaptation
28
Rationale:
(2) Integrated processes: nursing process evaluation; client need: physiological integrity; pharmacological therapies;
RATIONALE
(1) This classification of drugs, which includes chlordiazepoxide (Librium), diazepam (Valium), clorazepate (Tranxene),
lorazepam (Ativan), and oxazepam (Serax), has a high potential for abuse, toxicity and lethal overdose, and it is
recommended that these drugs be used for a short time only (1-2 weeks). (2) By binding with ?-aminobutyric acid, the
benzodiazepine agent decreases anxiety and produces a sedative effect by blocking the release of ?-aminobutyric acid.
(3) Although drugs in this classification have a tranquilizing effect without sedation, they may also numb emotions and
decrease one’s enthusiasm for life. (4) Benzodiazepines interfere with normal coping mechanisms and may cause an
increase in irritability, aggression, hostility, and depression.
QID: 7318 C16 (228 h 337) Antidepressants are used in the treatment of depressive disorders caused by emotional,
physical, chemical, and/or environmental stressors. Regarding the classifications of antidepressants, the nurse knows
that:
1. Tricyclic antidepressants decrease the level of neurotransmitters in cases in which an increase in neurotransmitters
causes depression
2. MAOIs are effective when administered over a short period; they are less toxic than other classifications
3. Tricyclic antidepressants are contraindicated in the treatment of depression associated with physiological symptoms
such as insomnia, fatigue, and irritability
4. Hypertensive crisis may result if MAQIs are taken with tyramine-rich foods, such as aged cheese, avocados, and
chicken livers
Rationale
(4) Integrated processes: nursing process — evaluation; client need: physiological integrity; pharmacological therapies;
RATIONALE
(1) Tricyclic antidepressants increase the level of the neurotransmitter serotonin or norepinephrine; a deficiency in
neurotransmitters is thought to cause depression. (2) MAOIs prevent the metabolism of neurotransmitters; they must be
given for long periods (2—6 weeks) and are more toxic. Those commonly used include isocarboxazid (Marplan),
pheneizine (Nardil), and tranylcypromine (Parriate). (3) Tricyclic antidepressants are used to treat the symptoms of
depression. In about 85% of the cases, individuals demonstrate an increase in mental alertness and physical activity
within a few days of beginning treatment. (4) Hypertensive crisis may result if MAOIs are taken with tyramine-rich
foods, such as aged cheese, avocados, bananas, and chicken livers. Clients should avoid drinking beer, red wine, and
caffeine-containing beverages.
QID: 7219 C 24(404-426 h 327-329) Personality disorders are maladaptive patterns of seeing, relating to, and thinking
about one’s environment. Nursing care for clients with personality disorders should include:
1. Reinforcing limits to counteract manipulative behavior
2. Allowing hostile exchanges that foster open expression
3. Assisting the client to focus by limiting diversional activities
4. Helping the client to build self-esteem by ignoring inappropriate behaviors
Rationale
mental health.
RATIONALE
(1) Many personality disorder clients are manipulative and do not have appropriate personal and social boundaries.
Limits must therefore be reinforced. (2) Interventions should encourage relaxed rather than hostile exchanges. (3)
Planned diversional activities are recommended in the care of clients with personality disorders. (4) Commonly
29
occurring inappropriate behaviors include blaming, accusing, and intimidating. The nurse should directly and clearly
identify inappropriate behaviors that alienate others
QID: 7320 C 11(143-147 h 315-317) During a therapeutic session, the client tells the nurse, “You’re just like my
mother, and you’re never going to change. First you tell me to talk about how I feel, then when I talk, you cut me off and
don’t let me finish a sentence.” This is an example of:
1. Conversion reaction
2. Blatant hostility
3. Displacement
4. Transference
Rationale
mental health.
RATIONALE
(1) In conversion reaction, unacceptable thoughts and feelings are repressed and manifest as physical symptoms. (2) The
client is not demonstrating hostility toward the nurse. The object of any hostility in this exchange would have to be the
client’s mother. (3) In displacement, a client transfers hostile or unacceptable behavior from one object to another. (4)
Transference is the result of unresolved childhood experiences with significant others; the client transfers unresolved
feelings to present relationships in an attempt to resolve them.
QID: 7321 C 22(364-368 h 341-343) A 40-year-old client with chronic schizophrenia and a history of multiple
hospitalizations is readmitted for noncompliance with medication therapy. The most common reason for noncompliance
with antipsychotic medications is:
1 Neuroleptics tend to produce unpleasant side effects and adverse reactions.
2. The medications are too expensive to purchase.
3. The client improves and believes that he no longer requires medication.
4. Neuroleptics are designed for short-term use only.
Rationale
RATIONALE
(1) The side effects include anticholinergic effects such as dry mouth, urinary retention, weight gain, and sexual
dysfunction. (2) Neuroleptics are not considered cost prohibitive, and many clients are subsidized through mental health
clinics. (3) In chronic mental illness, clients are usually aware of their need for medication therapy (4) Neuroleptics are
designed for long-term use in mental illness.
QID: 7322 C 24(410-411 h 237) The nurse on the unit presents the client’s medication in a pill cup already opened. The
client refuses to take the medication, stating, “1 don’t know what that is.” A nursing intervention to educate the client
and promote compliance would be to:
1. Tell the client what the medication is and encourage him or her to take it.
2. Obtain an unopened labeled dose and show the client the medication.
3. Reassure the client that it is the right medication and that it is important that it be taken.
4. Tell the client if he or she refuses to take the medication orally, it will be administered intramuscularly.
Rationale
(2) Integrated processes: nursing process — implementation; teaching/learning; client need: physiological integrity;
pharmacological therapies; content area: psychiatric-mental health.
RATIONALE
30
(1) The paranoid client is mistrustful; your explanations will not be accepted. (2) This action removes the stimulus on
which this mistrust is based. (3) The paranoid client’s feelings of mistrust are not helped by reassurance. (4) This is and
will be perceived by the client as a threat and will further exacerbate the trust issues.
QID: 7323 C 22(410-411 h 237) During dinner a client refuses to eat, stating, “You are serving me dog flesh.” The best
response for the nurse would be:
1. “Don’t be silly, we don’t eat dog meat here.”
2. “What makes you think this is dog flesh?”
3. “Don’t worry; I’ll get you something else.”
4. “If you don’t want to eat, is up to you.”
Rationale
RATIONALE
(1) This is a demeaning and superficial response that attacks the client’s self-esteem. (2) This open-ended question
allows the client to express his or her perception and provides an opportunity for intervention. (3) This response indicates
that the nurse is contributing to the client’s delusional structure. (4) This noninterventional response makes no attempt to
assess the client’s perception or to provide the client with the opportunity for reality orientation.
QID: 7324 C 22(364-368 h 341-343) For the client with a history of noncompliance with medication therapy, the
physician has decided to prescribe decanoate neuroleptics. Client and family teaching for this medication should include
the following:
1. These neuroleptic medications have few side effects.
2. A special diet is required while on this medication.
3. Blood levels to assess effectiveness must be drawn monthly
4. The medication is given IM every 2-4 weeks.
Rationale
(4) Integrated processes: nursing process — planning; teaching/learning; client need: physiological integrity;
pharmacological therapies; content area: psychiatric-mental health.
RATIONALE
(1) There are only two decanoate drugs: haloperidol (Haldol) and fluphenazine (Prolixin). Their delivery is different;
both have side effects. (2) The client is not required to adhere to a special diet while taking neuroleptics. (3) Behavioral
changes and improvement in thought reorganization are used to measure the effectiveness of neuroleptics. (4) The
decanoate salt is slowly absorbed and has a sustained duration of action that decreases the need for frequent dosing. The
dose amount and frequency are highly individualized and determined by the resolution of specific symptoms
QID: 7325 C 22(357-362 h 338-339) A 23-year-old female client has been admitted to the inpatient psychiatric unit with
a diagnosis of catatonic schizophrenia. She appears weak and pale. The nurse would expect to observe which behaviors
in this client?
1. Scratching and catlike motions of the extremities
2. Exaggerated suspiciousness and excessive food intake
3. Stuporous withdrawal, hallucinations, and delusions
4. Sexual preoccupation and word salad
Rationale
mental health.
RATIONALE
31
(1) This is not a characteristic of catatonic schizophrenia. (2) This is a characteristic of paranoid schizophrenia that is not
generally seen in catatonic schizophrenia. The symptoms can result in an unwillingness or inability to eat. (3) Stuporous
withdrawal, hallucinations, and delusions are characteristics of catatonic schizophrenia. (4) Sexual preoccupation is more
a characteristic of sexual disorders and the manic phase of bipolar disorder. Word salad is a speech pattern in which
words do not make sense, and is not characteristic of catatonic schizophrenia.
QID: 7326 C 24(404-426 h 327-329) A 28-year-old male client with a history of antisocial personality disorder is
admitted to the psychiatric unit because of a suicide attempt while in jail awaiting trial for assault. The client acts very
disinterested in treatment and has developed a rapport with several clients whom he is influencing in negative ways. In
evaluating his progress, the nurse recognizes that he:
1. Could make behavioral changes within a short time if motivated.
2. May not be motivated to change his behavior or lifestyle.
3. Manipulates others but does not manipulate family members.
4. Usually requires intensive psychotropic drug therapy, which he refuses.
Rationale
mental health.
RATIONALE
(1) Clients with antisocial personality disorder reject social norms as limits and exhibit poor impulse control. This client
cannot be expected to monitor his own behavior effectively (2) Establishing clear, consistent limits on behavior will
contribute to this client’s ability to interact appropriately on the unit. (3) Peer Interaction offers the opportunity for the
client to receive feedback about his interactions with others. Encouraging peer interaction also helps model social norms.
(4) Clients with antisocial personality disorder come from dysfunctional families and have poor, often volatile,
interpersonal relationships. The nurse cannot expect these families and significant others to participate effectively with
the client in treatment.
QID: 7327 C 23(375 h 330) A 15-year-old girl is admitted with a diagnosis of anorexia. She is an honor student and
participates in school activities. She is 40% below expected weight, states that she is fat, and demonstrates uncooperative
behavior during the admission process. In anorexia, the client has a distorted view of:
1. Self-esteem and self-worth
2. Ability to control
3. Self-image and intellect
4. Need to mature
Rationale
(3) Integrated processes: nursing process —data collection; client need: psychosocial integrity; content area: psychiatric-
mental health.
RATI ONALE
(1) Although therapy serves to reinforce self-esteem and self- worth, this is not at the basis of the deficit. (2) Exerting
control over eating habits and weight provides positive reinforcement; the client feels in control and able to live in an
otherwise out-of- control environment. (3) Although the client may “see” herself as “fat,” this is a figurative distortion
and does not include intellect. (4) The need to mature is not a part of this struggle and does not enter into the
consideration of how to deal with her environment.
QID: 7328 C 29(556-558 h 353) A 7-year-old boy is admitted for evaluation. His history reveals multiple reports by
teachers that he is unable to sit still in class, is aggressive with the other children, and cannot concentrate on a task more
than 5 minutes. An appropriate nursing intervention for the first few days includes:
1. Set clear, concise behavior expectations with consistent limits.
2. Put him in time-out if he does not follow the rules.
3. Observe his behavior and assess for patterns.
32
4. Ask him why he is acting as he is.
Rationale
mental health.
RATIONALE
(1) Behaviors that he is currently exhibiting are usually accompanied by low frustration level and easy distractibility
initially he will not be able to meet concise behavioral expectations and will react with increased agitation. (2) Isolation
will not provide him with the feedback he needs. He may see this only as another step in ritualistic behavior without
recognizing its relationship to inappropriate behavior. (3) This intervention is most important at this time. Even though
he has a short attention span and appears unable to concentrate, the sequence of behaviors may provide insight. (4)
Initially, he will not know how to respond; at this point he lacks the insight to provide this information.
QID: 7329 C 21(343 h 337) A physician prescribes lithium for a client who was recently admitted to a unit. The nurse
knows the following to be true of this medication:
1. Onset of therapeutic effect is 7—14 days; side effects include fine tremors and blurred vision.
2. Nausea and vomiting are common side effects that are treated symptomatically with daily low doses of antiemetics.
3. Therapeutic effect is minimal, and noncompliance is difficult to detect; blood levels are therefore drawn weekly
4. IM administration results in immediate relief of symptoms, and effects usually last 27—48 hours.
Correct; 1 chapter 21 text pg 343 meds 99, 102, 103 hesi 337
Rationale
(1) Integrated processes: nursing process — planning; client need: physiological integrity; pharmacological therapies;
RATIONALE
(1) To minimize side effects, therapeutic levels of lithium are reached over 7—14 days. (2) These are not “common” side
effects of lithium therapy and prophylactic treatment is not required. (3) Noncompliance results in the reappearance of
symptoms and is therefore observable. (4) Lithium is not a short-onset, fast-acting drug. It is intended for use in long-
term care.
QID: 7330 C 21(343 h 337) Three weeks after beginning lithium therapy, a client appears lethargic and ataxic and has a
decreased level of consciousness. These symptoms indicate:
1. A decrease in therapeutic levels
2. Toxic ranges of lithium
3. Maximum therapeutic effectiveness of lithium
4. Expected side effects of lithium
Rationale
RATIONALE
(1) Decrease in therapeutic levels results in agitated behavior. (2) Toxic ranges are possibly a result of self-
administration error or noncompliance. (3) Lithium therapy is intended to control symptoms while allowing maximum
level of functioning. (4) Lethargy and other emotional blunting symptoms are not expected side effects of lithium
therapy
QID: 7331 C 21(343 h 337) In the case of suspected lithium toxicity, the best intervention for the nurse is to:
1. Assess the most current laboratory values and force fluids
2. Hold the next dose and draw a serum level
3. Notify the physician and wait for instructions
4. Give the medication and assess for further side effects
33
Rationale
(3) Integrated processes: nursing process implementation; client need: physiological integrity; reduction of risk potential;
RATIONALE
(1) Lithium levels would be the most significant laboratory value at this time. Forcing fluids would not be the priority
intervention. (2) The concern is toxicity, which would require direct intervention to reverse, rather than passive
intervention, such as withholding a dose of lithium. (3) This is the most appropriate and priority nursing intervention in
this situation in which a toxic level appears to have accumulated. (4) This intervention would result in further elevation
of lithium levels and more critical symptoms as toxicity worsens.
QID:7332 C 27(491-492 h 337) In the United States, older adults are more frequently the recipients of health care than
are other age groups because:
1 They are prone to chronic illness and depression and require long-term therapy
2. Single-adult households are more common among older people, and this often means that family resources are less
available
3. They are lonely, and health-care providers traditionally provide understanding and comfort
4. Physiological changes in older adults are irreversible and require planned health-care interventions.
Rationale
RATIONALE
(1) This response is a prejudiced opinion that stereotypes older adults. Not all older adults are “prone” to depression, and
not all require long-term care. (2) It is estimated that 20%—25% of all United States households are occupied by single
adults. For the older adult, this means that there are fewer times when family members or significant others are in close
enough proximity to respond to health-care needs. (3) This response is a stereotypical statement that is untrue. (4) Not all
physiological changes in older adults are irreversible.
QID: 7333 C22 (379, 301 h 320-323) During an assessment of a client admitted for anxiety disorder, the nurse
determines that the client has been using addictive substances as a means of coping. When managing patient care, which
one of the following would be considered a long-term goal?
1. Client will demonstrate ability to cope without exhibiting dependency behavior by the time of discharge.
2. Client will participate in decision-making regarding addictive substance use within 3 days.
3. Client will willingly attend therapy activities.
4. Client will verbalize desire to control the use of addictive substances within 7 days.
Correct; 1 chapter 22 text pg 379, 301 meds 89-92 hesi 320-323
Rationale
(1) Integrated processes: nursing process —planning; client need: psychosocial integrity; content area: psychiatric-
mental health.
RATIONALE
(1) Long-term goals should focus on the client’s ability to learn alternate coping skills. (2) Short-term goals are within a
specific time frame. (2). Three days. (3) This goal has no time frame. (4) Although this is a long-term goal, it does not
indicate a plan of action.
QID: 7334 C 23(383 h 332-338) In psychosocial terms, the consequences are grave for a pregnant client admitted for
bipolar disorder and opiate addiction. Which of the following should be part of the initial management regimen?
1. Physiological crisis
2. Symptomatically assessed
3. Psychological crisis
34
4. Promotion of abstinence
Rationale
(1) Integrated processes: nursing process —planning; client need: physiological integrity; physiological adaptation;
RATIONALE
(1) When an acute physical condition is present, the initial management of physiological care that supports homeostatic
regulation takes priority over other health needs of the client. (2) Physiological care takes priority over other health needs
of the client. (3) Physiological care takes priority over other health needs of the client. (4) Physiological care takes
priority over other health needs of the client.
QID: 7335 C 22(375-401 h 330-331) During the nursing management phase with a client diagnosed as having an eating
disorder, which one of the following may indicate that the client has a need for providing relief from a negative
emotional state?
1. Forming close and intimate relationships.
2. Exhibiting impulse control problems and self- mutilation.
3. Experiencing modest overt conflict.
4. Requesting frequent periods of dependency
Rationale
mental health.
RATIONALE
(1) The client will not likely have any close friends because of the secretive nature of the symptoms. (2) Self-mutilation,
alcohol abuse, and shoplifting may be a means of providing relief and soothing from negative emotional state. (3) Clients
with eating disorders come from families that exhibit overt conflict. (4) The onset of the eating disorder may coincide
with periods of greater autonomy during which time the individual feels ill-equipped to manage independence
QID: 7336 C 24(428-462 h 344) The nurse is caring for a client who admits to abusing marijuana and alcohol. After
assessing the following risk factors for substance abuse, which one factor should the nurse initially manage?
1. Loss of social role
2. Co-occurring psychiatric diagnoses
3. Poor sense of self-worth
4. Codependency
Rationale
mental health.
RATIONALE
(1) Multiple social crises have contributed to the risk for drug abuse (loss of job opportunities, cultural, and social roles).
(2) Substance use problems are common among psychiatric clients. Mental health nurses should routinely assess all
clients for these problems. Substance use may be causing the psychopathology (a substance-induced mental disorder).
Clients may use substances to self-medicate the symptoms of their mental disorder. (3) Substance abusers have low self-
esteem and difficulty expressing emotions. (4) Codependency refers to a family member who alternately rescues and
blames the person abusing substances.
QID: 7337 C 21(336 h 344) When a client is alcohol dependent, which of the following is the medication of choice used
for detoxification?
1. Benzodiazepines
2. Barbituates
35
3. Methadone
4. Clozapine
Rationale
(1) Integrated processes: nursing process — planning; client need: physiological integrity; pharmacological therapies;
RATIONALE
(1) When a client is alcohol dependent, benzodiazepines are the medication of choice regardless of the other addictive
properties used for the management of alcohol withdrawal. Benzodiazepines help prevent delirium tremens. (2)
Barbituates, specifically phenobarbital, are used in a client who is addicted to alcohol and benzodiazepines. (3)
Methadone is frequently used to treat heroin and morphine (opiate) addiction. (4) Clozapine is an antipsychotic
medication used in the treatment of schizophrenia.
QID: 7338 C 19(287-288 h 320) Which of the following methods may the nurse use for managing the symptoms of
stress when helping a client improve his/her well being? (Select all that apply.)
1. Therapeutic touch
2. Exercise
3. Imagery
4. Acupuncture
5. Medication
6. Counseling sessions
Correct; 1, 2, 3 chapter 19 text pg 287-288 meds 90 hesi 320
Rationale
(1, 2, 3) Integrated processes: nursing process — implementation; client need: psychosocial integrity; content area:
RATIONALE
(1) Therapeutic touch includes relaxation techniques that promote comfort, reduce anxiety, and alleviate stress and may
improve coping skills. (2) Exercise can reduce the emotional and behavioral responses to stress. (3) Imagery helps
achieve relaxation and/or direct attention away from undesirable sensations. (4) Acupunture is performed by a certified
acupuncturist and not by a nurse. (5) Medication is given only with physician’s order. (6) Counseling is done by licensed
professional social worker, not the nurse.
QID: 7339 C 21(352-372 h 338-343) When managing agitated and aggressive clients, which of the following disorders
would most likely be a source of concern for the psychiatric nurse? (Select all that apply.)
1. Major depressive disorders
2. Organic brain disorder
3. Psychotic conditions
4. Personality disorders
5. Transient ischemic attacks
6. Vegetative state
Correct; 2, 3, 4 chapter 21 text pg 352-372 meds 93-95 hesi 338-343
Rationale
(2, 3, 4) Integrated processes: nursing process — data collection; client need: psychosocial integrity; content area:
RATIONALE
(1) Clients diagnosed with a major depressive disorder report decreased energy, tiredness, fatigue, anxiety, irritability,
hopelessness, despair, and impaired ability to think, concentrate, and make decisions. (2) Behavior changes of clients
with organic brain disorder include frustration, irritability, verbal or physical aggression, and violence. (3) Clients who
are psychotic cognitively impaired exhibit common behavioral responses which include frustration, aggression, agitation,
and the potential for violence and negativism. (4) Characteristics of personality disorders include tantrums, angry
36
outbursts, impulsiveness, and unpredictable behavior that may be displayed as a physical attack toward another person.
(5) Transient ischemic attacks (TlAs) do not create personality disorders. (6) A vegetative state implies that the
individual has limited cognitive ability and does not act out with aggression and violence.
QID: 7340 C19 (287 h 320) When assisting a client in the management of stress reduction, select all of the listed
feelings that the client experiences during periods of anxiety
1. “I find it difficult to concentrate because of distracting thoughts.”
2. “My stomach gets tied in knots.”
3. “I get constipation.”
4. “I pace up and down nervously”
5. “1 cannot urinate very well.”
6. “1 feel so peaceful.”
Correct; 1, 2, 4 chapter 19 text pg 287 meds 90 hesi 320
Rationale
(1, 2, 4) Integrated processes: nursing process — planning; client need: psychosocial integrity; content area: psychiatric-
mental health.
RATIONALE
(1) Client is expressing anxiety symptoms cognitively. (2) This is a physical response to stress and anxiety. (3) Diarrhea
is usually the physical response to stress and anxiety. (4) Client’s emotions are exhibited through behavioral symptoms.
During periods of anxiety, clients present with physical, emotional, cognitive, and behavioral symptoms. (5) Urinary
frequency is a physical response to stress and anxiety. (6) This is not a physical response to stress and anxiety
QID: 7341 C21 (364 h 341) When the nurse manages a client’s psychotherapeutic medication regimen, which of the
following factors may affect medication compliance? (Select all that apply.)
1. Positive side effects of the medication
2. Feelings of loss of personal control.
3. Fear of dependence and addiction.
4. Comorbidity
5. Acceptance of the disease process
6. Delegating medication administration to a family member
Rationale
(2, 3, 4) Integrated processes: nursing process — evaluation; client need: physiological integrity; pharmacological
RATIONALE
(1) Negative side effects of medications very often cause the client to feel worse from the treatment, including
interference in decision-making ability (2) Administering medications to clients places the nurse in a position of control
which may result in the client feeling loss of personal control. (3) Studies have shown that clients fear addiction to
prescribed psychotherapeutic medications. (4) Concurrent substance use is a risk factor for noncompliance. (5) Denial of
the disease process affects the client’s ability to comply with medication regimen. (6) Having family members
administer medications results in the client feeling loss of personal control.
QID: 7342 C 15(196-203 h 315) When working with family members of a mentally ill client, which of the following
behaviors/attitudes may the nurse observe toward the mentally ill member?
(Select all that apply)
1. Recurrent grief
2. Feelings of guilt
3. Happiness
4. Powerlessness and fear
5. Gratitude and thanksgiving
6. Denial that a problem exists
37
Correct; 1, 2, 4 chapter 15 text pg 196-203 meds 86 hesi 315
Rationale
(1, 2, 4) Integrated processes: nursing process — data collection; client need: psychosocial integrity; content area:
RATIONALE
(1) Because mental illness is usually cyclical, grief tends to be recurrent. (2) Family members often feel guilty about the
relative’s illness and blame themselves. (3) Anger may be directed toward the mentally ill client but it is more often
directed toward other family members and against mental health providers. (4) Family members feel powerlessness and
frustrated when dealing with a long-term illness. (5) Family members often feel guilty about the relative’s illness and
blame themselves. (6) Family members often feel guilty about the relative’s illness and blame themselves
QID: 7343 C 33(648 h 350) A client admitted to the emergency room states that she has been sexually abused. Which of
the following nurse managed interventions would initially be implemented?
1. Recommend a battered women’s shelter.
2. Create a support system.
3. Collect and document vital evidence.
4. Respond judgmentally to the episodic nature of the abuse.
Rationale
effective care environment; coordinated care; content area: psychiatric-mental health.
RATIONALE
(1) Recommending a shelter should not be the initial intervention. It may also communicate that the problem is too
distasteful to handle. (2) Creating a support system is important, but not the initial intervention. (3) Because of the
alleged recent attack, physical evidence and accurate documentation is needed for potential legal action. (4) An
immediate response of nonjudgmental listening and psychological support is essential.
QID: 7344 C 11(143 h 315) Which of the following are outcomes related to the patient advocacy role? (Select all that
apply.)
1. Meet the patient’s needs.
2. Provide value for services rendered.
3. Focus on the discharge needs of the patient.
4. Prepare nurse to meet self-care needs.
5. Meet family’s needs.
6. Prepare physician to meet hospital’s needs.
Rationale
(1, 2, 3) Integrated processes: nursing process — evaluation; client need: safe, effective care environment; coordinated
RATIONALE
(1) Mental health providers meet the physical and emotional needs of their patients. (2) Nurses and hospital/clinic
providers assist clients with available health-care services, influence the quality of existing services, and develop new
resources. (3) Discharge needs are determined during the assessment phase of the nursing process. (4) Health-care
providers assist patients with improving self-care and the importance of living as independently as possible. (5) Mental
health providers meet the physical and emotional needs of their patients. (6) Health-care providers assist patients with
improving self-care and the importance of living as independently as possible.
QID: 7345 C 17(252-372 h 338-343) When communicating with a client who is actively psychotic, the nurse should be
aware of which factors that negatively affect the interaction? (Select all that apply.)
1. Hallucinations and delusions
38
2. Consistent adherence to psychotropic medications
3. Motivation and grooming skills
4. Disorganized behavior
5. Client’s acceptance of disease
6. Family’s acceptance of disease
Correct; 1, 4 chapter 17 text pg 252-372 meds 93-95 hesi 338-343
Rationale
(1, 4) Integrated processes: nursing process —evaluation; client need: psychosocial integrity; content area: psychiatric
mental health.
RATIONALE
(1) Hallucinations and delusions are overt symptoms of schizophrenia and may cause the nurse anxiety if he or she lacks
knowledge about psychosis. (2) The nurse and the client may have been partners in medication-based planning to help
the client take control over his or her medication regimen and would nor negatively affect the interaction. (3) Motivation
and grooming are reality based and should not necessarily interfere with the nurse-client interaction. (4) Disorganized
speech and behavior presents as a distortion of normal functioning and does interfere with the communication process.
(5) Client’s acceptance of disease does not affect the nurse- client interaction in a negative manner. (6) Family’s
acceptance of the disease does not affect the nurse-client interaction in a negative manner
QID: 7346 C (h) When managing client care, which professional ethical obligations are important for the nurse to
implement? (Select all that apply.)
1. Improve standards of client care.
2. Provide services with respect to human dignity
3. Safeguard the nurse’s rights,
4. Evaluate necessity, appropriateness of health care services.
5. Negate client’s privacy.
6. Require client to accept all treatments.
Correct; 1, 2, 4 text pg 52-65 meds 113
Rationale
(1, 2, 4) Integrated processes: nursing process — planning; client need: safe, effective care environment; coordinated
RATIONALE
(1) Improving standards of client care is a critical ethical issue and is part of the principles in the ethical code for all
nurses. (2) Providing services with respect to human dignity is a critical ethical issue and is part of the principles in the
ethical code for all nurses. (3) Safeguarding the client’s rights to privacy is a critical ethical issue and is part of the
principles in the ethical code for all nurses. (4) Evaluating necessity and appropriateness of health care are critical ethical
issues and are part of the principles in the ethical code for all nurses.
(5) Safeguarding the client’s rights to privacy is a critical ethical issue and is part of the principles in the ethical code for
all nurses. (6) Providing services with respect to human dignity is a critical ethical issue and is part of the principles in
the ethical code for all nurses. Client has the right to refuse treatments.
QID: 7347 C 11(143-147 h 315-317) Which of the following barriers within the health care system hinder the
development of the nurse-client relationship?
1. Profusion of value placed on caring.
2. Conflicting professional commitments
3. Client anxiety
4. Communication conflict with other health professionals
Rationale
(4) Integrated processes: nursing process — evaluation; client need: safe, effective care environment; coordinated care;
39
RATIONALE
(1) Rather than a profusion of value, within the health-care system, there is a lack of emphasis placed on the value of
caring. (2) Within the nurse, there are conflicting professional commitments as the nurse strives to deliver quality care.
(3) Within the client, there is a feeling of anxiety and lack of personal space. (4) Within the health-care system, a
communication conflict with other health professionals has been identified as a barrier to nurse-client relationship.
QID: 7348 C11 (143-147 h 315-317) The most common form of violence in the workplace is against health-care
providers. Which one of the following situations puts health-care workers at risk?
1. The use of brutal force to disable a violent client.
2. Adequate staffing patterns.
3. Educational programs on workplace violence.
4. Identification of potential areas for violence.
Rationale
(1) Integrated processes: nursing process — evaluation; client need: safe, effective care environment; safety and
infection control; content area: psychiatric-mental health.
RATIONALE
(1) On a mental health unit, the degree of force considered necessary to deal with aggressive behavior is limited to those
staff persons that are necessary to gain control of the client. The health-care provider is not justified in using brutal
physical force to disable a client. (2) With adequate staffing, nurses involved in risk management may ensure client
safety (3) Educating employees on work place violence may ensure that staff assess potential risk situations before they
develop in order to maintain milieu control and safety (4) Potential areas for violence should be identified and corrective
steps taken to reduce unreasonable risks to health-care workers
QID: 7349 C 11(143-147 h 315-317) Which one of the following should the nurse keep in mind when managing a
verbally hostile client?
1. Maintain a threatening body posture.
2. Disrespect the buffer zone.
3. Provide the client with multiple choices.
4. Maintain a staring eye contact.
Rationale
(3) Integrated processes: nursing process planning; client need: psychosocial integrity; content area: psychiatric-mental
health
RATIONALE
(1) If the nurse’s body posture suggests. physical contact or physical aggression, this nonverbal behavior may provoke
the client causing a violent reaction. (2) If the client’s body language suggests imminent physical aggression,
establishing a safe body zone is important. (3) Give the client choices and allow the client to understand that actions
taken are directly related to the choices the client makes. (4) The nurse should not turn his or her back on the client.
Maintaining unchallenging eye contact should help the nurse anticipate the client’s next move
QID: 7350 C 12(152-167 h 315) When managing and maintaining a safe and secure therapeutic milieu, which one of the
following goals is a nursing responsibility?
1. Control or set limits on threats and aggressive acts.
2. Condone violent and/or aggressive behavior.
3. Screen all visitors for weapons.
4. Limit psychosocial skills.
Rationale
40
mental health.
RATIONALE
(1) It is the nurse’s responsibility to set limits to ensure a safe and therapeutic milieu. Those who try to control or set
limits on aggressive acts are sanctioning violence. (2) Condoning or ignoring violent and/or aggressive behavior may be
setting the stage for future violence in the milieu. (3) Weapon screening is not a nursing responsibility. It is the
responsibility of the agency security system. (4) It is important and a nursing responsibility to assist clients with
psychosocial skills
QID: 7351 C 17(263-265 h 315-317) There are several issues pertinent to managing triage of mental health clients
during emergency care. Which one of the following is a critical strategy?
1. Medical screening as described by the federal regulations.
2. Client’s condition should determine the type of screening that is required.
3. Reimbursement is required prior to screening.
4. Immediate transfer to an inpatient setting.
Rationale
mental health.
RATIONALE
(1) Medical screening is not described by federal regulations. (2) Clearly, the physical and emotional condition of the
client is a determinant in the screening that is necessary (3) In an emergency situation, a client must be stabilized prior to
requesting reimbursement. (4) A client must be screened and stabilized prior to transferring to an inpatient setting.
Depending on the findings of the assessment, a transfer to an inpatient setting may not always be necessary or
appropriate
QID: 7352 C 12(152-157 h 315) Milieu therapy is important for mental health clients. Which of the following processes
would provide the best possible environment? (Select all that apply.)
1. Family and/or significant other support.
2. Care by unlicensed personnel (UP).
3. Limited use of ancillary therapies.
4. Structured interaction.
5. Excessive stimuli
6. Deny family support
Correct; 1, 4 chapter 12 text pg 152-157 meds 86-87 hesi 315
Rationale
(1, 4) Integrated processes: nursing process planning; client need: psychosocial integrity; content area: psychiatric-
mental health.
RATIONALE
(1) Family is viewed as a part of the client’s life and ties should be maintained if at all possible. (2) Nursing provides
leadership, assumes responsibility in promoting therapeutic milieu, and is responsible for coordination of unit activities.
(3) When therapies are limited, it is difficult to provide therapy using the total environment and to sustain a therapeutic
community (4) Structured interaction allows clients to interact with others and discuss daily chores, behavioral
expectations, respect toward others, and unit rules and regulations. Leadership in this situation may be assumed by a
client who is elected or volunteers. (5) Excessive stimuli reduces a therapeutic environment. (6) Family is viewed as a
part of the client’s life and ties should be maintained if at all possible.
QID: 7353 C 2(16-19 h 315-317) The Decade of the Brain saw trememdous growth in:
1. New highly ‘effective medications’.
2. Models of treatments that focus on biopsychosocial orientation.
3. Resources for follow-up care.
41
4. Inpatient education.
Rationale
(1) Integrated processes: nursing process — assessment; client need: physiological integrity; physiological
RATIONALE
(1) The Decade of the Brain saw a change in practice in mental health care through the development of new
antipsychotic, antidepressant with fewer side effects. (2) Treatment approaches rely heavily on biological
interventions rather than on biopsychosocial ones. There is a need to integrate the psychobiological component
with the long-standing psychosocial perspective of nursing care. (3) During the deinstitutionalization period, there
was a shift toward community resources for follow-up care. (4) There is lack of sufficient time in inpatient settings
to provide client education that will help them with compliance.
QID: 7354 C 11(143-147 h 315-317) When managing the care of the chronically mentally ill, which of the following
should the nurse address? (Select all that apply.)
1. Meet the physical and psychological needs of the client across the health care continuum.
2. Recognize that the client’s needs stay constant.
3. Recognize that illness preventions are important in all stages of illness.
4. Acquire more information about the effects of managed health care.
5. Recognize that the family’s needs stay constant.
6. Recognize that prevention is not as important as illness treatment.
Correct; 1, 3, 4 chapter 11 text pg 143-147 meds 88-89 hesi 315-317
Rationale
(1, 3, 4) Integrated processes: nursing process — planning; client need: psychosocial integrity; content area: psychiatric-
mental health.
RATIONAL.E
(1) Chronically mentally ill clients require a health-care delivery system that meets all aspects of their health illness
continuum. (2) The nurse must recognize that the health-care needs of the chronically mentally ill fluctuate and do not
remain constant. (3) Client’s need for health promotion and disease and illness prevention are important in all stages of
the client’s illness. (4) When the nurse increases her or his knowledge about availability of care and quality of care, she
or he can emphasize continuity of care, prevention and health promotion, and education in self-care management. (5)
The nurse must recognize that the health-care needs of the family fluctuate and do not remain constant. (6) Client’s need
for health promotion and disease and illness prevention is important in all stages of the client’s illness.
QID: 7355 C11 (143-147 h 315-317) The client says to the nurse, “I’m physically and emotionally healthy” Which
response by the nurse would support the client’s thinking?
1. “That statement is cause for concern,”
2. “1 have observed that you accept yourself as a person.”
3. “That statement is not based on sound judgment.”
4. “What makes you think that you are emotionally healthy?”
Rationale
RATIONALE
(1) This response negates the client’s thinking. (2) This statement acknowledges the client’s thinking and is
nonaccusatory. (3) This response is judgmental and may put the client on the defensive. (4) This statement is seeking
clarification that is not needed.
42
QID: 7356 C 22(354 h 338) A hostile client is admitted with very little insight, disorganized speech, poor contact with
reality, and severe personality decompensation. This behavior is most suggestive of which of the following disorders?
1. Personality disorder
2. Psychosis
3. Neurosis
4. Psychophysiological disorder
Rationale
mental health.
RATIONALE
(1) Personality disorder patterns of behavior are inflexible and maladaptive, causing significant functional impairment.
(2) A person suffering from psychosis may exhibit a disturbance in one or more major areas of functioning. (3) Neurosis
is an (4) Self-destructive behavior is confidential information and not available for public knowledge. emotional
disturbance of all kinds other than psychosis. (4) This is a group of disorders characterized by physical symptoms that
are affected by emotional factors.
QID: 7357 C 2(7-13 h 315-318) A nurse on the obstetrical unit was preparing a client for discharge after the birth
of a son. The client suddenly developed blindness. After an intensive workup, no physical problems were evident.
Which of the following defense mechanism was the client using?
1. Regression
2. Repression
4. Conversion formation
Correct; 4 chapter 2 text pg 7-13 meds 87-88 hesi 315, 318
Rationale
(4) Integrated processes: nursing process — data collection; client need: psychosocial integrity; content area:
RATIONALE
(1) Regression is a retreat to an earlier stage of development.
(2) Repression banishes or excludes unacceptable impulses and thoughts from consciousness. (3) Reaction
formation allows a person to adopt attitudes and behaviors that are opposite of his or her impulses. (4) The client
was using conversion formation, which is the process of converting emotional stress into impaired physical
functions
QID: 7358 C9 (143-147 h 315-317) A salesman hoards all personal receipts, junk mail, news clippings, and restaurant
napkins. He tells the nurse that he has no control over his behavior. What is the most appropriate nursing intervention?
1. Form a therapeutic alliance with the client.
2. Assist the client to prevent the ritualistic behaviors.
3. Encourage the client to rationalize his irrational behaviors.
4. Refer the client to hypnosis
Rationale
RATIONALE
(1) Forming a therapeutic alliance with the client reduces the threat that the nurse may pose to the client. (2) The goal of
therapy is to assist the client to reduce anxiety and learn to delay ritualistic behavior. (3) Clients use compulsive rituals to
control anxiety. Rationalizing irrational behaviors is not an appropriate intervention because it may cause the anxiety
level to increase. (4) Referring the client is not the most appropriate nursing intervention.
43
QID: 7359 C2 (7-13 h 315-318) The nurse is assessing a client who is a substance abuser. During the interview, the
client minimizes the problem when he says to the nurse, “I use every day, but it rarely interferes with my work.”
The client is using which defense mechanism?
1.Projection
2. Displacement
4. Denial
Rationale
RATIONALE
(1) Projection enables a person to justify his or her own unacceptable feelings and impulses by attributing the
behaviors to others. (2) Displacement operates unconsciously and is used by an individual to transfer hostile and
aggressive feelings from one object to another object or person. (3) Reaction formation enables a person to adopt
attitudes and behaviors that are opposite to his or her own behaviors. (4) Denial is characterized by avoidance of
disagreeable realities and unconscious refusal to acknowledge a thought, feeling, need, or desire. The client is
denying that he has a substance abuse problem
QID: 7360 C 5(56-65 h 14-16) A 30-year-old client was given 5 mg of haloperidol (Haldol) for agitation. The client’s
chart was clearly stamped “Allergic: H.ALDOL.” The client suffered anaphylactic shock and died, The family sued for:
1. Intentional tort
2. Negligence
3. An overdose of Haldol
4. Assault
Rationale
(2) Integrated processes: nursing process — implementation; client need: safe, effective care environment; safety and
RATIONALE
(1) An intentional tort is a willful act that violates another person’s rights. The nurse did not intentionally give Haldol to
harm the client. (2) The nursing action was an unreasonable or careless act. The nurse is negligent and liable for the
client’s death. (3) The amount of Haldol given was within a therapeutic range. (4) An assault is a threatening act that
causes another person to be afraid.
QID: 7361 C 5(61-62 h 14-16) A 27-year-old female client, who slashed both wrists, was admitted to the psychiatric
unit under a physician’s emergency certificate (PEC). She requested an immediate discharge. Which is the best response
by the nurse?
1. “I understand that you are self-destructive. I cannot let you leave.”
2. “You must sign this legal document, which indicates that you are leaving the hospital against medical advice
(American Medical Association).”
3. “Discuss the issue with your physician.”
4. “I will notify your minister.”
Rationale
(1) Integrated processes: nursing process — implementation; client need: safe, effective care environment; safety and
RATIONALE
44
(1) A client who is harmful to self may be detained until it has been determined that there are no further indications of
self-destructive behavior. (2) A client may sign a legal document to be discharged (American Medical Association).
However, because of self-destructive behavior, it is important to maintain a safe environment for all clients. (3) This is
not the best response. This situation calls for a nursing intervention.
QID: 7362 C 5(59-60 h 14-16) A 27-year-old client diagnosed as having borderline personality disorder called her
attorney reporting client abuse and that the institution was holding her hostage. The nurse is aware that this is an example
of:
1. Breach of confidentiality
2. Right of confidentiality
3. Failure to provide communication
4. Failure to comply with telephone rules
Rationale
(2) Integrated processes: nursing process — evaluation; client need: safe, effective care environment; coordinated care;
RATIONALE
(1) The client is disclosing information about herself. (2) Privileged communication is the right of all clients to discuss
information with their attorney (3) Information cannot be disclosed without a client’s permission. (4) Psychiatric clients
have the right to reasonable access to telephones.
QID: 7363 C 15(206-211 h 317) The activity therapist informs the nurse that she will be helping supervise a 15-person
outing scheduled for early afternoon. The nurse would be correct in telling the therapist that:
1. “It a good idea for the clients to participate in an outing.”
2. “That is not a safe practice. A 2:15 ratio is too many clients.”
3. “I will be glad to participate.”
4. “Have you requested additional help?”
Rationale
RATIONALE
(1) Clients need outside activity However, having a safe ratio is essential. (2) To manage effectively, client groups
should not be larger than 10 persons. (3) The response supports unsafe care practices. (4) This is an appropriate response.
However, the therapist needs to be reminded that health-care practices must be delivered safely
QID: 7364 C 11(143-147 h 315) A 32-year-old client lost control of her behavior. She threatened staff and other clients
and broke several windows. She was escorted to the seclusion room and put in four-point restraints. Which statement is
most correct when explaining the situation to the client?
1. “This is a form of punishment for losing control.”
2. “This is a means of providing safety for you and everyone else on the unit.”
3. “The length of time is undetermined.”
4. “The staff will do periodic checks.”
Rationale
effective care environment; safety and infection control; Content area: psychiatric-mental health.
RATIONALE
45
(1) Restraints and seclusion are not a form of punishment. (2) It is important to provide safeguards in order to protect
clients who are out of control. (3) It is against the law to leave a client in restraints and seclusion for an undetermined
length of time.
(4) Clients in restraints or seclusion must be checked on a routine basis according to the hospital policy
QID: 7365 C 15(206-211 h 317) Which of the following ethical guidelines do not relate to client rights?
1. Informed consent
2. Treatment
3. Refusal of treatment
4. Judicial commitment
Rationale
RATIONALE
(1) Clients have the right to informed consent. (2) Clients have the right to treatment under the U.S. Constitution. (3)
Clients have the right to refuse treatment under the U.S. Constitution. (4) Judicial commitment is not one of the eight
ethical guidelines.
QID: 7366 C 19(287-288 h 320) A 34-year-old female client suffering from numbness of the extremities, trembling, and
dyspnea is admitted with a diagnosis of severe anxiety disorder. An initial nursing intervention should be to:
1. Discuss functional coping measures.
2. Determine the source of the problem.
3. Quickly administer an anxiolytic medication.
4. Provide safety and comfort.
Rationale
(4) Integrated processes: nursing process — implementation; caring, client need: safe, effective care environment; safety
and infection control; content area: psychiatric-mental health.
RATIONALE
(1) In severe anxiety, the sensory perception is greatly reduced, lessening the capacity to problem solve. (2) The source
of the problem should be probed only if the person is experiencing mild and well-controlled anxiety (3) An anxiolytic
medication may be ordered by the physician, but the initial intervention is to assure the client of safety and provide
psychological support. (4) Clients exhibiting severe anxiety require immediate psychological and sometimes physical
support.
QID: 7367 C 27(490 h 351) A 42-year-old male client experienced a severe psychic trauma 1 month ago. He developed
paralysis of the lower extremities. Which of the following is the best nursing intervention?
1. Encourage the client to talk about his feelings.
2. Assess the client for organic causes of paralysis.
3. Provide range-of-motion (ROM) to the lower extremities.
4. Encourage discussion of future goals
Rationale
RATIONALE
(1) Verbalization of feelings is not the first priority (2) The first priority is to rule out a neurological disorder. (3)
Physical therapy should not be attempted until organic causes are ruled out.
(4) Assistance with future planning is important, but not this time
46
QID: 7368 C21 (342-344 h 332-338) Which of the following foods would be most appropriate for a client in the manic
phase?
1. Finger sandwiches, orange slices, and a banana
2. Pasta, meatballs, and a salad
3. Chicken fried steak with sauce and a salad
4. Beef stew, mashed potatoes, and a banana
Rationale
(1) Integrated processes: nursing process — implementation; client need: physiological integrity; basic care and comfort;
RATIONALE
(1) Provide preferred nutritious snacks. Making them accessible throughout the day will help replenish burned calories.
(2) The client is too hyperactive to sit for a meal. (3) This is not a balanced meal. (4) This is a meal that requires the
client to sit
QID: 7369 C 22(352-372 h 338-343) A female client accused her roommate of stealing her comb and began biting,
clawing, and scratching. Which of the following would be the best nursing intervention?
1. Provide a safe environment for both clients.
2. Notify the lawyer advocate.
3. Isolate the aggressor and place in restraints.
4. Discuss the angry behavior and available consequences.
Rationale
(1) Integrated processes: nursing process implementation; client need: safe, effective care environment; safety and
RATIONALE
(1) Client safety is the nurse’s first priority (2) If a client is dissatisfied with psychiatric or mental health care, the lawyer
advocate may be contacted by the client. (3) Restraints dehumanize and interfere with a client’s autonomy. It is
important to use alternative strategies. (4) Because anger narrows the perceptual field, postpone discussion of anger and
consequences until the client is in control.
QID: 7370 C 22(352-372 h 338-343) A 23-year-old client physically attacks another person on the psychiatric unit and
accuses the person of stealing. The nurse is aware that his behavior is an example of:
1. Displacement
2. Impulsive behavior
3. Identification
4. Impulse gratification
Rationale
mental health.
RATIONALE
(1) Displacement operates on an unconscious level. An emotion, idea, or wish is transferred from the original object to a
more acceptable substitute. (2) Poor control of impulsive behavior shows limited insight and poor judgment. (3)
Identification is an ego defense mechanism whereby a person tries to become like someone he or she admires. (4)
Gratification or a source of satisfaction comes from getting needs met. This client has poor impulse control.
47
QID: 7371 C 22(352-372 h 338-343) In a conversation between the nurse and a 50-year- old female client, the client
tells the nurse that the hospital staff poisoned her meal and she refuses to eat. The most appropriate nursing intervention
is to:
1. Focus on the delusion.
2. Focus on the fears and insecurities.
3. Agree with the client’s decision.
4. Challenge the client’s delusional system.
Rationale
RATIONALE
(1) Focusing on the delusional content may increase anxiety. (2) Focusing on the fears and insecurities promotes the
client’s trust and willingness to be helped. (3) Agreeing with the client may reinforce the delusion. (4) Challenging the
client’s delusional system is not appropriate because it may increase tension and force the client to defend it.
QID: 7372 C 22(352-372 h 338-343) The emergency room nurse encounters a 20-year-old female wandering around
and exhibiting extreme hyperactivity and bizarre behavior. She laughs, giggles, and is annoying to staff and other clients.
Her thoughts are poorly organized. The main focus on nursing care for this client would be to:
1. Provide a safe environment.
2. Encourage social interaction.
3. Discuss the bizarre behavior.
4. Provide information regarding illness.
Rationale
RATIONALE
(1) The client is unable to control her mental state of health. Providing a safe environment with reduced external stimuli
will provide feelings of security and safety (2) Social interactions should not be encouraged until after the mood has been
stabilized. (3) Discussion of the bizarre behavior may increase anxiety and cause anger and a defensive attitude. (4) With
disorganized thoughts, the client may not be capable of processing the information.
QID: 7373 C 22(352-372 h 338-343) A 70-year-old was admitted to a psychiatric unit because he physically abused his
wife. He said to the nurse, “My wife is having an affair with an 18-year- old and I want it investigated.” The best
response by the nurse is:
1. “That remark is absolutely ridiculous.”
2. “I understand that you are upset. We will talk about it.”
3. “That seems rather doubtful.”
4. “An 18-year-old is too young. He does not want your wife.”
Rationale
RATIONALE
(1) This response criticizes the client and may cause unnecessary anger and conflict. (2) This response gives recognition
and acknowledgement of feelings. (3) Denying the belief serves no purpose, because delusional ideas are not eliminated
by this approach. (4) This response rejects the client’s belief and may cause the client to limit further interaction.
48
QID: 7374 C 24(410-411 h 237) In planning care for a delusional, paranoid person, it is important for the nurse to
consider which one of the following characteristics?
1. Bright affect and extreme suspiciousness
2. Motor immobility
3. Regressive and primitive behaviors
4. Anger and aggressive acts
Rationale
mental health.
RATIONALE
(1) Paranoid clients exhibit a fiat, dull affect and suspicious behaviors. (2) Abnormalities in motor behavior are
characteristics of catatonic schizophrenia. (3) Regressive and primitive features are present in disorganized
schizophrenia. (4) The paranoid client is often angry aggressive, and guarded
QID: 7375 C 24(412-415 h 328) A 28-year-old client, diagnosed as having borderline personality disorder, presented at
the mental health clinic and demanded to see a counselor immediately Which one of the following is the best nursing
strategy?
1. Instruct the client to leave the clinic.
2. Confront demanding behaviors.
3. Explain the rules and set limits.
4. Help the client problem-solve.
Rationale
RATIONALE
(1) Instructing the client to leave without an explanation may cause anger and alienation. (2) Confrontation in an open
setting may be perceived as punitive. (3) Clear boundaries and set limits will provide firm structure necessary for clients
diagnosed with a personality disorder. (4) One of the health teachings of a person diagnosed with borderline personality
disorder is problem solving, which is a long-term issue
QID: 7376 C 33(637-642 h 348) A 15-year-old girl tells the nurse that she wants to talk with her mother. The nurse is
aware that the girl’s mother does not want any further contact with her daughter. The client asks permission to use the
telephone. What is the nurse’s best response?
1. “Why do you want to call your mother?”
2. “No, not at this time. Tell me more about how you feel toward your mother.”
3. “I don’t believe it will be healthy to call her.”
4. “Tell me how you feel, now that your mother has abandoned you.”
Rationale
(2) Integrated processes: nursing process — implementation; client need: psychosocial psychiatric mental health
RATIONALE
(1) Asking the client a “why question can be intimidating daring and implies that the client hat defend the request (2).
This response is direct and explores the relationship, between mother and daughter that may provide relevant
information.
(3) This response is judgmental and opposes the client’s request. (4) Probing for information that is difficult to answer
may place the client on the defensive.
49
QID: 7377 C 24(412-415 h 328) In assessing a client with borderline personality disorder, the nurse should be aware of
which one of the following traits?
1. Predictability
2. Controlled anger
3. Primitive dissociation
4. Stable and friendly relationships
Rationale
mental health.
RATIONALE
(1) These clients are unpredictable due to impulsiveness and lack of responsibility (2) These persons demonstrate poorly
controlled anger. (3) Clients diagnosed as having a borderline personality disorder use the defense mechanism of
splitting. (4) One criterion for the borderline personality disorder is a pattern of unstable and intense interpersonal
relationships.
QID: 7378 C 21(334 h 332-338) A long-term goal for the nurse in planning care for a depressed, suicidal client would
be to:
1. Provide him with a safe and structured environment.
2. Assist him to develop more effective coping mechanisms.
3. Have him sign a “no-suicide” contract.
4. Isolate him from stressful situations that may precipitate a depressive episode.
Rationale
mental health.
RATIONALE
(1) This statement represents a short-term goal. (2) Long-term therapy should be directed toward assisting the client to
cope effectively with stress. (3) Suicide contracts represent short- term interventions. (4) This statement represents an
unrealistic goal. Stressful situations cannot be avoided in reality.
QID: 7379 C 29(553-569 h 353-354) A 21-year-old female client tells the nurse that she finds it necessary to
occasionally masturbate and asks for a professional opinion. The best statement by the nurse is:
1. “Only men masturbate to relieve tension.”
2. “There is a possibility that masturbation causes voyeurism.”
3. “Masturbation causes an orgasmic disorder in both males and females.”
4. “Masturbation releases tension that is sexual in nature.”
Rationale
(4) Integrated processes: nursing process — implementation; teaching/learning; client need: psychosocial integrity;
RATIONALE
(1) Masturbation is a common practice among both sexes. (2) There is no research that indicates masturbation causes
voyeurism. (3) There is no evidence that masturbation causes any organic disorder. (4) Masturbation is used to release
tension and frustration. Both sexes obtain sexual satisfaction.
QID: 7380 C 28(519-530 h 340-341) A 26-year-old woman on a psychiatric unit refuses to sleep in her room because she
says that it is “bugged”. The most appropriate way in which the nurse might initially handle this situation is to:
1. Simply state the room is not bugged.
2. Change the room.
50
3. Ask her why she believes the room is bugged.
4. Ignored her delusion.
Rationale
(1) Integrated processes: nursing process — implementation, caring; client need: psychosocial integrity; content area:
psychiatric nursing.
RATIONALE
(1) Psychiatric clients cannot be reasoned with or argued with because they believe a delusion to be true. The best
approach is a simple statement of reality. (2) Changing bet room would feed her delusion. (3) Psychiatric clients cannot
identify why, but they accept a delusion as being true. (4) This option does not point out the reality
QID: 7381 C 24(401-411 h 237) A 31-year-old client is admitted to a psychiatric unit. She thinks that her coworkers are
accusing her of indiscretions and spring on her. The initial nursing goal is directed at:
1. Joining in group activities.
2. Establishing trust with staff.
3. Limiting contacts with other clients.
4. Allowing coworkers to visit.
Rationale
(2) Integrated processes: nursing process — planning, caring; client need: psychosocial integrity; content area:
RATIONALE
(1) Joining in group activities initially is inappropriate until she is less delusional. (2) Establishing trust is of primary
importance because she is so paranoid and lacks trust in others. (3) Limiting contacts with other clients is important, but
developing a sense of trust with staff is the priority (4) Coworkers should not visit until she becomes less delusional
QID: 7382 C33 (638-642 h 348-353) Causing mental distress by name calling, isolating, ignoring, or ridiculing is an
example of:
1. Psychological abuse.
2. Physical abuse.
3. Active neglect.
4. Passive neglect
Rationale
(1) Integrated processes: nursing process — evaluation; client need: psychosocial integrity; content area: psychiatric
nursing.
RATIONALE
(1) Psychological abuse is causing mental distress by name calling, isolating, ignoring, or ridiculing an individual. (2)
Excessive or improper use of physical force on an individual is physical abuse. (3) Active neglect is deliberately denying
ordered health care to an individual. (4) Passive neglect is the unintentional abuse in which the caregiver does not do
something that is required because of a lack of skills, knowledge, or ability
QID: 7383 C 24(406-407 h 348-353) A 7-year-old child has been hospitalized for dehydration and vomiting. It would be
most important for the nurse to remember which of the following?
1. Fear is related to body injury, loss of control, and death, and mutilation fantasies are common.
2. A child may view hospitalization as a punishment for thoughts.
3. Fears are related to body image.
4. A child may exhibit regressive behavior such as whining, tantrums, and thumb sucking
51
Rationale
(1) Integrated processes: nursing process — evaluation, caring; client need: health promotion and maintenance; content
area: psychiatric nursing.
RATIONALE-
(1) In the 7-year-old child, fears are related to body injury; allow the child to participate in procedures and prepare the
child in advance. (2) For the 4- to 5-year-old child, the child’s magical thoughts and fantasies may distort the hospital
experience. The nurse should explain simply the relationship between cause, illness, and treatment. (3) For the 12- to l8-
year-old adolescent, fears are related to body image. The nurse should promote privacy provide detailed information, and
promote self-care, (4) The 16-month-old to 4-year-old toddler is resistive and exhibits regressive behaviors such as
tantrums. Provide for routines and promote care by parents.
QID: 7384 C2 (8-9 h 348-353) According to Maslow’s hierarchy, the first priority in nursing actions must be
aimed at:
1. Moving toward satisfaction of creative and emotional needs as early as possible.
2. Helping the client gain respect from the others to prevent loneliness.
3. Doing first things first: meeting the client’s physiological needs before moving on to other needs.
4. Helping the client to establish close relationships with as many persons as possible.
Category: physiologic integrity basic care and comfort
Rationale
(3) Integrated processes: nursing process — planning; cheat need: physiological integrity; basic care and comfort;
content area: psychiatric nursing.
RATIONALE
(1) Physiological needs are first priority (2) This action relates to love and belonging, which come after
physiological needs. (3) If physiological needs are not met, psychological needs cannot be met. Maslow’s hierarchy
goes from physical needs to safety and security to love and belonging, and to self-esteem and self-actualization, (4)
This action relates to love and belonging and is a lower priority than physiological and safety and security needs
QID: 7385 C 24(406-407 h 348-353) A 14-year-old adolescent is admitted to a behavioral management unit. When
planning care, the nurse recognizes that the central task of early adolescence is:
2. Identify versus role confusion.
4. Integrity versus despair
Rationale
RATIONALE
(1) Industry versus inferiority is characteristic of the school- age child. (2) Erikson stages of development indicate that
the early adolescent is achieving role identity (3) Intimacy versus isolation is characteristic of the young adult. (4)
Integrity versus despair is characteristic of the older adult.
QID: 7386 C21 (334 h 332-352) While working on a psychiatric unit, the nurse is especially careful to observe depressed
clients:
1. In the early morning.
2. In the afternoon.
3. In the evening.
4. At visiting time.
Rationale
52
(1) Integrated processes: nursing process evaluation; client need: psychosocial integrity; content area: psychiatric
nursing.
RATIONALE
(1) Morning-evening variation in symptoms occurs with psychotic depression. The client is most depressed in the
morning and experiences a slight elevation of mood as the day progresses. (2) Mood is usually better in the afternoon;
select another option. (3) Mood is usually elevated toward evening; select another answer. (4) Visiting time may either
increase or decrease mood, depending on the client’s relationship with the visitors.
QID: 7387 C 22(357-358 h 332-338) A 25-year-old client with a diagnosis of schizophrenia is sitting in a corner rocking
to and fro, twisting her hands. One of the best initial approaches by the nurse is to:
1. Bring the client some warm milk.
2. Hug the client.
3. Bring the client a deck of cards.
4. Sit quietly by the client.
Rationale
RATIONALE
(1) Because the basic trauma in schizophrenia is a disturbed parent-infant relationship, giving the client some milk will
promote trust. (2) Hugging is very intrusive; select another option. (3) Bringing the client a deck of cards is an option,
but there are better ones. (4) This is an excellent option; sitting quietly with the client may help to decrease agitation and
promotes sharing of feelings. However, there is a better option.
QID: 7388 C 27(491-492 h 351-352) What is the responsibility of the hospital nurse in maintaining an older person’s
mental health?
1. Assess for signs abuse.
2. Teach instruction for home care to both older person and family.
3. Assess for signs of social isolation.
4. Teach ways to cope with aging.
Rationale
(2) Integrated processes: nursing process — implementation, teaching/learning; client need: psychosocial integrity;
RATIONALE
(1) Hospital nurses are not able to view the family dynamics that may indicate abuse during the short stay in the hospital.
(2) Hospital nurses have the responsibility in the discharge planning and teaching of older clients and their families to
reduce anxiety and promote mental health. (3) Hospital nurses may not be able to assess social isolation during the short
stay in the hospital. (4) Because of the short stay in the hospital, the nurse will not be able to teach effective ways to cope
with aging
QID: 7389 C 18(263-265 h 317) The nurse working in a nursing home identifies which kind of activity that a nursing
home resident can have some control over?
1. Administration of routine medications.
2. Requesting that certain staff members be assigned to him or her.
3. Complete control of the food plan.
4. Type and time of bath.
Category: physiologic integrity basic care and comfort
Rationale
53
(4) Integrated processes: nursing process — implementation, caring; client need: physiological integrity; basic care and
comfort; content area: psychiatric nursing.
RATIONALE
(1) Whether to take medications ordered “as needed” is not an example of the kind of activity that a nursing home
resident can have some control over. (2) Assignment of staff members is not the responsibility of a nursing home
resident. (3) Participating in a partial choice of food plan is an example of the kind of activity that a nursing home
resident can have some control over, but the control is not complete. (4) Type and time of bath is an example of the kind
of activity that a nursing home resident can have some control over.
QID: 7390 C 27(491-492 h 351-352) Which nursing intervention can be used to prevent loneliness in a nursing home
resident?
1. Allow clients to wander in other residents’ rooms.
2. Provide group learning.
3. Provide individual one to one contact.
4. Limit communication for the residents with dementia.
Rationale
RATIONALE
(1) Allowing a resident to wander into another resident’s room is inappropriate and does not prevent loneliness. (2)
Group activities may be helpful, but one-to-one contact is most beneficial. (3) Group activities may be helpful, but
people can feel lonely even in a group without some one-to-one contact and communication. (4) Effective
communication, even with patients with dementia, should be a primary goal of all nursing home staff members.
QID: 7391 C 27(491-492 h 351-352) What interpersonal impact does humor have on an older person?
1. Humor serves as an outlet for inner tension and anxieties.
2. Older persons are more likely to be offended when jokes about aging are told by people of their own age group.
3. Humor helps to establish relationships.
4. Humor stimulates alertness.
Rationale
(3) Integrated processes: nursing process evaluation, caring; client need: psychosocial integrity; content area: psychiatric
nursing.
RATIONALE
(1) Humor serving as an outlet for inner tensions and anxieties is a psychological effect. (2) Older persons are less
offended when people of their own age group joke about aging than when younger persons joke about aging. (3)
Interpersonally, humor has been referred to as a “social lubricant” because it helps to establish relationships and promote
group cohesion. (4) Stimulating awareness is a physiological effect of humor.
QID: 7392 C 27(491-492 h 351-352) What type of humor intervention can a nurse use in any setting with an older
person?
1. Tease the older person even if it is against his or her wishes.
2. Wear scary costumes for effect.
3. Tell grim stories.
4. Use cartoons in teaching materials.
Rationale
54
RATIONALE
(1) Teasing an older person without his or her consent is a violation of the person’s boundaries. (2) Funny costumes,
false noses, and hats, not scaty costumes, can be worn for visual impact. (3) Funny stories or jokes should be told rather
than grim or frightening stories. (4) Post or otherwise share cartoons with clients and their families. Use cartoons as
teaching materials.
QID: 7393 C 27(491-492 h 351-352) The nurse is orienting a 78 –year- old client to her new room in the long-term care
facility. The nurse instructs the client to:
1. Stay away from the men’s hall
2. Refrain from socializing in lounge
3. Personalize her living space with personal possessions
4. Be aware that she will be treated as if she were “sick”
Rationale
(3) Integrated processes: nursing process — implementation, communication and documentation; client need:
psychosocial integrity; content area: psychiatric nursing.
RATIONALE
(1) This response is not appropriate. (2) The lounge is to be used for socializing. (3) Residents and their families should
be encouraged to personalize the living space by plating personal possessions. (4) The resident is less likely to be labeled
as “sick” if she personalizes the living space
QID: 7394 C 27(491-492 h 351-352) How can the nurse intervene to make the dining area and meal time pleasant in a
long-term care facility?
1. Serve the food quickly and remove the trays on time
2. Seat residents alphabetically
3. Seat residents according to social preferences
4. Have residents eat alone in their rooms
Category: physiological integrity basic care and comfort
Rationale
(3) Integrated processes: nursing process — implementation, caring; client need: physiological integrity; basic care and
comfort; content area: psychiatric nursing.
RATIONALE
(1) Serve the food to give the resident ample time to eat. (2) Meal service times for residents with behavioral problems
should be staggered. (3) Having to eat with others who behave disruptively during meals is a very unpleasant experience;
nurses should seat the residents according to social preference. (4) Mealtime can be a time for socializing.
QID: 7395 C 13(169-182 h 315) A client who is in mechanical restraints asks the nurse when they can be removed.
Which one of the following is the best response by the nurse?
1. “Please tell me why you were physically violet”
2. “When apologies are made for creating such a disturbances
3. “When your behavior is under control and you are no longer a danger to yourself or others”
4. “When the medication has calmed your violet behavior”
Rationale
(3) Integrated processes: nursing process — planning: client need: safe, effective care environment: safety and infection
control; content area: psychiatric nursing.
RATIONALE
(1) “Why” questions may put the client on the defensive and increase the agitated state. (2) Apologies are no assurance
that the client has the ability to control behavior. (3) The decision to release the client from mechanical restraints is based
55
on assessment data that indicate the client’s ability to control his violent behavior. (4) Current medication practice
involves a combination of neuroleptics and antianxiety medications. However, there is no assurance that the medication
will calm violent behavior.
QID: 7396 C 27(491-492 h 351-352) The nurse, in planning program activities for clients in a day treatment setting
should:
1. Facilitate diversional activities for the lower-functioning clients
2. Focus on pathology
3. Provide for meaningful social interaction
4. Provide for multifaceted needs
Rationale
(3) Integrated processes: nursing process — planning; client need: psychosocial integrity; content area: psychiatric
nursing.
RATIONALE
(1) Diversional activities for lower-functioning clients may precipitate anxiety and regression. (2) Program activities
should focus on strengths rather than on pathology. This approach may help the client to relinquish the sick role and to
demonstrate more adaptive behavior. (3) Day treatment centers provide social interaction and recreational and learning
activities for persons who might otherwise be isolated. (4) Day treatment centers provide social skills training,
opportunities for socialization, structure, and support for the client. The remaining needs are provided by significant
others.
QID: 7397 C 2(7-13 h 351) A teenage girl is very angry about a test she failed in school today and accuses the
teacher of wanting to make her feel “stupid”. This is an example of:
1. Anger
2. Repression
3. Projection
4. Denial
Rationale
(3) Integrated processes: nursing process — evaluation; client need: psychosocial integrity; content area:
RATIONALE
(1) An expression of anger would be stating feelings about the self without blaming others. (2) Repression is
excluding memories from awareness. (3) Projection, an adaptive mechanism for dealing with inner stress, is the
attribution of one’s own feelings, ideas, or characteristics (usually undesirable ones) to another person. (4) Denial
is ignoring or refusing to accept disagreeable realities
QID: 7398 C 19(284-285 h 321-322) A 52-year-old male client is admitted with a possible myocardial infarction. His
wife is very frightened and asks the nurse, “Is he going to die? Which would be the most appropriate response by the
nurse?
1. “I really cant tell you that; you’ll have to talk to his doctor”
2. “You have to be brave for your husband now; let’s not talk like that.”
3. “I know you’re scared; would you like to sit and talk for a while?”
4. Perhaps your husband is not really as sick as he appears. Most people don’t die from a heart attack.”
Rationale
RATIONALE
56
(1) This response will not decrease her anxiety. (2) This response will not decrease her anxiety. (3) Therapeutic
communication is crucial at this time. Listen to the client’s wife and allow her to ventilate her feelings. Provide the
opportunity for her to express her feelings and fears; to ask further questions; and to seek comfort, support, and
understanding. This is the best response for the circumstances. (4) This response will not decrease her anxiety.
QID: 7399 C 19(280-284 h 320) When doing preoperative and postoperative teaching with a client who is very anxious,
the nurse must remember that:
1. The client’s stress level is only temporary
2. The client may not be able to follow directions or explanations given at this time
3. The client may have a lot of misplaced hostility and may be non-compliant
4. The client’s anxiety is probably not related to fear of the unknown
Rationale
nursing.
RATIONALE
(1) The anxiety may not be temporary (2) Anxiety is an emotional response to a threat to one’s self-esteem or well-being.
Clients undergoing a surgical procedure are often highly stressed and unable to follow directions or explanations given.
The nurse first needs to listen, allow the client to express any fears, and answer questions before giving teaching or
explanation. (3) This statement may or may not be true, but it does not address anxiety (4) Anxiety may or may not be
related to fear of the unknown. This is not the best response.
QID: 7400 C 19(280-284 h 320) Nurses can experience anxiety, especially in a new or an unknown situation, such as
performing a procedure for the first time. Which of the following will help to decrease the nurse’s anxiety in such a
situation?
1. Ask another team member to do the procedure
2. Relax and remain confident, and performance will be effective
3. Ask questions and review the procedure, because knowledge and competence help to allay anxiety
4. Assume that anxiety often releases hormones that improve effectiveness and performance.
Rationale
(3) Integrated processes: nursing process — planning, communication and documentation; client need: psychosocial
integrity; content area: psychiatric nursing.
RATIONALE
(1) This strategy might help to reduce the nurse’s anxiety, but it is not the best response. (2) The nurse may have
confidence, but the anxiety will still remain. (3) Anxiety often impairs functioning and can also lead to errors in
judgment and performance. Nurses unfamiliar with a procedure need to take time to review it, to ask questions, and to
remember that knowledge and competence guard against anxiety and that as knowledge and competence increase,
anxiety lessens. (4) This statement may be true, depending on the level of anxiety This is not the best response.
QID: 7401C 6(76-78 h 332) A client has just been told by the physician that his condition is extremely grave and the
prognosis very poor. When the nurse enters his room he says, “The doctor said I am just fine and can go home today.”
What is the probable rationale for his statement?
1. He refuses to believe what the doctor has said and is using denial as a means of coping
2. He probably misunderstood the doctor’s explanation
3. He is bargaining in an attempt to be discharged and postpone facing his prognosis
4. He is depressed and just wants to go home and pretend he didn’t hear what the doctor said
Correct; 1 chapter 6 text pg 76-78 meds 95,98 hesi 332
Rationale
57
nursing.
RATIONALE
(1) Clients often at first deny the seriousness of their illness and go through elaborate mental “gymnastics” (such as
denial) to prove to themselves that this is not really happening to them. This mental mechanism is a means of helping
them to cope, until they are able to begin to deal with the reality of their illness. (2) It is more likely that he is in denial
rather than not hearing the physician. (3) Bargaining is a later stage of coping with a grave prognosis. (4) Depression is a
later stage of coping with a grave prognosis.
QID: 7402 C5 (56-65 h 14-16) Nurse encounters many ethical dilemmas in their practice. Which of the following could
be considered an ethical dilemma?
1. A client refuses to take digoxin as ordered
2. A terminally ill client’s pain is not being properly managed
3. A child is admitted with signs and symptoms of physical abuse
4. The nurse observes another nurse on the unit taking a controlled substance that was meant for a client
Rationale
care; content area: psychiatric nursing.
RATIONALE
(1) A client’s refusal to take medication is not an ethical dilemma. (2) This choice does not meet the definition of an
ethical dilemma. (3) Physical abuse is reportable by law; thus there is no ethical dilemma. (4) An ethical dilemma occurs
when there is a conflict of values. Ethics concerns what is right or wrong; values influence how one perceives others and
how one acts. In option 4, the nurse’s values come into conflict, because the nurse does not want to report the colleague
but knows that he or she needs help and that the behavior could endanger clients. As a professional, the nurse is
accountable to maintain standards of practice and assumes an ethical responsibility to clients.
QID: 7403 C 29(533-569 h 353-354) A 15-year-old client thinks that she is pregnant and wants an abortion. She does
not want her parents to know. The nurse’s best advice is to:
1. Tell her parents anyway
2. Encourage her to talk with the father of her child
3. Encourage her not to have abortion
4. Help her to make an appointment with the local clinic
Correct; 4 chapter 29 text pg 533-569 meds hesi 353-354
Rationale
(4) Integrated processes: nursing process data collection communication and documentation; client need: psychosocial
RATIONALE
(1) Telling her parents would not be respecting her privacy or confidentiality (2) The nurse might suggest this, but the
nurse does not know whether the client knows who the father is or whether she has an ongoing relationship with him. (3)
The nurse remains nonjudgmental regarding a client’s abortion. (4) The clinic staff will help her with counseling and
explore reasons for the abortion. The nurse respects the confidentiality of the client.
QID: 7404 C 11(143-147 h 315-317) Which of the following statement reflects a value conflict that may influence
interpersonal relationships?
1. The client says, “My pain is worse today”
2. The nurse says, “All alcoholics are manipulative.”
3. The nurse aide says, “Not all drug users are worthless.”
4. The client says, “Not all nurses are unfeeling.”
58
Rationale
RATIONALE
(1) There is no value statement here. The client is making a subjective comment. (2) The nurse is being judgmental when
he or she classifies people into groups and assumes that all people are the same. (3) There is no value conflict in this
statement. The aide is being respectful of people. (4) There is not a value conflict in this statement.
QID: 7405 C11 (143-147 h 315-317 ) Unacceptable manipulative behavior is best controlled by:
1. Prevention
2. Controlling
3. Limit setting
4. Firmness
Rationale
RATIONALE
(1) The nurse cannot prevent manipulative behavior. (2) The nurse cannot control manipulative behavior. (3) It is
essential that the nurse enforce limit setting to help control manipulative behavior. (4) Firmness is not as successful in
controlling manipulative behavior as limit setting.
QID: 7406 C 22(357-358 h 338) A 22-year-old client is admitted to the psychiatric unit with a diagnosis of
schizophrenia, which was first diagnosed 2 years ago. The client is disheveled and has not bathed recently. The parents
inform you that the client has not left her room for 10 days. On admission, the client tells the nurse, “They lied, I didn’t
kill my mother. You’re killers.” This response is an example of:
1. Grandiose delusions
2. Auditory hallucinations
3. Persecutory hallucinations
4. Paranoid delusions
Rationale
nursing.
RATIONALE
(1) This is an example of persecutory hallucinations, not grandiose delusions, such as thinking that the person is a
superior being. (2) This is an example of persecutory hallucinations, not auditory hallucinations, such as hearing voices
that do not exist. (3) Persecutory hallucinations occur when people think that someone is after them for something they
did not do or that is not reality based. (4) Paranoid delusions occur when the individual thinks that someone is blaming
him or her incorrectly
QID: 7407 C 22(357-358 h 338) A schizophrenic client tells the nurse, “They lied; I did not kill my mother” The nurse’s
best response to the client about the mother is:
1. “I just saw your mother; she’s fine”
2. “Tell me more about your mother”
3. “I’ll put you in an isolation room”
4. “I’ll have your mother come to see you now”
Rationale
59
nursing.
RATIONALE
(1) The client may not believe this statement by the nurse. (2) The best intervention is to get the client to talk about her
mother and her feelings. (3) Isolation will not be beneficial in this situation. (4) If the client is hallucinating, the presence
of the mother may encourage more erratic behavior.
QID: 7408 C22 (357-358 h 338) A client is actively hallucinating and withdrawn. The nurse wants to engage the client
in a reality-oriented activity. The best approach is:
1. To state, “I‘d like you to be my partner in this game”
2. To insist that the client join a group activity
3. To explain the benefits of a group activity
4. To ask “Would you like to play checkers?”
Rationale
RATIONALE
(1) The client needs simple, straightforward directions. (2) To insist on the client’s joining may aggravate the condition.
(3) Explaining the benefits will not be successful The client is too ill at this time. (4) The client is not ready to make
decisions at this time.
QID: 7409 C27 (491-492 h 351-352) A 77-year-old client with thrombocytopenia and dementia like to talk about her
younger day and occasionally confabulates. This behavior:
1. Prevents aggression
2. Gain attention
3. Indicate acute pyschosis
4. Maintains self-esteem
Rationale
nursing.
RATIONALE
(1) Confabulation does not prevent aggression. (2) The person does not confabulate to get attention but confabulates for
self- esteem. (3) Confabulation does not denote acute psychosis. (4) Confabulation increases self-esteem
QID: 7410 C 31(603-622 h 335) A high-risk factor in a potential suicide client is:
1. Increased physical activity.
2. A recent change in mood.
3. Hypersomnia.
4. Crying; increased verbal activity.
Rationale
RATIONALE
(1) Increased physical activity is not specific for suicide. (2) Most suicidal persons give verbal or behavioral (mood
change) warnings before committing suicide. They feel and act less depressed because they have come to terms with a
decision to end their lives. (3) Hypersomnia is not specific for suicide. (4) Increased verbal activity is not specific for
suicide.
60
QID: 7411 C 21(334 h 332-338) A client is terminally ill. When the nurse enters the room, it is evident that the client has
been crying. A statement to enhance communication would be:
1. “You seem sad and depressed today; what is the problem?”
2. “How are you feeling today?”
3. “Come on, cheer up, I’m sure things will look brighter tomorrow.”
4. “I see that you have been crying. Would you like to talk about it?’
Rationale
RATIONALE
(1) This option does not display an open communication system. (2) This option does not display an open
communication system. (3) This option does not display an open communication system. (4) This is an open-ended
statement that shows that the nurse has observed the client’s distress and allows verbalization of feelings
QID: 7412 C 2(7-13 h 315) A client who is a two-pack/day cigarette smoker changes the topic of conversation
whenever her smoking is brought up. This psychological defense mechanism is called:
1. Sublimation
2. Repression
3. Denial
4. Compensation
Rationale
(3) Integrated processes: nursing process data collection; client need: psychosocial integrity; content area:
RATIONALE
(1) Sublimation is acceptance of a socially approved substitute. (2) Repression is involuntary exclusion of an
undesirable thought from the memory. (3) Denial is a refusal to admit the reality of or to acknowledge the
presence of something painful. (4) Compensation is the process by which a person makes up for a deficiency by
emphasizing an asset.
QID: 7413 C 19(280-284 h 320) A 34-year-old client has been recently admitted to the hospital for the third time this
past month with anxiety, nausea and vomiting, and a tentative diagnosis of hypochondriasis. Which of the following
statements correctly defines these orders?
1. The outward manifestation of anger that the client is not able to express directly and that is manifested in physical
symptoms.
2. The inability to acknowledge thoughts or feelings in oneself and attributing them to another.
3. A defense used by the ego when it does not wish to remember a painful feeling or emotion.
4. A defense by the ego when it feels severely threatened or during periods of internal psychic stress
Rationale
(1) Integrated processes: nursing process data collection; client need: psychosocial integrity; content area: psychiatric
nursing.
RATIONALE
(1) Hypochondriasis is a defense used by the ego when it has real or imagined aggressive, critical feelings toward others.
The critical feelings are turned back on the ego and are experienced as guilt, often transformed into physical complaints.
(2) This is projection. (3) This is suppression. (4) This is repression.
61
QID: 7414 C 21(334 h 332-338) A nurse in a long-term psychiatric unit finds that a client with depression has not
showered for a week and is very unkempt in appearance. The nurse would:
1. Do nothing and wait until the client is ready to shower on his or her own.
2. Tell the client to go and shower now.
3. Assist the client in gathering the necessary items to bathe.
4. Obtain physical help and carry the client to the shower.
Rationale
RATIONALE
(1) Doing nothing will not meet the client’s basic grooming needs. (2) Telling the client to bathe may not accomplish the
task. (3) Clients with depression frequently do not have the energy to take care of their personal grooming needs. The
nurse assists with these needs without fostering dependence. (4) This option will not promote independence.
QID: 7415 C22 (357-358 h 338) A 22-year-old computer programmer was admitted last night with schizophrenia. He is
watching television in the day room. As the nurse approaches him, he says, “Leave me alone, don’t bother me.” The
nurse would:
1. Introduce himself or herself and stay with him for a while.
2. Stay at his side for an hour to let him know that he is not in control.
3. Leave with plans to return in 1 hour
4. Gently touch his hand and offer help
Rationale
RATIONALE
(1) The nurse will stay with the client initially for a short period to begin developing trust. (2) It is not necessary to stay
for an hour; besides, this is not a matter of control. (3) The best plan is to stay a short while and then return later. (4)
Therapeutic touch is not appropriate until trust is established.
QID: 7416 C 2(7-13 h 315) A 34-year-old client is scheduled for major surgery. Since admission, the client has
been very demanding, continuously calling the nurse to straighten a pillow and pour a glass of water. The nurse
identifies this as an example of which defense mechanism?
1. Regression
2. Conversion
3. Denial
4. Projection
Rationale
RATIONALE
(1) Regression is adopting behavioral patterns characteristic of an earlier stage to reduce stress. (2) Conversion is
channeling psychological stress into physical symptoms. (3) Denial occurs when the anxiety-producing situations
are rejected as they actually are. (4) Projection is attributing undesirable symptoms to other people or objects.
62
QID: 7417 C 19(285-287 h 321-322) A single father brings his 17-year-old daughter to the clinic because she refuses to
leave the house for fear of meeting someone she does not know. He wants to know what condition is called. The nurse
explains that it is called:
1. Acrophobia
2. Xenophobia
3. Claustrophobia
4. Agoraphobia
Rationale
(2) Integrated processes: nursing process — planning, teaching/learning; client need: psychosocial integrity; content
area: psychiatric nursing.
RATIONALE
(1) Acrophobia is fear of height. (2) Xenophobia is fear of strangers. (3) Claustrophobia is fear of enclosed spaces. (4)
Agoraphobia is fear of open spaces.
QID: 7418 C 23(375 h 330) During change of shift report, the nurse reports that a new admission has bulimia. The nurse
recognizes that bulimia is:
1. A phobia of obesity.
2. A disorder associated with starvation.
3. A disorder associated with vomiting.
4. A disorder associated with bingeing and vomiting.
Rationale
nursing.
RATIONALE
(1) Bulimia is not a phobia. (2) Anorexia is a disorder involving starving oneself. (3) Bulimia is more than just vomiting.
(4) Bulimia is eating massive amounts of food and then purging by either vomiting or taking laxatives.
QID: 7419 C 27(491-492 h 351-352) A 78-year-old client with senile dementia is wandering the halls in a long-term
care facility. He is looking for his 5-year-old son. The nurse would:
1. Ask him when he last saw his son.
2. Remind him that his son is now a grown man.
3. Ask him to describe his son.
4. Help him back to his room.
Rationale
RATIONALE
(1) This action will only reinforce his confusion. (2) This is a short-term solution and may initiate a defense mechanism.
(3) If he can describe his son, this reinforces his confusion. He does not have a 5-year old son. (4) This action will help
to orient him to his surroundings.
QID: 7420 C 27(491-492 h 351-352) A home-health nurse is caring for a client with a colostomy. Her family asks the
nurse for advice on coping with their father, who has organic brain syndrome. He is very forgetful and gets angry when
the family reminds him that he should remember. The nurse’s best advice for the family is that they should:
1. Place him in a long-term care facility because he is potentially dangerous to himself.
2. Give detailed instructions to him when he does something wrong.
3. Reorient him when he loses contact with reality.
63
4. Provide flexibility in his daily activities.
Rationale
(3) Integrated processes: nursing process — implementation, teaching/learning; client need: psychosocial integrity;
RATIONALE
(1) He may be potentially dangerous to himself, but the family is not asking to have him placed in a long-term care
facility. (2) Giving detailed instructions to clients with organic brain syndrome will only increase their confusion. (3)
Organic brain syndrome clients need frequent reality orientation. (4) This will only increase his anxiety and confusion.
QID: 7421 C 24(412-415 h 328) A 22-year-old client with a antisocial personality refuses to participate in group
activities and makes fun of other clients, calling them “nut cases.” Which of the following nursing plans would be most
effective for the staff to follow?
1. Isolate the client from the other clients to avoid disturbing them with the name calling.
2. Set ground rules.
3. Call a team meeting to discuss the treatment plan.
4. Require the client’s participation in all group activities.
Rationale
(3) Integrated processes: nursing process — planning, communication and documentation; client need: psychosocial
RATIONALE
(1) This approach will reinforce the antisocial behavior. (2) Setting ground rules does not mean the client will follow
them. (3) This approach ensures that all team members are engaged in the treatment plan. (4) Requiring participation
does not mean that the client will participate.
QID: 7422 C24 (410-411 h 327) A 44-year-old paranoid client is admitted for corrective orthopedic surgery. He refuses
oral medication, saying that the nurse is trying to poison him. The nurse would:
1. Insist that he take the medicine because it not poison.
2. Skip the medicine and report the behavior to the physician.
3. Give him the choice of taking it orally or IM.
4. Ask him why he thinks it is poison
Rationale
(3) Integrated processes: nursing process — implementation; client need: physiological integrity; pharmacological
therapies; content area: psychiatric nursing.
RATIONALE
(1) The nurse is pitting himself or herself against the client. (2) This is not an option; he needs his medication or his
behavior will get worse. (3) Giving him a choice allows him to have some control. (4) The client is paranoid; he does not
know why he thinks this. This approach will only reinforce his paranoid thoughts
QID: 7423 C 21(334 h 332-338) A 24-year-old female client has refused to get out of bed for 3 days. Her mother brings
her to hospital. The client is given a diagnosis of depression. After 4 days on the unit, she refuses to take her oral
medicine because she says it is causing her to have difficulty seeing. The nurse would:
1. Administer the medication IM.
2. Hold the medicine until the client is evaluated further.
3. Insist that she take the medicine orally.
4. Confine her to her room until she is ready to take her medicine
64
Rationale
(2) Integrated processes: nursing process evaluation; client need: physiological integrity; pharmacological therapies;
RATIONALE
(1) The client needs her symptoms evaluated; giving the medicine IM is inappropriate at this time. (2) Holding the
medicine until the client symptoms can be evaluated is the correct choice. (3) Insisting that she takes her medicine will
not control her visual problems. (4) The client needs to be evaluated, not confined to her room.
QID: 7424 C 17(252-258 h 337) A 45-year-old client has just had electroconvulsive therapy. The nurse would:
1. Take his vital signs every 5-10 minutes.
2. Observe the client for nausea and vomiting.
3. Reorient the client to time and place.
4. Place the client on bed rest for the next 24 hours
Category: physiologic integrity reduction and risk potential
Rationale
potential; content area: psychiatric nursing.
RATIONALE
(1) It is not necessary to take vital signs every 5-10 minutes after electroconvulsive therapy (2) Nausea and vomiting are
not usual side effects of electroconvulsive therapy (3) Clients undergoing electroconvulsive therapy are usually confused
after therapy and need reorientation. (4) Bed rest is not required after electroconvulsive therapy
QID: 7425 C 11(143-147 h 315) A woman who is 8 months pregnant is at the clinic for her regular appointment. She
confides in the nurse that her husband wants her to bottle-feed the baby. He thinks that breast-feeding will distort her
breasts. She asks the nurse’s opinion. The nurse’s response is:
1. “To please your husband, you should bottle-feed.”
2. “Have you tried talking with your mother about the problem?”
3. “You should discuss this with your doctor.”
4. “What would you like to do?”
Rationale
RATIONALE
(1) The nurse should be a client advocate. This statement is the nurse’s opinion. (2) The problem is between the husband
and wife, not the woman’s mother. (3) The woman is asking the nurse for help. This is not the best response. (4) This
statement will help the client to discuss her feelings before any decision is made.
QID: 7426 C 19(280-284 h 320) It is apparent that a 24-year-old client is going to abort. She is very apprehensive.
Which of the following statement is best to give the client’s support?
1. “Just try to stay calm; everything will be all right.”
2. “Is this your first spontaneous abortion?”
3. “It is best to abort now rather than later on in your pregnancy.”
4. “I will stay with you to help you through this.”
Rationale
(4) Integrated processes: nursing process — implementation, caring; client need: health promotion and maintenance;
RATIONALE
65
(1) The nurse does not know that everything will be all right. This is false reassurance. (2) This statement will not help to
ease the client apprehension. (3) This statement may increase the client’s apprehension. (4) Remaining with the client
will help to provide support through the aborting process.
QID: 7427 C 22(357-358 h 338) A 19-year-old female client is admitted to the psychiatric unit because she talks to
herself, is suspicious of other people, laughs inappropriately, and hears voices telling her to kill herself. She is sitting in
the lounge quietly talking to a card table. The nurse would:
1. Ignore the behavior; she is not bothering anyone.
2. Try to engage her in some physical activity.
3. Tell her to stop talking.
4. Ask her with whom is she talking.
Rationale
RATIONALE
(1) Ignoring the behavior reinforces the hallucinations. (2) Engaging the client in physical activity helps to decrease
hallucinations. (3) Telling her to stop talking may increase her agitation. (4) She probably does not know with whom she
is talking, and this response reinforces the hallucinations.
QID: 7428 C22 (352-372 h 338-343) A 48-year-old male client is in restraints for severe agitation. The best way to
assess whether he is ready to have the restraints removed is:
1. Give him a sedative, wait 30 minutes, and then remove the restraints.
2. Check his pupils for dilation.
3. Observe him for tense muscles.
4. Ask him if she is in control now.
Category: safe effective; care environment
Rationale
(3) Integrated processes: nursing process data collection; client need: safe, effective care environment; safety and
infection control; content area: psychiatric nursing.
RATIONALE
(1) Giving a sedative may be an unnecessary intervention. (2) Dilated pupils will not tell the nurse if the client is
agitated. (3) A client with relaxed muscles is not agitated. (4) He may say yes, but he is not in control and may then hurt
himself or someone else.
QID: 7429 C 22(352-372 h 338-343) A 54-year-old client is having delusions. It is important that the nurse:
1. Correct the delusions
2. Not talk about the delusions
3. Tell the client to think about something else
4. Not disagree with the client about the delusions.
Rationale
RATIONALE
(1) Correcting the delusions will make them more fixed. (2) Avoiding talking about the delusions is not therapeutic. (3)
This response is not therapeutic. (4) If the nurse disagrees with the client, the delusions become more fixed.
QID: 7430 C 22(352-372 h 338-343) A nurse enters the room of a 36-year-old client who is speaking as if someone else
is in the room. He wants to introduce the nurse to his friend. The nurse’s best response is to:
66
1. Offer to give him some medication.
2. Tell him that no one is there except the client and nurse.
3. Ask him what the person’s name is.
4. Ask him to describe his friend.
Rationale
RATIONALE
(1) Giving him medication right now will not stop his delusions. (2) This is therapeutic without reinforcing his delusions.
(3) This response would reinforce his delusions. (4) This response would reinforce his delusions.
QID: 7431 C 22(352-372 h 338-343) A delusional client thinks the rest of the clients are “out to take his things.” The
best nursing response to this behavior is:
1. Ignore it because it is not hurting anyone.
2. Correct the thinking each time the client says it.
3. Involve the client in a physical activity.
4. Ask the client to clarify what he means
Rationale
RATIONALE
(1) Ignoring the behavior reinforces the delusions. (2) Correcting the behavior may lead to an argument and reinforce the
delusions. (3) Physical activity may help the delusions to diminish. (4) This approach reinforces the delusion.
QID: 7432 C 7(76-78 h 332) A 42-year-old client has just delivered a stillborn infant. She is rather upset and quietly
crying. The nurse’s best response to comfort her is:
1. Assure her that everything will be okay.
2. Ask her if she would like to talk about why she is crying.
3. Tell her to not worry; she can have another baby.
4. Tell her that this is best because the baby would have had other problems.
Correct; 2 chapter 7 text pg 76-78 meds 95, 98 hesi 332
Rationale
RATIONALE
(1) This response is false reassurance. (2) Asking the client if she wishes to talk about the event is therapeutic. (3) This is
not a therapeutic response, and the nurse does not know the client’s wishes at this time. (4) This is not a therapeutic
response.
QID: 7433 C 33(684-656 h 332) A 23-year-old woman who has been raped presents herself in the emergency room. The
nurse’s first action is to:
1. Report it to the police.
2. Report it to the supervisor.
3. Determine her most immediate needs.
4. Call her family for support.
Rationale
67
RATIONALE
(1) Although the nurse would notify the police, this is not the first priority (2) Although the nurse may report it to the
supervisor, this is not the first priority (3) The first priority is to determine the client’s immediate needs so she can
establish a sense of control. (4) The nurse would not call her family until she has agreed to their being called.
7434 QID: C11 (142-147 h 315) A 45-year-old client is scheduled for knee surgery. Because he does not like the
hospital food, his wife brings food from home. He is on a regular diet. The nurse’s first response is to:
1. Ask her to not do this. It is against hospital policy.
2. Make a referral to the dietitian.
3. Allow the client to eat the food.
4. Take the food away.
Category: physiologic integrity Basic care and comfort
Rationale
RATIONALE
(1) Although it may be against hospital policy, it should not be and the client should be allowed to eat the food. (2) A
dietitian should be consulted at a later time. The immediate priority is to let the client eat the food. (3) The client is on a
regular diet; he can eat the food. (4) Do not take the food away
QID: 7435 C 11(143-147 h 315) A 57-year-old Mexican client with a myocardial infarction has been transferred to the
cardiac step-down unit. The extended family comes to visit. The most appropriate action is to:
1. Restrict visitors to two at a time.
2. Ask for a family member to help control visitors on a rotational basis.
3. Ask the physician to speak with the family.
4. Act as the control person.
Rationale
(2) Integrated processes: nursing process—planning; client need: psychosocial integrity; content area: psychiatric
nursing.
RATIONALE
(1) Restricting visitors in this cultural group may not help the situation. (2) Eliciting the help of family members will
give the client and family some autonomy. In the Mexican culture, it is a family obligation for all family members to
visit the hospitalized family member. (3) Control of visitors is a nursing function, not a physician function. (4) Acting as
the control person will not give the family autonomy.
QID: 7436 C11 (143-147 h 315) A 35-year-old client in a long-term care facility has terminal breast cancer. She is
taking herbal tea for her indigestion. The nurse’s first action is to:
1. Carefully explain that herbal teas are not permitted.
2. Report the situation to her physician.
3. Report the situation to the pharmacist.
4. Allow her to take the herbal teas.
Correct; 4 chapter 11 text pg 143-147 meds 88-89 hesi315
Category: physiologic integrity Basic care and comfort
Rationale
RATIONALE
68
(1) There is no reason why the client cannot take herbal teas. They do not interfere with other treatments. (2) The nurse
may report the situation to the physician later, but the first action is to let her drink her herbal tea. (3) The nurse may
report the situation to the pharmacist later so it can be added to her profile, but the initial action is to let the client drink
her herbal tea. (4) Herbal tea gives the client some relief and autonomy
QID: 7437 C 11(143-147 h 315) A 34-year-old client with a new diagnosis of insulin-dependent diabetes refuses to take
insulin when she goes home. She tells the nurse that God will take care of her. The nurse’s most appropriate action is to:
1. Ask her physician to prescribe an oral hypoglycemic agent.
2. Have the chaplain talk with her.
3. Ask her physician to talk with her about this “nonsense.”
4. Explain to her that God cannot heal diabetes.
Rationale
RATIONALE
(1) Oral hypoglycemic medications do not work for insulin- dependent diabetes mellitus. (2) Because this is a spiritual
and religious issue, the chaplain may have more influence with the client. (3) Clients’ beliefs should never be labeled as
nonsense. (4) This statement is an example of cultural imposition.
QID: 7438 C11 (143-147 h 315) A 72-year-old Filipino client is in the long-term care facility for cancer of the lung. The
client is reluctant to cough and deep breathe, maintains a rigid position in bed, and refuses needed pain medication. The
best initial approach is to:
1. Give the pain medication.
2. Ask the physician to order the medicine around the clock instead of on an as-needed basis.
3. Explore the reasons for not taking the pain medication.
4. Report the situation to the nursing supervisor.
Rationale
RATIONALE
(1) This action negates client autonomy and rights. (2) The physician may eventually order the medicine around the
clock, but this is not the first action. (3) Exploring the reason for not taking the medicine is the first action. Many
Filipino clients are stoical about pain because “it is Gods will.” (4) Although the nurse may report the situation to the
nursing supervisor, the first action is to explore the client’s reasons for not taking the pain medication.
QID: 7439 C 11(143-147 h 315) A 63-year-old client being prepared for surgery becomes visibly upset when the nurse
tries to remove a beheaded bracelet from the client’s wrist. The nurse should:
1. Tape the bracelet in place.
2. Encourage the family to remove the bracelet.
3. Delay the surgery until the bracelet is removed.
4. Enclose the hand and wrist in a mitten.
Rationale
RATIONALE
69
(1) Tape the bracelet in place. The bracelet provides for spiritual needs. (2) It is not necessary to have the family remove
the bracelet. (3) It is not necessary to delay the surgery. (4) Do not enclose the hand in a mitten. The nail beds will be
used in surgery to help determine oxygenation.
QID: 7440 C 11(143-147 h 315) A 76-year-old client with CHF has just expired. Several family members are at the
bedside. One of the daughters sits on the floor and begins to wail. The nurse would:
1. Tell her that everything will be okay.
2. Help her to sit in a chair.
3. Call the physician for a tranquilizer.
4. Stay close to her and ask if she needs anything.
Rationale
(4) Integrated processes: nursing process implementation, caring; client need: psychosocial integrity; content area:
RATIONALE
(1) This statement is an attempt to console the client but is inappropriate. (2) She may not want to sit in a chair. (3)
Calling the physician is not a first priority. (4) This behavior may be culture bound, and the most appropriate action at
this time is to remain close to her and offer support.
QID: 7441 C 25(428-462 h 344) Nursing care for the substance abuse client experiencing alcohol withdrawal delirium
includes:
1. Maintaining seizure precautions
2. Restricting fluid intake
3. Increasing sensory stimuli
4. Applying ankle and wrist restraints
Rationale
(1) Integrated processes: nursing process — implementation; client need: physiological integrity; physiological
adaptation; content area: psychiatric.
RATIONALE
(1) These clients are at high risk for seizures during the first week after cessation of alcohol intake. (2) Fluid intake
should be increased to prevent dehydration. (3) Environmental stimuli should be decreased to prevent precipitation of
seizures. (4) Application of restraints may cause the client to increase his or her physical activity and may eventually
lead to exhaustion.
QID: 7442 C 25(143-147 h 315-317) The nurse is aware that many clients admitted to a psychiatric unit are concerned
about:
1. Confidentiality
2. Anonymity
3. Insanity defense
4. Moral distress
Rationale
care; content area: psychiatric.
RATIONALE
1. Because of the stigma associated with a mental illness, many clients are fearful of rejection and reprisal. The nurse
protects the psychological space of the client through confidentiality. (2) It is impossible for clients to be anonymous
during a hospital stay. (3) Insanity defense is a concern for only those mentally ill hospitalized clients diagnosed as
70
criminally insane. (4) The health-care provider, not the mentally ill client, experiences moral distress during an ethical
dilemma
QID: 7443 C 11(76-78 ) Many clients have difficulty expressing anger. Which one of the following nursing
interventions would assist a client with expressing anger appropriately?
1. Isolate from others
2. Encourage acting out
3. Encourage verbalization
4. Introduce self-care improvement
Correct; 3 chapter 11 text pg 76-78 meds 95,98 hesi
Rationale
(3) Integrated processes: nursing process implementation; client need: psychosocial integrity; content area: psychiatric.
RATIONALE
(1) Isolation from others may lead to more hostility (2) Acting out indicates aggressiveness, which is not a healthy
behavior. (3) Encourage clients to communicate anger without abridging the rights of others. (4) Improving self-care
may increase self- esteem but will not decrease anger.
QID: 7444 C 7(7-13 h 315) The client reported to the nurse that the therapy session was a failure and a waste of time.
The client then remarked, “The next time, I’ll just sit there and be a nonparticipant.” What defense mechanism is the
client demonstrating?
1. Compensation
2. Identification
3. Rationalization
4. Projection
Rationale
(3) Integrated processes: nursing process — data collection; client need: psychosocial integrity; content area: psychiatric.
RATIONALE
(1) Compensation is the process by which a person attempts to make up for real or perceived deficits by strongly
emphasizing some other feature that he or she regards as an asset. (2) Identification operates unconsciously and is an
attempt to modify behavior and to pattern oneself after another person. (3) Rationalization is used to justify ideas,
actions, or feelings with seemingly acceptable reasons or explanations. (4) Projection enables a person to justify his or
her own unacceptable feelings and impulses by attributing the behaviors to others
QID: 7445 C 2(7-13 h 315) During the initial interview, the client tells the nurse that he grew up on the “wrong
side of the tracks.” He feels rejected by his family, socially unacceptable, and works hard to become the meanest
fighter in his block. Which of the following defense mechanisms is the client exhibiting?
1. Projection
2. Compensation
3. Rationalization
4. Sublimation
Rationale
psychiatric.
RATIONALE
(1) Projection enables a person to justify his or her own acceptable feelings and impulses by attributing the
behaviors to others. (2) Compensation is the process by which a person attempts to make up for real or perceived
deficits by strongly emphasizing some other features that he regards as an asset. (3) Reaction formation is the
71
development of attitudes and behaviors that are opposite to what one really feels or would like to do. (4)
Rationalization is used to justify ideas, actions, or feelings with seemingly acceptable reasons or explanations
QID: 7446 C 2(7-13 h 315) A 10-year-old girl hit a playmate with a baseball bat. The school nurse intervened in
the incident. The girl shouted, “He hit me. He hit me. He hit me.” Which of the following defense mechanisms is
the girl exhibiting?
1. Displacement
2. Projection
3. Rationalization
4. Sublimation
Rationale
psychiatric.
RATIONALE
(1) Displacement is a shift of emotions from a person or object to another neutral or less-threatening person or
object. (2) Projection enables a person to identify his or her own unacceptable feelings and impulses by
attributing the behaviors to others. (3) Rationalization is used to justify ideas, actions, or feelings with seemingly
acceptable reasons or explanation. (4) Sublimation allows a person to divert unacceptable impulses and motives
into personally and socially acceptable channels.
QID: 7447 C 29(533-569 h 353-354) A 3-year-old girl excited about having a new brother and welcomed him home with
a hug and a kiss. After a few days, she started wetting her pants and told her mother that she wanted a diaper. This is
most suggestive of:
1. Regression
2. Undoing
3. Repression
Rationale
RATIONALE
(1) Regression is partial or symbolic return to earlier stages of development. (2) Undoing is used to amend or reverse
previous thoughts, feelings, or actions. (3) Repression is an involuntary exclusion of unacceptable feelings or thoughts
that are automatically pushed into one’s unconscious. (4) Reaction formation enables a person to adopt attitudes and
behaviors that are opposite to his or her own impulses
QID: 7448 C 5(59-60 h 14-16) A psychiatric nurse was instructed by the attending psychiatrist to administer 10 mg of
haloperidol (Haldol) to a severely dysfunctional client. The client refused all medications. Which was the best nursing
action?
1. Restrain the client and give the medication IM.
2. Accept the client’s decision.
3. Plead with the client to reconsider.
4. Obtain a discharge order for noncompliance.
Rationale
psychiatric.
RATIONALE
72
(1) The client has the right to refuse treatment. Restraining and forcing the medication is against the client’s
constitutional rights and “The Patient Self-Determination Act.” (2) The client has a right to self-determination. Accept
the client’s decision. (3)
Pleading is not a therapeutic nursing intervention. Paternalism is operating and may not be beneficial. (4) This response
is not a good choice
QID: 7449 C 5(59-60 h 14-16) On admission to a psychiatric unit, a 22-year-old male client signed a voluntary
admission form. After a period of 12 hours, the client informs the nurse of his desire to leave by yelling. “I don’t need to
be here. Let me out.” What is the best response by the nurse?
1. ”You can’t leave the hospital.”
2. “Think about staying for 1 week.”
3. “Please sign this legal form indicating your intentions and wait 24 hours.”
4. “Ask your doctor about discharge so he can start legal procedures.”
Rationale
psychiatric.
RATIONALE
(1) Psychiatric clients have the right to leave the hospital if they are not a danger to self or others. (2) The nurse may ask
the client to remain hospitalized, but this is not the best response. (3) When clients demand discharge from a psychiatric
unit, they are asked to put their intentions in writing. They may be detained against their will for a period of time
depending on the laws of the state. (4) This is not the best response. However, a client may discuss discharge with the
physician.
QID: 7450 C 11(143-147 h 315-317) Disclosure of information, beyond members of the multidisciplinary team,
without the consent of the client is a breach of:
1. Anonymity
2. Confidentiality
3. Duty
4. Habeas corpus
Rationale
RATIONALE
(1) Anonymity is a situation in which the name is not disclosed. (2) Disclosure of information by psychiatric
professionals is limited to authorized individuals. (3) It is not a duty to provide information to anyone unless the client
has provided authorization. (4) Habeas corpus provides for patients held against their will to be discharged immediately,
if judged sane.
QID: 7451 C 5(59-60 h 14-16) Psychiatric clients have a right to refuse treatment. When persuasion and manipulation
are used to get the client engaged in treatment, the nurse is aware that:
1. The client has no fundamental right to refuse treatment.
2. There is a responsibility to complete treatment once it is started.
3. Paternalism is operating.
4. Constitutional rights are abused.
Rationale
73
RATIONALE
(1) Psychiatric clients have the right to refuse treatment under the U.S. Constitution. (2) Clients have the right to refuse
treatment once started. (3) Paternalism is operating when the nurse uses persuasion and manipulation to get the client
actively engaged in treatment that is believed best for the client. (4) There is no indication that the client constitutional
rights have been abused.
QID: 7452 C 5(59-60 h 14-16) A 29-year-old man client admitted himself for psychiatric treatment. The nurse
determines that this admission is:
1. Voluntary
2. Judicial
3. Informal
4. Involuntary
Rationale
(1) Integrated processes: nursing process — data collection; client need: safe, effective care environment; coordinated
RATIONALE
(1) The client voluntarily admitted himself for psychiatric care. (2) A state determines judicial commitment. (3) Informal
admission resembles an admission to a general hospital. (4) Involuntary admission is characterized by an unwilling and
forceful admission.
QID: 7453 C 19(280-284 h 320) The most effective nursing interventions to assists a client who is experiencing
moderate anxiety are to:
1. Focus on anxiety reduction.
2. Probe the cause.
3. Investigate decomposition behaviors.
4. Accept the level of anxiety.
5. Support health coping behaviors.
6. Monitor levels of consciousness.
Correct; 1, 5 chapter 19 text pg 280-284 meds 89 hesi 320
Rationale
(1, 5) Integrated processes: nursing process — implementation; client need: psychosocial integrity; content area:
psychiatric.
RATIONALE
(1) The first priority is to reduce the anxiety to a tolerable level to prevent pathological behavior. (2) Probing the cause of
anxiety is recommended only if the client is experiencing mild or well-controlled anxiety (3) In moderate anxiety the
perceptual field narrows and the person remains alert. Decompensation is unlikely at this level. (4) Anxiety is on a
continuum that becomes problematic if there is no appropriate intervention. (5) Instructing the client on healthy coping
behaviors can help reduce anxiety (6) In moderate anxiety the perceptual field narrows and the person remains alert.
QID: 7454 C19 (284-285 h 321-322) At the time of admission, a female client suffered from insomnia, shortness of
breath, and a rapid pulse. The client was agitated and stated that she was going crazy and losing control. The diagnosis
was panic disorder. The nursing plan of care should include:
1. Large doses of antianxiety medications
2. Family education
3. The etiology and management of panic disorders
4. Cognitive restructuring
Rationale
(3) Integrated processes: nursing process — planning; client need: psychosocial integrity; content area: psychiatric.
74
RATIONALE
(1) Antianxiety medications should be used cautiously and sparingly because of the addictive properties. The
medications may alleviate the symptoms of anxiety but they interfere with understanding the source of the anxiety. (2)
Anxiety that is communicated interpersonally often affects family members. The immediate focus should be on the
client. (3) Educating clients is one of the essential nursing responsibilities. (4) Cognitive restructuring is associated with
community-based therapy
QID: 7455 C 19(289-290 h 323-324) After a complete diagnosis work-up for a client with neurobiological changes, it
was determined that the client was experiencing post-traumatic stress disorder (PTSD). In planning care for the client,
the nurse should be aware that:
1. The symptoms are a mechanism, which help him cope with an unacceptable situation.
2. The symptoms are a mechanism, which help him cope and support his dependence.
3. The symptoms are a means to manipulate others.
4. The symptoms develop from a nonspecific psychic event.
Rationale
(1) Integrated processes: nursing process planning; client need: psychosocial integrity; content area: psychiatric.
RATIONALE
(1) Physical symptoms are a defense mechanism that absorbs and neutralizes the anxiety generated by unacceptable,
unconscious impulses. (2) The symptoms are not voluntarily controlled. Dependence is not a key issue. (3) Symptoms
arise from anxiety and are not used to manipulate others. (4) The symptoms develop from exposure to a specific
traumatic event.
QID: 7456 C 19(285-287 h 321-322) A 25-year-old female client tells the nurse that she has an irrational fear of spiders
and goes out of her way to avoid them. In planning care for the client, it is important for the nurse to know that:
1. The client has displaced a conscious conflict to an object symbolically related to the conflict.
2. The anxiety is free-floating.
3. The client accepts the source of distress.
4. The behavioral style of phobic clients is avoidance.
Rationale
RATIONALE
(1) The development of phobic behavior is fear that arises through a process of displacing an unconscious conflict to an
external object symbolically related to the conflict. (2) Free- floating anxiety is not tied to a specific stimulus. (3) The
client is seeking help for her phobic behavior. (4) Persons suffering from phobic behaviors use avoidance.
QID: 7457 C 19(285-287 h 321-322) During the multidisciplinary team conference, the client explained that she was
terrified of rain and practiced avoidance. The team members understand that the client is:
1. Controlling the intensity of the anxiety
2. Fearful of the internal source of distress
3. Aware of the basic source of the anxiety
4. Attempting to undo the source of anxiety
Rationale
RAT1ONALE
(1) The phobic person controls the intensity of the anxiety by avoiding the object with which the anxiety is associated.
(2) The phobic person fears a specific external object rather than the internal source of distress. (3) Because phobias are
75
displaced fears and at an unconscious level, the basic source is out of awareness. (4) This is not a good choice because
the source of anxiety is an internal conflict at an unconscious level.
QID: 7458 C 21(352-372 h 338-343) A female client continues to exhibit seductive behavior, pressured speech, and
psychomotor agitation. Which of the following is the best nursing intervention?
1. Provide a safe environment
2. Indicate that the behavior is not acceptable
3. Encourage group activity
4. Promote highly competitive activities
Rationale
psychiatric.
RATIONALE
(1) Promoting client safety by providing a quiet environment may calm the hyperactive client. (2) This intervention
shows little understanding of the disease. (3) Because of the psychomotor agitation, the client may have difficulty
remaining in a group activity. Constant disruptions create distractions. (4) Avoid highly competitive activities because
they may bring out hostility and aggressive behaviors
QID: 7459 C 21(352-372 h 338-343) A scantily dressed client approached the nurse, saying “I am a striptease dancer
and I am ready for visitors.” Which action by the nurse would be most appropriate?
1. Inform the client that all privileges will be suspended indefinitely.
2. Assure the client that her behavior is appropriate.
3. Redirect the client to her room and assist her with a change of clothes.
4. Allow the client to remain as dressed.
Rationale
psychiatric.
RATIONALE
(1) Matter-of-fact intervention, rather than an angry approach, is more effective. (2) Providing false assurances is not an
appropriate form of treatment. (3) Keep the client’s dignity in mind at all times. (4) The lack of an appropriate
intervention is a form of rejection. Inappropriate behaviors may cause future embarrassment.
QID: 7460 C 21(342-344 h 332-338) The activity therapist is implementing an individualized program for a manic
exhibiting hostility and excessive energy. Which of the following activities would be most appropriate?
1. Writing short stories
2. Team sports
3. Ping-pong
4. Walking
Rationale
(4) Integrated processes: nursing process implementation; client need: psychosocial integrity; content area: psychiatric.
RATIONALE
(1) A person with excessive energy is unable to sit and concentrate for any length of time. (2) Team sports will provide a
release of excess energy but may create unnecessary external stimuli. (3) Competition is to be discouraged during the
manic phase because it may cause overly aggressive behaviors. (4) Walking is the best choice because it is less
competitive and provides an opportunity for the release of energy
76
QID: 7461 C 21(342-344 h 332-338) A 40-year-old male client discharged from a psychiatric unit 4 days ago presented
at the clinic talking loudly, cursing, and crying. Family members stated that they are unable to cope with the behavior
and alternative living arrangements must be made. Which living arrangements are most suitable?
1. Long-term psychiatric hospitalization
2. Nursing home placement
3. Group home placement
4. Independent living
Rationale
psychiatric.
RATIONALE
(1) Long-term psychiatric care fosters dependence. The goal of therapy is to promote independence. (2) A nursing home
client becomes dependent on the system. (3) A group home will assist the client with structure and help him to develop a
level of independence. (4) The client requires some form of structure, which is not available with independent living.
QID: 7462 C 22(364-368 h 341-343) The physician orders fluoxetine (Prozac) for a depressed client. Which of the
following should the nurse remember about fluoxetine?
1. Because fluoxetine is a tricyclic antidepressant, it may precipitate a hypertensive crisis.
2. The therapeutic effect of the drug occurs 2-4 weeks after treatment is begun.
3. Foods such as aged cheese, yoghurt, soy sauce, and bananas should not be eaten with this drug.
4. Fluoxetine may be administered safely in combination with monoamine oxidate (MAO) inhibitors.
Rationale
(2) Integrated processes: nursing process — implementation; client need: physiological integrity; pharmacological
therapies; content area: psychiatric.
RATIONALE
(1) Fluoxetine is not a tricyclic antidepressant. It is an atypical antidepressant. (2) This statement is true. (3) These foods
are high in tyramine and should be avoided when the client is taking MAO inhibitors. Fluoxetine is not an MAO
inhibitor. (4) Patal reactions have been reported in clients receiving fluoxetine in combination with MAO inhibitors
QID: 7463 C4 (7-13 h 315) The nurse is caring for a 38-year-old man who was in an automobile accident 3 months
ago. He complains of neck pain and brags about the pending insurance settlement. The nurse suspects that the
client is:
1. Malingering
2. Suffering from conversion reaction
3. Exhibiting somatization disorder
4. A hypochondriac
Rationale
(1) Integrated processes: nursing process — planning; client need: psychosocial integrity; content area:
psychiatric.
RATIONALE
(1) Because the client is complaining of neck pain and bragging about an insurance settlement, the nurse suspects
he is feigning pain. (2) Conversion is a defense mechanism operating unconsciously The client clearly states his
motive. (3) Somatization disorder applies to clients who have sought medical attention for recurrent and multiple
somatic complaints. (4) Hypochondriasis is characterized by constantly worrying about health or fear of having
some disease.
77
QID: 7464 C22 (352-372 h 338-343) A 58-year-old client is admitted to the psychiatric unit. During the nursing
assessment, the client states, “My mother just walked by the window and I saw her go into the nurse’s station.” This
behavior is an example of:
1. Hallucinations
2. Fantasies
3. Delusions
4. Derealization
Rationale
RATIONALE
(1) A hallucination is a false sensory perception in the absence of an actual external stimulus. (2) Fantasies are a defense
mechanism used in an attempt to resolve an emotional conflict. (3) A delusion is a false belief based on incorrect
inference about external reality even with evidence to the contrary. (4) Derealization is a perception that the immediate
environment is suddenly strange.
QID: 7465 C 22(352-372 h 338-343) In caring for 39-year-old client who acknowledges noncompliance and
demonstrates bizarre behaviors, neologism, and thought insertion, the nurse should:
1. Convey acceptance of the client.
2. Spend time focusing on thought insertion.
3. Ignore the behaviors.
4. Assist with identification of target symptoms.
Rationale
psychiatric.
RATIONALE
(1) Conveying acceptance shows that the nurse is willing to meet the client’s needs. (2) Thought insertion is only one
symptom that contributes to the client’s behavior. (3) Ignoring the behaviors may create a nontherapeutic relationship
because it does not convey acceptance. (4) Before attempting to probe for the target symptoms, the client should show
improvement in the disease process.
QID: 7466 C 27(491-492 h 351-352) How does a nurse develop a culturally appropriate care plan for an older person?
1. By listening to the family’s perception of the client’s problem.
2. By allowing family members time to discuss their perception of the client’s problem.
3. By acknowledging the older person’s viewpoint.
4. By recommending a treatment plan based on the physician’s recommendation.
Rationale
(3) Integrated processes: nursing process - implementation, communication and documentation: client need: safe,
effective care environment; coordinated care; content area: psychiatric nursing.
RATIONALE
(1) The nurse should listen with understanding to the older person’s own perception of the problem, not the family’s (2)
The nurse needs to explain his or her own perception of the problem. (3) The nurse should acknowledge and discuss the
differences and similarities between the older persons and the nurse’s viewpoint. (4) The nurse should recommend a
treatment plan within the constraints of his or her own ideas and those of the client
QID: 7467 C 33(635-347 h 348-350) The psychosocial climate which the pediatric nurse should try to establish when
dealing with suspected family violence is:
1. Judgmental attitude
78
2. Disgust and avoidance
3. Supportive treatment
4. Punitive
Rationale
psychiatric.
RATIONALE
(1) Being judgmental is nontherapeutic in dealing with suspected family violence. (2) Disgust and avoidance is
nontherapeutic in dealing with suspected family violence (3) Creating a supportive environment is important in dealing
with suspected family violence. (4) Punitive treatment is nontherapeutic in dealing with suspected family violence.
QID: 7468 C 19(280-284 h 320) A 53-year-old client with arthritis is having difficulty sleeping because of anxiety. The
most appropriate activity to promote sleep is:
1. Administer a tranquilizer
2. Administer a sleeping pill
3. Help the client to explore feelings
4. Provide a snack with warm milk
Rationale
RATIONALE
(1) This intervention does not help the client to understand the anxiety (2) This intervention does not help the client to
understand the anxiety (3) The most appropriate initial intervention is to help the client to understand the anxiety (4) This
activity may help the client to sleep, but it does not help the client to understand the anxiety
QID: 7469 C11 (143-147 h 315-317) Which of the following communication techniques would be most effective for the
nurse during a nurse-client interaction?
1. Facilitative
2. Nonverbal
3. Public
4. Intrapersonal
Rationale
psychiatric.
RATIONALE
(1) Facilitative communication moves beyond social chitchat and into an interpersonal relationship. Interpersonal
communication plays a major role in psychiatric nursing. (2) Nonverbal communication does not include the spoken
word. However, it may influence the outcome of the interaction. (3) Public communication occurs when speaking to a
group. (4) Intrapersonal communication occurs when persons communicate between themselves.
QID: 7470 C 11(143-147 h 315-317) The nurse enters the room of a 50-year-old client, who is lying in a fetal position
with his head covered, and says, “How are you feeling this morning?” the client responds, “I’m feeling fine.” The
behavior exhibited by the client is:
1. Assertive
2. Aggressive
3. Passive
4. Passive-aggressive
79
Rationale
psychiatric.
RATIONALE
(1) Assertive behavior is an accurate statement about feelings, beliefs, and opinions. It is stated in a manner that
promotes self-respect and respects others. (2) Aggressive behavior is inconsiderate, offensive, and violates the basic
rights of others.
(3) Passive behavior is a response that discounts one own rights in order to avoid conflict. (4) Passive-aggressive
behavior is expressed through sarcasm, resistance, manipulation, procrastination, and the use of covert aggression instead
of words
QID: 7471 C 18(263-265 h 315-317) Accurate and complete documentation in a client’s record in mental health
facilities:
1. Should reflect the nursing process.
2. Should be available to all hospital personnel.
3. Make it an illegal document.
4. Guarantee pertinent and accurate information.
Rationale
(1) Integrated processes: nursing process — implementation, communication and documentation; client need:
psychosocial integrity; content area: psychiatric.
RATIONALE
(1) Documentation related to delivery of care must reflect the use of the nursing process. (2) Information in a client
record is confidential and available to authorized personnel only. (3) The client’s record is a legal document. (4)
There is no guarantee that documentation is pertinent or accurate,
QID: 7472 C 22(357-358 h 338) An 18-year-old newly diagnosed schizophrenic client exhibits withdrawn, regressive,
and isolative behaviors. The nurse’s initial approach should be to:
1. Speak in realistic, literal terms.
2. Use self-disclosure.
3. Demand information.
4. Explain in depth the rules and regulations.
Category:
Rationale
psychiatric.
RATIONALE
(1) When addressing a client with schizophrenic disorder, use realistic and concrete terms. (2) The use of self-disclosure
is inappropriate if the client cannot benefit from it. (3) Demanding information is a barrier to communication. (4) It is
important to keep the conversation simple until the client has a better understanding of his disease process.
QID: 7473 C 22(364-368 h 341-343) A client receives haloperidol (Halclol) 5mg t.i.d. Several days later, the nurse
notices that she is walking stifflywith a shuffling gait. What is the priority nursing action at this time?
1. Take her blood pressure before her next dose.
2. Withhold the Haldol until the manifestation disappears.
3. Chart observations on the client’s record.
4. Obtain an order for an antiparkinsonian drug.
80
Rationale
1. No, this is not a necessary intervention. This would be correct if the client were experiencing postural hypotension. It
is not the correct option for the manifestation of a shuffling gait. Select another option.
2. No, this is not necessary. This option only would be appropriate for unusually severe extrapyramidat side effects.
There is a better option.
3. Wrong choice. The nurse should chart observations, but this is not the priority action. Try again.
4. Correct. The client is experiencing parkinsonian side effects to the Haldol. The nurse should obtain an order from the
psychiatrist for an antiparkinsonian drug to counter these side effects.
QID: 7474 C19 (285-287 h 321-322) A nurse working with a client with agoraphobia recognizes that the most effective
technique for treatment of agoraphobia is:
I. Repeated exposure to situations that she fears.
2. Distraction each time she brings up her problem.
3. Teaching relaxation techniques.
4. Gradual desensitization by controlled exposure to the situation she fears.
Category: psychological integrity
Rationale
1. Wrong. Repeated exposure to situations she fears will create even greater anxiety. This is not the correct option.
2. Wrong choice! Distraction will not assist her to overcome her fear and anxiety.
3. Teaching relaxation techniques is helpful, but there is a better technique to treat agoraphobia.
4. Correct. Desensitization is a type of behavioral therapy. The client is gradually exposed to the feared situation under
controlled conditions and learns to overcome the anxious response.
QID: 7475 C 19(288-289 h 322-323) A 48-year-old man hospitalized for an obsessive-compulsive disorder has recurring
thoughts that he has mouth odors that are offensive to others. He has mouth care rituals that occupy a good deal of his
waking hours and caused him to be fired from his last job. The nurse knows that these manifestations most likely
represent:
1. A method of reducing anxiety.
2. A form of manipulation to avoid work.
3. An attention-getting strategy.
4. A rationalization for avoiding social contact.
Rationale
1. Correct. The ritualized behaviors of a person with an obsessive-compulsive disorder are an attempt to control anxiety.
2. This is not correct. The behavioral rituals performed by a person with an obsessive-compulsive disorder cannot be
controlled, so they cannot be considered attempts to manipulate the environment.
3. This is not correct. Obsessive-compulsive behaviors may draw attention to the individual, but the individual is most
often embarrassed about them and will go to great lengths to conceal the rituals from others.
4. No, persons with obsessive-compulsive behaviors are compelled to perform their rituals and usually derive no pleasure
from carrying them out. Try again.
Correct; 1
QID: 7476 C19 (288-289 h 321-322) A client explains that, for the past 10 years, she has been unable to leave her house
without her husband or daughter. If she tries to go out alone, she becomes very anxious and must quickly return inside.
The nurse interviewing her identifies the probable cause as:
1. Conversion disorder.
2. Agoraphobia.
3. Panic disorder.
4. Obsessive-compulsive disorder.
81
Rationale
I. This is not the correct choice. Conversion disorder is an anxiety disorder in which the client has the physical
manifestations suggesting a medical problem (such as blindness or paralysis) but far which no organic pathology can be
diagnosed.
2. Correct. Agoraphobia is the fear and subsequent avoidance of places or situations from which escape might be
difficult. The most common form of this disorder is avoiding open public places, such as shopping malls, and fear of
leaving one’s home.
3. This is not the correct answer. Panic disorder is characterized by recurrent panic attacks that are not associated with
any specific stimulus or situation, but seem to occur spontaneously.
4. No. Obsessive-compulsive disorders are characterized by recurrent obsessional thoughts and/or ritualized behaviors.
QID: 7477 C 22(364-368 h 341-343) The nurse, in caring for psychiatric clients, knows that tardive dyskinesia:
1. Is a movement disorder caused by antipsychotic drugs.
2. Occurs within the first few days of treatment in most clients.
3. Improves rapidly if the offending drug is discontinued.
4. Is treated with antiparkinsonan drugs.
Category: physiological integrity; pharmacological adaptation
Rationale
1. Correct! Tardive dyskinesia is a serious movement disorder caused by treatment with certain antipsychotic drugs.
2. Wrong. Most clients with tardive dyskinesia develop the condition after taking antipsychotics for many years. It rarely
occurs shortly after beginning antipsychotic drug therapy.
3. Tardive dyskinesia occurs because antipsychotics block the transmission of dopamine in the basal ganglia. When the
dosage of antipsychotic medication is reduced, or the drug is discontinued, dopamine is again released and floods the
neurons, which demonstrate a supersensitivity to its presence. Try again.
4. Not correct. There currently is no treatment for tardive dyskinesia.
QID: 7478 C 15(206-211 h 317) A client attends group therapy daily. The nurse understands that the most important
benefit of group therapy is to:
1. Provide the opportunity to develop social skills.
2. Improve the client’s orientation to reality.
3. Gain support and encouragement from other persons.
4. Develop greater insight into herself and her problems through the feedback provided by the other members.
Rationale
1. Although clients in group therapy do develop better social skills, this is not the primary focus of the treatment. This is
not the correct option.
2. Depressed persons have a negative view of themselves and their situations, and same depressed persons have
delusions. Group therapy, however, is not a technique for reality orientation. This is not the correct option.
3. This is incorrect because this is not the most important benefit of group therapy. Be sure to read all the options before
selecting the one that is the best!
4. Correct. Group therapy provides benefits that occur through the feedback and validation of the other members.
QID: 7479 C 17(252-258 h 357-358) In providing care to a client who is receiving ECT, the nurse knows that this
treatment:
1. Usually requires 10 days to three weeks before depression is noticeably improved.
2. Results in a high incidence of chronic memory problems.
3. Is effective for 60% of persons who receive it.
4. Is used for persons who have not responded to antidepressants.
Category: physiological integrity physiological adaptation
Rationale
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1. This is incorrect. ECT has a significantly more rapid onset of action than antidepressants and may be used for very
severely depressed persons who are also highly suicidal.
2. This is incorrect. The side effects of ECT are transient and may include short-term memory loss. It rarely causes
chronic memory problems.
3. Incorrect statement. ECT is effective treatment for more than 80% of depressed persons who receive it. It does,
however, tend to be associated with a high relapse rate.
4. Correct. ECT is not the first choice of treatment for most depressed persons. It is used for individuals who have not
responded to antidepressants or who have had adverse reactions to these drugs.
QID: 7480 C 21(338 h 357-358) A client, 34, is admitted for the third time to a psychiatric hospital with a diagnosis of
schizophrenia. The police found her wandering along the highway. When questioned, she was unable to give coherent
answers. During the admission procedure, the nurse notices that her appearance is unkempt and she appears to be
actively hallucinating. The initial nursing assessment is:
1. Her mental status.
2. Her ability to follow directions.
3. Her perception of reality
4. Her physical health needs.
Rationale
1. Wrong! This is important, but it is not the highest initial priority.
2. No. Although this is an important part of the assessment of her mental status, it is not the highest initial priority.
3. Wrong choice. Her perception of reality is important for setting realistic goals and determining safety needs, but it is
not the initial priority.
4. Correct. The client’s problems may be due to a physical illness or injury, or to fluid and electrolyte imbalance.
Assessing her physical health needs should be the initial priority for the nurse.
QID: 7481 C21 (338 h 357-358) In caring for a client with schizophrenic disorder who is receiving an antipsychotic
medication, the nurse knows that which of the following statements about the “dopamine hypothesis” is inaccurate?
1. Most antipsychotic drugs block the effects of dopamine and receptor sites in the brain.
2. Amphetamine enhances dopamine activity in the brain and can cause a psychotic response that is indistinguishable
from paranoid schizophrenia.
3. The potency of antipsychotic drugs seems to be related to their antidopamine action.
4. Schizophrenic clients excrete excessive amounts of dopamine in their urine.
Category: physiological integrity; pharmacological adaptation
Rationale
1. Wrong choice. This is an accurate statement. This negative response stem is asking for an option that is
INACCURATE.
2. Wrong choice. This is an accurate statement. This negative response stem is asking for an option that is
INACCURATE.
3. Wrong choice. This is an accurate statement. The antidopamine action has been used to develop newer antipsychotic
drugs. Remember, this question has a negative response stem and is asking for an option that is INACCURATE.
4. Correct. Schizophrenic clients do not excrete excessive amounts of dopamine in their urine. The dopamine hypothesis
refers to the theory that an excess of brain dopamine may be the cause of schizophrenia.
QID: 7482 C 11(143-147 h 315-317) When the nurse is making morning rounds, a client says, “I almost died last night.”
The most therapeutic nursing response is:
1. “You made it through the night.”
2. “Patients do have dreams that they die when they are hospitalized.”
3. “Are you feeling okay now?”
4. “That must have been frightening for you. Tell me more about it.”
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Category: psychosocial integrity
Rationale
1. Wrong! At best, this response may appear to be reassuring, but in fact it does not place any value on the client’s
concerns or feelings. At worst, it appears to make light of what might have been a serious situation! Therapeutic
responses focus on the client’s feelings and promote further communication with the nurse. This is not therapeutic.
2. No. This response focuses on inappropriate persons (“patients” in general). It is a generalization that offers false
assurance and actually contradicts the client, since he did not state that he had a dream. The nurse needs to validate and
clarify the client’s concerns.
3. This is not the most therapeutic response. The nurse may appear to be addressing the “here and now,” but this simple
“yes/no” question does not address the clients concern and thus does not encourage communication. The client might
even infer that the nurse thinks his concern about dying is not’ valid if he is “okay” now Although the client should be
assessed for his present status, his comment to the nurse indicates that he is concerned most about “almost dying.” The
nurse’s response should address that concern.
4. Excellent choice! This response directly addresses the concern of the client. The nurse uses the communication tool of
empathy in responding to this client’s concerns and encourages further communication with the client about them.
QID: 7483 C 11(143-147 h 315-317) The nursing assistant says to the nurse, “This client is incontinent of stool three or
four times a day. I get angry when I think that he is doing it just to get attention. I think adult diapers should be used for
him.” How should the nurse initially respond to the nursing assistant?
1. “You probably are right. Soiling the bed is one way of getting attention from the nursing staff.”
2. “Changing his bed and cleaning him must be tiresome for you. Next time it happens, I’ll help you.”
3. “It’s upsetting to see an adult regress.”
4. “Why don’t you spend more time with him if you think that he is behaving this way to get more attention?”
Rationale
1. This response is not therapeutic because it does not address the nursing assistant’s feelings and does not encourage
expression of feelings. The communication block of showing approval can be identified by the phrase, “you probably are
right.”
2. This response shows empathy on the part of the nurse, but does not encourage any further expression of feelings. The
nurse needs to obtain more information about the nursing assistant’s statement concerning the client’s soiling the bed
purposely in order to provide therapeutic communication.
3. Excellent! This response encourages further communication with the nursing assistant because it is empathetic and
offers a possible explanation of the client’s behavior. This response is therapeutic for the nursing assistant who is the
client in this question.
4. No, this is not therapeutic. The nursing assistant is the client in this question. This response begins with a non-
therapeutic “why” question and does not address the feelings of the client. It also gives advice, which blocks
communication. Finally, it fails to address the client’s feelings.
QID: 7484 C 7(76-78 h 315-317 ) A hospitalized client has just found out that her mother has died of a heart attack. She
is crying and has her face buried in the pillow. The most appropriate nursing response is to:
1. Return in 15 minutes to see how the client is doing.
2. Sit with the client for a little while.
3. Tell the client that she will feel better in the morning.
4. Share with the client that you lost your mother within the last year and that you know how she feels.
Rationale
1. No! This response does not promote therapeutic communication for the “here and now” of this question. By leaving,
the nurse indicates to the client an unwillingness to stay with her during this stressful time. If the client wanted to
communicate, there wouldn’t be anyone to listen.
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2. Very good! The nurse lets the client know that she is important by providing time for her. Being silent is a
communication tool that is appropriate during times of grieving. This response also addresses the “here and now” in this
question.
3. This response devalues the client’s feelings and puts them on hold. This response does not encourage therapeutic
communication. It also offers false assurance, since the client may not feel better in the morning.
4. This response focuses on an inappropriate person (the nurse). This response inhibits communication since it implies
that there is no need for the client to express her own feelings. There also is an assumption by the nurse that grieving is
the same for everyone. This response is not therapeutic for the client.
QID: 7485 C 11(143-147 h 315-317) An elderly client is constantly putting her call light on. When the nurse answers the
light, the client does not appear to need anything. Which action by the nurse is least appropriate?
1. Ask the members of the family if they can spend more time with the client.
2. Remove the call light from easy reach of the client.
3. Make frequent visits to the client’s room.
4. Spend more time in the client’s room while charting.
Rationale
1. Wrong choice! This action is appropriate. Family members are often willing to help in caring for a client if they are
asked or given some direction. You are looking for an INAPPROPRIATE action.
2. Correct answer! The call light should NEVER be taken from a client! The client could fall trying to reach for the call
light or attempting to get out of bed in order to get someone’s attention. This action does not provide for the client’s
safety.
3. Wrong choice! This action is most appropriate. Frequently stopping by the client’s room provides the client with some
reassurance that someone is available to assist if needed. Many times clients feel alone and isolated, and use the call bell
to get attention. You are looking for an INAPPROPRIATE action.
4. Wrong choice! This action would be quite appropriate. To help alleviate the client’s feelings of isolation, the caregiver
can perform tasks such as charting while sitting in a chair in the client’s room, rather than at the nurses’ station. You are
looking for an INAPPROPRIATE action.
QID: 7486 C 27(491-492 h 351-352) A client is confused and disoriented when admitted to the hospital. The doctor has
ordered bed rest. Before leaving the client’s room, the most important nursing action to provide for the client’s safety is:
1. Placing all of the client’s belongings in a safe place.
2. Placing the bed in the highest position with the side rails up.
3. Placing the bed in the lowest position with the side rails up.
4. Explaining where everything is in the room.
Rationale
1. This action is appropriate, but it is not the most important action in providing for the client’s safety. Be sure to read all
the options before selecting the best one!
2. No! Placing the bed in the highest position puts the client at risk for falling.
3. Good work! This option provides for the client’s safety by reducing the risk of falling.
4. No, the client is confused and disoriented, and may not understand explanations. Try again.
QID: 7487 C 33(637 h 348-350) In which of the following cases would the nurse suspect physical abuse?
1. A three-year-old female with 15% burns in a splash pattem over the face and chest, reportedly sustained when she
pulled on the tablecloth and a teapot fell, spilling over her.
2. A 4-month-old male with many bruises on bony prominences, in various stages of healing. The child is reportedly
clumsy.
3. A six-year-old with a spiral fracture of the tibia and fibula that reportedly occurred while riding his bicycle.
4. A nine-month-old near drowning who reportedly climbed into the tub and turned on the water.
85
Rationale
I. This is not a likely abuse case, because the history is consistent with the injury. Toddlers frequently help themselves up
by pulling on objects that may be unstable. The splash of bums would occur from head downward.
2. This is not a likely abuse case. Toddlers have recently mastered walking and do have many falls and collisions. Since
the bruises are in various stages of healing and over bony prominences, this indicates falling on several occasions.
3. This is not a likely abuse case. Spiral fractures can be caused by physical abuse, but this six-year-old child is just
mastering the riding of a bicycle. This injury is consistent with having a foot caught in the spokes of the bike, which
would cause the twisting and fracture.
4. Good work! Maybe a nine-month-old could climb into the tub, but turn the water on? This should definitely be
followed up. There seems to be a real discrepancy between the story and the expected developmental capability of the
infant.
QID: 7488 C 11(143-147 h 315-317) The nurse is preparing a seven-year-old female for hospitalization. The child had a
previous hospital experience. To best prepare this child, the nurse would:
1. Suggest role playing and provide materials.
2. Remind the child of the experience of her past hospitalization.
3. Read her a story about another child having a similar operation.
4. Tell her she is only going in to have her throat checked.
Rationale
1. Yes, concrete experiences are the most meaningful learning for a school-aged child. This is the rationale for pediatric
orientation programs. Even if there is inadequate time for her to participate in such a program, a shortened version where
she could practice with a mask and other equipment in a non-threatening environment would be helpful.
2. Not the best choice! Be careful! Past experiences may not have been positive, and may even have been traumatic.
3. No, this isn’t the best response. This is somewhat abstract, and abstract thinking is not highly developed in the seven-
year-old child. Think about how you learned what an operation was really like for a client.
4. Wrong! Never lie to a child. This is inappropriate under any circumstances.
QID: 7489 C21 (342-343 h 333-334) A registered nurse, who has previously been treated for an addiction to
hydromorphone (Dilaudid), is being treated on the psychiatric unit for anxiety and associated somatic manifestations.
The psychiatrist orders propranolol (Inderal) for her anxiety. The client recognizes the medication and states, “There
must be some mistake. I don’t have any cardiac problems.” Which statement offers the best nursing response?
1. “This drug was ordered because you have a history of drug abuse and your psychiatrist doesn’t want to prescribe
anything that could lead to physical dependence.”
2. “This drug also has a psychiatric use. It is not only used for cardiac problems.”
3. “There is no mistake. Your psychiatrist ordered lnderal for you. Do you have a history of hypertension?”
4. “Inderal is used to control anxiety in persons like yourself, who have a lot of physical manifestations of anxiety.”
Rationale
1. This is not the best option. The client’s history of drug abuse may be a factor, but it is not the primary reason why
Inderal was ordered. Read all the options before selecting the best one!
2. This is a true statement, but it is not the best response to the client’s comments. The nurse can give her a better
explanation. Try again and read all the options before selecting the best one!
3. This is not correct. Inderal is used to treat hypertension, but this is not the reason it was prescribed for the client.
Select the option that correctly addresses the client’s question.
4. Correct. Somatic manifestations of anxiety, like the client’s, are often treated effectively with the beta-blockers. Her
history of narcotic abuse probably also was a factor in her psychiatrist’s decision to prescribe Inderal because it is not
associated with physical dependence. This is the best option, because it is the most accurate response to the client’s
question.
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QID: 7490 C 27(491-492 h 351-352) A confused elderly client is on strict bedrest. Which nursing intervention will
provide for this client’s safety?
1. Place the client in a room away from the noise and confusion of the nurses’ station.
2. Avoid the use of nightlights, since they tend to distort images and confuse clients.
3. Discuss with the client the need for restraints if she continues to get out of bed.
4. Provide opportunities for regular toileting, and include this information in the client’s care plan.
Rationale
1. This is an inappropriate nursing action. Any client who is confused should be placed in a room near the nursing station
—not away from it. Try again!
2. This is inappropriate. A nightlight is generally used for confused clients, because it decreases image distortion and
enhances reality. Also, the use of a nightlight helps orient clients to the hospital environment.
3. This option is a good distractor, because it implies that by talking to the client, the nurse may be able to lessen her
confusion. Wrong! If the client is confused, then the issue of safety requires that the nurse should focus on how to adapt
the client’s environment to decrease the risk of accidents.
4. Excellent! This client is confused, which means there is a high safety risk due to decreased ability to perceive danger.
Providing opportunities for regular toileting helps ensure that the client’s basic needs for elimination will be met, and
will greatly reduce the risk of the client’s falling while trying to get up and go to the bathroom without the assistance of
the nurse. This nursing action provides for the comfort and safety of the client, and it should be recorded in the plan of
care.
QID: 7491 C 33(635-647 h 348-350) The nurse should avoid reporting which of the following events to a government
agency?
1. Births.
2. Child abuse.
3. Marital quarrels.
4. Typhoid fever.
Rationale
1. This is not correct. Births are required to be reported. The nurse should follow the institution’s procedures.
2. This is not correct. Child abuse must be reported, and the nurse should follow the institution’s procedures.
3. Very good! Marital quarrels are not subject to reporting requirements. This client data is protected by the client’s right
to privacy.
4. Typhoid fever, a communicable disease, must be reported.
QID: 7492 C 5(59-60 h 14-16) The nurse understands that which of the following is outside the scope of a client’s right
of privacy:
1. Not having a gunshot wound reported, upon timely request.
2. Refusing to receive visitors.
3. Wearing one’s own clothing.
4. Requesting the presence of a member of the same sex during a physical examination.
Rationale
1. Good work! Gunshot wounds must be reported. The nurse should follow the institution’s procedures.
2. Wrong choice. Clients have the right to maintain privacy by choosing their company, and they may choose not to
receive visitors. You are looking for something that is NOT a privacy right of the client.
3. Wrong choice. The client has the right to wear personal clothing unless it interferes with medical procedures. An
example of a situation where personal clothing would interfere is surgery. You are looking for something that is NOT a
privacy right of the client.
87
4. Wrong choice. The client does have this right, and such a request should be respected by the nurse. You are looking
for something that is NOT a privacy right of the client.
QID: 7493 C 33(637 h 348-350) The home health nurse notes several suspicious bruises and old burns on a 10-month-
old child while making an initial home visit. The priority nursing action to provide for the child’s safety is:
1. Call the child protection hotline and report possible abuse.
2. Discuss the family with the physician and social worker at the next team meeting.
3. Tell the mother that child protection will be notified if injuries are noted on the next visit.
4. Carefully record the visit for follow-up.
Rationale
1. Absolutely correct! As a mandated reporter the nurse is obligated to report any cases of suspected abuse. The reporter
does not need to prove the case, just report the facts known. This is the law. This is also the first action to take in
providing for the child’s safety.
2. No! The nurse could be considered negligent according to the laws of the state within which the nurse practices,
because this is too long a delay before possible action that could protect the child.
3. No, this action will drive the family underground and will not help you develop a therapeutic relationship with the
mother. She is likely not to be at home the next time you visit. Choose again.
4. No, you didn’t do anything that will either stop the abuse or initiate an immediate investigation. Hint:
What does “mandated reporter” mean?
QID: 7494 C 16(228 h 337) In caring for an elderly psychiatric client who is severely depressed, the nurse knows that
elderly clients:
1. Cannot be safely treated with tricyclic antidepressants.
2. Require lower doses of antidepressants than younger clients.
3. Respond more quickly to the therapeutic effects of antidepressants than younger clients.
4. Can be treated safely and effectively with all antidepressants.
Rationale
1. Wrong choice. A careful assessment must be done to rule out clients with cardiac problems or glaucoma. An elderly
client who does not have these medical problems can safely be treated with antidepressants, especially those that have a
lower incidence of anticholinergic side effects.
2. Correct. Elderly clients are treated with lower doses because of their increased sensitivity to the anticholinergic and
cardiovascular side effects.
3. Incorrect. Response rates can take up to three or four weeks for all clients, regardless of age.
4. This is not the correct choice. It is best to avoid treating elderly clients with certain anti depressants that have a higher
incidence of anticholinergic or orthostatic hypotensive side effects.
QID: 7495 C 25(428-462 h 344-347) An unconscious 18-year-old man is brought to the emergency room with heroine
overdose. After the client regains consciousness, he is transferred to the substance abuse treatment unit. The signs and
manifestations of heroin withdrawal are written in the nursing care plan. Which behavior should the nurse anticipate will
occur early in the withdrawal process?
1. Vomiting and diarrhea.
2. Sneezing and rhinorrhea.
3. Restlessness and irritability.
4. Yawning and diaphoresis.
Category: physiologic integrity physiologic adaptation
Rationale
1. This is not correct. Vomiting and diarrhea are usually late, rather than early, signs of heroin withdrawal.
2. This is not correct. Sneezing and rhinorrhea are usually late, rather than early, signs of heroin withdrawaL
88
3. Correct. Restlessness, irritability, piloerection (gooseflesh), tremors, and loss of appetite are all early signs of heroin
withdrawal
4. This is not correct. Yawning and diaphoresis are usually late, rather than early, signs of heroin withdrawal.
QID: 7496 C 25(428-462 h 344-347) In caring for a client being treated for withdrawal syndrome, the nurse knows that
many drugs are associated with a life-threatening abstinence syndrome. However, this is not true for all addictive drugs.
Which of the following drug groups is least likely to present a medical crisis during withdrawal?
1. Narcotics.
2. Barbiturates.
3. Alcohol.
4. Benzodiazepines.
Rationale
1. Very good! The abstinence syndrome following narcotic abuse is uncomfortable but is not life-threatening.
2. This is not correct. The abstinence syndrome associated with barbiturate abuse can involve seizures and lead to death.
3. This is not correct. Alcohol withdrawal can involve seizures and lead to death if not medically managed.
4. This is not correct. The abstinence syndrome associated with the prolonged use of benzodiazepine anti-anxiety agents
can involve seizures and lead to death.
QID: 7497 C 25(428-462 h 344-347) A high school student speaks to the school nurse about a friend who is abusing
cocaine. He wants to know the best way to influence his friend to stop. The nurse’s response is based on what knowledge
about cocaine?
1. Cocaine use rarely interferes with academic or career activities.
2. Cocaine abuse is difficult to treat because of its abstinence syndrome.
3. Cocaine does more psychological harm than physical damage.
4. Cocaine use is highly reinforcing.
Rationale
1. This is not correct. Cocaine use is frequently associated with family, financial, academic, and career disruptions
2. This is not the best option. Cocaine abuse results in a powerful psychological dependence. Repeated abuse is
associated with an abstinence syndrome of fatigue, depression, prolonged sleep and increased appetite with overeating.
This abstinence syndrome is unpleasant but not life-threatening unless the depression becomes suicidal.
3. This is not correct. Medical complications of cocaine use include severe weight loss, hepatitis, cerebrovascular stroke,
and cardiac arrest.
4. Correct. Because of cocaine’s effects on the neurotransmitters that regulate mood and other psychological processes, it
is highly reinforcing of self-administration. Cocaine abuse is very difficult to treat. Some abusers are treated successfully
as outpatients, but many require inpatient treatment programs.
QID: 7498 C 25(428-462 h 344-347) In caring for alcoholic clients, the nurse knows that the category of drugs
commonly used to manage alcohol - withdrawal is:
1. Antipsychotic drugs.
2. Barbiturates.
3. Anti-anxiety agents.
4. Anticonvulsants.
Rationale
I. This is not correct. Antipsychotics are used to treat psychotic manifestations. They are not used to manage alcohol
withdrawal.
2. This is not correct. Barbiturates are potent central nervous system depressants. They are not used during alcohol
withdrawal.
89
3. Correct. Anti-anxiety agents, such as chlordiazepoxide (Librium) and diazepam (Valium), are long acting central
nervous system depressants that are used to treat alcohol withdrawal. They are substituted for alcohol during the
withdrawal process to prevent the occurrence of delirium tremens and to minimize withdrawal manifestations.
4. This is not correct. Magnesium sulfate or other anticonvulsants may be used to prevent seizures during detoxification
in clients with a history of seizures. Anticonvulsants, however, are not commonly used in alcohol withdrawal for clients
who do not have a history of seizures.
QID: 7499 C 25(428-462 h 344-347) After detoxification, the client begins the rehabilitation phase of treatment. He tells
the nurse that he cannot imagine living his life without alcohol. The nurse’s best response is based on the knowledge that
the client will:
1. Be more successful if he focuses on goals for short periods of time, such as “today” or “this week.”
2. Likely drink again when under stress.
3. Not be successful if he is not strongly motivated.
4. Require treatment with Antabuse to maintain sobriety.
Rationale
1. Correct. Clients are less overwhelmed by the thought of sobriety when they set short-term goals that focus on “today”
or “this week.” Dealing with shorter periods of time is more manageable. The AA maxim, “One day at a time,” is a
reflection of this principle.
2. This could be true, but it is not the best option because it would not be the basis for a helpful response for this client.
3. Motivation is important but the statement by the client does not indicate a lack of motivation. Moreover, motivation
alone is not sufficient to maintain sobriety. The client must also develop the skills to maintain sobriety. Can you identify
the basis for a therapeutic response that addresses the client’s concerns?
4. Wrong! Ant abuse is used for individuals who lack cause contamination of the lacrimal duct and possibly the other eye
the ability to abstain from alcohol without fear of adverse consequences. There is no data to indicate that this client
requires Antabuse, since he is just beginning his rehabilitation program.
QID: 7500 C25 (428-462 h 344-347) An unconscious 18-year-old man is brought to the emergency room by two
friends, who report he took an overdose of heroin. Anarcotic antagonist, naloxone (Narcan) is administered. After giving
the medication, the nurse should monitor this client closely for signs of:
1. Respiratory depression.
2. Seizure activity.
3. Nausea.
4. Kidney failure.
Rationale
1. Congratulations! Narcan displaces the opioid from the receptor sites in neurons and dramatically reverses the effects
of the drug overdose. The client must still be monitored closely, however, because Narcan has a short duration of action
and its effect may wear off before the overdosed drug has been sufficiently eliminated. If the client returns to a coma,
naloxone must be given again.
2. This is not correct. Seizure activity is not associated with either heroin overdose or the use of Narcan.
3. This is not correct. Nausea is not associated with either heroin overdose or the use of Narcan. Nausea, however, is one
of the late developing manifestations of heroin withdrawal.
4. This is not correct. Kidney failure is not associated with either heroin overdose or the use of Narcan.
QID: 7501 C 17(252-258 h 316-317) A client’s husband asks to speak to the nurse about what effects he and his wife
should expect after she is treated with electroconvulsive therapy (ECT). He says, “I know it will improve her depression,
but couldn’t it also turn her into a vegetable?” After explaining that ECT will not cause any brain damage, what
additional information can the nurse ethically give him?
90
1. “The main side effects are temporary and may include mild confusion, a slight headache, and short-term memory
problems.”
2. “Most clients have no adverse effects to this treatment. In rare cases it has been known to cause fractures resulting
from the induced seizure.”
3. “Some clients with cardiac problems have been known to have a heart attack, but we will monitor her closely to be
certain this does not happen.”
4. “There are no permanent adverse effects associated with this treatment. The only common side effect is short-term
memory problems that last for a few weeks.”
Rationale
1. Correct. The main side effects are mild disorientation and confusion immediately after the treatment, a slight
headache, and short-term memory problems. In formation about the treatment should be presented by the treating
psychiatrist, but the nurse should reinforce this information and answer any questions the client and family may have.
2. Incorrect. There are several possible adverse effects to ECT but fractures is not one of them. Before receiving the
treatment, the client is medicated with a muscle relaxant to prevent any muscle contractions, and resulting fractures,
during the brain seizure.
3. This option is actually incorrect and would be inappropriate to present to a client or family member. Clients receive a
complete medical history and physical exam before being scheduled for ECT In addition, any client with heart disease
should receive a cardiology consultation and clearance before receiving ECT. ECT is not done when a client has a
history of recent myocardial infarction or aneurysm.
4. This option, while technically correct, is not truthful. Whenever general anesthesia is used there is a small risk of
death, Clients need to be accurately informed of both the risks and benefits so they can make an informed decision.
QID: 7502 C 21(338 h 357-358) The nurse admitting a client to the psychiatric unit asks what factors, such as a recent
change in his life, may have contributed to his hospitalization. He replies, “Change….change is money…. when you
have money you make the change.” This statement an example of:
1. Clanging.
2. Echolalia.
3. Perseveration.
4. Flight of ideas.
Rationale
1. Correct. Clanging is speech in which sounds, rather than conceptual relationships, govern word choice. It is most
commonly associated with schizophrenia and mania.
2. Wrong choice! Echolalia is the repetition or “echoing” of the words or phrases of others. This is not the correct option.
3. Wrong. Perseveration is the persistent repetition of words or ideas so that once an individual uses a particular word it
recurs. It is most commonly associated with organic mental disorders or schizophrenia.
4. Sorry. Flight of ideas refers to a nearly continuous flow of accelerated speech with abrupt changes from topic to topic
before the original topic is completed. It is most frequently associated with manic episodes but is also seen in other
conditions.
QID: 7503 C 21(343 h 337) The nurse is to instruct a client to recognize beginning signs of lithium toxicity, which
include:
1. Nystagmus, irregular tremor, decreased urine output
2. Tinnitus, blurred vision, slurred speech.
3. Incoordination, muscle twitching, severe diarrhea.
4. Mild ataxia, coarse hand tremors, difficulty concentrating.
Rationale
91
1. These are signs of severe lithium intoxication. The key word in this question is “beginning. “Read the options again,
and identify the signs of beginning intoxication.
2. These are signs of moderate lithium intoxication. The key word in this question is “beginning.” Read the options
again, and identify the signs of beginning intoxication.
3. These are signs of moderate lithium intoxication. The key word in this question is “beginning.” Read the options
again, and identify the signs of beginning intoxication.
4. Very good! If these manifestations occur, the client should stop the medication and call his or her psychiatrist
immediately. The client should also call the psychiatrist if vomiting, diarrhea, tinnitus, blurred vision, nystagmus,
decreased urine output, seizures, or irregular pulse the manifestations of moderate or severe lithium toxicity occur.
Lithium toxicity can lead to cardiac arrest and death.
QID: 7504 C 25(428-462 h 344-347) A newly admitted client in the alcoholic treatment unit tells the nurse he has not
had anything to drink for 24 hours prior to admission. He complains of feeling anxious and shaky Based on the nurse’s
knowledge of alcohol withdrawal, what other behaviors could the nurse expect the client to display during the early
phase of his alcohol withdrawal?
1. Coarse tremors, tachycardia, insomnia.
2. Confusion, visual hallucinations, delusions.
3. Disorientation, confabulation, memory deficits.
4. Incoordination, impaired thinking, irregular eye movements.
Rationale
1. Correct. The earliest signs of alcohol withdrawal are anxiety, anorexia, insomnia, and tremor. Tachycardia of 120-140
beats per minute persists throughout withdrawal. Pulse rates are closely monitored during the withdrawal process to
assess the client’s condition and need for medication.
2. This is not correct. The onset of confusion, visual hallucinations, and delusional activity indicates delirium tremens,
now called alcohol withdrawal delirium, which is a potentially fatal complication of alcohol withdrawal that occurs when
the withdrawal process has not been medically managed. It begins the second or third day after the client’s last drink and
lasts 48 to 72 hours.
3. This is not correct. Disorientation, confabulation and memory deficits are manifestations of alcohol-. amnestic
disorder or Korsakoff’s syndrome. Thiamine deficiency, a physical disorder associated with chronic alcoholism, is
thought to cause this syndrome.
4. This is not correct. Incoordination, impaired thinking, and irregular eye movements are seen in Wernicke ‘s syndrome,
a rare disorder of central nervous system metabolism associated with thiamine deficiency and seen chiefly in chronic
alcoholics.
QID: 7505 C11 (143-147 h 315-317) A client is in the hospital because of severe weight loss and refusal to eat. The
physician ordered the insertion of a nasogastric tube for feeding. The nurse finds the client with the tube removed. The
client tells that nurse that he “doesn’t need that thing.” The most appropriate response by the nurse is:
1. “You shouldn’t have done that! Now I have to put it down again.”
2. “Why did you pull that tube out? Do you want to die?”
3. “Tell me what you don’t like about the tube.”
4. “Your doctor is going to be very upset with you for doing this.”
Rationale
1. Wrong! This response indicates that the nurse is inconvenienced by the client’s actions. Furthermore, “You shouldn’t
have done that!” is a judgmental statement, which is non-therapeutic. This is not an appropriate response.
2. This response is judgmental because it implies that the client did something wrong. It may also imply that he did it
because he wants to die, and the nurse does not know the client’s reason for his action. The nurse’s response also puts the
client on the defensive by requesting an explanation with a “why” question, which a block to therapeutic communication
is.
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3. Correct. This response allows the client to tell the nurse how he feels about the tube and what it means to him. It
promotes therapeutic communication and doesn’t judge the client’s actions. This response is therapeutic for the client.
4. This response focuses not on the client but on the doctor. It also expresses the opinion of the nurse, which is not
important. The response is judgmental in that it implies that the client did something that is wrong. Therapeutic
communication promotes the expression of the client’s feelings. This option doesn’t promote any communication and is
not therapeutic.
QID: 7506 C21 (352-372 h 338-343) The doctor has ordered restraints for a very agitated client. When applying
restraints to the client, which nursing action is inappropriate?
1. Using the least restrictive type of restraint that will effectively protect the client from injury.
2. Fastening the restraints to the bed frame.
3. Tying the restraint with a knot that cannot be undone easily, in order to prevent the client from untying it.
4. Explaining to the client and family the type of restraint and the reason for applying the restraint.
Rationale
1. No, this action is appropriate. Over-restraining a client can intensify the problems caused by immobility. The question
asks you to identify an action that is INAPPROPRIATE. Try again!
2. Wrong choice, this is a correct nursing action. The bed frame, rather than the side rails should be used to attach the
restraints because the bed frame is more stable. Lowering side rails that have restraints attached can result in injury to the
client. The question asks you to identify an INAPPROPRIATE action. Make another selection.
3. Correct choice, this is something that the nurse should not do! Restraints should be tied with knots that can be undone
easily, in case the client’s well being necessitates removal of the restraints. To protect the client from releasing the
restraints, the knot should be placed where the client cannot reach it.
4. Wrong choice, this is a correct nursing action. Restraints can increase the client’s confusion and cause anger and
hostility in the client and family. Art explanation concerning the client’s safety can help to promote understanding and
cooperation. The question asks you to identify an IIVAFPROPRJATE action. Make another choice.
QID: 7507 C 29(536-539 ) A mother expresses concern about her infant’s lack of eye muscle control at two days of age.
Her neighbor’s daughter is mentally retarded and her eyes cross the same way. What is the nurse’s best reply?
1. “You should probably talk to the doctor about your concerns.”
2. “Newborns all lack the ability to control eye movement until they are three to four months of age.”
3. “I will take the baby back to the nursery and assess other neuromuscular activity.”
4. “It’s nothing to worry about.”
Correct; 2 chapter 29 text pg 536-539 meds 110 hesi
Rationale
1. Wrong! This suggests there could be a problem that the physician needs to know about.
2. Good choice. Lack of eye muscle control is present in all newborns. This mother needs to know this so she will not
think this is abnormal. This response is therapeutic because it addresses the client’s concerns and provides correct
information.
3. No, this statement suggests that the lack of eye muscle control warrants further assessment of the newborn.
4. Wrong. This statement is not therapeutic. It does not reassure the mother that this finding is normal, and it ignores her
fears.
QID: 7508 C 24(406-407) Which activity would the nurse encourage in order to meet the developmental needs of a 12-
month-old hospitalized client?
1. A cradle gym across crib.
2. Push-pull toys
3. Finger paints.
4. A stick horse.
Correct; 2 chapter 24 text pg 406-407 meds 83-84
93
Rationale
I. Incorrect. Although this encourages fine motor skills, you have not matched the age of the client with the activity that
is needed to improve skills. This could also be a safety issue, since the child may be able to stand and could strangle on
the cradle gym. Try again.
2. Great, correct choice! Walking is the skill that is being perfected at this age, and push-pull toys will encourage the
client to walk unaided.
3. Incorrect. Reread the question and think about the skill level of this age child. Try again.
4. Incorrect. This is beyond the ability of the client and could be a safety concern. Make another selection.
QID: 7509 C 12(161 h 337) A hospitalized client is disoriented, confused, and agitated, and is receiving lorazepam
(Ativan). Because the client is receiving Ativan, which nursing action is a priority?
1. Observing the client for early signs of tardive dyskinesia.
2. Warning the client not to drive her automobile or engage in activities that require alertness.
3. Frequently checking the client’s serum level of medication.
4. Monitoring the client closely when she ambulates.
Rationale
1. Wrong. Tardive dyskinesia is an adverse effect of antipsychotics, not Ativan. This is not the correct option.
2. This is not a priority for the client while she is hospitalized. Try again.
3. Serum levels are checked frequently when elderly clients are taking the tricyclic antidepressants and lithium, but this
is not necessary for Ativan. Choose another option.
4. Correct. Elderly clients may become dizzy or ataxic when taking benzodiazepines, like Ativan. They should be
monitored closely when they are out of bed and ambulatory, to prevent falls and possible injuries.
QID: 7510 C 21(343 h 337) A client taking lithium is discharged. After five days, she tells the nurse that she is still
having difficulty with hyperactivity. She asks how long it will take for her lithium to be effective. The best explanation
by the nurse is:
1. “Each person is different. Lithium usually takes one to two weeks to be effective.”
2. “We are monitoring your blood level to see when it is in the therapeutic range. At that point your manifestations
should be controlled.”
3. “You should see an immediate improvement. I will call your psychiatrist so she can increase your dose.”
4. “You will begin to see some improvement when your blood level reaches the therapeutic range but it still may be a
while before your manifestations are controlled.”
Rationale
1. This is a possibility, because it is a true statement but there is a better answer. Read the other options.
2. This is not a true statement. Manifestations only begin to remit after the blood level reaches the therapeutic range. It
can take up to two weeks for the client to achieve maximum effect.
3. This statement is not correct. Lithium dosage is prescribed based on the client’s blood level, not clinical
manifestations.
4. Correct. There is a lag between the time when the lithium level reaches the normal range and the manic episode is
under control. The length of time this takes varies among clients.
QID: 7511 C 17(252-253 h 316-317) After a series of nine ECT treatments, a client reports that his depressive
manifestations are gone. However, he does complain of short-term memory loss. The initial nursing action is to:
1. Report the problem immediately to his psychiatrist.
2. Encourage him to ventilate his feelings about the problem.
3. Explain that this memory loss is only temporary, and his memory will return to normal in four to eight weeks.
94
4. Tell him that this is a side effect of the treatment, and he can expect his memory to return to normal in five to ten days.
Rationale
1. The nurse should chart this manifestation, but it does not need to be reported immediately to the psychiatrist because it
is an expected outcome of the ECT treatments.
2. This action is not incorrect, but it is not the initial nursing action because the client has not been given some important
information about his memory problems.
3. Correct. Research indicates that short-term memory problems are temporary outcomes of ECT treatment. While the
length of time the client has these memory problems differs among individuals, it is a temporary effect that usually does
not last longer than two months.
4. This response is only partially true. Temporary memory problems are a common side effect of ECT The length of time
the client experiences these memory problems differs among individuals but it most often lasts for a longer period of
time than five to 10 days.
QID: 7512 C 17(228 h 337) When caring for elderly clients who are treated with antidepressant medication, the nurse
knows that:
1. They will probably require a higher doses of medication than a younger person.
2. Psychotherapy and medication together are usually more effective than either alone in treating elderly depressed
clients.
3. Antidepressant medications are not usually tolerated well by elderly clients because of their many side effects.
4. Antidepressants are expensive medications, and the potential results may not be worth their cost.
Correct; 2 chapter 17 text 228 meds 99-102 hesi 337
Rationale
1. This is not true. Elderly persons, and other clients with coexisting medical problems, are related with LOWER doses
of antidepressants. ‘
2. Correct. Treatment that includes both psychotherapy and antidepressant medication is usually more effective in
treating elderly clients with clinical depression than either modality is when used alone.
3. Not the correct choice. Elderly clients are more sensitive to the side effects of antidepressants. The elderly also are
more likely to be taking other drugs for medical problems which could lead to drug interactions. Nevertheless, elders can
still be effectively treated with antidepressants when their responses to the drug treatment are monitored closely. Select
again.
4. This is not true. Treatment with antidepressants when combined with psychotherapy, is an effective way to treat
depression in the elderly. With proper treatment, the depressed elderly can helped and can live fulfilling lives.
QID: 7513 C 31(603-622 h 335) Although most depressed clients do not attempt suicide, an estimated 80% of persons
with depression do have suicidal thoughts. In caring for an elderly widower with agitated depression who has trouble
sleeping, the nurse considers that his risk of suicide is:
1. No different than for any other depressed client
2. Lower than that of an elderly man who has never married.
3. Quite low.
4. Extremely high.
Rationale
1. Wrong. An elderly client with agitated depression has a higher risk of suicide than that of most groups of depressed
clients. This is especially true for clients who have persistent insomnia.
2. Wrong. Elderly men who have never married a lower risk of suicide than those who are widowed, separated, or
divorced.
3. Wrong. There are several factors that identify this client as at high risk for suicide. Select the correct option, and
review the rationale.
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4. You are right. Elderly widowers with agitated depression are one of the groups with the highest risk for suicide.
Persistent insomnia in this client is an additional risk factor. The nursing care plan should reflect that this client is at high
risk for suicide.
QID: 7514 C 28(383 h 322-338) A 30-year-old single man who works as a computer analyst is admitted to the hospital
with a diagnosis of bipolar depression, acute manic episode. When taking a nursing history the nurse would identify
which information that would support this diagnosis?
1. He describes himself as a “loner” with a history of being withdrawn and aloof in relationships.
2. His paternal grandfather had mood swings all his life and died in a mental institution.
3. He had a similar episode when in college. He dropped out of school without finishing his degree, and his friends say
he was never the same again.
4. His parents were divorced when he was a young child.
Rationale
I. This is not correct. Most manic clients have had successful relationships and are quite sociable with many
acquaintances. In contrast, schizophrenic clients are more likely to be described as aloof and withdrawn.
2. Correct. Most manic clients come from a family where a close relative also suffered from a unipolar or bipolar
disorder. The theory that genetic factors are involved in the occurrence of manic-depressive illness results from this
observation.
3. Ninety percent of manic clients have periods of normal or near normal behavior between manic episodes. Most clients
do not experience chronic deterioration after an acute episode of illness.
4. There is no evidence that a divorce in the family causes manic illness. This is not the correct option.
QID: 7515 C 21(343 h 337) Before administering lithium, the nurse checks the client’s latest lab report for her serum
lithium level and notes a level of 1.2 mEq/L. What is the best action for the nurse to take next?
1. Administer the next prescribed dose of lithium.
2. Suggest the blood test be repeated.
3. Withhold the next dose of lithium and notify the psychiatrist of the lab results.
4. Ask the client how she is feeling, to identify any untoward effects.
Rationale
I. Although the lithium level is within the therapeutic range, it is at the very top of the range. This action is a possibility,
but it could be unsafe. Read the other options to see if there is a better choice.
2 This action could be appropriate, but it is not the best action for the nurse to take next. Read the other options.
3. This is not correct. The lithium level is still within the normal range, so withholding the lithium is not an appropriate
nursing action.
4. Correct! A lithium level of 1.2 mEq/L is at the top of the therapeutic range. Before the nurse can safely give the next
dose, the client can be assessed for any signs of lithium toxicity. If the client has none, give the medication as prescribed.
QID: 7516 C 21(330-332 h 332-338) When a client’s mother comes to visit, the client does not acknowledge her greeting
and lies down on her bed, curling up into the fetal position. After talking with the client’s mother, the nurse returns to the
client’s room. The client is still lying in a fetal position. What action by the nurse would be most therapeutic at this time?
1. Ask the client to get up and put away the clothing her mother has brought in.
2. Ask the client why she responded to her mother that way.
3. Sit in a chair next to the bed and ask the client to talk about what happened when her mother visited.
4. Explain unit expectations about how visitors are to be treated.
Correct; 3 chapter 21 text pg 330-332 med 98-99 hesi 332-338
Rationale
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1. This is not correct. The nurse is avoiding the client’s response to her mother’s visit by switching the focus to another
task. The nurse is not conveying that she/he is a trustworthy person to help the client with her recovery, because she/he is
not dealing with issues as they come up during the day.
2. This is not correct. The nurse is attempting to gather data in order to do an assessment of what transpired. However,
the client will most likely not be able or willing to respond to a direct question that is phrased in this manner. In asking
“why” questions, the nurse is requiring an explanation, which is characteristic of an authority figure and is not
therapeutic in the nurse-client relationship. “Why” questions may also make the client feel intimidated.
3. Correct. The nurse is being available to talk about the situation that just occurred. The nurse is doing this in a way that
does not put further pressure on the client. If the client is not able to talk about her mother’s visit, the nurse should say
that she/he will stay with her for a few more minutes and they can sit quietly without talking. This further action will
convey that the nurse is willing to accept the client as she is and begin to establish the basis for a therapeutic relationship.
4. This is not correct. In discussing unit rules instead of helping the client deal with her feelings about her mother’s visit,
the nurse is addressing an inappropriate issue. The issue in this question is the client’s response to her mother’s visit.
QID: 7517 C 21(330-332 h 332-338) A depressed client has not bathed or changed her clothes during the two days she
has been on the psychiatric unit. When the nurse suggests that she take a shower, the client states an emphatic “No!” and
turns her back to the nurse. What is the best action for the nurse to take initially?
I. Withdraw and return at a later time.
2. Question the client about her resistance to showering.
3. Get another staff member to help get the client into the shower.
4. Tell her she will be much more acceptable to other people on the unit if she cleans up and changes her clothes.
Rationale
1. Correct. The nurse should withdraw to avoid a power struggle with the client. Later, the nurse can return and offer to
help her gather together the things she will need and gently lead her to the shower. This directive approach does not
require a decision on the part of the client, so she is more likely to cooperate with the nurse.
2. This is not correct. The client’s behavior indicates her anxiety level has increased. She will probably not be able to
explain her resistance to showering.
3. Wrong. If two staff members overpower the client, they will destroy any trust she may have started to develop with the
staff and will further undermining her feelings of self-worth. This is not the correct option.
4. This is not correct. This response would cause harm to the client’s self-esteem and self-worth. Try again.
QID: 7518 C 7(76-78 h 332-338) The nurse is caring for a client who is mourning a recent loss. The nurse understands
that it is inaccurate to state that mourning:
1. Is a normal response to loss.
2. Functions to free the individual from an attachment to the lost object so that future relationships can be established.
3. Is accompanied by a growing realization that the loss has occurred.
4. Occurs only in humans.
Rationale
1. Wrong choice. The process of mourning or grieving is a normal response to a loss. This is a true statement, so it isn’t
the correct option in this question with a negative response stem.
2. Wrong choice. The ultimate goal of mourning is to free the individual from too close an attachment to the lost object
and permits the person to move on and establish new relationships. This is a. true statement, so it isn’t the correct option
in this question with a negative response stem.
3. Wrong choice. The initial phase of the grief process is usually shock and denial. This is followed by a growing
realization that the loss has occurred. This is a true statement, so it isn’t the correct option in this question with a negative
response stem.
4. Good work! This option is NOT a true statement. Mourning occurs in animals other than humans, particularly those
that form individual attachments, such as primates and household pets.
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QID: 7519 C21 (330-332 h 332-338) After her first night in the hospital, a depressed client complains of feeling too tired
to get out of bed in the morning. In planning how to deal with this therapeutically, the nurse is guided by the knowledge
that:
1. Helping to mobilize the client physically will also help to improve her emotional state.
2. Most people do require more rest when they are depressed.
3. It is best to wait until the client indicates that she is ready to participate in structured activities.
4. Encouraging the client to get up and come out on the ward will only increase her feelings of worthlessness and guilt.
Rationale
1. Correct. Mobilizing persons who are depressed helps to convey that it is possible to change, and thus counters feelings
of hopelessness. Also, activity helps shift the client’s preoccupation with self to interests in the outside world.
2. This is not correct. Persons who are depressed lack energy and often sleep excessively, but the sleep and rest are not
restorative, as they would be for the nondepressed person.
3. Depressed persons are reluctant to initiate any activity on their own. This cannot be the correct option.
4. This option is not a true statement! Try another option.
QID: 7520 C 21(330-332 h 332-338) The nurse learns that a depressed client is an expert at crewel embroidery. The
nurse asks the client if she will teach her crewelwork. Which of the following is the best rationale for this nursing
intervention?
1. To assess the client’s ability to communicate clearly.
2. To distract the client from thinking about her problems.
3. To reinforce the client’s identity as a homemaker.
4. To use the client’s strengths to build self-esteem.
Rationale
I Wrong Depression may interfere with a person’s willingness to communicate, but it is not prim only a communication
disorder.
2. Engaging a depressed person in a productive task is one way to intemipt or limit the amount of time spent focusing on
negative evaluations of him or herself. There is a better option, however.
3. Wrong. There is no data to support this as the client’s occupation or identity. Do not “read into” the question. Try
again.
4. Correct. The nurse is attempting to reinforce the client’s self-worth by providing an opportunity for the client to
succeed at a task that earns positive feedback from the nurse.
QID: 7521 C 29(533-569 h 353-354) A disruptive 10-year-old child is having difficulty interacting with other children
on the unit. Which nursing action would be best initially?
1. Have a unit conference with other staff members and discuss strategies to solve the problem.
2. Talk to the child about the behavior that is causing the problem and identify possible solutions.
3. Tell the other children to stop teasing the client and to observe for changes in the client’s behavior.
4. Tell the client’s mother that she needs to talk to her son about his disruptive behavior.
Rationale
I. No, try again. The client in this question is the child, and the issue is disruptive behavior. This option is only indirectly
related to the client. This is not the best option.
2. You are correct. Since the child is the client in this question, the correct answer must be related to him. This option
deals directly with the issue of the client’s behavior.
3. The client in this question is the child, not the other children on the unit. The answer should be related to the client.
Also, “telling” the other children what to do about the problem is characteristic of an authority figure and is not
therapeutic in the nurse- client relationship. The nurse’s response must be therapeutic for the client.
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4. Wrong. This option focuses on inappropriate person, the client’s mother. Also, “telling” the client’s mother what she
“needs” to do is characteristic of an authority figure and is not therapeutic in the nurse-client relationship.
QID: 7522 C 23(375-401 h 330-331) A 16-year-old, 5’4” high school student is admitted to an eating disorders program
by her psychiatrist. She tells the admitting nurse she has lost 25 pounds over the past month and now weighs 85 pounds.
In assessing the client, the nurse would identify which manifestations as early characteristics of anorexia nervosa?
1. Appetite loss, amenorrhea, bradycardia, loss of 15% of pre-illness body weight.
2. Appetite loss, amenorrhea, tachycardia, hyperactivity.
3. Tachycardia, insomnia, fear of obesity, bulimia.
4. Amenorrhea, bradycardia, disturbed body image, loss of 15% of pre-illness body weight.
Rationale
1. Clients with anorexia usually experience amenorrhea, bradycardia, and loss of 15% of pre-illness body weight.
Although they voluntarily refuse to eat, they do not typically experience appetite loss until they have been ill for a long
time. Try another selection.
2. Clients with anorexia do experience amenorrhea and hyperactivity, but they do not experience tachycardia. Appetite
loss does not occur until the late stages of the illness. Try again.
3. This is not the best option. Clients with anorexia do experience amenorrhea, and fear of obesity. They do not typically
experience insomnia; and while many clients do have bulimia, many do not.
4. Correct. Amenorrhea, bradycardia, disturbed body image, and loss of 15% of pre-illness body weight are among the
most common early manifestations in anorexic clients.
QID: 7523 C 23(375-401 h 30-331) The nurse realizes a typical characteristic of girls with anorexia nervosa is:
1. They fail to comply with their parents’ wishes or societal expectations.
2. They exercise relentlessly.
3. They are truthful in reporting their eating habits
4. They have problems with self-control.
Rationale
1. This is not correct. Girls with anorexia nervosa are often described as thoughtful, obedient at home, and excellent
students.
2. Great choice! Many girls with anorexia nervosa participate in sports and other athletic activities. They also tend to
exercise relentlessly in their efforts to lose more weight
3. This is not correct. Clients with anorexia nervosa will often do whatever is necessary to continue losing weight,
including lying to their parents and physicians about their eating patterns.
4. Wrong. Clients with anorexia nervosa do not have problems with self-control. They are most a preoccupied with
compulsive over-control.
QID: 7524 C 23(375-401 h 330-331) In caring for a bulimic client, the nurse understands that in contrast to clients with
anorexia nervosa, did with bulimia characteristically
1. Recognize that their eating behavior is abnormal
2. Rarely suffer serious medical consequences.
3. Have positive feelings about their eating patterns
4. Vomit or use laxatives after an eating binge to purge the food.
Rationale
1. Correct. Bulimic clients are aware that their eating behavior is abnormal, and during binges fear that they won’t be
able to eating voluntarily. Anorexic clients typically deny that they have an eating disorder.
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2. Wrong. Bulimia is associated with many medical problems, and some can become life-threatening. The most common
problems are menstrual irregularities, enlarged parotid glands, dental caries esophagitis, tears or rupture of the esophagus
hypokalemia, and aspiration pneumonia.
3. Wrong. Bulimics often suffer from depression are self-critical and intensely ashamed of their eating behavior. In
contrast, anorexics often express a sense of pride about their eating behavior loss of weight.
4. Wrong. Both bulimic and anorexic clients terminate eating binges by self-induced vomiting or laxative use.
QID: 7525 C 21(342-344 h 332-338) Which activity would be most appropriate for the nurse to suggest to a manic
client?
1. A daily walk on the hospital grounds.
2. Playing a computer game with another client
3. Participation in a basketball game with other clients.
4. Reading quietly in his room.
Rationale
1. Correct. Physical exercise involving large motor skills is an appropriate way for him to work off excess energy and
emotional tension.
2. This is not correct. Competitive games will tend to increase his anxiety and tension and therefore escalate his
hyperactivity.
3. Incorrect response! Basketball games tend to be competitive and overly stimulating. This activity would escalate his
hyperactive behavior.
4. This is not correct. Because mania is associated with a short attention span and high level of distractibility, the client
usually is not able to sit and read quietly by himself.
QID: 7526 C 21(330-332 h 332-338) An 18-year-old client is hospitalized for treatment of severe depression. Because of
the client’s condition, which approach is most appropriate for the nurse to include in the client’s plan of care?
1. Giving the client choices.
2. Spending time with the client.
3. Providing a chess game.
4. Encouraging decision-making.
Rationale
1. Wrong! Making choices is difficult for a depressed client.
2. Yes! You made the right selection! Because depressed clients frequently have suicidal tendencies, the best nursing
action for the client is to spend time with her. This will provide for her safety and promote her sense of self-esteem.
3. Try again. An intellectual game such as chess would not be a good activity for a depressed client. Non-intellectual
activities such as latch hook or needle work would be a better choice. Read all of the other options, and then Ely to select
the best one.
4. Try again! Decision-making is difficult for a depressed client.
QID: 7527 C 27(491-492 h 351-352) The nurse observes an elderly client trying to climb over the side rails of the bed.
When placing a vest restraint on the client, the client’s daughter says to the nurse, “My mother does not need to be tied
down in bed. I’ve been caring for her for years, and she hasn’t fallen out of bed yet.” Which response is therapeutic for
the daughter?
1. “I just saw your mother trying to climb over the side rails. Since I am concerned about her falling and hurting herself, I
think this is best for her safety.”
2. “Tell me how you managed to care for her at home.”
3. “Hospital policy requires restraint vests on clients who are at risk for falling. I just saw your mother trying to climb
over the rails. You don’t want her to get hurt, do you?”
4. “The elderly may become confused in an unfamiliar place and do things they wouldn’t do at home. It is difficult to see
her restrained. While you are with her, the restraints can be off. Let me know when you are ready to leave.”
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Rationale
1. Wrong. The client’s safety is the issue in this question. Since the daughter and nurse are with her, she is not in
immediate danger. It is important to note that the client in this test question is the daughter, and the nurse should address
the daughter’s concerns. This response focuses on safety and restraints, and not on the client’s (the daughter’s) concerns
about her mother being tied down.
2. Wrong. This response does not focus on the issue in the question, which concerns the client’s feelings about restraints
being placed on her mother. This option may be appropriate later in the conversation, but is not the best initial response.
3. Wrong. This response implies that the daughter is not interested in her mother’s safety and makes her defensive. It
also focuses on hospital policy and not the daughter’s concerns.
4. Excellent! This option focuses on the daughter’s concerns and provides information and rationale for the restraints. It
also provides for safety and offers a compromise to the daughter the addresses her concern and gives her some control.
QID: 7528 C 27(491-492 h 351-352) The nurse is preparing to give an elderly client a bath. The client says to the nurse,
“I don’t think that I need a bath today. I just had one yesterday. My skin is going to get too dry. I bathe completely every
other day at home. Which response by the nurse is best?
1. “My head nurse wants all the client bathed daily because it decreases the number of germ on your skin that cause
infection. Would you like to talk to the head nurse about your concerns?”
2. “A bath can make you feel refreshed and make the day seem brighter. Don’t you agree?”
3. “Would you like to compromise and just wash our face and hands today?”
4. “I heard you say that you didn’t want a bath today.”
Rationale
1. Incorrect choice. This option blocks communication by “passing the buck” to the head nurse and by referring to an
inappropriate issue (the head nurse’s wishes and beliefs.). The nurse should address the client’s concerns.
2. Wrong. The client is concerned about dry skin, and this cliché does not address the client’s concerns. It is an
inappropriate response.
3. Excellent! Allowing the client to make a choice in her plan of care promotes a sense of independence and self-worth.
The issue in this question is not a physiological need or a safety issue.
4. Not the best choice. Restatement is used to clarify and allow the client to express her feelings — but this client has
already explained to the nurse why she doesn’t want a bath. This tool is inappropriate in this question.
QID: 7529 C 27(491-942 h 351-352) The nurse finds an elderly client on bedrest standing next to her bed. The side rails
are in the up position, and the client’s IV is pulled out. The client is confused, does not have an identification bracelet on,
and cannot remember her name. What should the nurse do first?
1. Help the client into bed, and remind her to call the nurse when she wants to get out of bed.
2. Help the client into bed, and then restart the IV
3. Place a restraining vest on the client.
4. Put an identification bracelet on the client and help her back to bed.
Rationale
1. Wrong. Reminding a confused client to use a call light is not an appropriate nursing action (the case situation tells you
that the client cannot remember her name, so she will probably not remember to use a call light). Since a physiological
need is not identified in this question, the safety of the client is the most important nursing consideration at this time. Try
again.
2. Wrong. The case scenario does not tell you whether the IV has life-saving medications or fluids infusing, so you
cannot assume that the IV is a physiological need. Do not “read into” the question!
Since a physiological need is not identified, the safety of the client is the most important nursing consideration at this
time. Try again.
3. Excellent! The case scenario tells you that a confused client on bedrest was found standing next to the bed with the
side rails up. This is an unsafe situation, since the client was at risk of falling when she got out of the bed.
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Such an injury can be life-threatening. Placing a restraining vest on the client will provide for her safety. In fact, this is
the only option that provides for the client’s immediate safety.
4. The client’s lack of an identification bracelet is an important safety concern. However, the case scenario tells you that
the client got out of a bed that had the side rails up. This is an unsafe situation, since the client is at risk for falling. Such
an injury can be life-threatening. After the immediate physical safety of the client is assured, an identification bracelet
can be obtained.
QID: 7530 C 27(491-492 h 351-352) The physician has ordered extremity restraints for safety reasons for a confused,
elderly client. After placing the client in extremity restraints, the priority nursing action is to:
1. Release each extremity every two hours for range of motion exercises.
2. Discuss the rationale for the restraints with the family members.
3. Reduce the client’s distress by dimming the lights and closing the door.
4. Tie the restraints to the side rails using a half bow knot.
Rationale
1. This is the priority action, because the client with restraints is at risk of circulatory problems and possible permanent
injury. Releasing the extremity for range of motion exercises addresses this risk, and allows the nurse to assess for
possible injury from the restraints.
2. While it would be important to discuss the use of restraints with the family, it is not a priority action. Actions that
ensure the safety of the client take priority.
3. The nurse should never isolate a restrained client by turning the lights off and closing the door. The client’s distress
might be increased. It is also important to visually check on a restrained client frequently.
4. The half bow knot is correct, but tying the restraints to the side rails is incorrect. The restraints are tied to the bed
frame. Because part of this option is incorrect, this cannot be the correct answer.
QID: 7531 C 29(533-569 h 353-354) The mother of a two-year-old who is hospitalized asks how she should handle her
son’s temper tantrums. The nurse should advise the mother to:
I. Restrain the child physically.
2. Ignore the behavior.
3. Let the child know his temper tantrums are not acceptable.
4. Play a game with him, or rock him quietly.
Rationale
1. Incorrect. This may actually cause the behavior to intensify. Select an option that will diminish the behavior.
2. Good work! This is the recommended approach, since it does not reinforce the behavior. Ignoring a negative behavior
is a basic concept in behavior modification.
3. No, this is not preferred. This behavior is due to lack of self-control, which is gradually being gained at this age. Select
again.
4. This would reinforce the negative behavior, so it is incorrect. Choose another answer.
QID: 7532 C 29(533-539 h 353-354) A hospitalized eight-year-old is losing a game of checkers. He stands up and says,
“I quit.” The nurse understands that this behavior probably is:
1. A personality change due to hospitalization.
2. Immaturity for his age.
3. A sign that this game is too hard for him.
4. Normal for his social development.
Rationale
1. No, this behavior is probably not a change. Select again.
2. Incorrect. Look for another reason for this behavior.
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3. No, this is an age appropriate activity. Remember, play is the way children learn. Try again.
4. Yes, you got it right. Children will frequently “quit” at this age if they can not succeed, until they learn that the social
interaction is more important than winning.
QID: 7084 C 19 (287 h 320 ) A client is treated for a major depression with nortriptyline (Pamelor) 150 mg. Which of
the following statements by the client indicates that she needs further instruction about this drug?
1. “I’m glad this medicine helps me. My husband and I would like to start our family as soon as possible.”
2. “If I should feel hopeless and suicidal again, I have the telephone number of my therapist to call for help.”
3. “I plan to see my psychiatrist regularly. She told me if I continue to do well, I can probably stop taking my medication
in nine to 12 months.”
4. “I hope I will not have to continue taking medicine forever. I guess I’ll have to see how I do.”
Correct; 1 Chpt:19 Text pg 287 Meds 90 Hesi 320
Client Category: physiological integrity pharmacology and parenteral therapies
Rationale:
1. Yes, the client needs further instruction! Tricycic antidepressants should be avoided during pregnancy, especially
during the first trimester, because they are associated with fetal anomalies.
2. No, this statement by the client is correct. Since
60% of depressed persons experience suicidal thoughts, each hospitalized client should have a plan for obtaining help if
these thoughts recur after discharge. The client’s statement indicates that she has a good plan to follow, which the nurse
should reinforce. The stem asks for the statement that indicates a knowledge deficit. Try again.
3. This is not the correct option. The client correctly understands that most clients remain on their antidepressant for nine
to 12 months after recovering from a episode of depression. A rebound depression can occur if the medication is
discontinued too soon. The client’s statement is appropriate, so it does not indicate a need for further instruction.
4. No, this is not the correct option. This is a realistic statement that does not indicate a need for further instruction. An
estimated 15% of clients with depressive illness develop chronic or recurring manifestations of depression. Clients
should remain under the care of a mental health professional after hospital discharge so their condition can be monitored.
The stem asks for the statement that indicates a knowledge deficit. Read the options again.
QID: 7085 C 19 (284-285 h 321-322) A client is treated in the emergency room for a panic attack. Thirty minutes after
receiving diazepam (Valium), he tells the nurse that he is feeling much calmer. “I can’t believe how scared I was. I will
do anything to avoid having another panic attack.” The most helpful nursing measure is to:
1. Advise him to admit himself to the psychiatric unit, where he can have a comprehensive evaluation in a protected
setting.
2. Suggest to him that he reduce the amount of stress in his life.
3. Make an appointment for outpatient psychotherapy to receive help with any emotional issues that might be responsible
for his panic attacks.
4. Tell him he can always return to the emergency room if he should have another panic attack.
Correct; 3 Chpt:19 Text pg 284-285 Meds 89-90 Hesi 321-322
Rationale:
1. This is incorrect. There is no data to support his need for inpatient treatment. Panic disorder is usually treated in an
outpatient setting.
2. This is not the best option for this question because stress reduction alone will not prevent future panic attacks. Look
again to select a better option.
3. Excellent! Panic attacks occur when the individual’s defense mechanisms fail to contain his anxiety. Psychotherapy
will help him learn to identify and resolve his emotional issues and conflicts and thereby prevent future panic attacks.
4. Wrong! This is not a helpful comment, because the client wants to prevent future panic attacks.
QID: 7086 C 19 (287 h 320 ) Two weeks after a client started taking amitriptyilne (Elavil), she reported that she was
sleeping better and her appetite had improved. She said, however, that she still felt hopeless and sad. In response to this
statement, the best nursing action is to:
1. Notify her physician so that she can be switched to another drug.
2. Ask her physician to increase her dose of Elavil.
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3. Explain that antidepressants often take three to four weeks to be fully effective.
4. Chart her complaints in the nursing notes.
Correct; 3 Chpt:19 Text pg 287 Meds pg 90 Hesi 320
Rationale:
1. This is not correct. Although the client’s physician will want to know how she is responding to her medication, this is
not the best option. Her antidepressant most likely will not be changed if she is experiencing some improvement in her
target manifestations. Note also that this action does not deal with client education, which is the issue raised in this
question. Try to identify an option that describes a better choice.
2. This is a possibility, but it is not the best nursing action because it does not deal with client education, which is the
issue raised in this question. Look at the other options and identify a better choice.
3. Correct. Tricyclic antidepressants have a lag time of three to four weeks before the client will experience significant
improvement. The client has only taken her medication for two weeks, so she still has manifestations of a depressed
mood, even though her sleep patterns and appetite have improved. This nursing action responds to the issue of client
education, which is the issue in this question.
4. This is an appropriate action, but it is not the best option because it does not address client education, which is the
issue in this question.
QID: 7087 C 19 ( 280-284 h 320) The best approach for the nurse to take initially with a client who has severe anxiety
is to:
1. Move the person to a calm, non-stimulating environment.
2. Encourage expression of feelings without attempting to modify defensive behavior.
3. Reduce the client’s level of anxiety by offering medication.
4. Suggest that the client engage in some automatic behavior, such as pacing, to reduce his anxiety level.
Correct; 2 Chpt:19 Text pg 280-284 Meds 89 Hesi 320
Client Category: psychosocial Integrity
Rationale:
1. This might be a good intervention, but this is not the best initial nursing action. Try again!
2. Correct. The nurse should encourage the client to further communicate by being available and listening in a
nonjudgmental manner. The initial goal is to support the client’s defenses to help him gain more control over his anxiety.
3. Wrong! Medication is indicated for panic levels of anxiety. Clients with a severe level of anxiety can be helped
without medication.
4. This might be a good intervention, but this is not the best initial nursing action There is a better option.
QID: 7088 C 19 (284-285 h 321-322) Which of the following actions would the nurse do first for a client in panic?
1. Determine the source of his anxiety by asking the client to describe the events before the anxiety occurred.
2. Provide privacy for the client by moving him to a quiet area away from other people, and leaving him alone so he can
regain control.
3. Help the client describe his feelings, to begin to diagnose the problem as anxiety.
4. Provide a sense of safety and security by remaining with the client, speaking in a calm manner and offering sedation if
needed.
Correct; 4 Chpt:19 Text 284-285 Meds 89-90 Hesi 321-322
Rationale:
1. Incorrect! Assisting the client to determine the source of his anxiety is appropriate in mild to moderate levels of
anxiety, but the client with a panic level of anxiety needs immediate relief from his overwhelming feelings.
2. Incorrect option.A client in panic should not be left alone.
3. Incorrect! The client in panic will not be able to deal coherently with his feelings until his level of anxiety is lowered.
4. Correct. The initial goal for a client in panic is to obtain relief. Staying with the client, speaking in a calm manner and
offering sedation are the best initial actions for the nurse.
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QID: 7089 C 21 ( 343 h 337) A discharged client will continue taking lithium and will be seen in the clinic on a regular
basis after discharge. The nurse understands that, as a possible result of long-term lithium therapy, the client is at risk for
developing:
I. Hyperthyroidism.
2. Hypoglycemia.
3. Impaired kidney function.
4. Gull stones.
Rationale:
1. This is not correct. Hypothyroidism is a risk of long- term lithium therapy, not hyperthyroidism.
2. This is not correct. Long-term lithium therapy is associated with diabetes insipidus, but not diabetes mellitus or
hypoglycemia. Read the options again to identify the correct answer.
3. Excellent! A major risk of long-term lithium therapy is impairment of the ability of the kidneys to concentrate urine,
which can progress to nephrogenic diabetes insipidus.
Good work!
4. This is not correct. Long-term lithium therapy is not associated with gall bladder disease
QID: 7090 C 21 ( 343 h 337) A discharged client will continue taking lithium and will be seen in the clinic on a regular
basis after discharge. The nurse understands that lithium toxicity could occur if the client:
1. Fasts.
2. Engages in mild exercise.
3. Increases her sodium intake.
4. Receives carbamazepine (Tegretol) therapy.
Rationale:
1. Correct. Crash dieting or fasting can lead to lithium toxicity because alterations in the sodium and electrolyte balance
can cause blood levels of lithium to rise.
2. Wrong. Mild exercise would not lead to lithium toxicity. Most clients are able to engage in strenuous exercise without
difficulty, but they should take care to replace any sodium that has been lost through profuse sweating.
3. Wrong. Increasing sodium intake will lead to excretion of lithium and a drop in lithium level should drop below the
therapeutic range, the client may have a relapse of her bipolar disorder.
4. Wrong. Tegretol is an anticonvulsant that is used to treat acute mania and prevent future manic episodes. It is most
often used alone in clients who cannot take lithium. When given with lithium, it has to be closely monitored because the
combination can produce manifestations of neurotoxicity in the client. It is not, however, associated with a dose-related
lithium toxicity.
QID: 7092 C 19 ( 298 h 320) The psychiatrist orders tranylcypromine (Parnate) for a depressed client who has not
responded to tricyclics. In preparing client teaching about diet, the nurse knows that the client may safely select:
1. Beer and red wine.
2. Cheddar cheese and sausage.
3. Cottage cheese and canned peaches.
4. Liver and Italian green beans.
Correct; 3 Chpt:19 Text 298 Meds 90 Hesi 320
Rationale:
1. Wrong. Beer and red wine must be avoided by a client on tranylcypromirie. You are looking for something that will
be SAFE for the client to consume.
2. Wrong. Cheddar, other aged cheeses, sausage, and other cured or aged meats should all be avoided by this client.
3. Correct. Cottage cheese and cream cheese are two cheeses that can be safely eaten because they are not aged. Also,
most fresh and canned fruits are allowed. Good work!
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4. Wrong. Liver and Italian green beans (fava beans) should be avoided.
QID: 7091 C 21 ( 343 h 337) A 75-year-old man is a psychiatric client taking lithium for a bipolar disorder. The nurse
knows that elderly clients:
1. Cannot be safely treated with lithium.
2. Take the same dosage of lithium as younger adults.
3. Treated with lithium have a therapeutic range of 0.6-0.8 mEq/L.
4. Treated with lithium have a therapeutic range of 0.6-1.4 mEq/L.
Correct; 3 Chpt:21 Text 343 meds 102 Hesi 337
Rationale:
1. Incorrect. Elderly clients who do not have cardiovascular problems or other medical problems that would be
contraindications can be treated safely with lithium.
2. Incorrect. In general, elderly clients are treated with lower doses of lithium. The dose is determined by the serum
levels, so some elders may take the same dosage as younger adults. This is not the answer.
3. Correct. The therapeutic range for elderly clients is narrower, with 0.8 mEq/L as the upper level. This is because
elderly clients, or clients with medical illness, may develop manifestations of neurotoxicity such as confusion and
disorientation.
4. This is incorrect! 1.4 mEq/L is too high for the upper limit. Elderly clients, or clients with medical illness, are at risk
for manifestations of neurotoxicity such as confusion and disorientation.
QID: 7093 C 21 ( 342 h 333) A 66-year-old man is an outpatient taking tricycle antidepressants. The client’s wife
telephones the clinic and tells the nurse that she has just found her husband lying unconscious and an empty bottle of his
medication on the nightstand. The nurse’s instructions to the wife are guided by the knowledge that overdoses of
tricyclic antidepressants are:
1. Medical emergencies.
2. Serious but rarely fatal.
3. Dangerous for clients in poor health.
4. Easily treated by inducing vomiting.
Rationale:
1. Correct! Tricyclics are among the most dangerous substances available when taken in overdose. Emergency medical
attention and hospitalization should be sought for any client who has overdosed, regardless of the amount ingested.
Serious, life-threatening manifestations can develop over the three to five days following the overdose.
2. This option is not a true statement. Tricyclics are extremely dangerous and often fatal if emergency medical care is not
obtained.
3. This is not a true statement because overdoses are equally dangerous for all clients, regardless of their heath status.
4. Although the ingested drug should be removed by gastric lavage or emesis, overdoses require additional medical
treatment, including close electrocardiographic monitoring. This cannot be the best answer to the question.
QID: 7094 C 21 (343 h 337) A manic client is readmitted to the hospital. After two weeks, her lithium level is within
the therapeutic range and she no longer has manic manifestations. Before discharge, what information should the nurse
give to the client about her diet when taking lithium?
1. Sodium intake should be restricted.
2. Fluid intake should be restricted to 1000 cc per day.
3. An adequate daily intake of sodium and fluids should be maintained.
4. Sodium and fluid intake should be increased.
Rationale:
1. Incorrect. Restricting sodium intake would cause the lithium level to rise, leading to a state of toxicity. A loss of
sodium through profuse sweating, vomiting, or diarrhea would also lead to toxicity.
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2. Incorrect. Clients on lithium should drink six to eight glasses of water a day to maintain a normal state of hydration.
This cannot be the correct answer.
3. Correct. Clients should be cautioned to maintain consistent intakes of sodium and fluids to avoid developing lithium
toxicity. If they should become physically ill, they should notify their psychiatrist at once.
4. Incorrect. Increasing sodium or fluid intake would lower the lithium. If the level should drop below the therapeutic
range, the client might relapse.
QID: 7095 C 22 ( 364 h 341) A client’s psychiatrist orders fluphenazine (Prolixin) 10 mg b.i.d. Before the first dose, the
client asks the nurse what the medicine is supposed to do. What response by the nurse would be most therapeutic for a
suspicious client?
1. “It will help you feel less anxious.”
2. “It is to help make your thinking clearer and decrease your fears.”
3. “This medication will help you maintain self- control.”
4. “This medication will help you get better.”
Rationale:
1. This is not a true statement. Antipsychotics are often sedating, but that is not their primary mode of action.
2. Correct. The primary reasons for prescribing antipsychotic for clients with problems like this is to improve their
thought processes and control delusional thoughts and hallucinations. This is an accurate and truthful statement so it is
the best response for the nurse to make.
3. This statement is true, but it is not the best response to this client’s question.
4. This statement is true, but it does not specifically answer the client’s question. It also could be interpreted as
patronizing
QID: 7096 C 19 ( 288 h 322) The nurse learns that an obsessive-compulsive client brushes his tongue several times a
day, and has developed several ulcerations on it. His nursing care plan should have as its highest initial priority:
1. The client will eliminate his brushing and mouth care rituals.
2. The client will verbalize the underlying cause of his behavior.
3. The client will seek out the nurse when he is feeling anxious.
4. The client will re-establish healthy tissue in his mouth and tongue.
Rationale:
1. This is not correct. This option is the goal of his treatment, but it is not the highest initial priority.
2. This goal may or may not be appropriate, as behavioral methods will most likely be used to treat his problems. This is
not the correct response, however, because it is not the highest initial priority.
3. This is an appropriate goal, but is not the highest initial priority for his care.
4. Correct. Restoring physiological integrity is the highest initial priority for this client. This will be done while working
on the long-term goal of decreasing the mouth care rituals.
QID: 7097 C 19 ( 285 h 321) A client on a psychiatric unit is very suspicious of the nursing staff and of other clients.
Her nurse would like to establish a therapeutic relationship with her. Which nursing action would promote doing this?
1. Avoid pressuring the client by waiting for her to initiate interactions with the nurse.
2. Approach the client frequently during the day for brief interactions.
3. Set aside a specific time each day to spend with the client.
4. Approach the client in a friendly manner offering to disclose some personal information so she will feel she knows the
nurse better.
Client Category: safe effective care environment
Rationale:
1. The nurse is not demonstrating trustworthiness by waiting for the client to initiate the interaction. This is not correct.
2. This approach might be effective. However, there is a better option.
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3. Correct. To promote a therapeutic relationship, it is best to set aside a specific time for the nurse and client to meet
together. It is also important that the nurse be consistent in order to earn the client’s trust.
4. This approach is promoting a social relationship and is not appropriate lithe nurse’s goal is to form a therapeutic
relationship.
QID: 7098 C 22 ( 357 h 338) A client asks the nurse to telephone her husband and ask him if he remembered to pick
up his suit at the cleaners. The nurse knows that her husband died five years before. The best nursing response is:
1. “It may seem like your husband is still here, but he died five years ago.”
2. “You miss your husband a lot, don’t you? It must seem like he’s almost here with you.”
3. “You’ve forgotten that your husband is dead, haven’t you?”
4. “Don’t worry. Your husband will remember to pick up his cleaning.”
Correct; 2 Chpt: 22 Text 357 Meds 93 Hesi 338
Rationale:
1. This response is an attempt to orient the client to reality, but it does not address the client’s feelings.
2. Correct. This nursing response validates the client’s feelings and acknowledges her experience. This is the best option
because the nurse is responding to the feelings underlying the client’s comment, instead of the disordered content. This
response uses the therapeutic communication tool of empathy.
3. This is not correct because the nurse responds only to the content in the client’s statement, and indicates no empathy
for how the client is feeling.
4. This is not correct. The nurse should not reinforce the client’s belief that her husband is still alive.
QID: 7099 C 12 ( 152 h 315) The nurse enters a client’s room. The client’s son tells the nurse, “You people can’t do
anything right. Ever since my father was admitted to this hospital, it has been one mistake after another. lam taking him
out of here before you kill him.” The appropriate response to the son is:
1. “You feel that your father is not being well taken care of?”
2. “We have the best intentions for the clients.”
3. “I’ll get the supervisor for you.”
4. “Your father hasn’t complained about the care. What specifically is the problem?”
Rationale:
1. Excellent! This response uses the communication tool of restatement. It focuses on the client’s issue, and it encourages
the son to express his concerns to the nurse. The nurse needs more information from the client before problem-solving
can occur. This response also focuses therapeutically on the “here and now”.
2. Incorrect. This response is a defensive remark by the nurse, which is a communication block. This response implies
that whatever is bothering the son cannot be valid, and this response may escalate the situation. A therapeutic response
would encourage the son to tell the nurse why he feels upset concerning his father’s care.
3. This response puts the feelings of the son on hold by asking him to wait until the supervisor arrives. Therapeutic
communication addresses the “here and now,” and does not “pass the buck” to another person. Indeed, the supervisor
may become involved, but the best response by the nurse is to address the client’s immediate needs.
4. This response focuses on the father, but the son is the one with the concerns. It implies that the son’s feelings cannot
be valid since his father has not voiced any complaints. This is not a therapeutic nursing response and it contains the
communication blocks of not addressing the client and devaluing his feelings.
QID: 7100 C 21 ( 332 h 332) The client is very confused and combative. The physician orders the client to be placed
in a jacket restraint and wrist restraints. In order to prevent injury to the client with restraints, the most important nursing
action is to:
1. Explain the procedure and reason for the restraints to the client and the family.
2. Remove the restraints and observe the extremities for circulation at least every four hours.
3. Tell the client that if he is more cooperative the restraints will not be necessary.
4. Document the use of restraints in the chart.
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Rationale:
1. This is an important part of nursing care. However, this action will not prevent injury to the client. This is not the
answer.
2. Very good. This nursing action will help prevent nerve and musculoskeletal injuries to the client as a result of poor
circulation caused by the restraints.
3. The case scenario tells you that the client is confused. Giving him this choice is inappropriate.
4. Documentation of the use of restraints and the client’s behavior that warranted their use for the client’s safety is very
important. However, this action will not prevent injury to the client. This is not the answer.
QID: 7101 C19 ( 279 h 320) The nurse knows that which of the following behaviors would indicate regression in a
hospitalized five-year- old?
1. Bedwetting several times a day.
2. Crying when mother leaves.
3. Eating only food from home.
4. Wanting his teddy bear for bedtime.
Rationale:
1. Correct. You would expect a five-year-old to be toilet trained. Incontinence is a commonly seen sign of regression in
young children.
2. No, this is not a sign of regression for this child. Separation anxiety is seen in children between the ages of six months
and five years. This is within normal for this child’s age. Make another choice.
3. No, this is not a sign of regression. Children frequently do not eat foods that are different. Sick children particularly do
not make changes in their dietary habits. Try again.
4. No, this is not a sign of regression. Many young children are attached to a familiar object from home, which is referred
to as a transitional object. Select again.
QID: 7102 C 21 ( 324 h 332) Which activity would be most appropriate for the nurse to suggest to a manic client?
1. A daily walk on the hospital grounds.
2. Playing a computer game with another client
3. Participation in a basketball game with other clients.
4. Reading quietly in his room.
Client Category: Health promotion and maintenance
Rationale:
1. Correct. Physical exercise involving large motor skills is an appropriate way for him to work off excess energy and
emotional tension.
2. This is not correct. Competitive games will tend to increase his anxiety and tension and therefore escalate his
hyperactivity.
3. Incorrect response! Basketball games tend to be competitive and overly stimulating. This activity would escalate his
hyperactive behavior.
4. This is not correct. Because mania is associated with a short attention span and high level of distractibility, the client
usually is not able to sit and read quietly by himself.
QID: 7103 C 21 ( 324 h 332) An 18-year-old client is hospitalized for treatment of severe depression. Because of the
client’s condition, which approach is most appropriate for the nurse to include in the client’s plan of care?
1. Giving the client choices.
2. Spending time with the client.
3. Providing a chess game.
4. Encouraging decision-making.
Correct; 2 chapter 21 Text 324 Meds 95 hesi 332
109
Rationale:
1. Wrong! Making choices is difficult for a depressed client.
2. Yes! You made the right selection! Because depressed clients frequently have suicidal tendencies, the best nursing
action for the client is to spend time with her. This will provide for her safety and promote her sense of self-esteem.
3. Try again. An intellectual game such as chess would not be a good activity for a depressed client. Non-intellectual
activities such as latch hook or needle work would be a better choice. Read all of the other options, and then try to select
the best one.
4. Try again! Decision-making is difficult for a depressed client.
QID: 7106 C 12 ( 152 h 315) The father of a four-year-old son tells the nurse that his child believes there are
“monsters and boogeyrnen” in his closet at bedtime. The nurse’s best suggestion for dealing with this problem is:
1. Letting the-child sleep with his parents.
2. Keeping a night light on in the child’s bedroom.
3. Tell the child that these fears are not real.
4. Staying with the child until he falls asleep.
Rationale:
1. Incorrect. This is apt to develop a habit that will interfere with the parents’ need for privacy and the child’s ability to
settle himself for sleep. Select again.
2. Yes, this is right! After the parent reassures the child, the light helps the child “see” for himself that there is nothing
hiding in tile shadows.
3. Incorrect. Although the “monsters and boogeymen” are not, the fears are real! This is not the best suggestion for the
child of age four, who has difficulty distinguishing between real and make-believe. Choose again.
4. Not recommended, since this encourages procrastination going to sleep. This easily becomes a habit that is difficult to
break. Make another choice.
QID: 7107 C 21 ( 324 h 332) The nurse caring for clients in a long-term care facility understands that remotivation
therapy is used to:
I. Stimulate and encourage social participation.
2. Reorient clients with cognitive problems.
3. Encourage clients to share memories of past experiences and events.
4. Resolve emotional problems.
Rationale:
1. Correct. The goals of remotivation therapy are to stimulate and encourage social participation using structured group
approaches.
2. This is not correct. This option describes reality orientation programs.
3. This is not correct. This option describes reminiscence therapy.
4. This is not correct. Psychotherapy, either individual or group, is used to assist clients to resolve emotional and
psychological difficulties. This is not the rationale for remotivation therapy.
QID: 7108 C 21 ( 324 h 332) The nurse is planning orientation to the unit for a new client who is severely depressed.
Which nursing approach is best initially?
1. Introduce the client to other clients on the unit and staff members.
2. Tour the unit and introduce her to everyone they meet on the way.
3. Explain the unit policies and answer any questions she may have.
4. Accompany the client to her room and stay with her while she unpacks, offering only minimal information.
Rationale:
1. This is not correct, because this approach would be overwhelming for the client at this time.
110
3. This is not the best approach initially because severely depressed persons are easily confused. Can you identify an
approach that uses another communication tool that is more suitable for the nurse to use in establishing a therapeutic
relationship with the client?
4. Correct. Severely depressed persons have problems with concentration and easily become confused. A nursing
approach that focuses on giving simple in formation, slowly and directly, is best. This initial approach also uses the
communication tool of offering self. The presence of the nurse conveys to the client that she is worthy of the nurse’s
attention, and will help the client adjust to her new surroundings.
QID: 7109 C 21 ( 324 h 322) In planning activities for a depressed client during his early stages of hospitalization,
which nursing plan is best?
I. Provide one activity a day, to avoid fatigue.
2. Let the client choose an activity that is appealing.
3. Provide a structured daily program of activities for the client.
4. Wait until the client’s mood improves and he indicates an interest in productive activity.
Rationale:
1. Providing only one activity a day will reinforce the client’s feelings of inadequacy and withdrawal. This is not the
correct option.
2. Wrong. The depressed person has great difficulty making decisions.
3. Correct. A regular schedule provides structure for the depressed client, who has difficulty making decisions and
providing structure for himself. Good work!
4. This is not a recommended approach because inactivity reinforces a depressed mood, by preventing satisfaction and
social recognition.
QID: 7110 C 21 (343 h 337) A client taking lithium is discharged from the hospital after being taught to recognize the
manifestations of lithium toxicity. The nurse knows learning has occurred when the client states that she will call the
psychiatrist if she experiences:
1. Vomiting and diarrhea
2. Fine hand tremor.
3. Polyuria.
4. Drowsiness and lethargy.
Rationale:
1. Correct. Vomiting and diarrhea are beginning signs of lithium toxicity. The client should omit the next dose of
lithium and contact the physician to obtain further instructions.
2. Fine hand tremor is a common side effect reported by about half of the clients on lithium. It is not a sign of impending
toxicity.
3. Polyuria is a common side effect reported by about 60% of the clients on lithium. It is not a sign of impending
toxicity.
4. Drowsiness and lethargy are common side effects of lithium and are not signs of impending toxicity.
QID: 7111 C 22 (354 h 338) The nurse understands that, for most clients with a cough that interferes with recovery,
guaifenesin (Robitussin) is the medication of choice because:
1. The respiratory system is not depressed.
2. There is an added analgesic effect.
3. It is considered more effective than a narcotic.
4. Guaifenesin is available without a prescription.
Rationale:
111
1. You are absolutely right. Guaifenesin is a non- narcotic antitussive. The narcotic antitussives depress the respiratory
system, leading to further complications.
2. No, this is not true. Actually, the analgesic effect is caused by the narcotic antitussives, not the non- narcotic
antitussives.
3. No, this is not true. Non-narcotic guaifenesin and the narcotic antitussives are considered equally effective.
4. This option is a true statement, but it is not the answer. The fact that a medication is available over- the-counter is not
necessarily a benefit. It may be more convenient for the client, but the client has less consistent, if any monitoring or
client teaching.
QID: 7112 C 21 (324 h 332) The nursing care plan for the antisocial client should stress:
1. Setting clear rules and expectations for the client’s behavior on the unit, with the consequences for any violations
clearly spelled out.
2. Ignoring the client’s past antisocial acts and focusing on current here-and-now issues.
3. Supervising the client’s behavior closely, to prevent any acting-out or destructive behavior while hospitalized.
4. Helping the client to identify feelings and gain insight into what motivates his behavior.
Rationale:
1. Correct. The most therapeutic environment for this client is one where reality therapy is practiced. Rules and
expectations should be clearly stated, along with the penalties for any behavioral violations. This is the best approach for
assisting the client to develop more adaptive behavior.
2. This is not correct. The client should be encouraged to discuss events leading up to his hospitalization, to help break
the pattern of denying responsibility for his own actions.
3. This is not correct. The staff should take measures to discourage acting-out or other destructive behaviors, but such
behavior cannot be prevented by closely supervising the client. There is a better option.
4. Reality therapy, a form of behavioral therapy, is more effective for clients with antisocial behaviors than is insight-
oriented treatment. This cannot be the correct option.
QID: 7113 C 21 ( 324 h 332) The nurse is caring for an elderly client who will soon be discharged to a long-term care
facility. What nursing action is most important for promoting her continued recovery?
1. Reviewing the client’s nursing care plan with the client’s daughter.
2. Discussing the client’s nursing care needs with her physician.
3. Telephoning the charge nurse at the long-term care facility to explain the client’s nursing care needs.
4. Sending a written summary of the nursing care plan for the client to the long-term care facility.
Rationale:
1. This is not the most important action. The family should know about the client’s needs for care, but there is a better
way to promote continuity of care.
2. This is not the best action, even for clients who will continue to use the same physician. Select the option that would
better promote the continuity of her nursing care.
3. This is a possibility, but it is not the priority action in promoting continuity of care.
4. Correct. A written summary of the nursing care plan for the client is the best way of conveying the client’s nursing
care needs to the nurses who will actually work with her in the long-term care facility.
QID: 7114 C 21 ( 324 h 332) The nurse working with elderly clients knows that organic mental disorders:
1. Are the most prevalent type of psychiatric problem in this age group?
2. Are almost always chronic.
3. Need careful evaluation as they may be caused by a medical problem that could be treated effectively.
4. Can be controlled with supportive and behavioral approaches, but eventually will lead to further deterioration and
death.
112
Rationale:
1. This is not a true statement. About 4% of persons over the age of 65 suffer from a dementia, with this percentage
increasing with age to about 20% of those over the age of 80. Depression is a psychiatric problem that is much more
common in elderly persons, with an estimated 15% to 20% of older adults affected at any point in time.
2. This is not a true statement because many of the organic mental disorders are acute and reversible.
3. Correct. Cognitive changes, such as memory problems, disorientation, and confusion, require careful evaluation to
determine whether a physiological or medical condition is responsible. The client’s cognitive state will return to normal
when the underlying cause is identified and effectively treated.
4. This statement is only partially true. Chronic and irreversible organic mental disorders, such as Alzheimer’s disease
and AIDS dementia complex, are called dementias. However, there are some dementias that can be reversed when
treated, such as the dementia caused by hypothyroidism. Delirium, a third type of organic mental disorder, has a rapid
onset and is reversible.
QID: 7115 C 21 ( 324 h 332) The nurse working with elderly clients should remember that dementia in the elderly:
1. Is easy to distinguish from depression.
2. May coexist with depression.
3. Is not affected by medications.
4. Cannot be concealed by the client.
Rationale:
1. This is not a true statement. Many times the manifestations of depression in an elderly client are mistaken for those of
dementia. Manifestations found in both conditions include apathy, memory loss, and disorientation. A thorough
assessment is needed to identify the appropriate disorder and treatment.
2. Correct. Persons with dementia, especially in the early stages of the disorder, may suffer a depression when the
individual becomes aware of his or her memory loss and other cognitive problems. Treatment of the depression will
improve the client’s cognitive functioning, but will not return it to a pre-dementia level
3. This is not a true statement. Certain medications, such as sedatives and hypnotics, affect alertness and other cognitive
functioning, and can make the manifestations of a dementia worse.
4. This is not a true statement. Denial is a common defense mechanism used by a client with dementia to deal with the
anxiety of the memory loss and other manifestations of dementia.
QID: 7116 C 21 ( 324 h 332) A depressed patient refuses to get out of bed, go to activities, or participate in any of the
unit’s programs. The most appropriate nursing action is to:
1. Tell her the rules of the unit are that no patient can remain in bed.
2. Suggest she should get out of bed or she will go hungry later.
3. Tell her that the nurse will assist her out of bed and help her to dress.
4. Allow her to remain in bed until she feels ready to join the other patients.
Correct; 3 Chpt:21 Text 324 Meds 95 hesi 332
Rationale:
(3) Be positive, definite, and specific about expectations. Do not give depressed patients a choice or try to convince them
to get out of bed. Physically assist the patient to get up and dressed to mobilize her.
QID: 7117 C 21 ( 324h 332) When encouraged to join an activity, a depressed patient on the psychiatric unit refuses and
says, “What’s the use?” The approach by the nurse that would be most effective is to:
1. Sit down beside her and ask her how she is feeling.
2. Tell her it is time for the activity, help her out of the chair, and go with her to the activity.
3. Convince her how helpful it will be to engage in the activity.
4. Tell her that this is a self-defeating attitude and it will only make her feel worse.
Rationale:
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(2) The nursing intervention is directed toward mobilizing the patient without asking her to make a decision or trying to
convince her to go. The nurse must be direct, specific, and not take no for an answer.
QID: 7118 C 21 ( 324 h 332) When a depressed patient becomes more active and there is evidence that her mood has
lifted, an appropriate goal to add to the nursing care plan is to:
1. Encourage her to go home for the weekend.
2. Move her to a room with three other patients.
3. Monitor her whereabouts at all times.
4. Begin to explore the reasons she became depressed.
Rationale:
(3) The goal is to implement suicide precautions because the danger of suicide is when the depression lifts and the
patient has the energy to formulate a plan. The nurse would not encourage her to go home (1) where she could not be
observed constantly. She could be moved into a room with other patients (2), but this is not the priority concern.
QID: 7119 C 22 ( 354 h 338) When a patient’s hallucinations become more insistent, demanding, and difficult to
ignore, the nurse assesses his mental status as:
1. Improving.
2. Deteriorating.
3. Remaining the same.
4. Showing more evidence of paranoia.
Rationale:
(2) The more demanding and absorbing hallucinations (hearing voices) become, the more the patient’s condition may be
deteriorating. Secondarily, this may indicate increased paranoia (4). Paranoid schizophrenia is only one form of
this condition, and hallucinations occur in all types of schizophrenia.
QID: 7120 C 15 ( 206 h 317) Group therapy has been an accepted method of treatment for psychiatric patients for
several years. The best rationale for this form of treatment is:
1. It is the most economical. One staff member can treat many patients.
2. The format of the therapy is realistic and does not deal with unconscious material.
3. It enables patients to become aware that others have problems and that they are not alone in their suffering.
4. It provides a social milieu similar to society in general, where the patient can relate to others and validate perceptions
in a realistic setting.
Rationale:
(4) Because many people’s problems occur in an interpersonal framework, the group setting is a way to correct faulty
perceptions, as well as to work on more effective ways of relating to others.
QID: 7121 C 21 ( 324 h 332) A 60-year-old male patient has been admitted to the psychiatric unit, with symptoms
ranging from fatigue, an inability to concentrate, and an inability to complete everyday tasks, to refusal to care for
himself and preferring to sleep all day. One of the first interventions should be aimed at:
1. Developing a good nursing care plan.
2. Talking to his wife for cues to help him.
3. Encouraging him to join activities on the unit.
4. Developing a structured routine for him to follow.
Rationale:
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(4) While a good nursing care plan is important, the priority would be to get the patient mobilized. Even without a
specific diagnosis, the nurse will realize that part of what is happening with the patient is a depressed mood. Providing a
structured plan of activities for the patient to follow will help his mood to lift and provide a focus so that he will not be
centered on internal suffering.
QID: 7122 C 21 ( 324 h 332) A patient becomes very dejected and states that life isn’t worth living and no one really
cares what happens to him. The best response from the nurse would be:
1. “Of course, people care. Your wife comes to visit every day.”
2. “Let’s not talk about sad things. Why don’t we play Ping-Pong?”
3. “I care about you, and I am concerned that you feel so down.”
4. “Tell me, who doesn’t care about you?”
Rationale:
(3) A depressed person needs to experience that someone is concerned for his welfare and that there is a person he can
relate to during his hospitalization. Answers (1) and (2) negate the patient’s feelings and answer (4) may focus on
uncomfortable thoughts that will deepen the depression.
QID: 7123 C 21 ( 324 h 332) A nurse observes a patient sitting alone in her room crying. As the nurse approaches her,
the patient states, “I’m feeling sad. I don’t want to talk now.” The nurse’s best response would be:
1. “It will help you feel better if you talk about it.”
2. “I’ll come back when you feel like talking.”
3. “I’ll stay with you a few minutes.”
4. “Sometimes it helps to talk.”
Rationale:
(3) Simply offering comfort by staying with the patient and being open for communiction is the most therapeutic. The
other responses place an additional burden on the patient if she does not wish to talk.
QID: 7124 C 21 ( 332 h 324) A client with the diagnosis of manic episode is racing around the psychiatric unit trying to
organize games with the patients. An appropriate nursing intervention is to:
1. Have the patients play Ping-Pong.
2. Suggest video exercises with the other patients.
3. Take the client outside for a walk.
4. Do nothing, as organizing a game is considered therapeutic.
Rationale:
(3) Engaging the patient in a large-muscle activity, like walking with the nurse, will direct the patient’s energy but not be
too stimulating, as would a competitive game such as Ping-Pong.
QID: 7125 C 22 ( 353 h 338) A male patient on the psychiatric unit becomes upset when a visitor does not show up,
and in a rage, breaks a chair. The first nursing intervention should be to:
1. Stay with the patient during the stressful time.
2. Ask direct questions about the patient’s behavior.
3. Set limits and restrict the patient’s behavior.
4. Plan with the client for how he can better handle frustration.
Rationale:
(3) The first intervention is to set firm, clear limits on his behavior. The nurse would also remain with the patient until he
calms down (1) and then encourage him to discuss his feelings rather than act out.
115
QID: 7126 C 19 ( 288 h 322) A patient with a diagnosis of obsessive compulsive disorder constantly does repetitive
cleaning. The nurse knows that this behavior is probably most basically an attempt to:
1. Decrease the anxiety to a tolerable level.
2. Focus attention on nonthreatening tasks.
3. Control others.
4. Decrease the time available for interaction with people.
Rationale:
(1) The primary reason for the compulsive activity is to decrease the anxiety caused by obsessive thoughts. The patient is
not trying to focus her attention on tasks (2), control others (3), or lessen interaction with others (4).
QID: 7127 C 22 ( 353 h 338) A patient has been admitted with a diagnosis of DTs. The nurse knows that the primary
reason the patient is so fearful and apprehensive is that:
1. He has a serious mental illness.
2. He may die, as 15 percent of the people with DTs do die.
3. His illusions and hallucinations are very real to him.
4. He has to give up alcohol until the symptoms recede.
Correct; 3 Chpt:22 Text 353 meds 93 Hesi 338
Rationale:
(3) A patient experiencing DTs may have illusions and/or hallucinations. These are very frightening to him because they
seem real and the patient does not recognize that they are part of his illness.
QID: 7128 C 19 ( 287 h 320) A patient is experiencing a high degree of anxiety. It is important to recognize if
additional help is required because:
1. If the patient is out of control, another person will help to decrease his anxiety level.
2. Being alone with an anxious patient is dangerous.
3. It will take another person to direct the patient into activities to relieve anxiety.
4. Hospital protocol for handling anxious patients requires at least two people.
Rationale: (1) If the patient and/or the situation gets out of control, anxiety will only increase. Additional help may
prevent this from occurring.
QID: 7129 C 21 ( 324h 332) Three days after admission for depression, a 54-year- old female patient approaches the
nurse and says, “I know I have cancer of the uterus. Can’t you let me stay in bed and have some peace before I die?” In
responding, the nurse must keep in mind that:
1. The patient must be postmenopausal.
2. Thoughts of disease are common in depressed patients.
3. Patients suffering from depression can be demanding, making many requests of the nurse.
4. Antidepressant medications frequently cause vaginal spotting.
Rationale:
(2) Concern with having a life-threatening disease is a common issue with depressed patients. While demanding
behavior (3) may be a symptom, it is not the issue here. Whether or not the patient is postmenopausal (1) is not
relevant.
QID: 7130 C 21 ( 324 h 332) As a depressed patient begins to participate in her treatment program, an indication that
she is ready for discharge will be when she has:
1. Formulated a plan to return home and continue therapy.
116
2. Talked to her boss about returning to work.
3. Identified her weak areas and is working on them.
4. Asked the staff for advice about her future.
Rationale:
(1) A plan to return home and continue therapy shows that the patient has begun to realistically and responsibly deal with
her problems. Talking to her boss (2) is positive but not as comprehensive as (1). Identifying and working on weak areas
(3) usually are intermediate steps toward discharge. In asking the staff for advice (4), the patient is not ready or willing to
accept responsibility for herself.
QID: 7131 C 21 ( 354 h 338) A schizophrenic patient is admitted to the psychiatric unit. As the nurse approaches the
patient with medication, he refuses it, accusing the nurse of trying to kill him. The nurse’s best strategy would be to tell
him that:
1. “It is not poison and you must take the medication.”
2. “I will give you an injection if necessary.”
3. “You may decide if you want to take the medication by mouth or injection, but you must take it.”
4. “It’s all right if you don’t take the medication right now.”
Rationale:
(3) Giving the patient a choice of how he would like to take his medication, while being firm that he must take it, gives
the patient a sense of control and helps to reduce the power struggle. Telling the patient that the medication is not poison
(1) will do little to persuade him to comply. Answer (2) would represent a punishment. The patient must take his
medication; therefore, answer (4) is not appropriate.
QID: 7132 C 21 ( 252 h 316) An elderly, depressed patient has orders for electroconvulsive therapy (ECT). Of the
medications administered, the primary purpose of a muscle relaxant is to:
1. Decrease anxiety before ECT.
2. Reduce complications from the procedure.
3. Reduce tension in the patient’s muscles.
4. Block vagal stimulation.
Rationale:
(2). The purpose of muscle relaxant is to reduce complications from convulsions that occur with ECT. This medication
would reduce muscle tension (3), but this answer is not as specific. Atropine is given to block vagal stimulation (4).
QID: 7133 C 21 ( 324 h 332) A 50-year-old patient has just been admitted to the psychiatric unit with a diagnosis of
depression. The nurse can best approach her by saying:
1. “You have just been admitted, and I’d like to show you the unit.”
2. “Would you like to come with me to occupational therapy and see if you can find a project you would enjoy?”
3. “My name is Mary. I will introduce you to all of the other patients.”
4. “My name is Mary. I am a nurse on this floor and I will be spending some time with you.”
Rationale:
(4) Acknowledge the patient by introducing yourself and start a one-to-one relationship by spending time with her. Let
the patient know that the nurse cares about her by staying with her.
QID: 7134 C 22 ( 354 h 338) A patient with a diagnosis of schizophrenia who threatened a neighbor with a knife was
placed on a 72-hour hold by the courts and the psychiatrist. The hold is up, and the psychiatrist and court must determine
if the patient is
117
1. Gravely disabled and unable to take care of himself.
2. A danger to himself and others.
3. Able to pay for his hospitalization and treatment.
4. Willing to remain in treatment if he is discharged.
Correct; 2 Cpt 22 Text pg 354 Meds 95 Hesi 338
Rationale:
(2) The staff and court must determine if the patient is a danger to self and others. Answer (1) may be a correct answer,
but the patient was admitted to the hospital for threatening a neighbor. Answers (3) and (4) are not pertinent to the
decision.
QID: 7135 C 19 ( 206 h 317) A patient tells the nurse that she is having a great deal of difficulty talking to her
husband. She says, “He treats me like a child. Nothing I say seems to matter to him.” The best response is
1. “Tell me more about how you and your husband communicate.”
2. “How do you feel about his reactions to you?”
3. “He sounds very childish himself.”
4. “Why do you think he treats you like a child?”
Rationale:
(2) The patient needs to recognize her feelings, and this response will assist her to do so. Answer (1) keeps the
conversation on the cognitive level and does not deal with her feelings. Answer (3) is making a judgment. Answer (4) is
asking for an intellectual analysis, which may or may not help the patient, and which may cause her to feel she must
justify herself.
QID: 7136 C 15 ( 187 h 317) As a male nurse is coming on duty, one of the patients meets him in the elevator and
says, “You look like a wreck today.” The best response would be
1. “You don’t look so good yourself.”
2. “If you can’t say anything nice, perhaps you shouldn’t say anything at all.”
3. “I don’t understand what you mean by that.”
4. “I was a little rushed this morning.”
Rationale:
(3) Asking for clarification of such a statement might reveal more feelings than implied by the casual comment. This
type of statement may be indicative of anger or projected feelings. Answer sarcastic, and (2) and (4) cut off further
exploration of what the patient may really be saying. It would not be appropriate to continue with a personal explanation
of why the nurse looks bad.
QID: 7137 C 19 ( 280 h 320) The nurse is in the dayroom with a group of patients when a patient who has been
quietly watching TV suddenly jumps up screaming and runs out of the room. The nurse’s priority intervention would be
to
1. Turn off the TV, and ask the group what they think about the patient’s behavior.
2. Follow after the patient to see what has happened.
3. Ignore the incident because these outbursts are frequent.
4. Send another patient out of the room to check on the agitated patient.
Rationale:
(2) The immediate priority is to find the patient and assess what further intervention may be needed. Whether or not the
behavior has happened frequently in the past (3) is irrelevant, because the behavior exhibited now is significant and
should be followed up. Sending another patient (4) is inappropriate as an immediate intervention may be necessary.
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QID: 7138 C 19 ( 160 h 320) A patient’s deafness has been diagnosed as conversion disorder. Nursing interventions
should be guided by which of the following?
1. The patient will probably express much anxiety about her deafness and require much reassurance.
2. The patient will have little or no awareness of the psychogenic cause of her deafness.
3. The patient’s need for the symptom should be respected; thus, secondary gains should be allowed.
4. The defense mechanisms of suppression and rationalization are involved in creating the symptom.
Rationale:
(2) This disorder has an unconscious mechanism in place; thus, there is a relative lack of distress or anxiety regarding the
symptom. The patient is likely to demonstrate “la belle indifference,” an unconcerned, indifferent attitude toward the loss
of function with no awareness of the psychogenic cause. Answer (3) is incorrect as secondary gains should be
minimized. Answer (4) is incorrect as repression and displacement are the operating mechanisms.
QID: 7139 C 12 ( 160 h 316) A nursing student failed her psychology final exam and spent the entire evening berating
the teacher and the course. This behavior would be an example of
1. Reaction-formation.
2. Compensation.
3. Projection.
4. Acting out.
Rationale:
(3) The patient is placing blame on others and not taking responsibility for her own behavior. Reaction-formation (1) is
preventing “dangerous” feelings from being expressed by exaggerating the opposite attitude. Compensation (2) is
covering up a weakness by emphasizing a desirable trait. Acting out (4) is not a defense mechanism.
QID: 7140 C 21 ( 335 h 324) In planning nursing care for the individual with a somatoform or psychosomatic illness,
the nurse needs to consider which of the following general concepts?
1. The nurse must incorporate concepts of adaptation, stress, body image, and anxiety.
2. The area of symptom formation may be symbolic to the patient.
3. Psychosomatic illnesses may be life threatening.
4. All of the above concepts are important.
Rationale:
(4) Psychosomatic illnesses involve the “holism” of the individual; thus, all three of the concepts are important. If the
nurse considers all of these concepts in planning nursing care, interventions will be therapeutic.
QID: 7141 C 19 ( 287 h 315) The most effective nursing intervention for a severely anxious patient who is pacing
vigorously would be to
1. Instruct her to sit down and quit pacing.
2. Place her in bed to reduce stimuli and allow rest.
3. Allow her to walk until she becomes physically tired.
4. Give her PRN medication and walk with her at a gradually slowing pace.
Rationale:
(4) This patient is in severe anxiety heading for a panic level. She requires immediate medication, constant attention, and
a gradual lessening of activity according to her expressed level of energy. With moderate anxiety, directed activity helps
to reduce the level.
119
QID: 7142 C 12 ( 152 h 315) A new staff nurse is on an orientation tour with the head nurse. A patient approaches her
and says, “I don’t belong here. Please try to get me out.” The staff nurse’s best response would be
1. “What would you do if you were out of the hospital?”
2, “I am a new staff member, and I’m on a tour. I’ll come back and talk with you later.”
3. “I think you should talk with the head nurse about that.”
4. “I can’t do anything about that.”
Rationale:
(2) As a new staff member, the nurse should clarify who she is and why she is there. She also should acknowledge the
patient’s attempt to initiate interaction by offering to talk at a more appropriate time. Answer (1) might be used in a later
interaction, but is not appropriate at this time.
QID: 7143 C 22 ( 353 h 338) A patient on the psychiatric unit frequently gets out of control and is inappropriately
aggressive. A plan to teach this patient how to cope would include
1. A problem-solving focus involving alternative responses.
2. Confronting the patient about this behavior.
3. Informing the patient of the consequences of his behavior (i.e., restraints).
4. Frequent times in seclusion as a part of a behavior modification program.
Correct; 1 Cpt 22 Text pg 353 Meds93 Hesi 338
Rationale:
(1) The most effective method is problem solving, allowing the patient to explore his feelings, responses, consequences,
and try out new, alternative responses. Confrontation (2) may only increase the maladaptive behavior. Threatening the
patient with restraints (3) or putting him in seclusion (4) is punitive, not creating a climate where he would learn new
behavior.
QID: 7144 C 21 ( 342 h 333) A patient in the hospital asks the nurse what the drug Prozac is used for. The best
response would be
1. “You had better ask your physician
2. “It is given for depression. Why do you ask?”
3. “It is an antidepressant medication that has fewer side effects than other drugs.”
4. “Why are you asking about Prozac?”
Correct; 2
Correct; 2 Cpt 21 Text pg 342 Meds`101 Hesi 333
Rationale:
(2) It is therapeutic to answer the question, then make an open-ended response to encourage the patient to talk. Answers
(1) and (3) close off communication and (4) does not answer the question.
QID: 7145 C 22 ( 353 h 338) Nursing responsibility working on a psychiatric unit includes being able to recognize
indications or signals of impending violent or assaultive behavior. This behavior could be:
1. Foul language.
2. Hallucinations that are threatening, new, and commanding in nature.
3. Sudden withdrawal and refusal to speak.
4. Increased tendency to approach people and make physical contact, such as touching faces.
Rationale:
(2) Violent behavior often occurs as a response to a real or imagined threat. Hallucinations can be threatening in nature.
Foul language may or may not be an indication of impending violence. Threatening hallucinations are more predictive of
possible acting out behavior.
120
QID: 7146 C 12 ( 206 h 317) A patient has been given the diagnosis of compulsive disorder. As part of her treatment
plan, the patient will join a daily group therapy session at 10:30 in the morning. The rationale for choosing this time of
day is
1. Anxious patients are more relaxed in the morning.
2. Mornings are better for group therapy because clients have the rest of the day to work through problems that come up
during the sessions.
3. Most groups are planned for the morning when physicians are on the unit.
4. The patient will have just completed her ritualistic activity.
Rationale:
(4) It is best to plan any activity, particularly therapy, to follow the compulsive activity because anxiety is lowest at this
time.
QID: 7147 C 12 ( 160 h 316) The nurse is providing care for a patient who just learned that she has terminal cancer.
The patient says to the nurse, “I don’t know why you are all so concerned; I’m not that sick.” The defense mechanism
she is using is
1. Denial.
2. Rationalization.
3. Projection.
4. Regression.
Rationale:
(1) The answer is denial. The patient is simply refusing to accept her terminal illness to protect herself from the
unpleasant reality of possible death. Denial is a stage of the grief process.
QID: 7148 C 12 ( 324 h 332) A depressed patient refuses to join group activities and sits in a corner all day. The
therapeutic intervention is to
1. Assign the patient to clean the unit kitchen.
2. Insist that the patient join group therapy.
3. Formulate a structured schedule of daily activities for the patient.
4. Allow the patient to not participate until medication is effective.
Correct; 3
Rationale:
(3) An important goal for depressed patients is to keep them busy with a structured schedule. It may be too early for the
patient to join a group, and cleaning the kitchen may not increase self-esteem.
QID: 7149 C 21 ( 332 h 324) A 30-year-old patient was admitted to the hospital with a diagnosis of bipolar disorder,
manic episode. She manifests an excess of energy and cannot sit still. The most useful activity that the nurse might
suggest for this patient would be to
1. Play volleyball outside.
2. Engage in group exercises.
3. Play table tennis in the day room.
4. Go outside for a walk with the nurse.
Correct; 4
Correct; Cpt 21 Text pg 332 Meds 93 Hesi 324
Rationale:
(4) This activity would channel her energy because it would involve large-muscle activity, but would not increase
external stimuli as group or competitive activities would.
121
QID: 7150 C 21 ( 343 h 337) A female patient’s disruptive behavior on the psychiatric unit has been extremely
annoying to the other patients. One approach the nurse may find effective is to
1. Tell the patient that she is bothering others and confine her to her room.
2. Ignore the patient’s behavior, realizing that it is consistent with her illness.
3. Set consistent limits on the patient’s behavior.
4. Make a definite, structured plan that the patient will have to follow
Correct; 3
Rationale:
(3) Setting limits is important to decrease the disruptive behavior and prevent the patient from being rejected by others
with subsequent lowering of self-esteem.
QID: 7151 C 21 ( 343 h 337) When assessing a patient who is taking lithium carbonate for a manic-type disorder, the
nurse should be alert for the expected side effect of :
1. Dehydration.
2. Muscle weakness.
3. Drowsiness.
4. Anuria.
Rationale:
(2) Muscle weakness is an expected side effect and one that the patient may have to learn to live with while on the
medication. Dehydration (1) is not a side effect that should be evaluated; drowsiness (3) is a toxic side effect. A usual
side effect is polyuria, not anuria (4).
QID: 7152 C 21 ( 324 h 332) A depressed 50-year-old patient is admitted to the psychiatric hospital. For the nurse
assigned to work with the patient and orient her to the unit, one of the first goals would be to:
1. Show the patient where she will be sleeping.
2. Introduce the patient to the other patients.
3. Allow the patient to move at her own pace in getting used to the unit.
4. Establish a nurse-patient relationship.
Correct; 4
Rationale:
(4) With a psychiatric patient, establishing a relationship in which she can begin to trust another person is a primary goal
and should begin during orientation. During this process, the nurse will also accomplish answers (1) and (2).
QID: 7153 C 22 ( 364 h 341) A 35 year-old patient is brought to the hospital by her husband. She has been hearing
voices, acting bizarre, and singing her sentences instead of talking. A tentative diagnosis of schizophrenic disorder is
made. The patient begins to take chlorpromazine (Thorazine) 200 mg TID, and by the second day, she is having limb
spasms and jerky movements. The nurse should assess this behavior as:
1. Dystonic movements.
2. Tardive dyskinesia.
3. Parkinsonism.
4. Extrapyramidal movements.
Rationale:
(1) Although these side effects are Parkinson-like (3) and are extrapyramidal (4), the more specific answer is dystonia,
the form that occurs in the first 1 or 2 days.
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QID: 7154 C 22 ( 364 h 341) The physician orders a medication to counteract the adverse effects of chiorpromazine
(Thorazine). The nurse expects that this medication will be
1. Haloperidol (Haldol).
2. Trifluoperazine hydrochloride (Stelazine).
3. Benztropine mesylate (Cogentin).
4. Levodopa (L-Dopa).
Rationale:
(3) The drugs of choice to counteract the extrapyramidal side effects are Cogentin or Artane. Haldol (1) and Stelazine (2)
may be used instead of Thorazine to control behavior; L-Dopa (4) is used in Parkinson’s disease, not for Parkinson-like
side effects.
QID: 7155 C 21 ( 252 h 316) A curarelike medication and a barbiturate are given to patients before electroconvulsive
therapy (ECT). The nurse understands that these medications will reduce the potential side effects of:
1. Cardiac arrest and loss of memory.
2. Convulsions and fractures.
3. Fractures and anxiety.
4. Anxiety and loss of memory
Rationale:
37. (3) The curarelike drug lessens strong muscular contractions during the convulsion that can cause fractures, and the
barbiturate is given to reduce anxiety by putting the patient to sleep for 5 to 10 minutes.
QID: 7156 C 12 ( 160 h 316) Regression is a defense mechanism used by psychiatric patients. The best description of
this mechanism is that it:
1. Is an immature way of responding.
2. Works most effectively to eliminate anxiety.
3. Fosters dependence.
4. Provides security through childlike behavior.
Rationale:
(2) Regression is a way to reduce anxiety and cope with different situations by going back to a time when the patient felt
more safe, secure, and comfortable.
QID: 7157 C 20 ( 303 h 326) A 25-year-old client is seen in the mental health clinic. She has had multiple surgeries,
and has visited over 20 physicians in the last year. She tells the nurse that no one can find anything wrong with her, but
she is sure she has a tumor. The nurse determines that the client is most likely experiencing:
1. Conversion disorder (somatoform disorder involving motor or sensory problems suggesting a neurologic condition)
2. Pain disorder. (This is not a pain disorder)
3. Body dysmorphic disorder. (Situation describes a pervasive subjective feeling of ugliness
4. Somatization disorder. (Correct response: This is a chronic, severe anxiety disorder in which client expresses
emotional turmoil/ conflict through physical complaints)
QID: 7158 C 22 ( 353 h 338) While conversing with the nurse, a hospitalized schizophrenic client repeats every word
that the nurse says. The nurse should document the client’s
1. Waxy flexibility. (Inappropriate posturing; wrong choice)
2. Echopraxia. (Repetitive irritation of movement; wrong choice)
3. Word salad. (Words phases with no meaning or logical coherence)
4. Echolalia. (Correct; Pathological parrot-like repetition of a word or phase)
123
Correct; 4 Cpt; 22 Text Pg 353 meds 93 Hesi 338
Client Category: Psychosocial integrity
QID: 7159 C 19 ( 288 h 322 ) The nurse observes a client who has been admitted to an inpatient psychiatric unit. The
client has washed her hands five times in the last 20 minutes. The nurse should document the client’s:
1. Fear of disease. (This is not fear)
2. Need for cleanliness. (The practice is too frequent for just a need for cleanliness)
3. Obsessive-compulsive behaviors. (Correct; This is compulsion to keep on washing hands)
4. Hatred of her body. (This is not hatred)
Correct; 3 Cpt; 19 Text Pg 288 Med Text Pg 91 Hesi Text Pg 322
QID: 7160 C 19 ( 289 h 323) One year ago a client who is a firefighter almost died while fighting a fire in his
neighborhood. The client lost his best friend in the fire. He visits the mental health clinic because he has been unable to
sleep and his wife is ready for a divorce. The nurse determines that the client is most likely experiencing:
1. Panic without agoraphobia. (This is not a situation of panic which occur with a real illness that has both physical and
psychological component)
2. Post-traumatic stress disorder. (Correct; Occur after one is involved in a traumatic event)
3. Generalized anxiety disorder. (Not correct; This is characterized by unrealistic or excessive anxiety and worry)
4. Somatization disorder. (Client express emotional conflict through physical complains
Correct; 2 Cpt; 19 Text Pg 289 Meds Text Pg 91 Hesi Text Pg 323
Client Category: psychosocial integrity
QID: 7161 C 21 (324 h 332) Adolescents with Bipolar Disorders:

1. Experience primarily depressive episodes (This is not the case with adolescents but in elderly)
2. Are likely to have both manic and depressive episodes (Correct; Commonly occurs in adolescents)
3. Rarely experience psychotic symptoms (May have some psychotic symptoms)
4. Experience primarily manic episodes (Adolescents experience both manic and depressive episodes)
Correct; 2 Cpt; 21 Text Pg 324 95 332
QID: 7162 C 21 (324 h 332) Which of the following is a neurotransmitter that is described as a mood-regulating
hormone?
1. L-dopa (This is not a hormone)
2. Serotonin (Correct; This is a Neurotransmitter that acts also as a hormone)
3. Epinephrine (This is a catecholamine not a Neurotransmitter (NT))
4. GABA (This is a NT)
Client Category: Physiological integrity
QID: 7163 C 21 (324 h 332) Bipolar disorders described as mental conditions are:
1. Psychosis-based (Psychotic disorders include schizophrenia and schizophrenia-like conditions)
2. Mood-based (Correct; Bipolar disorders are mood disorders)
3. Personality-based (Bipolar disorders are not personality based)
4. Self-mutilation-based (Bipolar disorder are not self mutilative)
QID: 7164 C 21( 324 h 332) The best form of treatment of bipolar disorder is which one of the following?
1. Psychotherapy (Good for disorders requiring understanding and insight into oneself)
2. Electroconvulsive therapy (Effective for depressive disorders)
3. Assertiveness training (Clients are taught how to relate to others using frank, honest and direct expressions whether
negative or positive)
124
4. Medication (Correct; These are effective for disorders requiring physico-biochemical alterations)
QID: 7165 C 21 (324 h 332) Which of the following practices are therapeutic to a client experiencing a manic episode?
1. Vigorous group games (This exercise is too stimulating for a manic client)
2. A talkative roommate (Too stimulating)
3. A no challenging atmosphere (Correct; Client with mania need a calm environment)
4. Competitive board games (Too challenging for a manic client)
Correct; 3 Cpt; 21 Text Pg 324 Meds Pg 95 Hesi Pg 332
QID: 7166 C 21 (324 h 332) A client with mania may express which of the following characteristics:
1. Assume too many responsibilities (Correct; Client with Maina is hyperacactive)
2. Concentrate on one task to the exclusion of all others (Not a manic client)
3. Be considerate of others (Not a manic client)
4. Work well with another client with mania (Not a manic client)
QID: 7167 C 19 (279 h 320) Which of the following physiological responses can be seen in a client with severe anxiety?
1. Sensory perceptions (Seen in thought disorders)
2. Salivation (Seen in some poisoning cases e.g. organophosphate)
3. Vital signs alterations (Correct)
4. Dexterity (Seen in some people with gait disorders)
Client Category: physiological integrity
QID: 7168 C 19 (279 h 320) Severe anxiety may escalate to a panic episode. A client with panic episode expresses which
of the following emotions?
1. Neutral (Clients with panic attacks are usually overwhelmed by the events)
2. Balanced (Clients with panic attacks are usually overwhelmed by the events)
3. Overwhelmed (This is correct; Panic attacks make client disturbed)
4. Drained (Clients with panic attacks are usually overwhelmed by the events)
QID: 7169 C 19 (285 h 321) Which one of the following refers to the technique of exposing a client to a fear-producing
sensation in a gradual manner?
1. Bio feed back (Correct; Involves gradual exposure to a fear-producing situation)
2. Imagining (A form of stress reduction technique involving imagery)
3. Relaxation techniques (Used for stress/ anxiety reduction)
4. Systematic desensitization (Gradual exposure to allergens)
QID: 7170 C 22 (353 h 338) With the biological theories of Schizophrenia, the neurotransmitter found to be in excess in
people with Schizophrenia is:
1. Dopamine (Correct; The excess NT in schizophrinia is dopamine)
2. Epinephrine (Wrong choice; This increases in fear, fright or flight situations though studies are inconclusive)
3. Serotonin (Wrong choice; Plays a role in anxiety situations)
4. norepinephrine (Wrong choice: This increases in fear, fright or flight situations though studies are inconclusive)
125
QID: 7171 C 21 (235 h 332) Affect describes how a person expresses an:
1. Opinion with emotion and vigor (Affect deals with mood that accompany ideas /actions)
2. Understanding of personal events, negative or positive (Incorrect: Affect deals with mood that accompany ideas
/actions)
3. Emotion that accompanies an idea verbally or nonverbally (correct choice)
4. Issue about which the person feels strongly (Affect involves feelings accompanying verbal or non verbal actions)
QID: 7172 C 21 (325 h 332) Major depression is a mood disorder that is distinguished by which one of the following
moods?
1. Euphoric mood (Seen in mania)
2. Depressed mood (Correct; Seen in depressive mood disorders)
3. Dysmorphic mood (Pervasive subjective feeling of ugliness)
4. Euthymic mood (Describes a state of some depression)
Correct; 2 ctp 21 Text Pg 325 Meds Pg 95 Hesi Pg 332
QID: 7173 C 19 (298 h 320) Which of the following behaviors is seen in a patient with generalized anxiety disorder
(GAD)?
1. Overeating (Seen in bulimia)
2. Concentration (Concentration on an important issue is a normal expectation)
3. Worrying (Correct; GAD is characterized by excessive worrying)
4. Sleeping (Seen in narcolepsy)
Correct; 3 Cpt; 19 Text Pg 298 Meds Pg 90 Hesi Pg He320
QID: 7174 C 19 (289 h 323) Johnny age 10 has experienced an extreme event that involved injury or threat. He feels
intense helplessness, and fear. He is unable to sleep or stay asleep. Based on this information, Johnny may be suffering
from:
1. OCD. (Obsessive-compulsive disorder is characterized by extreme obsessions/ repetitive behaviors)
2. ADHD. (Attention deficit hyperactivity disorder clients are usually restless and not attentive)
3. GAD. (Generalized anxiety disorder is characterized by excessive worrying)
4. PTSD. (Correct; Post traumatic stress disorder occur after one is involved/ witnesses a traumatic event)
QID: 7175 C 21 (324 h 332) A client is diagnosed with a major depressive disorder. This client differs from a client
diagnosed with manic episode in that the client with a major depressive disorder will exhibit
1. Euphoric moods throughout the day. (This is exhibited in a manic episode)
2. Markedly diminished interest in activities. (Correct; A major depressed client is usually withdrawn)
3. Psychomotor agitation. (This is seen with schizophrenia)
4. Increased talking. (Seen in a client with mania)
QID: 7176 C 21 (324 h 332) A client who is hospitalized for major depression is lying on the floor and in a very
depressed state. The nurse should assess the client for potential
1. Manic swings. (This is not seen in depression but in mania)
2. Anger toward other clients on the unit. (Not a characteristic of a major depression)
126
3. Increased hyperactivity. (This is seen in mania)
4. Suicide attempts. (Correct; Client may have suicidal thoughts and hence attempt suicide)
Client Category: Safe effective care environment
QID: 7177 C 21 (324 h 332) Which nursing diagnosis for a client with an affective disorder would have the highest
priority?
1. Activity intolerance (This is a priority nursing diagnosis with attention deficit hyperactivity disorder)
2. Risk for self-directed violence (Correct; Self-directed violence is common with mood disorders)
3. Self-care deficit (May occur in client with mania/ client has no time for self care)
4. Powerlessness (This occurs in grief)
QID: 7178 C 22 (353 h 338) The client is hearing voices and seeing things that are not there. He complains of having no
energy and not caring about anything. His physician would diagnose his problem as schizophrenia and prescribe which
medication:
1. Antiepileptic. (These symptoms are for schizophrenia, not epilepsy)
2. Antipsychotic. (Correct; These condition is a schizophrenic-like disorder and is treated with antipsychotics)
3. Antidepressant. (The condition does not describe depression but schizophrenia)
4. Antianxiety drug. (In schizophrenia there is no anxiety features to warrant antianxiety drugs)
Client Category: Physiological integrity: Pharmacology and parenteral therapies
QID: 7179 C 22 (353 h 338) Schizophrenia is a mental disorder where an individual has disturbances in which of the
following:
1. Pain levels and ataxia.(Incorrect)
2. Thinking and behavior.(Correct; Schizophrenia involves alterations in thought processes)
3. Speech and hearing abilities.(This describes dump and deaf)
4. Fine and gross motor activities (This describes a neuro-muscular disorder)
Client Category: physiological integrity
QID: 7180 C 22 (353 h 338) When a client states “Look at the bat in the corner of the room” and the nurse does not see
a bat in the corner of the room, the nurse assesses that the client is having:
1. A neologism (Refer to use of new words coined by a person which others don’t understand)
2. A delusion. (Fixed false beliefs true to the facts and not accepted by other members of same culture)
3. Hallucination. (Correct; Seeing things that in reality are not there)
4. An illusion. (Misperception of a real external stimulus)
QID: 7181 C 21 (353 h 338) Which of the following characteristics describes a schizoaffective disorder?
1. Personality disorder and symptoms of schizophrenia (Scizophrenia forms part of schizo-affective disorders but not
personality disorders).
2. Learning disorder and symptoms of schizophrenia. (Learning disorders are not part of schizo-affective disorders)
3. Major depressive episode and symptoms of schizophrenia. (Correct; The condition includes mood and thought
disorders)
4. Conversion disorder and symptoms of schizophrenia (There is no conversion disorder in schizoaffective disorders)
QID: 7182 C 21 (332 h 324) Dysthymia refers to a mood disorder whose characteristics can be described as:
127
1. More severe, more debilitating depression. (Incorrect; It’s usually less severe)
2. More severe, less chronic depression. (Incorrect; Usually less severe but more chronic)
3. Less severe, more chronic depression. (Correct; Clients experience symptoms similar to severe depression but it’s
less severe and more chronic)
4. Less severe, more short-term depression. (Incorrect; Clients experience symptoms similar to severe depression but
it’s less severe and more chronic)
QID: 7183 C 21 (324 h 332) When medicating a client with depression, the nurse must check to be sure that the:
1. Medication is working. (Not correct; Medication has to be taken first)
2. Client has swallowed the medication. (Correct; Depressed client may pretend to have taken the drugs but throw them
away)
3. Client has food to take with the medication. (Some medicines need empty stomach)
4. Client is willing to take the medication. (Client has be shown the importance of taking the medication first)
Client Category: pharmacology and parenteral therapies
QID: 7184 C 21 ( 324 h 332) Mania is a Bipolar disorders characterized by which of the following symptom?
1. Omnipotence and dejavu. (Manic clients feel euphoric and excited)
2. Energy and ennui. (Manic clients feel euphoric and excited)
3. Insecurity and intense anxiety. (This reflects is phobia)
4. Extreme irritability and excitement. (Correct; client demonstrates a state of extreme excitement and euphoria)
Correct; 4 Cpt; 21 Text pg 324 Meds Text pg 95 Hesi Text pg 332
QID: 7185 C 12 ( 160 h 316) Reaction formation is a coping mechanism used during episodes of mania, characterized
by an underlying:
1. Depression, although the client acts happy. (Correct; Reaction formation involves unconscious demonstration of the
opposite behavior, attitude or feeling of what one would normally show in a given situation)
2. Psychosis, although the client acts oriented. (Incorrect; Reaction formation involves unconscious demonstration of
the opposite behavior, attitude or feeling of what one would normally show in a given situation)
3. Personality disorder, although the client acts calm. (Incorrect; Reaction formation involves unconscious
demonstration of the opposite behavior, attitude or feeling of what one would normally show in a given situation)
4. Dementia, although the client acts coherent. (Incorrect; Reaction formation involves unconscious demonstration of
the opposite behavior, attitude or feeling of what one would normally show in a given situation)
Correct; 1 Cpt; 12 Text Text pg 160 Meds Text pg 99 Hesi Text pg 316
Correct: 1
QID: 7186 C 21 ( 342 h 337) A client taking lithium is at risk of developing which important toxic side effect?
1. Ataxia. (Occur with typical antipsychotics)
2. Confusion (Correct; Lithium toxicity can cause drowsiness,stupor and even death)
3. Nystagmus. (Lithium causes blurred not nystagmus)
4. Alopecia. (Occur with cytotoxics)
Client Category: Pharmacological and parenteral therapies
QID: 7187 C 19 (280 h 320) Anxiety is different from fear, in that anxiety is
1. Directed toward a specific situation. (Not necessarily so, anxiety can occur from within with feelings of helplessness)
2. Focused on external forces. (Some are focused on internal forces)
3. Recurring with similar circumstances. (Not necessarily true)
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4. Characterized by alertness and a vague, uneasy feeling. (Correct; Client has decreased interest and unable to
concentrate)
client category: psychosocial integrity
QID: 7188 C 19 (284 h 321) Panic disorder characteristics include which one of the following:
1. Brief periods of mild fear accompanied by physical symptoms. (Fear is intense not mild)
2. Long periods of mild fear accompanied by psychosomatic symptoms. (No psychosomatic symptoms)
3. Brief periods of intense fear accompanied by physical symptoms. (Correct)
4. Long periods of intense fear accompanied by short attention span. (Intense fear is accompanied by clinical symptoms)
QID: 7189 C 19 ( 288 h 328) Which one of the following refers to the repetitive behaviors that a person feels driven to
perform in a response to an obsession?
1. Confessions. (Refer to owning up of one’s misdeeds)
2. Confabulations. (Muttering word without a specific meaning)
3. Conversions. (Refer to somatoform disorder that involve motor or sensory problems suggesting a neurologic
condition)
4. Compulsions. (Correct; Prefers to compulsive forces that make one repeat actions)
QID: 7190 C 20 ( 303 h 326) A client who is diagnosed with hypochondriasis is usually pre-occupied with fear of
which of the following:
1. Having a serious illness. (Correct; Clients present with exaggerated /unrealistic physical complains)
2. Heights. (This is acrophobia)
3. Losing his or her job (This is not a specific phobic situation)
4. Having sexual relations. (Androphobia usually describes fear of men)
QID: 7191 C 19 ( 288 h 328) Which one of the following medications can be used to treat obsessive compulsive
disorder?
1. Gamma-aminobutyric acid. (Releases of this is enhanced by anxiolytic drugs)
2. Norepinephrine. (This is a resuscitatory drug)
3. Lithium. (This is an anti-psychotic)
4. Clomipramine. (Correct; This is an anti-depressant used to treat anxiety that’s associated with obsessive-compulsive
disorder)
Client Category: Pharmacology and parenteral therapies
QID: 7192 C 12 ( 152 h 315) An inpatient client on a psychiatric unit is scheduled for hand surgery to correct an injury.
To help the client cope with the upcoming surgery, the nurse should provide the client with:
1. Very little information as this may increase the client’s anxiety. (This is not an appropriate practice)
2. Long and detailed explanations of the procedure to be performed.(Will not address client’s concerns)
3. Booklets and pamphlets that describe the procedure to be performed. (May not read the information)
4. Brief objective and concrete answers to the client’s questions.(This answers client’s concerns)
Client Category: Health promotion and health maintenance
QID: 7193 C 12 (160 h 316) The nurse is caring for a 17-year-old client whose mother abandoned her as a young child.
The client avoids any female authority figures and is having difficulty with a female teacher at her school. The client
tells the nurse “I know she can’t stand me!” The nurse determines that the client is using a defense mechanism termed:
129
1. Projection. (Correct; This is unconscious assignment of unacceptable thoughts of self to others)
2. Regression. (Retreat to past developmental stages/ behaviors)
3. Denial. (Unconsciously not accepting to face the reality)
4. Delusions. (False beliefs)
Correct: 1
QID: 7194 C 21 (354 h 338) A client hospitalized in an inpatient psychiatric unit appears extremely restless and
anxious. The nurse should document the client’s:
1. Akathisia. (Correct; Irresistible urge to keep on moving)
2. Akinesia. (This describes reduced movement)
3. Parkinsonia. (Staggering gait and involuntary movements)
4. Akinesthesia. (Not having power to move)
QID: 7195 C 13 ( 169 h 315) Crisis intervention is most effective if it occurs:

1. In an acute care setting. (Incorrect: the environment has to be supportive for a crisis intervention)
2. In a community setting. (Incorrect: the environment has to be supportive for a crisis intervention)
3. In a home setting. (Incorrect: the environment has to be supportive for a crisis intervention)
4. In a supportive environment. (Correct: Crisis intervention is more effective if the environment is supportive)
Correct; 4 Text pg 169 Meds Text pg 86 Hesi Text pg 315
Correct: 4
QID: 7196 C13 ( 280 h 320) A recently divorced client presents to an emergency department with symptoms of
anxiety. These symptoms are likely the result of a/an:
1. Depressive disorder (Incorrect; anxiety resulted from the divorce situation)
2. Developmental crisis. (This is not a developmental disorder but anxiety due to a situation)
3. Anxiety disorder. (Incorrect; anxiety resulted from the divorce situation)
4. Situational crisis. (Correct; Anxiety resulted from the divorce situation)
QID: 7197 C 21 ( 324 h 332) A client who is hospitalized in an inpatient psychiatric setting appears withdrawn and
quiet after admission. The type of therapeutic approach advisable for this client is:
1. Frequent interactions with the entire health care team. (This is not therapeutic)
2. Social isolation from the other clients on the unit. (This is not therapeutic)
3. A one-to-one relationship with a staff member. (Correct; This will encourage the client to open up to the staff whom
he/she has gotten used to)
4. Numerous relationships with the other clients on the unit. (This is not therapeutic)
QID: 7198 C12 ( 152 h 315) The nurse praises a client for taking a shower without a reminder. This is an example of:
1. Complimentary therapy. (These are non conventional therapies)
2. Positive reinforcement. (Correct)
3. Operant conditioning. (Results of one’s determine whether behavior recurs in future)
4. Behavior modification. (Not correct: No behavior is being modified)
Correct; 2 Cpt; 12 Text Pg152 Meds Text pg 85 Hesi Text pg 315
130
QID: 7199 C 18 ( 206 h 317) The nurse is leading a group of women in weekly sessions. All of the women have lost a
child due to terminal illness. This type of group is called a/an:
1. Instructional group. (This is a group with a need to be taught on a certain topic)
2. Support group. (Correct; Have experienced similar losses and can share and support each other)
3. Therapy group. (This is for people with a certain mental or disease condition for purposes of seeking ways of
recovery)
4. Grief group. (This is for people who are mourning a loss)
QID: 7200 C 18 ( 206 h 317) The nurse is conducting group therapy sessions for a group of individuals who are
experiencing post-traumatic stress syndrome. The role of the nurse is to:
1. Encourage the group members to express their feelings. (Helps them to overcome the event)
2. Offer advice on how to cope with problems of daily living. (This is not therapeutic)
3. Keep the conversation directed in an appropriate manner. (This is not an appropriate nurse’s role)
4. Discourage hostility among the group members. (This is not an appropriate nurse’s role)
QID: 7201 C 22( 364 h 341) The nurse is caring for an elderly female client who has been taking Thorazine for seven
weeks. The client has developed a fever and tells the nurse that her throat is sore. The nurse should:
1. Ask the client if she is allergic to aspirin. (This will not help in managing the client)
2. Provide the client with a soothing mouthwash. (This will not help in managing the client)
3. Review the client’s most recent blood work. (Correct; To assess drug levels and monitor for toxicity)
4. Inspect the client’s skin for dermatitis.(Sore throat indicates drug toxicity and drug levels in blood need to be
determined)
QID: 7202 C 21 ( 324 h 332) Observation is an important aspect of nursing care. It is especially important in the care of
the withdrawn client because it:
1. Helps in the understanding the client’s feelings (Correct)
2. Tells the staff how ill the client is (Not always the case)
3. It is important in making a diagnosis. (Not always)
4. Indicates the degree of psychic depression (Not always)
QID: 7203 C 17 (324 h 332) A 23-years-old has been admitted to a psychiatric hospital after a month of unusual
behavior that included eating and sleeping very little, talking and singing constantly, and frequent shopping sprees. In the
hospital, the client is demanding bossy, and sarcastic. The symptoms the client is exhibiting are usually in clients with
the diagnosis of:
1. Major depression (Not depression; client is not withdrawn)
2. Mood disorder (Correct mania presents in this manner)
3. Personality disorder (Not a personality disorder)
4. Schizophrenic disorder (Schizophrenia does not have the given features)
QID: 7204 C 17 ( 252 h 316) A severely depressed client is to have electro-convulsive therapy (ECT). The nurse, when
discussing this therapy, should tell the client that:
1. There will be a memory loss as a result of the treatment (No memory loss with ECT; just temporary disorientation)
131
2. Sleep will be induced and treatment will not cause pain. (Correct; this is true of ECT )
3. With new methods of administration, treatment is totally safe (Give correct information to client)
4. It is better not to talk about it, but the client can ask any question (The client has the right to know the truth about his
treatment)
QID: 7205 C 17( 252 h 316) A 46 years old male client has just awakened from his scheduled ECT treatment. The most
appropriate nursing intervention would be to:
1. Arrange for the dietary staff to bring a lunch tray. (Orient the client first once awake)
2. Get the client up and out of bed as soon as possible and back into the units routine (This is not a safe practice. Orient
the client once awake)
3. Orient the client to time and place and tell him that he just had treatment (Clients are usually disoriented post ECT)
4. Take the blood pressure and pulse rate every 15 minutes until the client is fully awake(Clients are usually disoriented
post ECT)
QID: 7206 C 22(364 h 341) A client receiving high-dosage chlorpromazine hydrochloride (Thorazine) has developed
tremors of both hands. The nurse should:
1. Withhold the medication (This is not an appropriate nursing action since the side effect is not life threatening)
2. Tell the patient it is transitory (This is false reassurance)
3. Give the client finger exercises to perform (Correct; Finger exercises help to reduce tremors)
4. Report the symptoms to the physician
Client Category: Pharmacological and parenteral therapies
QID: 7207 C 14 ( 187 h 315) A student nurse is assigned to work in the psychiatric unit. The student asks the clinical
instructor, “How do I introduce myself?” Which of the following responses, if given by the nurse instructor is most
appropriate?
1. “You introduce yourself by your first name only” (Not correct; a partial introduction; client needs to know you fully.)
2. “Don’t say anything unless the client asks you”. (Not correct; Client has a right to know you.)
3. “Although you’ll be wearing a name tag informing the client that you’re a student nurse is appropriate” (Correct
response.)
4. “It’s okay to inform the client that you’re a newly employed professional nurse assigned to work in the unit” (No need
to lie to the client.)
Correct; 3 Cpt; 14 Text pg 187 MEDS Text pg 16-19 HESI Text pg 315
QID: 7208 C 12 ( 160 h 316) A student nurse asks the nurse “Are Ego defense mechanisms useful?” Which of the
following responses from the nurse is least appropriate?
1. They are used to resolve a mental conflict. (A correct response.)
2. They reduce anxiety or fear. (A correct response.)
3. They protect one’s self-esteem. (A correct response.)
4. They are always therapeutic. (Ego defense mechanisms are not always therapeutic.)
Correct; 4 Cpt; 12 Text pg 160 Meds pg 86 Hesi Pg 316
QID: 7209 C 12 ( 152 h 315) A risk nursing diagnosis:

1. Focus on clinical judgment about an individual or community transitioning from a specific level to a higher level of
wellness. ( This is not a description of a risk nursing diagnosis)
2. Refers to a cluster of actual or high risk diagnoses that are predicted to be present because of certain event. ( This is
not a description of a risk nursing diagnosis)
132
3. Is based on the nurse’s clinical judgment of the client’s degree of vulnerability to the development of a specific
problem. ( Correct: The nurses assesses the degree of vulnerability and determines riskyness)
4. Is based on the nurse’s clinical judgment on review of validated data:
Correct; 3 Cpt; 12 Text pg 152 meds Pg 85 Hesi Pg 315
Correct: 3
QID: 7210 C 12 ( 152 h 315) The following is list of interventions used by all nurses in the psychiatric-mental health
clinical setting EXCEPT:
1. Case management. (Correct; Nurses follow cases up for appropriate management)
2. Health education. (Health education is given by nurses)
3. Counseling. (This is a role performed by nurses)
4. Pharmacologic agent prescription. (This is not a nurse’s role)
Correct; 4 Cpt; 12 Text pg 152 Meds Pg 85 Hesi Pg 315
Client Category: health promotion and maintenance
Correct: 4
QID: 7211 C 12 ( 152 h 315) A client scheduled for an abdominal surgical operation asks the nurse if she will be able to
eat all types of food after the operation. The nurse responds, “Don’t worry, everything will be okay”. Which type of non
therapeutic communication does the nurse demonstrate?
1. False reassurance. (This nurse’s statement reflects false reassurance.)
2. Giving advice. (The nurses is not giving advice.)
3. A judgmental attitude. (This is not a judgment but false reassurance.)
4. Failure to listen. (Not the correct response.)
QID: 7212 C 12 (169 h 315) An example of stunned-inactive response to a crisis is:

1. Rapid speech;
2. Flushed face;
3. Hyperactivity;
4. Inactivity; (Correct: stunned-inactive response to a crisis is characterized by inactivity, cold clammy skin, pale
appearance. Rapid speech, hyperactivity and flushed face are characteristics of high anxiety emotional shock)
Client Category: Psychosocial integrity)
Correct: 4
QID: 7213 C 19 ( 289 h 323) A disaster victim may experience the following transitional periods during the recovery
process, Except:
1. Heroic period. (The victim is traumatized)
2. Honeymoon period. (The victim is traumatized)
3. Period of disillusionment. (The victim is traumatized and may have illusions)
4. All of the above. (A client in recovery post trauma does not experience heroism or honeymoon-like. He may have
illusions)
QID: 7214 C 21 ( 325 h 332) An appropriate intervention by the nurse therapist during rational emotive therapy is the
one that:
1. Hypnotizes client (Client has to be part of solution to his concerns by developing problem-solving skills)
2. Rejects unrealistic behavior displayed by client (This is not therapeutic)
3. Promotes problem-solving abilities, social skills, and assertiveness (Correct; This approach is therapeutic)
4. Encourages discussion of emotional conflicts; (Not entirely correct)
133
Correct; 3 Cpt; 21 Text pg 325 Meds Pg 95, 98 Hesi Pg 332
QID: 7215 C 21 ( 325 h 332) An emotionally stable client is:

1. Able to interact with others without displaying undue anger, fear or frustration. (Correct; One has to be in control of
self)
2. Often inflexible and run risk of neglecting the perception of others. (Not correct: One has to be flexible)
3. Who does not make decisions until he or she aware of all the facts pertaining to ascertain situation (One need to have
decision-making abilities)
4. None of the above (Choice 1 is correct.)
Correct; 1 Cpt; 21 Text pg 325 Meds Pg 95, 98 Hesi Pg 332
QID: 7216 C 19 ( 287 h 320-321) Which of these drugs is not usually used for anxiety disorder?
A. Atenolol (Tenormin)( Is used to control palpitations associated with anxiety)
B. Venlafaxine (effexor)( Is used to treat anxiety)
C. Propanolol (Inderal( Is used to control palpitations associated with anxiety)
D. Promethazine (Phenergan)( This is Anti-emetic for treating nausea and vomiting
Correct; 4 Cpt; 19 Text pg 287 Meds Pg 90 Hesi Pg 320 – 321
Rationale:
The ans is 4; the first 3 can be used for anxiety disorder
QID: 7217 C 17 ( 252 h 337) The primary function of the electroconvulsive therapy (ECT) is to:
1. Inhibit neuronal transmission in the brain. (This is done by drugs)
2. Induce convulsive seizures in neurons in the entire brain. (Correct; This helps to reorganize neuronal electrical
discharges)
3. Enhance the activity of monoamine oxidase enzyme. (Done by drugs)
4. To correct all behavioral alterations. (This is not achievable with ECT)
Correct; 2 Cpt; 17 Text pg 252 meds 99 hesi 337
QID: 7218 C 17 ( 252 h 316) The ECT that produces a sleep-like state without the presence of convulsions is called?
1. Electroparesis (Studies electrical pathways)
2. Electroshock therapy (Initial reference to ECT)
3. Electronarcosis (Correct; Induces sleep and no convulsions witnessed)
4. Electrophysiotherapy (Physiology of electrical discharges)
Correct; 3 Cpt; 17 Text pg 252 meds 99 hesi316
Client Category: pharmacology and parenteral therapies
QID: 7219 C17 ( 252 h 316) Indicators for ECT use include all of the following, EXCEPT:
1. Schizophrenia
2. Obsessive-compulsive disorder
3. Delusional depression
4. Somatization disorders (Not correct)
Correct; 4 Cpt; 17 Text pg 252 99 316
Client Category: physiology integrity
Rationale:
Schizophrenia observe compulse and delusional depression can all be treated with ECT unlike somatization disorders
which involve physical symptoms
QID: 7220 C17 ( 252 h 316) Which of the following statements about the use of ECT is correct?
134
1. ECT maybe used to treat pregnant women. (Correct)
2. ECT is effective in treatment of personality disorders. ( ECT does not treat PD)
3. ECT is contraindicated in treatment of depression in children. (ECT can be used for depression in children ECT
cannot treat movement disorder because they are mainly of organic origin)
4. ECT is the treatment of choice in the treatment of movement disorders. (ECT can safely be used with expectant
mothers)
Correct; 1 Text pg 252 meds 99 hesi 316
Client Category: physiologic integrity pharmacology & parenteral therapies
QID: 7221 C 17 ( 252 h 316) The most common adverse effects reported by clients during ECT include:
1. Pulmonary distress
2. Headache
3. Vertebral fractures
4. Permanent memory loss
Correct; 2 Cpt; 17 Text pg 252 99 316
Client Category: physiology integrity pharmacology and parenteral therapies
Rationale:
Headaches are the most commonly reported side effects to ECT. ECT does not cause pulmonary distress but may be
associated with temporary memory loss and extremity fractures
QID: 7222 C 19 ( 280 h 320) A nurse is assessing a client suspected of having an anxiety disorder. The client asks the
nurse, “How does fear differ from anxiety?” The nurse would appropriately state that fear differs from anxiety because
fear:
1. Is just a symptom. (It is physiological and emotional response to danger)
2. Describe feelings of uncertainty, uneasiness and tension. (This is more of a phobia than fear)
3. Is the body’s physiologic and emotional response to a known or recognized danger. (Correct choice)
4. Does not differ from anxiety at all. ( Fear and anxiety are different since fear is a response to a known or recognized
danger while anxiety can occur without a recognized danger)
Correct; 3 Cpt;19 text pg 280 meds 89 hesi 320
Client Category: physiologic integrity
QID: 7223 C 19( 280 h 320) Anxiety that is always present and is accompanied by a feeling of dread is referred to as:
1. Anxiety trait. (Refer to existence of a genetic component that denote presence of anxiety)
2. Anxiety state. (Situation when one is anxious)
3. Free-floating anxiety. ( One has a dreadful feeling accompanying anxiety)
4. Signal anxiety. (Periodic warning of anxiety)
Correct; 3 Cpt;19 text pg 280 meds 89 hesi 320
QID: 7224 C 19 ( 280 h 320) According to the psychoanalytic theory, anxiety is the:
1. Result of unresolved, unconscious conflicts between impulses for aggressive or libidinal gratification and the ego’s
recognition of the external damage that could result from gratification. (This includes unconscious conflict of childhood
and loss of parental love or attention)
2. The learned or conditioned response to a stressful event or perceived danger. (This is in behavioral theory)
3. Result of increased levels of serotonin in raphe nucleus, thalamus and basal ganglia. (This is biogenic theory/Biologic
theory)
4. None of the above (Choice 1 is correct)
Correct; 1 Cpt;19 Text Pg 280 Meds Pg 89 Hesi Pg 320
QID: 7225 C 19 ( 280 h 320) A nurse assessing a client with anxiety disorder identifies which of the following
physiologic symptom(s) of anxiety? Select all that apply
1. Irritability
135
2. Blurred vision
3. Dilated pupils
4. Hypervigilance
5. Crying
6. Diaphoresis
Correct; 2, 3, 6 Cpt; 19 Text pg 280 Meds Pg 89 Hesi Pg 320
QID: 7226 C 20 ( 303 h 326) Which of the following is an appropriate outcome for a client treated for a somatoform
and dissociative disorder?
1. The client will have diminished episodes of confusion related to amnesia as fugue improves.
2. The client will verbalize feelings related to anxiety
3. The client will demonstrate an improved ability to express self
4. The client will express confidence in self
Rationale:
Outcomes focus on client’s ability to recognize his or her own anxiety identity stressors and ways to modify or eliminate
stressors and develop effective coping skills
QID: 7227 C 20 ( 303 h 326) One of the following is not a somatoform disorders;
1. Obsessive – compulsiveness disorder
2. Conversion disorder
3. Pain disorder
4. Hypochondriasis
Correct; 1 Cpt;20 Text Pg 303 Meds Pg 91 Hesi pg 326
Rationale:
Somatoform disorders includes conversion disorders, pain disorders somatization disorder, alprechondrias, Body
dysmophic disorders, undifferentiated somatoform disorder and somatoform disorder not otherwise specified
QID: 7228 C 21 ( 324 h332) A nurse caring for a client with a mood disorder is aware that the risk factor(s) for mood
disorders include, (select all that apply)
1. Prior episodes of depression
2. Male gender
3. Prior suicide attempts
4. Intrapartum period
5. Adequate social support
Correct; 1, 3 Cpt; 21 text 324 meds 95 hesi 332
Rationale:
1. Risk factors for moral disorders include prior episodes of depression, family history prior suicide attempts, female
gender, age younger than 40 poor pattern period medical immobility, low of social support, stressful life events, correct
alcohol use, presence of anxiety or other disorder
QID: 7229 C 21 ( 324 h 332) Studies of twins have shown that if an identical twin develops a mood disorder, the other
twin has a 70% chance of developing the disorder. This statement is true according to which theory about the etiology of
mood disorders?
1. Biochemical theory. (Biogenic amines and Norepinephrine serotonin have been known to regulate mood)
2. Neuroendocrine regulation. (High level of cortisol have been known in people with mood disorders)
3. Genetic theory. (Genetic theory studies have revealed a higher correction of mood disorder with genetic relationship
with 70% in identical twins. This circulation however decreases with siblings. Parents or children of person with mood
disorder)
136
4. Behavioral theory. (Regarded as acquired or learned behavior)
QID: 7230 C 15 ( 353 h 338) Most people initially develop the symptoms of Schizophrenia during:
1. Childhood or adolescence
2. Adolescence or early adulthood
3. Early-or middle adulthood
4. Middle-or older adulthood
Correct; 2 Cpt; 15 Text pg 353 Meds Pg 93 Hesi pg 338
Correct; 2
Rationale:
Initial development of schizophrenia symptoms usually during adolescence or early adulthood. This can then manifest
through life with periods of severe and less severe symptoms
QID: 7231 C (193 h 317) An advantage to group therapy for persons with eating disorders is
1. Sharing problems with others reduces the isolation the client feels
2. Members can learn from one another
3. Members can practice skills learned in group sessions
4. All of the above
Correct; 4 Text pg 193 Meds Pg 86 Hesi pg 317
Rationale:
All these responses are appropriate advantages of group therapy for people with eating disorders
QID: 7232 C 21( 324 h 332) The client is depressed. Although in contact with reality, she is unable to dress and prepare
food for herself. The client is considered to be:
1. Acting out. (This is a characteristics pretence behavior which is not seen in depression)
2. Mentally ill. (Depression is a disorder and client depressed is unable to function and considered mentally ill)
3. Extremely healthy (Client who is depressed is not healthy)
4. Going through a phase (Depressed client who is unable to function is not going through a phase)
QID: 2971 C 1 (2) Your first assignment in the psychiatric-mental health clinical setting is to provide care for a
female client who appears sad and verbalizes hopelessness to the staff. You are uncertain how to approach the
client. Which of the following actions would be the most effective?
1. Ask a peer to introduce you to the client (No: This is not appropriate)
2. Wait for the client to approach you to avoid bothering the client (No: Not an appropriate behavior)
3. Ask a staff member what approach is usually effective with the client (No: The student need to take the
initiative)
4. Discuss your feelings with your instructor before approaching the client (Correct: Instructor will guide you on
the appropriate way to approach clients)
Correct; 4 Pg 2 chapter 1
QID: 2972 C1 (3) One of your peers states that your assigned client looks like a “drug addict.” Which of the
following best describes your peer?
Introvert (No: Is a quiet individual who lets others initiate interaction and prefers to be a follower)
Judgmental attitude (Correct: Arrived at this option based on own valves without enough facts)
Extrovert (Wrong: Is an outgoing person who relates more easily with others and things in the environment)
Prejudice (Wrong: Feeling of intolerance about someone or somethings)
137
QID: 2973 C1 (3) A nurse assigns a student nurse to care for a client with a mental illness. The student asks,
“What should I do if the client becomes violent?” What should be the nurse’s best response?
“Take off for your own safety”(Incorrect: This is not therapeutic)
“Call for help so as to apply restraint”(Incorrect: Need to notify your instructor and nursing staff)
“Notify your instructor and a member of the nursing staff immediately”(Correct: You need to report immediately
and follow instructions given)
None of the above (Wrong: option C above is correct)
Correct; 3 PG 3 chapter 1
QID: 2974 C1 (3) Persons who display judgmental attitudes are often:
Flexible and open-minded (Incorrect: Judgmental persons are neither flexible nor open-minded)
Inflexible and risk neglecting the perception of others (Correct: Yes they are inflexible and neglect perception of
others)
Open-minded and risk neglecting the perception of others (Incorrect: They are not open-minded)
Apt to arrive at an opinion based on what others feel or think (Incorrect: Do not base opinions on others feelings
or thoughts)
QID: 2975 C1 (4) When assuming the role of a student nurse in the psychiatric-mental health setting, which
behavior would be least effective in helping to achieve personal and professional growth?
Completing a task for a client instead of repeatedly prompting him to finish it (Correct: This will not help client
become independent)
Taking time to adjust to a slower pace (This is a correct behavior. Look for the inappropriate one)
Avoiding frustration when a client refuses to interact (This is correct behavior. Look for the inappropriate one)
Using listening and observing skills through-out the client’s care (This is correct behavior. Look for the
inappropriate one)
QID: 2976 C1 (3) As part of your preparation for your psychiatric-mental health rotation, you and your
classmates participate in self-awareness exercise. Which of the following statements would indicate that you and
your classmates have developed some self-awareness? Select all that apply.
“I’m basically a quiet, thinking kind of person.”(Correct: Is aware of self)
“My back of spontaneity can be a problem sometimes.”(Correct: Aware of limitation)
“I usually don’t take things at face value.”(Correct: Is non judgmental)
“My personality is just fine.”(Incorrect: has no limitations)
“People being inflexible frustrates me.”(Correct: Aware of effects of some personality traits)
“I usually try to stay on schedule.”(Correct: Aware of self weakness)
Correct; 1, 2, 3, 5, 6 Pg 3 chapter 1
QID: 2977 C2 (9) Which of the following would the nurse expect as the least likely reason for using defense
mechanisms?
1. Improved insight (Not a reason for using defence mechanism; hence is the correct option)
2. Protection of self-esteem (This is a reason for using defence mechanism. Hence not the correct option)
3. Reduce anxiety (This is a reason for using defence mechanism. Hence not the correct option)
4. Resolution of a mental conflict (This is a reason for using defence mechanism. Hence not the correct option)
QID: 2978 C 2(9) A client talks to the nurse about safe, neutral topics, without revealing feelings or emotions. The
nurse determines that the client’s motivation for remaining on this superficial level of communication is most
likely which of the following?
Fear of rejection by the nurse (Correct: The client feared rejection by the nurse)
Lack of awareness of feeling (Incorrect: The client had the feelings but did not reveal them)
138
Poor communication ability (Incorrect: client was able to communicate. Hence not the correct option)
Poor emotional maturity (Incorrect: This is not the reason for not revealing feelings or emotions)
QID: 2979 C2 (10) A student nurse asks a psychiatric nurse instructor why she became a teacher. The instructor
replied that she became a teacher because she was unable to master clinical competencies. The student
understands that the nurse is expressing which of the following ego defense mechanisms?
Substitution (Correct: This is unconscious replacement of unacceptable emotions, needs, attitudes with those that
are more acceptable)
Sublimation (Incorrect: Unconscious rechanneling of intolerable/socially unacceptable impulses/behavior into
activities that are personally, socially acceptable)
Projection (Incorrect: Unconscious assignment of acceptable thoughts/characteristics of self to other)
Introjection (Incorrect: Unconscious application of the philosophy ideas and attitudes of another person to one’s
self)
QID: 2980 C 2(13) The characteristics of the mental health include; (select all that apply)
Feeling inadequate (Incorrect: This is not mental health characteristics)
Being optimistic (Correct: Having hope is a mental health characteristics)
Displaying poor judgment (Incorrect: This is not mental health characteristics)
Ability to solve problems (Correct: Being able to tackle problems is a characteristics of mental health )
Inability to perceive reality (Incorrect: One needs to be able to perceive reality to be mentally healthy)
Correct; 2, 4 PG 13 chapter 2
QID: 2981 C 2(18) Which of the following nursing functions is different in current psychiatric-mental health
nursing practice when compared with practice from 1915 to 1935?
Careful client assessment (Incorrect: This practice is the same currently as practiced then)
Concerns about the effect of environmental conditions (Incorrect: This practice is the same currently as practiced
then)
Focus on understanding the causes of mental illness (Incorrect: This practice is the same currently as practiced
then)
Use of nursing diagnosis (Correct: Use of nursing diagnosis began later)
QID: 2982 C 2(20) The certified nurse practitioner of psychiatric nursing performs which of the following
functions not performed by the psychiatric nurse generalist?
1. Case management and health promotion (Incorrect: Is also performed by psychiatric nurse generalist)
2. Counseling and establishment of nursing diagnosis (Incorrect: Is also performed by psychiatric nurse
generalist)
3. Health teaching and milieu therapy (Incorrect: Is also performed by psychiatric nurse generalist)
4. Psychotherapy and prescribing medications (Correct: This is only done by nurse practitioner of psychiatric
nursing)
QID: 2983 C 3(27) The impact of psychoanalytic theory on nursing is that nurses:
Recognized that interventions could be used to bring about changes in thought and feelings (Incorrect: This came
with behavior theory)
Developed an understanding of individual and family behaviors (Incorrect: Was the impact of family systems
theory)
Began to focus on human behavior, early stages of sexual development (Correct: This came with psychoanalytic
theory of sigmuid freud)
139
Recognized that personality development begins at birth and continues a cross the lifespan until death (Incorrect:
was the impact of developmental theory of Eric Erikson)
QID: 2984 C3 (27-28) Nursing theorists concur in viewing humans as beings who are primarily which of the
following?
Biologic (Incorrect; This is part of what human beings are)
Holistic (Correct; Humans are physiological, physiological social and spiritual beings)
Psychological (Incorrect; This is part of what human beings are)
None of the above (Incorrect; Option B is correct)
Correct; 2 Pg 27-28 chapter 3
QID: 2985 C 3(29) The nurse refers a client with a nursing diagnosis of “Dysfunctional Grieving related to the
death of a spouse” to a grief support group. The nurse’s recommendation emphasizes coping mechanisms in
adaptation, illustrating which of the following nursing theories?
Levine (Incorrect; Talks about conservation theory)
Henderson (Incorrect; Talks about Needs theory)
Peplau (incorrect; Talks of adaptation theory)
Roy (Correct; Talks of adaptation theory)
QID: 2986 C 3 (30) The psychiatric nurse focuses on the use of self as a therapeutic tool and evaluates nursing
actions according to client response. Which of the following best describes this nurse’s practice?
Interaction oriented (Correct; Used by nurses who rely on interactions. View selves as therapeutic tools)
Eclectic (Incorrect; This incorporates clients’ own resources as unique person)
Needs oriented (Incorrect; Here nurses are actively doing and functioning)
Outcome oriented (Incorrect; Used by nurses who rely on interaction)
QID: 2987 C 30(3) An individualized style that incorporates the client’s own resources as a unique person with
the most suitable theoretical model, is:
Eclectic Approach (Correct; This is an individual style)
Outcome-oriented Approach (Incorrect; Used by nurses who are goal setters)
Needs-oriented Approach (Incorrect; Here are actively doing and functioning)
Interaction-oriented Approach (Incorrect; Used by nurses who rely on interaction)
QID: 2988 C 3 (34) One of the reasons why nurses fail to provide spiritual care to culturally diverse clients,
according to Andrews and Boyle, is that the nurse may:
View religious and spiritual needs as a community matter (Incorrect; Nurses know this as private matter)
Lack knowledge about the religious beliefs or spirituality of others (Correct; This is one of the reasons)
Differentiate spiritual needs from psychosocial needs (Incorrect; Nurses mistake spiritual needs for psychosocial
needs)
Believe that the spiritual needs of clients are responsibility of an individual or the client (Incorrect; Believe are
the responsibilities to a family or pastor)
QID: 2989 C4 (43) The client from Koreas who is admitted to the inpatient psychiatric unit has difficulty
speaking English. Which of the following interventions would be best?
Communicating with gestures and pictures (Incorrect; Will not understand client need)
Evaluating client’s understanding of written English (Incorrect; if one cannot speak, then writing in English may
still be a problem)
Planning to assign the client to a private room (Incorrect; Will not help understand client need)
140
Using the service of a translator (Correct; To understand the needs of the client and help accordingly)
QID: 2990 C 4(36) A Hispanic client requests that a curandero visit the psychiatric unit to perform a healing
ceremony. The nurse facilitates this visit by advocating for the client in the treatment team meeting. According to
Madeline Leininger’s model, the nurse is demonstrating:
1. Accommodation/negotiation (Yes: Nurse adapts nursing care to accommodate client’s beliefs)
2. Preservation/maintenance (Incorrect: Nurse assists client in maintaining practices)
3. Repatterning/restructuring (Incorrect: Nurse educates client to practices not conducive to health)
4. Supporting/providing (No: This is not what the nurse is demonstrating)
QID: 2991 C4 (40) The nurse prepares to administer an antianxiety medication to an adult client who is Asian
American. The nurse anticipates which of the following about the dosage of this medication?
Equal to the usual adult dose (Incorrect; They metabolize more slowly)
Higher than the usual adult dose (incorrect; They metabolize more slowly)
Lower than the usual adult dose (Correct; These clients metabolize these drugs more slowly)
Spaced evenly around the clock (incorrect; They metabolize more slowly)
QID: 2992 C 4(41) Rootwork syndrome is associated with cultures of which of the following?
Korea (No; Do not have root work syndrome)
Africa American (Correct; Illness are associated to witchcrafts sorcery or evil)
Latin American (Incorrect; Do not have root work syndrome)
All of the above (Incorrect; Option 2 is correct)
QID: 2993 C4 (45) The nurse uses which of the following when determining problem areas for the client with a
mental illness who is from the Philippines?
Yes-no direct questioning (Incorrect; This is not the correct approach)
Indirect questioning (Correct; This is the appropriate approach)
Confrontational strategies (Incorrect; This is not the correct approach)
Family-provided information (Incorrect; This is not the correct approach)
QID: 2994 C4 (41) A client of Native Indian descent is found to have the culture-bound syndrome of ghost
sickness. Which of the following would the nurse expect to assess? Select as many as apply.
Uncontrollable crying and shouting (Incorrect: Applies to a taquede nerriors of latin-Americans)
Preoccupation with death and the deceased (Correct: Applies to ghost sickness)
Indigestion and anorexia (Incorrect: This is the Koreas Hwa-byung)
Bad dreams and hallucinations (Correct: Applies to ghost sickness)
Feelings of anxiety and danger (Correct: Applies to ghost sickness)
Sudden outburst of agitation and aggression (Incorrect: Applies to Boufee delivante of west Africans)
Correct; 2, 4, 5 Pg 41 chapter 4
QID: 2995 C 5(54) A client has signed the consent for electroconvulsive therapy (ECT) treatments scheduled to begin in
the morning. The client tells the nurse, “I really don’t know why l need this procedure, but everybody has been telling
me that it is the best thing.” The basis for the ethical dilemma facing the nurse in this situation most likely involves
which of the following?
Determining whether client has given informed consent (Correct: Client sounds like he is not informed on what will
happen and why he needs it)
Identifying whether client and family disagree on treatment (Incorrect: Client is not informed)
Deciding whether client is expressing anxiety about treatment (Incorrect: Client is not informed)
Judging whether treatment team is following ethical principles (Incorrect: Client is not informed)
141
QID: 2996 C5 (56) One of the following elements must be present to constitute nursing malpractice,
Ability to act in an acceptable way (Incorrect: This is not malpractice)
Approximate cause (Correct: There should be a close connection between nurses conduct and resultant injury)
Ability to conform to the required standard of care (Incorrect: This is not malpractice)
Likelihood of potential damage (Incorrect: There should be actual injury)
QID: 2997 C 5(58) The nurse fails to assess a client in physical restraints according to the frequency stipulated in the
hospital’s policy. The nurse’s behavior could legally constitute which of the following?
False imprisonment (Incorrect: Refer to intentional or injustifiable detention)
Breach of client privacy (Incorrect: Refer to right to be left alone without intrusion)
Defamation (Incorrect: Refer to injury to a persons’ reputation)
Negligence (Correct: Refer to failure to act or conduct that falls below accepted standard)
QID: 2998 C 5(58) Which of the following represents inappropriate maintenance of client confidentiality by the
psychiatric nurse?
Discussing client’s current problems and past history in treatment team meeting (Incorrect: This is appropriate)
Explaining to client’s visitor that is inappropriate to discuss client’s care (Incorrect: This is appropriate)
Sending copy of client records to referring agency without client’s written consent (Correct: This is a breach of client’s
confidentiality)
Telling a coworker that it is inappropriate to discuss client’s problems in the cafeteria (Incorrect: This is appropriate)
QID: 2999 C 5(61) Which of the following represents appropriate criteria for the involuntary admission of a client into a
psychiatric facility?
Client who is competent but refuses admission (Incorrect; Does not need involuntary admission)
Client who has threatened suicide (Correct; Client need involuntary admission for close monitoring)
Client who has a long history of mental illness (Incorrect; Does not need involuntary admission)
Client whose family has requested admission (Incorrect; Does not need involuntary admission)
QID: 3000 C6 (68) The scope of forensic nursing practice encompasses:

Application of the nursing-related sciences (Correct: appropriate)
Application of the forensic aspects of health care in specific investigation (Correct: appropriate)
Treatment of trauma victims and perpetrators of violence and traumatic accidents (Correct: appropriate)
All of the above (Correct: All the above are included in the scope of forensic practice)
Correct; 4 Ref: PG 68 chapter 6
QID: 3001 C 6 (71) The forensic nurse is incorporating information about a client’s phenotype and gene function in the
client’s plan of care. The nurse is involved with:
Genomic health care (Correct: Deals with issues of genetic therapy)
E-practice (Incorrect: Involve use of electronic technology in health care delivery)
Pharmacogenomics (Incorrect: Involves drug prescribing based on client’s own a structure)
Euthanasia (Incorrect: Refers to “mercy killing”
QID: 3002 C6 (69) Which of the following is least descriptive of forensic nursing practice?
Wide-ranging client population serviced (Incorrect: Its a true statement, the question require false statement)
Independent yet collaborative practice role (Incorrect: Its a true statement, the question require false statement)
Responsibilities independent of the legal system (Correct: Forensic nursing work closely with the legal system)
142
Collection of necessary evidence (Incorrect: Its a true statement, the question require false statement)
QID: 3003 C6 (70) When describing the specific activities related to forensic nursing, which of the following would the
nurse be least likely to include?
1. Reviewing the medical record of a victim of assault and battery (Incorrect: This will be included in the forensic
information)
2. Testifying as an expert witness in a criminal court proceeding (Incorrect: This will be included in the forensic
information)
3. Providing emotional support to a victim of intimate partner violence (Incorrect: This will be included in the forensic
information)
4. Providing direct care of a hospitalized patient who was injured in an automobile accident (Correct; This is not part of
forensic nursing)
QID: 3005 C 6 (71) A forensic Nurse understands that pharmacogenomics is?

Prescribing drugs based on the clients complete DNA structure.(Correct: This designates pharmacogenomics )
Use of electronic technology in the delivery of health care (Incorrect: Refers to e-practice)
A plan of care that utilizes information related to phenotype responses and gene functions (Incorrect: Refers to genomic
health care)
Collection of evidential material required by law enforcement or medical examiners (Incorrect: This is a function of the
forensic nurse)
QID: 3006 C 1 (76) Dysfuctional grief,

Is usually caused by an actual or perceived loss of someone or something of great value (Correct: Occur if one is unable
to work through the grief)
Is a normal, appropriate emotional response to an external and consciously recognized loss. (Incorrect: It is not a normal
response)
Describes an individual’s outward expression of grief regarding the loss of a love object or person (Incorrect: This
mourning)
Is feeling of sadness, insomnia, poor appetite and desolation.(Incorrect: This is bereavement)
QID: 3007 C 7 (77-78) When assessing a client experiencing dysfunctional grief, which of the following would the nurse
expect to assess? Select all that apply
Changes in libido (Correct: This occurs in dysfunctional grief)
Acknowledgement of the loss (Incorrect: This occur in functional grief)
Diminished ability to concentrate (Correct: This occurs in dysfunctional grief)
Expressions of hostility (Correct: This occurs in dysfunctional grief)
Reliving of past experiences(Correct: This occurs in dysfunctional grief)
Correct; 1, 3, 4, 5 Pg 77-78 chapter 7
QID: 3008 C7 (76) A woman diagnosed with terminal breast cancer discusses with her husband her wishes for end of
life care, including her funeral. Which type of loss is this couple experiencing?
Perceived loss (Incorrect; Is a loss recognized only by the client)
Anticipatory loss (Correct; Client is aware the loss will occur)
Temporary loss (Incorrect; Loss that is not everlasting)
Sudden loss (Incorrect: This is an immediate unexpected loss)
143
QID: 3009 C 7 (85) A client whose husband died last month of a sudden cardiac arrest tells you that her 4-year-old child
asks, “When is Daddy coming home?” When explaining to the mother about the child’s concept of death, which of the
following would you include?
Death is an irreversible process (Incorrect: The 4-year old will not comprehend death in this manner)
Death is a final state (Incorrect: The 4-year old will not comprehend death in this manner)
Death is a destructive force (Incorrect: The 4-year old will not comprehend death in this manner)
Death is a destructive force (Correct: The 4-year old will comprehend it this way)
QID: 3010 C 7 (81) An emotional response associated with suffering at end of life is?
Avoidance (Incorrect; This is a behavioral associated with suffering at end of life
Fatigue (Incorrect; This is a physical response)
Verbalization of a sense of emptiness (Incorrect; This is a spiritual response)
Frustration (Correct; This is a correct emotional response to suffering at end of life)
QID: 3011 C 7 (80) Palliative care differs from hospice care because palliative care
May be provided in the early stages of a chronic disease (Correct; Because it’s the active total care in diseases not
responding to curative treatment)
Requires that a client is a Medicare recipient (Incorrect; Not a necessary requirement)
Does not provide care for hospitalized clients (Incorrect; It provides care in these clients)
Does not provide spiritual support for family members (Incorrect; It provides spiritual support)
QID: 3012 C 7 (82) Several health care agencies have addressed the issue of pain management for terminally ill clients.
In 1991, which of the following issued a position statement regarding the promotion of comfort and relief of pain in
dying clients?
The agency for Health Care Policy and Research (Incorrect; Coined the ABCDE mnemonic for pain assessment and
management)
The Joint Commission Accrediation of Healthcare Organizations (Incorrect; Issued pain treatment standards)
The American Nurses Association (Correct; Maintained relieve of pain are obligations of the nurse)
The world Health Organization (Incorrect; Developed an analgesic ladder in 1996)
QID: 3013 C8 (92) Which of the following reflects most accurately the direct impact of managed care on psychiatric
nursing care planning?
Assessing and planning for client care must occur in a short period of time.(Correct; The nurse coordinate all)
Family members need to be involved in planning care (Incorrect; Not necessary of client admission and discharge facts)
Clients require follow-up provision for continuum of care(Incorrect; Not necessarily)
All treatment team members should be involved with planning (Incorrect; Not necessarily. Nurse coordinates all facets
of care)
QID: 3014 C 8 (92) The quality assurance nurse,

Serves as a discharge planner (Incorrect; Not always the case)
Is accountable for the overall quality Care being delivered (Correct; Ensures the standard are adhered to)
Coordinates the continuum of care (Incorrect; Not directly the coordinator of care)
None of the above (Incorrect: Option 2 is correct)
QID: 3015 C8 (94) The nurse manager in an LTC unit is talking with the family of a newly admitted client with a
diagnosis of schizophrenia, paranoid type. The daughter voices concern that her father’s behavior seems worse since his
admission. Which of the following is the best action the nurse can take?
Explain that psychotropic medication can be adapted according to behavior (Incorrect: Not dealing with client concerns)
144
Initiate treatment-team review of the client’s behavior since admission (Correct: This team will identify how client has
been and recommend actions accordingly)
Speak to the nursing assistants about the client’s current behavior (In correct: This is not therapeutic)
Refer client’s daughter to the physician in charge of her father’s care (Incorrect: Not solving clients problems)
QID: 3016 C8 (98) An example of residential treatment program includes:

1. Group homes (Correct; These are part of residential treatment programs)
2. Individualized therapy (Incorrect: Is part of day-treatment program interventions)
3. Recreational therapy (Incorrect: Is part of day-treatment program interventions)
4. Group therapy (Incorrect: Is part of day-treatment program interventions)
QID: 3017 C 8(100) The nurse working in a community mental health center is asked to speak to a parent teacher group
at an elementary school regarding discipline issues. This is an example of which of the following functions of
community mental health centers?
Concern with total community populations (Correct; Demonstrations concern with entire community population)
Emphasis on primary prevention (Incorrect; This is not part of CMHCs)
Provision of continuity of care (Incorrect; This falls under medical care of CMHCs)
All of the above (Incorrect; Only option A is correct)
QID: 3018 C 8 (98) When preparing a teaching plan for the family of a client who will be receiving psychiatric home
care, which of the following would the nurse incorporate into the teaching plan? Select all that apply.
This type of care, although effective, can be costly (Incorrect; Its fairly affordable not too costly)
There is less disruption in the client’s relationship with family (Correct; Client is managed at home)
Clients typically receive less satisfaction from this type of care (Correct; Clients May not get enough satisfaction)
The client can engage in all types of recreational community activities (Incorrect; May be engage in all types due to
disease process)
Correct; 2, 3 Pg 98 chapter 8
QID: 3308 C 9(106 h315) Which of the following statements about the nursing process is correct?
It is a four – step problem solving approach (Wrong: It is a five step process)
It sets the practice of nursing in motion though it does not serve as a monitor of quality nursing care (Wrong; It serves as
a monitor for quality nursing care)
Nursing in all specialties practice the first step (Correct; First step ensures assessment which cuts across all specialities)
All of the above (Wrong only 3 is correct)
Correct; 3 PAGE 106 hesi 315 chapter 9
QID: 3445 C 9 (106 h 315-317) During assessment the nurse understands that the objective data may be obtained by all
of the following methods EXCEPT:
Interviewing (Correct; This gives subjective data as reported by the client)
Palpation (This gives objective data. Look for option that give subjective data)
Percussion (This gives objective data. Look for option that give subjective data)
Auscultation (This gives objective data. Look for option that give subjective data)
Correct; 1 PAGE 106 hesi 315-317 chapter 9
QID: 3446 C 9 (106 h 315) During a physician examination, a client state,” I hate my life and I want to die”. The nurse
knows that,
This is an example of a subjective data (Correct; This is a statement from the client)
Such negative statements about oneself are not considered as data (Wrong; Its part from subjective data)
This is a measurable and tangible data.(Wrong; Its part of subjective statement for client and is subjective data)
145
This is an example of a mixed data (Wrong; This is a subjective statement from the client)
QID: 3447 C 9 (112 h 326) When the nurse is caring for a client admitted for treatment of mental illness, the client states
“my friend wants to eat. God will kill all the sinners”. The nurse understands that this client could NOT have which of
the following diagnosis?
Schizophrenia (Wrong; This is a thought disorder where communication is impaired)
Dementia (Wrong; Clients with impaired communications due to thought disorders have dementia and delusions)
Delusion (Wrong; Clients with impaired communications due to thought disorders have dementia and delusions)
Conversion (Correct; Clients with impaired communications due to thought disorders do not have conversion disorders)
QID: 3448 C 9 (114 h 315) The following terms are associated with orientation and consciousness. Place them in the
proper chronological order, beginning from the earliest to the most recent.
1. Delirium
2. Confusion
3. Coma
4. Stupor
5. Clouding of consciousness
Correct; 2, 5, 4, 1, 3 PAGE 114 hesi 315 chapter 9
(Hint: Write the digits corresponding to the order in which you think they should follow. Example (1,2,3,4)
Rationales:
(This chrological order reflect the decrease in their ability to grasp significant of their environment or existing situation
or clearness of conscious process
QID: 3449 C 9 ( 120 h 315)When documenting the assessment data, the psychiatric nurse is aware that the
documentation should be:
1. Objective
2. Legible
3. Logical
4. All of the above
Documentation should be clear, objective, legible and logical for it to be understood and to communicate. Option D is
inclusive
QID: 3450 C 10 (125 h 315-317) A nurse working in the psychiatric unit is assessing a newly admitted client with
delusional disorder. After the nurse has explored the client ability to function biologically, behaviorally, cognitively,
culturally, psychological, and spiritually; what would be the next immediate nursing action?
Formulation of a nursing plan of care (Wrong; Planning for nursing care is the third step of nursing process)
Checking of the client’s response to interventions (Wrong; This is the evaluation phase of the nursing process)
Formulation of nursing diagnosis (Correct; This is the second step after assessment)
Implementation of the nursing action (Wrong; This is the 4th step of the nursing process)
Correct; 3 PAGE 125 hesi 315 - 317 chapter 10
QID: 3451 C 10 (126 h 315-317)A nurse caring for a client with renal failure and metabolic acidosis has diagnosed
anxiety related to physical condition and hospitalization as evidenced by tremulous voice, increase verbalization with
pressured speech and diaphoresis. Which of the following classifications does this diagnosis fit?
Wellness nursing diagnosis (Wrong; This is an actual nursing diagnosis)
Syndrome nursing diagnosis (Wrong; This is an actual nursing diagnosis)
Risk nursing diagnosis (Wrong; The client has anxiety now and is not at risk for anxiety)
Actual nursing diagnosis (Correct; Its an actual nursing diagnosis because the client is anxious)
Correct; 4 PAGE 126 hesi 315-317 chapter 10
146
QID: 3452 C 10 (127)Which of the following statement about the diagnostic and statistical manual of mental disorders
4th edition, text Revision (DSM- IV- TR) is NOT appropriate?
Used by clinical nurse specialists only when a psychiatric problem exists (Correct; This is not an appropriate option.
DSM-IV-TR is used by clinicians and researchers of many different disciplines in various settings)
Used to identify and communicate accurate public health statistics (Wrong; This is true but we are looking for
inappropriate option)
Insurance companies require a diagnosis using the DSM- IV- TR (Wrong; This is correct statement, look for the
inappropriate one)
All of the above (Wrong; Option 1 is wrong and hence is the correct one)
Correct; 1 PAGE 127 chapter 10
QID: 3453 C 10 (128) A nurse notes that a client has delirium due to a general medical condition. This clinical disorder
is a part of which Axis of the DSM-IV –TR multiaxial system?
III (Wrong; These are general medical conditions)
I (Correct; These are clinical disorders and other medical conditions that may be a of clinical attention)
IV ( Wrong; These are psychosocial and environmental problems)
V ( Wrong; These are global assessments of functioning)
QID: 3454 C 10 (129 h 315, 316, 317) During the formation of expected outcomes for a client with a nursing diagnosis:
Disturbed sleep pattern related to anxiety secondary to physical illness as evidenced by the inability to fall asleep, the
nurse is aware that which of the following type of client behavior’s could impede the formulation of expected outcomes?
Select all that apply.
Noncompliance ( Correct; Failure to comply could impede formulation of expected outcomes)
Manipulation (Correct; Clients manipulation can interfere with expected outcomes)
Demonstration of trust ( Wrong; Trustworthiness facilitate formation for expected outcomes)
Verbalization of multiple complaints (Correct; Multiple complains confuse expected outcome formulation)
Increased independence from caregivers(Wrong; Independence promotes expected outcome formulation and
achievement)
Correct; 1, 2, 4 PAGE 129 hesi 315, 316, 317 chapter 10
QID: 3455 C 10 (129 h 315) Priority setting is a key element in;

Evaluation of care (Wrong; Prioritization is key in the planning phase)
Plan of care( Correct; Prioritization is essential to attend to urgent medical first)
Outcome identification (Wrong; Prioritization is key in the planning phase)
None of the above (Wrong; Not true, option 2 is correct)
QID: 3456 C10 (130) A nurse is using the standardized nursing plan of care for a client with anxiety and fear. The nurse
understands that the clinical pathways:
Map the sequence of the standards of the care that are necessary to achieve desired outcomes (Correct; These correctly
describes clinical pathways)
Are plan of care that contain interdisciplinary practice guidelines (Wrong; These are critical pathways)
Offer a method to represent assessment data visually and enhance critical thinking (Wrong; These are concept maps)
Are used to treat medical and surgical disorder only (Wrong; They are used to achieve desired outcomes for a specific
disorder or condition, within a period of time)
QID: 3457 C 11 (136) All the following environmental factors may influence communication EXCEPT,
1. Place (This influence communication. Look for option that does not)
2. Time (This influence communication. Look for option that does not)
3. Noise level (This influence communication. Look for option that does not)
4. Altitude ( Correct; This factor influence communication but, it is not an environmental factor)
147
Correct: 4
QID: 3458 C 11 (139 h 315, 316, 317) A nurse notes that the client she is caring maintains a distance of 12 to 25 feet
when talking to the nurse. The client demonstrates which type of spatial territory?
1. Intimate zone (Wrong: Refer to actions involving body contact eg. touching, hugging and wrestling)
2. Personal zone(Wrong: Refer to arms length distance (11/2 – 4 feet) with some body contact eg, holding hands)
3. Social zone( Wrong: Refer to 1 – 12 feet distance eg. formal business)
4.Public zone (Correct: Refer to 12 -25 feet distance with no physical contact and minimal eye contact)
Correct; 4 PAGE 139 hesi 315,316, 317 chapter 11
QID: 3459 C 11 (139 h 315, 316, 317) A nurse is observing a student nurse communicating with a client. She notes
that the student is sitting in a chair, leaning forward slighting and maintains eye contacts with a client. The nurse
understands that the student is:
Bored (Wrong: Occur if one is slumped in a chair or doodling on a pad.)
Demonstrating cowardice (Wrong: Occur when one looks fearful)
Indifferent ( Wrong: Occur when one does not look concerned or look concerned or listen to what client says showing
unconcern)
Interested in what the client says (Correct: The behavior demonstrates concern and interest to get what is said)
Correct; 4 PAGE 139 hesi 315,316,317 chapter 11
QID: 3460 C 11 (140 h 315, 316, 317) One way in which social communication differs from the therapeutic
communication, according to purtilo and haddad (2002), is that in social communication:
1. Personal goals are set by the client (Wrong: Occur in therapeutic communication)
2. Constructive dependency, and independence are promoted (Wrong: Occur in therapeutic communication)
3. A personal or intimate relationship occurs (Correct; This occur in social communication)
4. Specialized professional skills are used while employing nursing interventions (Wrong: Occur in therapeutic
communication)
Correct; 3 PAGE 140 hesi 315, 316, 317 chapter 11
Correct: 3
QID: 3461 C 11 (141 h 315, 316, 317) A client is talking to the nurse:
Client : “I can’t sleep. I stay awake all night”
Nurse : You can’t sleep at night?
The nurse demonstrates the use of which therapeutic communication technique?
Reflection (Wrong: Try to understand what client has said by putting it in a question form)
Restating (Correct: States exactly what the client has said in summary)
Exploration (Wrong: One enquires for more information about something)
Voicing doubt (Wrong: Attempts to show disbelief with what is said)
QID: 3462C 9 (111) Which of the following term describe the impaired communication? Select all that apply
1. Coherence (Incorrect: This occurs in effective communication)
2. Blocking (Correct; Refer to sudden stop page in flow talking or thinking)
3. Slang usage (Incorrect; This can occur with certain age groups e.g teenagers)
4. Circumstantiality (Correct; Refer to giving unnecessary details)
5. Clang association (Correct; Refer to use word sounds to substitute for logic 1, 2&5 describe impaired communication)
Correct; 2, 4, 5 PAGE 111 chapter 9
QID: 3463 C 11 (145 h 315, 316, 317)The conditions essential for a therapeutic relationship, according to Rogers (1961),
are all of the following EXCEPT?
1. Empathy (Correct; condition look for one that is not correct. Ability to zero in a client’s feeling)
2. Confrontation ( This is a correct condition: An accepting gentle manner once one is used to a client)
148
3. Respect (Correct; The client deserves high regard. Look for the incorrect option)
4. Giving advice (This is the false option that is the right option. Giving advice is not essential for a therapeutic
communication)
Correct: 4
QID: 3465 11 C (149 h 315, 316, 317) A nurse is observing a psychiatric student nurse interacting with a client:
STUDENT: “How do you feel about your doctor’s recommendations?”(Maintaining eye contact; sitting)
CLIENT: “I guess he knows what he is doing” (Breaks eye contact; nervously)
The nurse interprets that the client is:
Beginning to disclose his feelings ( Wrong: Client is disclosing feelings but is uncomfortable with the conversation)
Responding to individual attention (Wrong: Client is not focusing to a specific part or individual attention)
Becoming uncomfortable with the conversation (Correct: Client does not want to continue the conversation)
None of the above (Wrong: Option 3 is correct)
QID: 3466 C 11 ( 153 h 315) Milieu therapy focuses on;

1. Social relationships (Correct; Milieu therapy refers to social environments therapy)
2. Occupational activities (Correct; This form part of social aspects of the therapy)
3. Recreational activities (Correct; This form part of social aspects of the therapy)
4. All of the above
QID: 3467 C 11 (153 h 315) Which of the following is/ are therapeutic milieus? Select all that apply
1. Ronald MSDonald House (Correct)
2. Respite programs (Correct; Options 1,2,3,4 all represent therapeutic environments where the biopsychogical needs of
individuals are met)
3. Hospice programs (Correct)
4. Halfway house (Correct)
5. Managed care programs (Wrong: Managed care programs and acute care programs do not reflect therapeutic milieus)
6. Acute care service (Wrong: Managed care programs and acute care programs do not reflect therapeutic milieus)
Correct; 1,2,3,4 PAGE 153 hesi 315 chapter 12
QID: 3468 C 12 (157 h 315) During a client teaching the nurse says “let’s discuss what you should do when you
experience what you describe as panic attack”. Which educational strategy does the nurse use?
1. Prioritizing the client’s needs ( Wrong: The nurse is presenting a specific information on what is to be done by the
client, not prioritizing)
2. Presenting specific information ( Correct; The nurse is presenting a specific information on what is to be done by the
3. Involving the client’s family members (Wrong: The nurse is talking to the client)
4. Reinforcing information (Wrong: This is not reinforcing but presenting specific information)
QID: 3469 C 12 (160 h 316)Which of the following nursing actions is appropriate for a client who has trouble falling
asleep and also feeling awake as soon as she get into bed?
Use bed exclusively for sleep (Incorrect; For those with more trouble staying asleep)
Inhale deeply and exhale slowly ( Incorrect; For those with racing minds)
Limit time spent in bed to normal sleep hours (Correct; This will help promote sleep)
Leave bedroom to perform activities if unable to sleep (Incorrect; For those with more trouble staying asleep)
QID: 3470 C 12 (161) During the client teaching on pain management, the client demonstrates a need for furthers
instructions when she says:
149
“Nonpharmacologic methods of pain management can diminish the emotional components of the pain” (Correct: This is
a correct option. Look for an incorrect option)
“Nonpharmacologic methods of pain managements may weaken the coping abilities” (This is a correct option as per mc
caffery and paserve. Look for incorrect one)
“Nonpharmacologic method of pain management can give clients a sense of control (This is a correct option, look for an
incorrect option)
Doperminergic drugs may NOT be required to minimize pain in clients with restless leg syndrome” (Correct: Opiates,
Doperminergic drugs or anticonvulsants may be required to minimize pain in clients with restless leg syndrome)
QID: 3471 C 12 (164 h 317-318) A behaviorist who uses unpleasant or anxious stimuli to change inappropriate behavior,
is using which type of behavior therapy?
1. Aversion therapy (Correct: Uses a chemical, visual images or drugs to change behavior)
2. Implosive (Incorrect: persons are exposed to intense forms of anxiety provoking situations)
3. Limit – setting (Incorrect: Limits the exposures)
4. Assertiveness training (Incorrect: Clients are taught how to relate appropriately to others using frank, direct
expressions)
Correct; 1 PAGE 164 hesi 317 -318 chapter 12
QID: 3472 C 12 (165) The Ward Atmosphere Scale (WAS) consist of all of the following subscale EXCEPT:
Client control of rules, schedules, and staff behavior (Correct; This is not part of WAS. It’s the staff not client who
control)
Program clarity of day –to-day routine (This is part of WAS, hence incorrect option)
Degree of spontaneity in the environment that allows the client to express feelings freely (This is part of WAS, hence
incorrect option)
Encouragement of verbalization of personal problems by clients (This is part of WAS, hence incorrect option)
QID: 3473 C 13 (170 h 315) A client who has been raped is crying loudly, wringing her hand and moving about
aimlessly. The nurse correctly understands that the client is undergoing which of the following crises?
Personal situational (Correct; The behavior is typical of a personal, situational crisis)
Public situational (Incorrect; This affect an entire community)
Maturational (Incorrect: These are developmental changes within an individual)
All of the above (Incorrect: Option A is the correct one.)
QID: 3475 C 13 (174 h 315) A young couple is told that their son has inoperable cancer. Which of the following
demonstrates a realistic perception of this situation?
1. The couple question seriousness of the illness ( Incorrect: This presents a distorted perception of the event)
2. They verbalized that the prognosis of the illness is poor because the cancer is inoperable (Correct: This presents
realistic perception of the event)
3. The situation leads to poor interpersonal relationship with both sets of parents (Incorrect: This demonstrates
inadequate situational support)
4. The couple is able to discuss their feelings and thoughts with each other (Incorrect: this demonstrates adequate defense
and/or coping skills)
Correct; 2 PAGE 174 chapter 13 hesi 315
Correct: 2
QID: 3454 C 10 (129 h 315, 316, 317) During the formation of expected outcomes for a client with a nursing diagnosis:
Disturbed sleep pattern related to anxiety secondary to physical illness as evidenced by the inability to fall asleep, the
nurse is aware that which of the following type of client behavior’s could impede the formulation of expected outcomes?
Select all that apply.
Noncompliance ( Correct; Failure to comply could impede formulation of expected outcomes)
150
Manipulation (Correct; Clients manipulation can interfere with expected outcomes)
Demonstration of trust ( Wrong; Trustworthiness facilitate formation for expected outcomes)
Verbalization of multiple complaints (Correct; Multiple complains confuse expected outcome formulation)
Increased independence from caregivers(Wrong; Independence promotes expected outcome formulation and
achievement)
Correct; 1, 2, 4 PAGE 129 hesi 315, 316, 317 chapter 10
QID: 3455 C 10 (129 h 315) Priority setting is a key element in;

Evaluation of care (Wrong; Prioritization is key in the planning phase)
Plan of care( Correct; Prioritization is essential to attend to urgent medical first)
Outcome identification (Wrong; Prioritization is key in the planning phase)
None of the above (Wrong; Not true, option 2 is correct)
QID: 3456 C10 (130) A nurse is using the standardized nursing plan of care for a client with anxiety and fear. The nurse
understands that the clinical pathways:
Map the sequence of the standards of the care that are necessary to achieve desired outcomes (Correct; These correctly
describes clinical pathways)
Are plan of care that contain interdisciplinary practice guidelines (Wrong; These are critical pathways)
Offer a method to represent assessment data visually and enhance critical thinking (Wrong; These are concept maps)
Are used to treat medical and surgical disorder only (Wrong; They are used to achieve desired outcomes for a specific
disorder or condition, within a period of time)
QID: 3457 C 11 (136) All the following environmental factors may influence communication EXCEPT,
1. Place (This influence communication. Look for option that does not)
2. Time (This influence communication. Look for option that does not)
3. Noise level (This influence communication. Look for option that does not)
4. Altitude ( Correct; This factor influence communication but, it is not an environmental factor)
QID: 3458 C 11 (139 h 315, 316, 317) A nurse notes that the client she is caring maintains a distance of 12 to 25 feet
when talking to the nurse. The client demonstrates which type of spatial territory?
1. Intimate zone (Wrong: Refer to actions involving body contact eg. touching, hugging and wrestling)
2. Personal zone(Wrong: Refer to arms length distance (11/2 – 4 feet) with some body contact eg, holding hands)
3. Social zone( Wrong: Refer to 1 – 12 feet distance eg. formal business)
4.Public zone (Correct: Refer to 12 -25 feet distance with no physical contact and minimal eye contact)
QID: 3459 C 11 (139 h 315, 316, 317) A nurse is observing a student nurse communicating with a client. She notes
that the student is sitting in a chair, leaning forward slighting and maintains eye contacts with a client. The nurse
understands that the student is:
Bored (Wrong: Occur if one is slumped in a chair or doodling on a pad.)
Demonstrating cowardice (Wrong: Occur when one looks fearful)
Indifferent ( Wrong: Occur when one does not look concerned or look concerned or listen to what client says showing
unconcern)
Interested in what the client says (Correct: The behavior demonstrates concern and interest to get what is said)
QID: 3460 C 11 (140 h 315, 316, 317) One way in which social communication differs from the therapeutic
communication, according to purtilo and haddad (2002), is that in social communication:
151
1. Personal goals are set by the client (Wrong: Occur in therapeutic communication)
2. Constructive dependency, and independence are promoted (Wrong: Occur in therapeutic communication)
3. A personal or intimate relationship occurs (Correct; This occur in social communication)
4. Specialized professional skills are used while employing nursing interventions (Wrong: Occur in therapeutic
communication)
QID: 3461 C 11 (141 h 315, 316, 317) A client is talking to the nurse:
Client : “I can’t sleep. I stay awake all night”
Nurse : You can’t sleep at night?
The nurse demonstrates the use of which therapeutic communication technique?
Reflection (Wrong: Try to understand what client has said by putting it in a question form)
Restating (Correct: States exactly what the client has said in summary)
Exploration (Wrong: One enquires for more information about something)
Voicing doubt (Wrong: Attempts to show disbelief with what is said)
QID: 3462C 9 (111) Which of the following term describe the impaired communication? Select all that apply
1. Coherence (Incorrect: This occurs in effective communication)
2. Blocking (Correct; Refer to sudden stop page in flow talking or thinking)
3. Slang usage (Incorrect; This can occur with certain age groups e.g teenagers)
4. Circumstantiality (Correct; Refer to giving unnecessary details)
5. Clang association (Correct; Refer to use word sounds to substitute for logic 1, 2&5 describe impaired communication)
Correct; 2, 4, 5 PAGE 111 chapter 9
QID: 3463 C 11 (145 h 315, 316, 317)The conditions essential for a therapeutic relationship, according to Rogers (1961),
are all of the following EXCEPT?
1. Empathy (Correct; condition look for one that is not correct. Ability to zero in a client’s feeling)
2. Confrontation ( This is a correct condition: An accepting gentle manner once one is used to a client)
3. Respect (Correct; The client deserves high regard. Look for the incorrect option)
4. Giving advice (This is the false option that is the right option. Giving advice is not essential for a therapeutic
communication)
QID: 3465 11 C (149 h 315, 316, 317) A nurse is observing a psychiatric student nurse interacting with a client:
STUDENT: “How do you feel about your doctor’s recommendations?”(Maintaining eye contact; sitting)
CLIENT: “I guess he knows what he is doing” (Breaks eye contact; nervously)
The nurse interprets that the client is:
Beginning to disclose his feelings ( Wrong: Client is disclosing feelings but is uncomfortable with the conversation)
Responding to individual attention (Wrong: Client is not focusing to a specific part or individual attention)
Becoming uncomfortable with the conversation (Correct: Client does not want to continue the conversation)
None of the above (Wrong: Option 3 is correct)
QID: 3466 C 11 ( 153 h 315) Milieu therapy focuses on;

1. Social relationships (Correct; Milieu therapy refers to social environments therapy)
2. Occupational activities (Correct; This form part of social aspects of the therapy)
3. Recreational activities (Correct; This form part of social aspects of the therapy)
4. All of the above
QID: 3467 C 11 (153 h 315) Which of the following is/ are therapeutic milieus? Select all that apply
1. Ronald MSDonald House (Correct)
152
2. Respite programs (Correct; Options 1,2,3,4 all represent therapeutic environments where the biopsychogical needs of
individuals are met)
3. Hospice programs (Correct)
4. Halfway house (Correct)
5. Managed care programs (Wrong: Managed care programs and acute care programs do not reflect therapeutic milieus)
6. Acute care service (Wrong: Managed care programs and acute care programs do not reflect therapeutic milieus)
Correct; 1,2,3,4 PAGE 153 hesi 315 chapter 12
QID: 3468 C 12 (157 h 315) During a client teaching the nurse says “let’s discuss what you should do when you
experience what you describe as panic attack”. Which educational strategy does the nurse use?
1. Prioritizing the client’s needs ( Wrong: The nurse is presenting a specific information on what is to be done by the
2. Presenting specific information ( Correct; The nurse is presenting a specific information on what is to be done by the
3. Involving the client’s family members (Wrong: The nurse is talking to the client)
4. Reinforcing information (Wrong: This is not reinforcing but presenting specific information)
QID: 3469 C 12 (160 h 316)Which of the following nursing actions is appropriate for a client who has trouble falling
asleep and also feeling awake as soon as she get into bed?
Use bed exclusively for sleep (Incorrect; For those with more trouble staying asleep)
Inhale deeply and exhale slowly ( Incorrect; For those with racing minds)
Limit time spent in bed to normal sleep hours (Correct; This will help promote sleep)
Leave bedroom to perform activities if unable to sleep (Incorrect; For those with more trouble staying asleep)
QID: 3470 C 12 (161) During the client teaching on pain management, the client demonstrates a need for furthers
instructions when she says:
“Nonpharmacologic methods of pain management can diminish the emotional components of the pain” (Correct: This is
a correct option. Look for an incorrect option)
“Nonpharmacologic methods of pain managements may weaken the coping abilities” (This is a correct option as per mc
caffery and paserve. Look for incorrect one)
“Nonpharmacologic method of pain management can give clients a sense of control (This is a correct option, look for an
incorrect option)
Doperminergic drugs may NOT be required to minimize pain in clients with restless leg syndrome” (Correct: Opiates,
Doperminergic drugs or anticonvulsants may be required to minimize pain in clients with restless leg syndrome)
QID: 3471 C 12 (164 h 317-318) A behaviorist who uses unpleasant or anxious stimuli to change inappropriate behavior,
is using which type of behavior therapy?
1. Aversion therapy (Correct: Uses a chemical, visual images or drugs to change behavior)
2. Implosive (Incorrect: persons are exposed to intense forms of anxiety provoking situations)
3. Limit – setting (Incorrect: Limits the exposures)
4. Assertiveness training (Incorrect: Clients are taught how to relate appropriately to others using frank, direct
expressions)
Correct; 1 PAGE 164 hesi 317 -318 chapter 12
QID: 3472 C 12 (165) The Ward Atmosphere Scale (WAS) consist of all of the following subscale EXCEPT:
Client control of rules, schedules, and staff behavior (Correct; This is not part of WAS. It’s the staff not client who
control)
Program clarity of day –to-day routine (This is part of WAS, hence incorrect option)
Degree of spontaneity in the environment that allows the client to express feelings freely (This is part of WAS, hence
incorrect option)
153
Encouragement of verbalization of personal problems by clients (This is part of WAS, hence incorrect option)
QID: 3473 C 13 (170 h 315) A client who has been raped is crying loudly, wringing her hand and moving about
aimlessly. The nurse correctly understands that the client is undergoing which of the following crises?
Personal situational (Correct; The behavior is typical of a personal, situational crisis)
Public situational (Incorrect; This affect an entire community)
Maturational (Incorrect: These are developmental changes within an individual)
All of the above (Incorrect: Option A is the correct one.)
QID: 3475 C 13 (174 h 315) A young couple is told that their son has inoperable cancer. Which of the following
demonstrates a realistic perception of this situation?
1. The couple question seriousness of the illness ( Incorrect: This presents a distorted perception of the event)
2. They verbalized that the prognosis of the illness is poor because the cancer is inoperable (Correct: This presents
realistic perception of the event)
3. The situation leads to poor interpersonal relationship with both sets of parents (Incorrect: This demonstrates
inadequate situational support)
4. The couple is able to discuss their feelings and thoughts with each other (Incorrect: this demonstrates adequate defense
and/or coping skills)
QID: 3476 C 13 (176 h 315) When dealing with a situational crisis the nurse should understand that;
The client in crisis does not initially perceive the crisis to be life threatening (Incorrect; Perceive it to be life threatening)
All crises have an aspect of an actual loss ( Incorrect: Have aspect of actual or perceived loss)
There is a decrease or loss communication with significant others. ( Correct; This is a usual occurrence)
Total displacement from familiar surroundings or significant other occur (Incorrect;Some displacement from familiar
surroundings or significant other occurs)
QID: 3477 C 13 (177) Nursing diagnoses for client experiencing a crisis may include all of the following EXCEPT:
1. Ineffective coping ( Correct)
2. Risk for injury (Correct)
3. Post- trauma Response (Correct)
4. All of the above (Correct; All these nursing diagnoses are applicable to a client experiencing a crisis)
Correct: 4
QID: 3478C 13 (178 h 315) The person who begins to intervene in a crisis is obligated:
To continue the intervention unless a more qualified person relieves him or her (Correct; Discontinuing care constitutes
abandonment)
To discuss with any person the crisis incident (Incorrect; this is a breach of confidentiality)
To touch the crisis victim without any regard to her or his consent (Incorrect: This could result in a charge for battery)
To discontinue care if no external support is forthcoming ( Incorrect: Is obliged to continue therapy until a more
qualified person relieve him/her)
QID: 3479 C 13 (180 h 315) The commonly exhibited clinical symptoms of an adolescent in crisis include all of the
following EXCEPT,
Agitation (Correct; Symptom this is one of the clinical symptoms of crisis in adolescents. Hence not the correct option)
Euphoria, usually within the first 24 hours (Incorrect; This is not a clinical symptom of an adolescent in crisis. Hence it
is the correct option)
154
Behavioral regression ( Correct; Symptoms this is one of the clinical symptoms of crisis in adolescents)
Poor concentration and loss of interest in school ( Correct; This is one of the clinical symptoms of crisis in adolescents
hence not the correct option)
QID: 3480 C 14 (185) An important factor common to all the techniques used in psychotherapy is the;
Family-client relationship ( Incorrect; This is not an important factor)
Client-tolerance to therapy (Incorrect; This is not an important factor)
Client –therapist relationship ( Correct; This is an important factor common to all techniques of psychotherapy)
Client-significant other relationship ( Incorrect; This is not an important factor)
QID: 3481 C 14 (185 h 318) The conscious or unconscious psychological defense against bringing repressed thoughts
into conscious awareness is referred to as:
1. Transference ( Incorrect: this is unconscious assignment to the therapist of feelings and attitudes originally associated
with important figures in his or her early life)
2. Counter-transference ( Incorrect: Emotional reaction to client based on therapists unconscious needs and conflicts)
3. Parataxis (Incorrect: Presence of distorted perception of judgment by client during therapy)
4. Resistance (Correct: This is the correct term for bringing repressed thoughts unconsciously or consciously)
Correct; 4 PAGE 185 chapter 14 HESI 318
QID: 3482 C 14 (186 h 316) An example of supportive therapy is:

Bereavement therapy (Correct; Others include brief cognitive therapy; brief solution – focused therapy)
Behavior therapy (Incorrect; include brief cognitive therapy; brief solution – focused therapy)
Cognitive analysis ( Incorrect; include brief cognitive therapy; brief solution –focused therapy)
All of the above (Incorrect; Only 1 is correct)
QID: 3483 C 14 (186 h 316) During the third phase of the individual psychotherapy:
The therapist and the client establish boundaries of the relationship (Incorrect; Occur in introductory phase)
The psychotherapy ceases when the client has achieved maximum benefit of therapy ( Correct; Occur during the
termination phase)
Open communication is established (Incorrect; Occur in introductory phase)
The therapist and client focus on the clients problems (Incorrect; Occur during working phase)
QID: 3484 C 14 (187 h 316)A nurse therapist is caring for a client who is undergoing reality therapy. Which of the
following statements describe an appropriate nursing intervention in this mode of treatment?
Applying learning principles to question illogical thinking ( Incorrect; Occur in rational – emotive therapy)
Encouraging discussion of emotional conflicts ( Incorrect; Occur in psychoanalysis)
Rejecting unrealistic behavior displaced by client ( Correct; This is an appropriate intervention by the nurse in this mode
of treatment)
Assisting client in exploring insight to work through conflict ( Incorrect; Occur in uncovering therapy)
QID: 3485 C 14 (188 h 316)The form of psychotherapy that involves a protocol between a nurse-therapist who provides
psychotherapy and a psychiatrist or nurse practioner who provides pharmacotherapy for the client is known as?
Solution-focused brief therapy (Incorrect; Focus on helping client construct solutions rather than solve problems)
Cognitive-behavioral therapy (Correct; This combines individual goals of cognitive therapy and behavior therapy)
Triangulated treatment ( Correct; Also known as split treatment psychotherapy, dual treatment or medication back up)
Brief interpersonal psychotherapy (Incorrect; Is a semi structured, psycho dynamically time-limited model
psychotherapy)
155
QID: 3486 C 14 (190 h 316) Which of the following statements is/ are appropriate for alternatives to psychotherapy?
1. E-therapy is effective and private
2. Videophone psychotherapy has been used with clients who received bone marrow transplant
3. Modified life therapy and insight-oriented therapy are used to treat depression in older clients
4. All of the above (All the statements are appropriate alternatives to psychotherapy)
QID: 3487 C 15 (195 h 317, 319) A nurse is assessing a 2-year old child at the pediatric clinic. The mother tells the nurse
that the child is her only child. The nurse recognizes that, according to Duvall’s family life cycle, the expected family
unit for this parent is?
Developing a stable family unit with new parent role (Correct; This occur in early child bearing stage (stage 1 )
Promoting school achievement of children (Incorrect; Occur in stage IV in families with school age children)
Promoting open communication in the family ( Incorrect; Occur in stage IV in families with school age children)
Family planning; whether to have children and when ( Incorrect; Occur with the couple where there is beginning of
families)
Correct; 1 PAGE 195 hesi 317, 319 chapter 15
QID: 3488 C 15 (195 h 317, 319) Health families are characterized by:
Reserved interactions among the family member (Incorrect: Demonstrate unhealthy family)
Societal guidance in determining the functioning level of the total family (Incorrect: Demonstrate unhealthy family)
The ability to communicate thoughts and feeling (Correct: This is demonstrated by healthy families)
The head of the family controlling other members ( Incorrect: Demonstrate unhealthy family)
Correct; 3 PAGE 195 hesi 317, 319 chapter 15
QID:3489 C 15 (197 h 317-319)The client in family therapy is the:

Head of the family ( Incorrect; The whole family system is considered as the client)
Children in the family (Incorrect; The whole family system is considered as the client)
The family system (Correct; This is looked at as a whole rather than any individual member)
All of the above (Incorrect; Only option 3 is correct)
QID: 3490 C 15 (198 h 315-317) Which of the following statements describe the overall goals of integrative approach in
family therapy?
Identity and remove the intrapersonal conflict (Correct)
Improve communication and problem-solving (Correct)
Promote more healthy relationships within the family ( Correct)
All of the above (Correct; The above statements are all overall goals of integrative therapy)
QID: 3491 C 15 (201 h 315-317) During the initial interview in the family therapy the nurse is interacting with the client
during the termination stage. Which is the main nurse action at this stage?
Synthesizing all the information (Incorrect; Occur at goal setting stage)
Setting the appointment for the next session (Correct; This is done at termination and initial interview ends)
Meeting the family and putting it at ease (Incorrect; Occur at engagement stage)
Identifying problems that concern the family (Incorrect; Occur at assessment stage)
Correct; 2 PAGE 201 chapter 15 hesi 315 - 317
QID: 3492 C15 (202 h 315) The nurse is caring for a family diagnosed with parental role conflict. The nurse understands
that:
156
One or more of the primary caregivers demonstrate real or potential inability to provide a constructive environment
(Incorrect; This reflects impaired parenting)
The family demonstrates destructive behavior in response to an inability to manage internal stressors due to inadequate
psychological resources ( Incorrect; This reflects disabled family coping)
A primary caregiver experiences or perceives a change in role in response to external factors such as illness (Correct;
This reflects parental role conflict)
The state in which a normally supportive family experiences a stressor that challenges effective functioning ability of the
family. ( Incorrect; Occur with interrupted family processes)
QID: 3493 C 15 (207 h 317, 319) An important intervention in the couple therapy of the contextual type is?
Directing concern toward issues involving both partners (Correct; This applies to contextual couple therapy)
Focusing on empathy and misperceptions ( Incorrect; Occur in empathy relations therapy)
Encouraging partners to identify their own behavior ( Incorrect; Occur in marital – relations therapy)
Reflecting position of partners ( Incorrect; Occur in object – relations therapy)
Correct; 1 PAGE 207 chapter 15 hesi 317, 319
QID: 3707 C 16 (216 h 342-343) The study of drug effects in clients and the expert use of drugs in the treatment of
psychiatric conditions is called?
1. Clinical psychopharmacology (Correct; This is the appropriate description)
2. Pharmacokinetics (Incorrect; This is the study of movements of drugs and their metabolites through the body)
3. Pharmacodynamics (Incorrect; This is the study of biochemical and physiological effects of drugs)
4. Therapeutic Index ( Incorrect; This is the ratio of affective dose to the toxic dose of drug)
Correct; 1 PG 216 hesi 342 -343 chapter 16
QID: 3708 C16 (217 h 343) Risperidone (Risperdal) exerts its effect by?
1. Blocking post-synaptic dopamine receptors (Incorrect; It blocks both dopamine and serotonin receptors)
2. Blocking both dopamine and serotonin receptors (Correct; This is how a typical antipsychotic drug exert their effects)
3. Selectively inhibiting serotonin reuptake (Incorrect; It blocks both dopamine and serotonin receptors)
4. All of the above (Incorrect; Option 2 is correct)
Correct; 2 PG 217 hesi 343 chapter 16
Q1D: 3709 C 16 (216) The following are the stages which the neurotransmitter undergoes in synaptic transmission.
Arrange them in the order of occurrence, starting with the first stage to the last;
1. Receptors binding
2. Cellular uptake
3. Transmitter metabolism
4. Synthesis
5. Transmitter release
6. Vesicular uptake
(Hint: Write the digits corresponding to the order in which you think they should follow. Example (1,2,3,4)
Correct; 4, 6, 5, 1, 2, 3 PG 216 chapter 16
Rationale: This sequence gives the correct steps which neurotransmitter undergo as they cross the synapse to bind to
receptors on the surface of the next neuron
QID: 3710 C 16 (218) Pharmacodynamics is the study of:

1. The movement of drugs and their metabolites through the body ( Incorrect; This is pharmacokinetics)
2. The biochemical and physiologic effects of drugs and the mechanisms by which the effects are produced (Correct;
This is the appropriate description)
3. The interactions among the neurotransmitters, neuropeptides, and hormones as they influence each other’s function in
the brain (Incorrect; these are secondary effects of a drug)
4. The final changes in the clinical symptoms induced by a drug, such as the stabilization of anxiety or depression
(Incorrect; This are the Tertiary effects)
157
QID: 3711 C 16 (218) Which of the following factors governs the distribution of a drug to the brain?
1. Regional blood flow (Correct)
2. Blood-brain barrier (Correct)
3. Drug’s affinity for receptors (Correct)
4. All of the above ( All these factors are correct; High blood flow, high lipid solubility and high receptor affinity
promote therapeutic actions of a drug)
QID: 3712 C 16 (223) What would be the most appropriate nursing action for a client experiencing constipation as an
adverse effect of a psychotropic drug?
1. Refer to dietitian (Incorrect)
2. Conduct a sexual history (Incorrect)
3. Promote fluid intake (Correct; To prevent constipation, promote adequate fluid intake, intake of fresh fruits and
vegetables and provide stool softners as prescribed)
4. Encourage taking medication with food (Incorrect)
QID: 3713 C 16(238 H 333) A client is taking monoamine oxidase inhibitors. The nurse instructs the client to avoid
taking aged cheese, beer, chocolate, yogurt and raisins because these foods may cause hypertensive crisis. This crisis is
attributed to,
1. Tyramine (Correct; Tyramine containing foods such as the ones given are avoided with monoamine oxidase
inhibitors)
2. Caffeine (Incorrect)
3. Nicotine (Incorrect)
4. Dopamine (Incorrect)
Correct; 1 PG 238 Hesi 333 chapter 16
QID: 3714 C 16(245) A client is taking Carbidopa/Levodopa (parcopa) for treatment of Parkinson’s disease. A
therapeutic effect of this medication include
1. Urinary retention (Incorrect; This is an adverse effect)
2. Decreased salivation (Correct; Anticholinergics decrease salivation, spasticity and tremors)
3. Drooling (Incorrect; This shows drug is not working effectively)
4. Insomnia (Incorrect; This is an adverse effect)
QID: 3715 C 17 (251 H 316) All of following procedures are examples of somatic therapy that were used in the early
20th century to treat the mentally ill clients, EXCEPT?
1. Vagus nerve stimulation (VNS) (Correct; This was not part of somatic theory used)
2. Psychosurgery ( Incorrect; Option 2, 3& 4 were part of Somatic theory used in the 20th century)
3. Sterilization ( Incorrect)
4. Clitoridectomy (Incorrect)
QID: 3716 C 17 (251 H 316-317) Which of the following are the present-day somatic therapies?
1. Psychopharmacology (correct)
2. Electroconvulsive therapy (correct)
3. Transcranial magnetic stimulation (TMS) (Correct)
4. All of the above (All these plus phototherapy, and vagus name stimulation are examples of present-day somatic
therapies)
Correct; 4 PG 251 Hesi 316 - 317 chapter 17
158
QID: 3717 C 17 (252 H 316) The primary function of the electroconvulsive therapy (ECT) is to:
1. Inhibit neuronal transmission in the brain ( Incorrect)
2. Induce convulsive seizures in neurons in the entire brain (Correct; ECT uses electric currents to induce convulsive
seizures in neurons in the entire brain to alleviate symptoms of major depression, schizophrenia or acute menic episodes)
3. Enhance the activity of monoamine oxidase enzyme (Incorrect)
4. To correct all behavior (Incorrect)
Correct; 2 PG 252 Hesi 316 chapter 17
QID: 3718 C 17(252) The ECT that produces a sleep-like state without the presence of convulsions is called?
1. Electroperesis (Incorrect; Refer to electrical paralysis)
2. Electroshock therapy (Incorrect; Introduced in 1938 by cerletti and Bin later became ECT)
3. Electronarcosis (Correct; Usually anesthetics and muscle relaxants are used)
4. Electrophysiotherapy (Incorrect; Refer to use of electrical currents in physiotherapy)
QID: 3719 C17 (253) Indicators for ECT use include all of the following, EXCEPT:
1. Schizophrenia (Incorrect)
2. Obsessive-compulsive disorder (Incorrect)
3. Delusional depression (Incorrect)
4. Somatization disorders (Correct; ECT can be used in depression Schzophrenia or depressive phase of bipolar disorder
and clients at risk for suicide plus obsessive- compulsive disorders and schizo affective disorder but not somatoform
disorders and personality disorders)
QID: 3720 C 17(253) Which of the following statements about the use of ECT is correct?
1. ECT maybe used to treat pregnant women (Correct; ECT can be used with special populations like pregnant women,
children or depressed adolescents, delusional or in manic episodes)
2. ECT is effective in treatment of personality disorders (Incorrect)
3. ECT is contraindicated in treatment of depression in children (Incorrect)
4. ECT is the treatment of choice in the treatment of movement disorders (Incorrect)
QID: 3721 C 17 (254) The most common adverse effects reported by clients during ECT include
1. Pulmonary distress (Incorrect)
2. Headache (Correct; the most common adverse effect includes headache, nausea disorientation and memory
disturbance. Rare skeletal complications have occurred. The memory loss is temporary and there is no pulmonary
distress.
3. Vertebral fractures (Incorrect)
4. Permanent memory loss (Incorrect)
QID: 3722 C 18 (262) The National centre for complementary and Alternative Medicine refers to complementary and
alternative medicine as,
1. Disease-treating practices that may be related to conventional medicine and not taught in medical school (Incorrect;
Not considered to be conventional medicine)
2. Disease-treating practices and disease-preventing practices, not typically used in hospitals, but is generally
reimbursed by insurance companies (Incorrect; Not re-imbursed by insurance companies)
3. Diseased-preventing practices or therapies, not considered to conventional medicine taught in medical schools ,and
typically used in hospitals (Incorrect; Not taught in medical school and not typically used in hospitals)
4. Disease treating and disease-preventing practices, not considered to be conventional medicine taught in medical
schools, not typically used in hospitals, and not generally reimbursed by insurance companies (Correct; This is the
appropriate description)
159
QID: 3723 C 18(262) The increasing popularity and use of the complementary and alternative medicine is attributed to:
1. Dissatisfaction with increasing health care costs (Correct)
2. Dissatisfaction with managed care restrictions (Correct)
3. Dissatisfaction with the focus on management of clinical symptoms rather than etiology (Correct)
4. All of the above ( All these are reasons for increasing popularity and use of complementary and alternative medicine)
QID: 3724 C 18 (263) The therapy that teaches clients how to control or change aspects of their bodies’ internal
environment is?
1. Biofeedback (Correct; This is the appropriate terminology)
2. Guided imagery (Incorrect; Refer to conscious use of chosen positive images to reduce stressors.
3. Hypnosis (Incorrect; refer to achieving a relaxed yet heightened state of awareness)
4. Medication (Incorrect; Clients sit quietly with eyes closed and focus mind on a single thought)
QID: 3725 C 18(263) One of the following is not a part of the massage therapy;
1. Healing touch (Incorrect; This is part of massage therapy)
2. Rolfing Incorrect: (Incorrect; This is part of massage therapy)
3. Trager therapy (Incorrect; This is part of massage therapy)
4. Homeotherapy (Correct; This is not part of massage therapy. It is based on the theory that the body posses the power
to heal itself)
QID: 3726 C 18(264 H 315) Holistic communication,

1. Recognizes that each person’s environment includes everything that surrounds the individual (Incorrect; this is
therapeutic environment)
2. Recognizes that holistic nursing theories provides the framework for all aspects of holistic nursing practice and
transformational leadership ( Incorrect; This is holistic nursing theories)
3. Ensures that each person experiences the presence of the nurse as authentic and sincere (Correct; This correctly refers
to holistic communication)
4. Engages in self-care and further development of own personal awareness (Incorrect; This is holistic nurse self-care)
QID: 3727 C 18(266) A biologically based practice is which of the following?

1. Vitalism (Incorrect; This is the same as Homeopathy)
2. Aromatherapy (Correct; Refer to controlled therapeutic use of essential oils for memorable outcome)
3. Homeopathy (Incorrect; Is based on theory that the body possesses power to heal self and is an alternative medical
system)
4. Alternative medical system (Incorrect; An example for this is Homeopathy)
QID: 3728 C 18(267) According to the American Herbal products Association, herbs which are considered safe when
used appropriately are grouped as:
1. Class I (Correct; Considered safe when used appropriately)
2. Class II (Incorrect; These are herbs with specific restrictions)
3. Class III (Incorrect; These are herbs labeled with instructions that one should use under supervision)
4. Class IV (Incorrect; These are herbs for which insufficient data are available)
160
QID: 3729 C 19 (280 H 320) A nurse is assessing a client suspected of having an anxiety disorder. The client asks the
nurse, “How does fear differ from anxiety?” The nurse would appropriately state that fear differs from anxiety because
fear,
1. Is just a symptom (Incorrect)
2. Describe feelings of uncertainty, uneasiness and tension (Incorrect; This refers to anxiety)
3. Is the body’s physiologic and emotional response to a known or recognized danger (Correct; Appropriate description
of fear)
4. Does not differ from anxiety at all (Incorrect; They are different as shown)
Correct; 3 PG 280 chapter 19 hesi 320
QID: 3730 C19 (281 H 320) Anxiety that is always present and is accompanied by a feeling of dread is referred to as:
1. Anxiety trait (Incorrect; Component of personality that has been proved over a long period)
2. Anxiety state (Incorrect; Occurs as a result of stressful situation in which person loses control of emotions)
3. Free-floating anxiety (Correct; The person may exhibit ritualistic and avoidance behavior (Phobic behavior)
4. Signal anxiety (Incorrect; A response to an anticipated event)
Correct; 3 PG 281 chapter 19 hesi 320
QID: 3731 C 19(282) According to the psychoanalytic theory, anxiety is the:

1. Result of unresolved, unconscious conflicts between impulses for aggressive or libidinal gratification and the ego’s
recognition of the external damage that could result from gratification (Correct; This is the appropriate description)
2. The learned or conditioned response to a stressful event or perceived danger (Incorrect; This is anxiety according to
cognitive behavior theory)
3. Result of increased levels of serotonin in raphe nucleus, thalamus and basal ganglia (Incorrect; This is true according
to biologic theory)
4. None of the above(Incorrect; only option 1 is correct)
QID: 3732 C 19(283 H 320-321) A nurse assessing a client with anxiety disorder identifies which of the following
physiologic symptom(s) of anxiety? Select all that apply:
1. Irritability (Incorrect)
2. Blurred vision (Correct)
3. Dilated pupils (Correct)
4. Hypervigilance (Incorrect)
5. Crying (Incorrect)
6. Diaphoresis (Correct)
Rationale: Physiologic symptoms of anxiety are many and include blurred vision, dilated pupils, diaphoresis, dyspnoea,
headache, insommia, tighteness in the chest and vertigo among others)
Correct; 2, 3, 6 PG 283 chapter 19 hesi 320 -321
QID: 3733 C 19(287 H 321-322) The husband of a client being assessed for a suspected anxiety disorder tells the nurse,
“She won’t go out for fear of being among the crowd. What kind of disorder is this?” What would be the most accurate
response?
1. Ochlophobia (Correct; Refers to fear of crowds)
2. Pathophobia (Incorrect; Refer to fear of disease)
3. Agoraphobia (Incorrect; Refer to fear of open places)
4. Acrophobia (Incorrect; Refer to fear of heights)
Correct; 1 PG 287 chapter 19 Hesi 321 - 322
QID: 3734 C19 (288 H 322) The urge to carry out an act within one’s mind is?
1. Ideational obsession (Incorrect; Refer to persistent, intrusive ideas that one is unable to suppress)
2. Ideational compulsion (Correct; Appropriate terminology)
3. Obsessive-compulsive disorder (Incorrect; disorder characterized by obsession or compulsion or both)
161
4. None of the above (Incorrect; Option 2 is correct)
Correct; 2 PG 288 chapter 19 Hesi 322
QID: 3735 C19 (294 H 322) Antidepresssants paroxetine (paxil), are the preferred drugs of choice in treatment of
anxiety disorders because:
1. They are cheaper than benzodiazepines (Incorrect; They are more effective and have no abuse or dependence
liabilities)
2. They cause less diarrhea than SSRI (Incorrect; They are more effective and have no abuse or dependence liabilities)
3. They have demonstrated effectiveness and lack of abuse and dependence liabilities (Correct; This is the appropriate
reason for this preference)
4. They are associated with very few side effects (Incorrect; They are more effective and have no abuse or dependence
liabilities)
QID: 3736 C 19 (296 H320-321) Which of these drugs is not usually used for anxiety disorder?
1. Atenolol (Tenormin) (Incorrect; This drug is used for anxiety disorders)
2. Venlafaxine (effexor) (Incorrect; This drug is used for anxiety disorders)
3. Propanolol (Inderal) (Incorrect; This drug is used for anxiety disorders)
4. Promethazine (Phenergan) (Correct Option; This drug is used to prevent nausea and vomiting)
Correct; 4 Chapter 19 pg 296 Hesi 320 -321
QID: 3737 C 20(304) According to the organ specificity theory:

1. A person responds to stress primarily with physical manifestations in one specific organ or system (Correct; This is
true as per organ specific theory and this show susceptibility to development of a specific disease)
2. Individuals present with symptoms suggesting a physical disorder without demonstrable organic findings to explain
the symptoms (Incorrect; This suggests a somatoform disorder)
3. Characteristics of dynamic family relationships may influence the development of a somatoform disorder (Incorrect;
This is true of biological genetic factors)
4. A person learns to produce a physiologic response to achieve a reward, attention or other reinforcement (Incorrect;
This is true according to learning theory)
QID: 3738 C20 (305 H 326) A person’s sudden and unexpected departure from home or work and inability to recall the
past is known as:
1. Dissociative amnesia (Incorrect; This is inability to recall important personal details)
2. Dissociative identity disorder (Incorrect; Also known as multiple personality disorder)
3. Dissociative fugue (Correct; Gives the appropriate description)
4. Depersonalization disorder (Incorrect; Refer to distorted perception of self, body and life)
QID: 3739 C 20 (306 H 326-327) One of the following is not a somatoform disorder:
1. Obsessive – compulsiveness disorder (Correct; This is an anxiety disorder, not somatoform)
2. Conversion disorder (Incorrect; This is an example of somatoform disorder)
3. Pain disorder (Incorrect; This is an example of somatoform disorder)
4. Hypochondriasis (Incorrect; This is an example of somatoform disorder)
QID: 3740 C20 (308) Conversion symptoms serve all of the following functions EXCEPT?
1. Permit the client to express a forbidden wish (Incorrect)
2. Impose punishment via the disabling symptom for a forbidden wish (Incorrect)
3. Allow gratification of dependency ( Incorrect)
4. None of the above (Conversion symptoms serve four functions as in options 1, 2 and 3 plus removing client from
overwhelming life threatening situation)
162
QID: 3741 C 20(311) The essential feature of dissociative disorder is:

1. The person may engage in complex social interactions (Incorrect; a feature in dissociative fugue)
2. A disruption of integrated functions of consciousness, memory, identify or perception of the environment (Correct;
Forms an essential feature in dissociative disorders)
3. The inability to recall an extensive amount of important personal information (Incorrect; Is a feature in dissociative
amnesia)
4. A rare occurrence (Incorrect; A feature in dissociative fugue.)
QID: 3742 C20 (312 H326-327) During the assessment of a client, the client states,” I feel as if I am out of my body.”
The nurse understands that this disorder is:
1. Anxiety disorder (Incorrect; Refer to feelings of uncertainty, uneasiness, oppression or tension)
2. Dissociative identity disorder (Incorrect; Also known as multiple personality disorder is example of dissociative
disorder)
3. Somatoform disorder (Incorrect; Refer to physiologic complains with no organic findings)
4. Depersonalization disorder (Correct; This is the appropriate terminology)
Correct; 4 PG 312 chapter 20 326 - 327
QID: 3743 C 20(316 H 316-327) Which of the following is an appropriate outcome for a client treated for a
somatoform and dissociative disorder?
1. The client will have diminished episodes of confusion related to amnesia as fugue improves (Correct)
2. The client will verbalize feelings related to anxiety (Incorrect)
3. The client will demonstrate an improved ability to express self (Incorrect)
4. The client will express confidence in self (Incorrect)
Rationale;
Outcome focus on a client’s ability to recognize owns anxiety, identify stressors, identify ways to eliminate stressors and
develop effective coping skills)
Correct; 1 PG 316 chapter 20 hesi 326 - 327
QID: 3744 C 20 (318) An important tricyclic antidepressant drug used for somatoform and dissociative disorder is?
1. Buspirone (Buspar) (Incorrect)
2. Sertraline (Zoloft) ( Incorrect)
3. Amitriptylline (Elavil) Correct; A Tricyclic anitidepressant used for the above two disorders)
4. Paroxetine (Paxil) (Incorrect)
QID: 3745 C21 (325 H 332) Infants who are separated from their mothers may exhibit signs of:
1. Anaclitic depression (Correct; Manifest as withdrawal, non responseveness, depression and vulnerability to physical
illness)
2. Bipolar disorder (Incorrect)
3. Withdrawal (Incorrect)
4. All of the above (Incorrect; Only option 1 is correct. Infants separated from the mother may exhibit symptoms of
anaclitic depression or failure to thrive)
QID: 3746 C 21(326 H 332-338) A nurse caring for a client with a mood disorder is aware that the risk factor(s) for
mood disorders include, (select all that apply)
1. Prior episodes of depression (Correct; Risk factors include female gender, post partum period, lack of social support
and stress for life events plus option 1 and 3.
2. Male gender (Incorrect)
3. Prior suicide attempts (Correct)
163
4. Intrapartum period (Incorrect)
5. Adequate social support (Incorrect)
Correct; 1, 3 PG 326 chapter 21 Hesi 332 - 338
QID: 3747 C 21(326) Studies of twins have shown that if an identical twin develops a mood disorder, the other twin has
a 70% chance of developing the disorder. This statement is true according to which theory about the etiology of mood
disorders?
1. Biochemical theory (Incorrect; Based on chemical compounds which influence mood)
2. Neuroendocrine regulation (Incorrect; Mood is affected by neuroendocrine regulation)
3. Genetic theory (Correct; This risk decreases to about 15% with siblings, parents and children of the affected person)
4. Behavioral theory (Incorrect; Mood disorders may be from acquired or learnt behavior)
QID: 3748 C21 (328) Which of the following statements about the pathophysiologic basis of depression is true?
1. Amygdala, an area of the brain, displays over activity in depressed people (Correct; Amygdala is overactive)
2. Depressed people have increased activity in the prefrontal cortex (Incorrect; Have decreased activity)
3. Activity of thalamus is decreased in depressed people (Incorrect; It is increased)
4. In depression, neurons produce excessive neurotransmitters (Incorrect; They produce low levels)
QID: 3749 C 21 (331 H 332-338) An important symptom of major depressive disorder is:
1. Cognitive agitation (Incorrect; There is psychomotor agitation or retardation)
2. Indecisiveness (Correct; There is reduced ability to concentrate or think)
3. Excessive drooling (Incorrect; They are physiological symptoms not associated with major depression)
4. Increased intracranial pressure (Incorrect; They are physiological symptoms not associated with major depression)
QID: 3750 C 21 (345) Which of the following complementary and alternative therapies may be used in the management
of mood disorders?
1. St. John’s wort
2. SAM-e (Correct)
3. Kava kava (Correct)
4. All of the above (Correct; Complementary and alternative therapies used in mood disorders include all in option 1, 2
and 3 plus Valerian and Qark Cohosh)
QID: 3751 C 22 (354) Which of the following statements about the schizophrenia is/are true? (Select all that apply).
1. It stems from physiologic malfunctioning of the brain (Correct; This is appropriate description)
2. More prevalent in women than men (Incorrect; More in men than women)
3. Persons with intelligence quotients of the genius level are immune to schizophrenia (Incorrect)
4. People with schizophrenia are more likely to be members of lower socioeconomic groups (Correct; Schizophrenia
affects all races, no cultural group is immune and no group is spared. It occurs thrice in those unmarried or divorced as
opposed to those married or not divorced)
5. Schizophrenia usually appears earlier in men than in women(Correct)
Correct; 1, 4, 5 PG354 chapter 22
QID: 3752 C 22 (356 H 338) An example of biochemical and neurostructural theory in the etiology of schizophrenia is:
1. Perinatal theory (Incorrect; Argues that risk exist if fetus is deprived of oxygen)
2. Pathophysiologic hypothesis (Incorrect; Argues its due to functional default in the brain)
3. Dopamine hypothesis(Correct; Says excessive dopamine allows nerve impulse to bombard the mesolimbic pathways)
4. Cultural theory (Incorrect; Relate it to faulty reaction to environment)
164
QID: 3753 C 22(357 H 338-339) The clinical symptoms of schizophrenia, referred to as the positive symptoms include
1. Anergia (Incorrect)
2. Anhedonia (Incorrect)
3. Poor eye contact (Incorrect)
4. Hallucinations (Correct; Positive symptoms reflect presence of overt psychiatric or distorted behavior eg.
Hallucinations, delusion, or suspiciousness)
QID: 3754 C 22(358 H 338) Type II schizophrenia is characterized by;

1. Acute onset of positive symptoms (Incorrect; Refer to type 1)
2. Acute onset of difficult in abstract thinking (Incorrect; Related to type 1)
3. A slow onset of negative symptoms (Correct)
4. Adequate response to typical neuroleptic medication (Incorrect; Related to type 1)
QID: 3755 C 22(359 H 338-339) The wife of a client suspected to have schizophrenia reports that her husband is
accusing her of poisoning his food, spending all his money, having an affair with his boss, and telling stories about him.
He reports that he had been receiving messages from Jesus Christ while watching television. The client is most likely
suffering from:
1. Schizophrenia, catatonic type (Incorrect)
2. Schizophrenia, paranoid type (Correct)
3. Schizophrenia, disorganized type (Incorrect)
4. Schizophrenia, residual type (Incorrect)
Rationale;
These symptoms reflect paranoid type of schizophrenia where there is preoccupation with one or more delusion or
frequent ammenty hallucinations)
QID: 3756 C 22 (363) An example of a nursing diagnosis for a client with schizophrenia is which of the following?
1. Disturbed sleep pattern related to the presence of auditory hallucinations (Correct)
2. Post-trauma syndrome related to physical and sexual assault (Incorrect; This doesn’t occur with schizophrenia but
with post-traumatic syndrome disorders)
3. Powerlessness related to obsessive-compulsive behavior (Incorrect; This occurs in this anxiety disorder)
4. All of the above (Incorrect; Only option 1 is correct)
QID: 3757 C 24 (405 h 327) Which of the following statements about the personality concept is incorrect?
1. A distinctive set of traits, behavior style, and patterns that make up our character and individuality (Incorrect; This is a
correct statement on personality concept)
2. Influenced by genetic endowments (Incorrect; This is a correct statement on personality concept)
3. Occur along a continuum (Incorrect; This is a correct statement on personality concept)
4. Life’s experience has little influence on personality development (Correct option; This statement is incorrect regarding
personality concept)
Correct; 4 pg 405 HESI 327 chapter 24
QID: 3758 C 24 (405) The Freud’s psychoanalytic theory of personality development consists of the following
categories EXCEPT:
1. Development of personality (Incorrect)
2. Structure of personality (Incorrect)
3. Dynamics of personality (Incorrect)
4. None of the above (Correct Option; All the above three categories are part of the Freud’s psychoanalytic theory)
165
Correct; 4 pg 405 chapter 24
QID: 3759 C 24 (405 h 327-329) According to Freud, id is:

1. An unconscious reservoir of primitive drives (Correct; It is the appropriate description of id)
2. Part of personality that meets and interacts with the outside world (Incorrect; This refers to ego)
3. Part of personality that acts as the censoring force (Incorrect; This refers to super ego)
4. Is the executive function of the personality (Incorrect; Relates to ego)
Correct; 1 pg 405 chapter 24 HESI 327 - 329
QID: 3760 C 24 (407 h 327-329) Which of the following resolutions of conflict are appropriate for a 2-year old child,
according to Erickson’s psychosocial theory?
1. Establishes mature relationship with a member of the opposite sex (Incorrect; Occur with Young adults (19 – 40 years)
2. Chooses a career or vocation (Incorrect; Occur at puberty and adolescents (12 – 18 years)
3. Displays self-control (Correct; Other appropriate resolutions include being cooperative, expression of self and viewing
self apart from parents)
4. Displays the ability to trust others (Incorrect; Occur in early infancy (from birth – 18 months)
Correct; 3
QID: 3761 C 24 (408 h 327-328) Which of the following disorders are cluster B personality disorders? Select all that
apply.
1. Antisocial (Correct)
2. Histrionic (Correct)
3. Dependent (Incorrect)
4. Schizoid (Incorrect)
5. Borderline (Correct)
Correct; 1, 2, 5 pg 408 chapter 24 HESI 327 -328
Rationale:
Cluster B personality disorders include antisocial, borderline, histrionic, and narcissistic personality disorders)
QID: 3762 C 24 (411 h 327-328) Magical thinking and superstitiousness are characteristics of which of the following
personality disorder?
1. Schizotypal personality disorder (Correct; Clients usually exhibit a disturbance in thought process referred to as
magical thinking, supestitiousness or telepathy)
2. Paranoid personality disorder (Incorrect)
3. Schizoid personality disorder (Incorrect)
Correct; 1 pg 411 HESI 327 - 328 chapter 24
QID: 3763 C 24 (414 h 328) A client with borderline personality disorder would be expected to use which of the
following defense mechanism?
1. Projective identification (Correct)
2. Splitting (Correct)
3. Denial (Correct)
4. All of the above (Correct; In borderline personality disorder, most commonly used defense mechanisms include
denial, splitting and projective dentification)
QID: 3764 C 24 (415 h 327-328) During the assessment of a client with a personality disorder, the nurse notes that the
client insists that the husband remain in the room during the examination. When the nurse discusses the treatment
options with the couple, the client asks her husband for his opinion. The client tells the nurse that her husband makes all
the “difficult” decisions. The nurse understands that the client is exhibiting clinical symptoms of?
1. Narcissistic personality disorder (Incorrect)
166
2. A dependent personality disorder (Correct; In dependent personality disorder, clients lack self confidence and are
unable to function in an independent role.)
3. Avoidant personality disorder (Incorrect)
4. Antisocial personality (Incorrect)
QID: 3765 C 24 (405 h 327-329) Which of the following statements is true about the disturbance of cognition for a
client with personality disorder?
1. Clients are never in contact with reality (Incorrect; Clients are usually in contact with reality)
2. Exhibits undistorted perceptions of self or events (Incorrect; Clients do not have distorted perceptions)
3. Cognitive ability may be difficult to assess if the client is suspicious (Correct)
4. Illusions are never exhibited by clients with schizotypal personality disorder (Incorrect; Clients usually exhibit
illusions)
QID: 3766 C 24 (412 h 328) Individuals with histrionic behavior are prone to conflict with law because of:
1. Failure to comply with social norms when meeting their needs (Incorrect; They like being the centre of attention)
2. Their extreme sensitivity to rejection and humiliation(Incorrect; They like being the centre of attention)
3. Their inappropriate sexually seductive or provocative behavior (Correct; Clients like being the centre of attention)
4. Their covert obstruction through manipulative behavior ((Incorrect; They like being the centre of attention)
Correct; 3 pg 412 chapter 24 HESI 328
QID: 3767 C 25 (430 h 344) Codependency refers to,

1. The person’s ability to obtain a desired effect from a specific dose of a drug (Incorrect; This is tolerance)
2. A state of chronic or recurrent drug intoxication (Incorrect; This is addiction)
3. Substance-seeking activities and pathological use patterns (Incorrect; This is behavioral dependence)
4. All the behavioral pattern of family members who have been significantly affected by another family member’s
substance use or abuse (Correct; This is the appropriate description of codependency)
Correct; 4 chapter 25 pg 430 HESI 344
QID: 3768 C 25 (431 h 344) According to the 2003 NCADI and NIAAA surveys, the proportion of all adults in the
United States who have had at least one episode of an alcohol related problem is?
1. 30 – 56% (Correct; This is the correct statistic as per NCADI and NIAAA surveys, 2003)
2. 20 – 28% (Incorrect; These are incorrect statistics)
3. 28 – 69%(Incorrect; These are incorrect statistics)
4. 62 – 83% (Incorrect; These are incorrect statistics)
QID: 3769 C 25 (432 h 344) A nurse is assessing a client suspected of alcoholism. Which of the following is not an
effect of alcohol in the reproductive system?
1. Prostatitis (Incorrect)
2. Release of sexual inhibition (Incorrect)
3. Genital defects (Incorrect)
4. Anemia (Correct; Reproductive system complications include prostatitis, voiding problems , sexual inhibition release,
heart defect in fetus, abnormal heads and limbs, genital defects and mental retardation)
QID: 3770 C 25 (434 h 344) Which of the following statements about the Biologic theories of the etiology of substance-
related disorders is true?
1. All drugs of abuse inhibit dopamine secretion (Incorrect; They stimulate its secretion)
2. Amphetamine provoke the release of dopamine (Correct; All drugs of abuse stimulate dopamine secretion)
3. Nicotine acts on a receptor for norepinephrine (Incorrect; Acts on a receptor for acetylcholine)
167
QID: 3771 C 25 (439 h 345) Physical effects of immediate cocaine intoxication include: Select all that apply
1. Immediate dilation of pupils (Correct)
2. Loss of appetite (Correct)
3. Constipation (Incorrect)
4. Chronic nose bleeds (Incorrect)
Rationale: Physical effects of cocaine intoxication include dilation of pupils, increase or decrease in BP, pulse,
respiration and body temperature, there is loss of appetite, nausea and vomiting, weight loss, insomia, agitation,seizure,
chest pain or coma)
Correct; 1, 2 pg 439 chapter 25 HESI 345
QID: 3772 C 25 (443) Which of the following is correct about the schedule III drugs?
1. High potential for abuse (Incorrect)
2. Acceptable medical use with severe restrictions (Incorrect)
3. Examples are: Cough syrups with codeine (Incorrect)
4. Examples are: Anabolic steroids (Correct; schedule III drugs have less potential for abuse are accepted for medical use
and include anabolic steroids, hydrocodeine,codeine and barbiturates)
QID: 3773 C 25 (456) Ruppert (1999) lists several behavioral modification tips to help ex-smokers stay tobacco free.
These behavior include all of the following except?
1. Maintain a routine schedule (Incorrect; This is one of the tips to help stay tobacco-free. Hence not the correct option)
2. Drinking plenty of water (Incorrect; This is one of the tips to help stay tobacco-free. Hence not the correct option)
3. Replacing items that have been associated with smoking (Incorrect; This is one of the tips to help stay tobacco-free.
Hence not the correct option)
4. All of the above (Correct; Other tips include avoiding substitution of food for tobacco, deep breath practice and
exercising or doing labour intensive tasks)
QID: 3774 C 26 (466) A nurse who is assessing a client with sexual disorder is aware that: how one views one’s self in
terms of being emotionally, romantically, sexually attracted to an individual of a particular gender is referred to as:
1. Sexual orientation (Correct; This is the appropriate terminology)
2. Sexual identity (Incorrect; Whether one is male or female )
3. Gender identity (Incorrect; refer how one views ones gender)
4. Sexual behavior (Incorrect; refers to how one respond to sexual impulses)
QID: 3775 C 26 (469) According to Gender Identify Research and Education Society (GIRES) 2003, the correct
comparison of sexual dysfunctions between men and women is:
1. 3% of men have dyspareunia compared to 40% women (Incorrect; compare to 15% women)
2. 33% of women have hypoactive sexual desire compared to 10% men (Correct; This is correct statistics)
3. 15% of women have premature ejaculation compared to 27% men (Incorrect; Its 27 % men and women)
4. 25% of women have incomplete orgasm compared to 20% men (Incorrect; Its 10% men versus 25% women)
QID: 3776 C 26 (495) Which of the following diseases is/are associated with dementia? Select all that apply.
1. Familial multiple system taupathy (Correct; This is build up of proteins in neurons and glial cells)
2. Myeloma (Incorrect)
3. Pick’s disease (Correct; This is atrophy and microscopic changes of front temporal regions)
4. Coagulability disorders (Incorrect; presence of neurologic changes. Myeloma and coagulability disorder are not
associated with dementia)
5. Parkinson’s disease (Correct)
168
Correct; 1, 3, 5 pg 495 chapter 26
QID: 3777 C 26 (497) An abnormal movement in which the client exhibits a peculiar flapping movement of
hyperextended hands is referred to as:
1. Dysgraphia (Incorrect; Refer to impaired ability to write)
2. Dysnomia (Incorrect; Refer to inability to name object)
3. Asterixis (correct; Refer to the abnormal movement seen in various delirious state)
4. None of the above (Incorrect; option 3 is correct)
QID: 3779 C 28 (522 H 340) Grandiose delusions are also referred to as:
1. Megalomania (Correct; Client believes he/she possesses unrecognized talent or insights or has made important
discovery)
2. Delusional parasitosis (Incorrect; Believe that clients are infected with insects bugs or have serious illness)
3. Erotomanic delusions( Incorrect; Believes a person of elevated social status loves her)
4. Paradoxical conduct (Incorrect; Client interprets all denials of love as seccret affirmation)
QID: 3780 C 29 (547) Combination of motor tics and involuntary vocal and verbal utterances that often are absence is
known as;
1. Ecopresis (Incorrect; Refer to passage of feces in inappropriate places)
2. Enuresis (Incorrect; Refer to repeated urination into bed/clothes)
3. Tourette’s syndrome (Correct; This is the correct terminology)
4. TIC (Incorrect; This is a rapid, largely involuntary movement or noise)
Correct; 3 page 547 chapter 29
QID: 3781 C 30 (576) Which of the following secondary factors influence aging?
1. Gender (Incorrect:
2. Genetic influences (Incorrect)
3. Education (Correct; Secondary factors influencing aging include employment, economic level, education, health
practices and societal attitude)
4. Culture and Race (Incorrect; Gender, genetic influence and culture and race are primary factors)
QID: 3782 C 30 (576). Popular theories of aging includes: Select all that apply
1. Free radical theory (Incorrect; Belongs to biological theories)
2. Immunologic theory ((Incorrect; Belongs to biological theories)
3. Wear and tear theory (Correct; Belongs to biological theories)
4. Stress adaptation theory (Correct; Popular theory of aging are only two as in 3 and 4)
5. Somatic mutation (Incorrect; Belongs to biological theories)
Correct; 3, 4 Pg 576 chapter 30
169

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QID: 7233 C 19(280-285 h 320) A 21-year-old secretary with a history of anxiety reactions is admitted to the emergency

QID: 7161 C 21 (324 h 332) Adolescents with Bipolar Disorders:

QID: 7195 C 13 ( 169 h 315) Crisis intervention is most effective if it occurs:

QID: 7209 C 12 ( 152 h 315) A risk nursing diagnosis:

QID: 7212 C 12 (169 h 315) An example of stunned-inactive response to a crisis is:

QID: 7215 C 21 ( 325 h 332) An emotionally stable client is:

QID: 3000 C6 (68) The scope of forensic nursing practice encompasses:

QID: 3005 C 6 (71) A forensic Nurse understands that pharmacogenomics is?

QID: 3006 C 1 (76) Dysfuctional grief,

QID: 3014 C 8 (92) The quality assurance nurse,

QID: 3016 C8 (98) An example of residential treatment program includes:

QID: 3455 C 10 (129 h 315) Priority setting is a key element in;

QID: 3466 C 11 ( 153 h 315) Milieu therapy focuses on;

QID: 3455 C 10 (129 h 315) Priority setting is a key element in;

QID: 3466 C 11 ( 153 h 315) Milieu therapy focuses on;

QID: 3482 C 14 (186 h 316) An example of supportive therapy is:

QID:3489 C 15 (197 h 317-319)The client in family therapy is the:

QID: 3710 C 16 (218) Pharmacodynamics is the study of:

QID: 3726 C 18(264 H 315) Holistic communication,

QID: 3727 C 18(266) A biologically based practice is which of the following?

QID: 3731 C 19(282) According to the psychoanalytic theory, anxiety is the:

QID: 3737 C 20(304) According to the organ specificity theory:

QID: 3741 C 20(311) The essential feature of dissociative disorder is:

QID: 3754 C 22(358 H 338) Type II schizophrenia is characterized by;

QID: 3759 C 24 (405 h 327-329) According to Freud, id is:

QID: 3767 C 25 (430 h 344) Codependency refers to,

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