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55. Which is the highest priority in the post ECT 63. One morning the nurse sees the client in a
care? depressed mood. The nurse asks her “What are you
A. Observe for confusion thinking about?” This communication technique is:
B. Monitor respiratory status A. focusing
C. Reorient to time, place and person B. validating
D. Document the client’s response to the treatment C. reflecting
D. giving broad opening
56. A 27 year old writer is admitted for the second 64. The client says to the nurse ” Pray for me” and
time accompanied by his wife. He is demanding, entrusts her wedding ring to the nurse. The nurse
arrogant talked fast and hyperactive. knows that this may signal which of the following:
Initially the nurse should plan this for a manic A. anxiety
client: B. suicidal ideation
A. set realistic limits to the client’s behavior C. Major depression
B. repeat verbal instructions as often as needed D. Hopelessness
C. allow the client to get out feelings to relieve
tension
D. assign a staff to be with the client at all times to 65. Which of the following interventions should be
help maintain control prioritized in the care of the suicidal client?
A. Remove all potentially harmful items from the
57. An activity appropriate for a manic client is: client’s room.
A. table tennis B. Allow the client to express feelings of
B. painting hopelessness.
C. chess C. Note the client’s capabilities to increase self
D. cleaning esteem.
D. Set a “no suicide” contract with the client.
58. The client is arrogant and manipulative. In
ensuring a therapeutic milieu, the nurse does one 66. A 14 year old male was admitted to a medical
of the following: ward due to bronchial asthma after learning that
A. Agree on a consistent approach among the staff his mother was leaving soon for U.K. to work as
assigned to the client. nurse.
B. Suggest that the client take a leading role in the The client has which of the following developmental
social activities focus:
C. Provide the client with extra time for one on one A. Establishing relationship with the opposite sex
sessions and career planning.
D. Allow the client to negotiate the plan of care B. Parental and societal responsibilities.
C. Establishing ones sense of competence in
59. The nurse exemplifies awareness of the rights school.
of a client whose anger is escalating by: D. Developing initial commitments and
A. Taking a directive role in verbalizing feelings collaboration in work
B. Using an authoritarian, confrontational approach
C. Putting the client in a seclusion room 67. The personality type of Ryan is:
D. Applying mechanical restraints A. conforming
B. dependent
60. A client on Lithium has diarrhea and vomiting. C. perfectionist
What should the nurse do first: D. masochistic
A. Recognize this as a drug interaction
B. Give the client Cogentin 68. The nurse ensures a therapeutic environment
C. Reassure the client that these are common side for the client. Which of the following best describes
effects of lithium therapy a therapeutic milieu?
D. Hold the next dose and obtain an order for a stat A. A therapy that rewards adaptive behavior
serum lithium level B. A cognitive approach to change behavior
C. A living, learning or working environment.
D. A permissive and congenial environment A. What is causing you to become agitated?
B. You need to stop that behavior now.
69. Included as priority of care for the client will be: C. You will need to be restrained if you do not
A. Encourage verbalization of concerns instead of change your behavior.
demonstrating them through the body D. You will need to be placed in seclusion.
B. Divert attention to ward activities
C. Place in semi-fowlers position and render O2 77. The nurse closely observes the client who has
inhalation as ordered been displaying aggressive behavior. The nurse
D. Help her recognize that her physical condition observes that the client’s anger is escalating.
has an emotional component Which approach is least helpful for the client at this
time?
70. The client is concerned about his coming A. Acknowledge the client’s behavior
discharge, manifested by being unusually sad. B. Maintain a safe distance from the client
Which is the most therapeutic approach by the C. Assist the client to an area that is quiet
nurse? D. Initiate confinement measures
A. “You are much better than when you were
admitted so there’s no reason to worry.” 78. The charge nurse of a psychiatric unit is
B. “What would you like to do now that you’re planning the client assignment for the day. The
about to go home?” most appropriate staff to be assigned to a client
C. “You seem to have concerns about going home.” with a potential for violence is which of the
D. “Aren’t you glad that you’re going home soon?” following:
A. A timid nurse
71. The most basic factor in the intervention with B. A mature experienced nurse
clients in the area of sexuality is: C. an inexperienced nurse
A. Knowledge about sexuality. D. a soft spoken nurse
B. Experience in dealing with clients with sexual
problems 79. The nurse exemplifies awareness of the rights
C. Comfort with one’s sexuality of a client whose anger is escalating by:
D. Ability to communicate effectively A. Taking a directive role in verbalizing feelings
B. Using an authoritarian, confrontational approach
72. Which of the following statements is true for C. Putting the client in a seclusion room
gender identity disorder? D. Applying mechanical restraints
A. It is the sexual pleasure derived from inanimate
objects. 80. The client jumps up and throws a chair out of
B. It is the pleasure derived from being humiliated the window. He was restrained after his behavior
and made to suffer can no longer be controlled by the staff. Which of
C. It is the pleasure of shocking the victim with these documentations indicates the safeguarding
exposure of the genitalia of the patient’s rights?
D. It is the desire to live or involve in reactions of A. There was a doctor’s order for
the opposite sex restraints/seclusion
B. The patient’s rights were explained to him.
73. The sexual response cycle in which the sexual C. The staff observed confidentiality
interest continues to build: D. The staff carried out less restrictive measures
A. Sexual Desire but were unsuccessful.
B. Sexual arousal
C. Orgasm 81. Clients with personality disorder will most
D. Resolution likely:
A. recover with therapeutic intervention
74. The inability to maintain the physiologic B. respond to antianxiety medication
requirements in sexual intercourse is: C. manifest enduring patterns of inflexible
A. Sexual Desire Disorder behaviors
B. Sexual Arousal Disorder D. Seek treatment willingly from some personally
C. Orgasm Disorder distressing symptoms
D. Sexual Pain disorder
82. A client tends to be insensitive to others,
engages in abusive behaviors and does not have a
75. The nurse asks a client to roll up his sleeves so sense of remorse. Which personality disorder is he
she can take his blood pressure. The client replies likely to have?
“If you want I can go naked for you.” The most A. Narcissistic
therapeutic response by the nurse is: B. Paranoid
A. “You’re attractive but I’m not interested.” C. Histrionic
B. “You wouldn’t be the first that I will see naked.” D. Antisocial
C. “I will report you to the guard if you don’t control
yourself.” 83. The client joins a support group and frequently
D. “I only need access to your arm. Putting up your preaches against abuse, is demonstrating the use
sleeve is fine.”. of:
A. denial
B. reaction formation
76. A nurse observes that a client with a potential
C. rationalization
for violence is agitated, pacing up and down the
D. projection
hallway and making aggressive remarks. Which of
the following statements is most appropriate to
84. A teenage girl is diagnosed to have borderline
make to this patient?
personality disorder. Which manifestations support
the diagnosis? C. She postpones the physical assessment until the
A. Lack of self esteem, strong dependency needs client is calm
and impulsive behavior D. Explains to the client that her reactions are
normal
B. social withdrawal, inadequacy, sensitivity to
rejection and criticism 94. Crisis intervention carried out to the client has
C. Suspicious, hypervigilance and coldness this primary goal:
D. Preoccupation with perfectionism, orderliness A. Assist the client to express her feelings
and need for control B. Help her identify her resources
C. Support her adaptive coping skills
85. The plan of care for clients with borderline D. Help her return to her pre-rape level of function
personality should include:
95. Five months after the incident the client
A. Limit setting and flexibility in schedule complains of difficulty to concentrate, poor
B. Giving medications to prevent acting out appetite, inability to sleep and guilt. She is likely
C. Restricting her from other clients suffering from:
D. Ensuring she adheres to certain restrictions A. Adjustment disorder
B. Somatoform Disorder
86. A 42 year old male client, is admitted in the C. Generalized Anxiety Disorder
D. Post traumatic disorder
ward because of bizarre behaviors. He is given a
diagnosis of schizophrenia paranoid type. 96. A 29 year old client newly diagnosed with
The client should have achieved the developmental breast cancer is pacing, with rapid speech
task of: headache and inability to focus with what the
A. Trust vs. mistrust doctor was saying.
B. Industry vs. inferiority The nurse assesses the level of anxiety as:
A. Mild
C. Generativity vs. stagnation
B. Moderate
D. Ego integrity vs. despair C. Severe
D. Panic
87. Clients who are suspicious primarily use
projection for which purpose: 97. Anxiety is caused by:
A. deny reality A. an objective threat
B. to deal with feelings and thoughts that are not B. a subjectively perceived threat
C. hostility turned to the self
acceptable
D. masked depression
C. to show resentment towards others
D. manipulate others 98. It would be most helpful for the nurse to deal
with a client with severe anxiety by:
A. Give specific instructions using speak in concise
88. The client says “ the NBI is out to get me.” The statements.
nurse’s best response is: B. Ask the client to identify the cause of her
A. “The NBI is not out to catch you.” anxiety.
B. “I don’t believe that.” C. Explain in detail the plan of care developed
C. “I don’t know anything about that. You are afraid D. Urge the client to focus on what the nurse is
of being harmed.” saying
D. “ What made you think of that.”
99. Which of the following medications will likely be
89. The client on Haldol has pill rolling tremors and ordered for the client?”
muscle rigidity. He is likely manifesting: A. Prozac
A. tardive dyskinesia B. Valium
B. Pseudoparkinsonism C. Risperdal
C. akathisia D. Lithium
D. dystonia
100. Which of the following is included in the health
90. The client is very hostile toward one of the staff teachings among clients receiving Valium?:
for no apparent reason. The client is manifesting: A. Avoid foods rich in tyramine.
A. Splitting B. Take the medication after meals.
B. Transference C. It is safe to stop it anytime after long term use.
C. Countertransference D. Double up the dose if the client forgets her
D. Resistance medication.