Multiple Choice
Identify the
choice that best completes the statement or answers the question.
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1.
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A nurse is assisting in preparing a plan of care
for the client who will be seen in the mental health clinic for the first time. In preparing for the
orientation phase of the therapeutic relationship, the nurse suggests addressing which of the
following issues?
a. | Facilitating behavioral
change | b. | Promoting problem-solving skills in the
client | c. | Promoting self-esteem in the
client | d. | The parameters of the
relationship |
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2.
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A nurse is reviewing the record of a client
admitted to the mental health unit and notes that the client was admitted by voluntary status. The
nurse determines that:
a. | The admission was made without the client’s
consent. | b. | The admission was mandated by court
order. | c. | The client has the right to demand and obtain release
from the hospital. | d. | The client was
committed by a group of designated mental health
professionals. |
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3.
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A client with a phobia will be treated for the
condition using a behavior modification technique known as systematic desensitization. The nurse
describes the components of this form of therapy to the client and instructs the client
that:
a. | The client will be introduced to short periods of
exposure to the phobic object while in a relaxed state. | b. | The client will talk to self to control actions more
effectively. | c. | The client will
meet with others with the same problem in a support group. | d. | The client will take medication daily to control the
condition. |
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4.
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A nurse is assisting in conducting a group therapy
session. A female client, who has shared with the group at a previous session that she isolates
herself when she feels depressed, suddenly gets up to leave. The appropriate nursing action is which
of the following?
a. | Lock the door so that the client cannot leave at this
potentially vulnerable time. | b. | Encourage the
client to stay and ask the client what she is feeling. | c. | Tell the client that it is not safe to leave. | d. | Tell the client that if she leaves, she cannot return to this therapy
group. |
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5.
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A mental health nurse on the evening shift is
receiving report about a client who was admitted to the nursing unit. The nurse is told that the
client was admitted by involuntary status. Based on this type of admission, the nurse would expect
that the client:
a. | Has the right to demand and obtain release from the
hospital | b. | Requested the admission | c. | Is in need of psychiatric treatment | d. | Provided written application to the facility for
admission |
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6.
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A nurse is reviewing the record of a client who is
hospitalized for treatment of a panic disorder. The nurse notes that the client was admitted by
voluntary hospitalization. During the day, the client runs down the hallway and demands release from
the hospital. The nurse notes that the client is exhibiting signs of anxiety and attempts to assist
the client back to the client’s hospital room. The next appropriate nursing action at this time
is which of the following?
a. | Notify the registered nurse
(RN). | b. | Help the client pack his or her personal belongings in
preparation for discharge. | c. | Inform the client
that discharge is not possible because of the type of admission process
involved. | d. | Call security and persuade the client to
stay. |
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7.
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A nurse in the psychiatric unit is reviewing the
records of the clients admitted to the nursing unit. A client with a history of violent behavior
approaches the nurse and demands immediate discharge from the hospital. The nurse notes that the
client was voluntarily admitted to the psychiatric unit. Which of the following is the appropriate
nursing action?
a. | Allow the client to leave. | b. | Attempt to persuade the client to stay. | c. | Call security to assist in restraining the client. | d. | Tell the client that the physician will be contacted regarding
discharge. |
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8.
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A nurse is assisting in conducting a group therapy
session. During the session a male client threatens to act out physically and states that he will
punch another member of the group. Which of the following is the appropriate initial nursing
action?
a. | Tell the client that he must leave
immediately. | b. | Call security to
come to the session immediately. | c. | Tell the client
that if he hits another client, he will be restrained and placed in
seclusion. | d. | Tell the client
that he may talk about his anger but cannot act on it during the group
session. |
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9.
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A nurse is assisting in preparing a plan of care
for a client with an autistic disorder. A behavior modification approach (operant conditioning) is
being used to care for the client to improve communication. Which of the following would be
appropriate for the nurse to suggest including in the plan of care?
a. | Provide consistent negative reinforcement to promote
appropriate behaviors. | b. | Avoid providing
rewards to the client. | c. | Reward the client
when a desired behavior is performed. | d. | Promote complete
independence in the client. |
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10.
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A nurse has been caring for a client with a
diagnosis of depression. The client says to the nurse, “I wish you would just be my
friend.” The appropriate response by the nurse is which of the following?
a. | “I am your
friend.” | b. | “Our
relationship is a therapeutic and helping one.” | c. | “I can’t be your friend. I’m the nurse and you’re the
client.” | d. | “You have
plenty of friends. You don’t need me to be your friend,
too.” |
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11.
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A nurse assists in making a plan of care for a
client and is developing goals that will help the client achieve an optimal level of functioning and
use resources. When the nurse enters the client’s room, the client says to the nurse,
“Could you ask the physician to let me have a pass for the weekend?” The appropriate
nursing response to assist the client in achieving the goal that has been set for this client is
which of the following?
a. | “When your physician comes in, I will ask for a
pass for the weekend.” | b. | “I will call
the physician and find out if you can have a pass so that you can make your
arrangements.” | c. | “When the
physician arrives on the unit, I will let him know that you have a
question.” | d. | “You
can’t have a pass for the weekend. You are not ready, and I’m sure that your physician
will say no.” |
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12.
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A nurse is collecting data on a client diagnosed
with mild depression. The client says to the nurse, “I haven't had an appetite at all for
the last few weeks.” Which of the following responses by the nurse would be
therapeutic?
a. | "Once the medication begins to work, you will begin
to feel better.” | b. | "Think about
everything that you have been through. It will take time for your appetite to
improve.” | c. | "The last few
weeks?" | d. | "You
haven’t had an appetite at all?" |
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13.
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The day nurses in a psychiatric unit are receiving
report from the night shift. During report, a client approaches the nurses’ station, becomes
very loud and angry, and demands to be seen by the physician immediately. The appropriate nursing
intervention is which of the following?
a. | Tell the client that the physician will be called as
soon as report is completed. | b. | Tell the client to
wait in her room until report is over. | c. | Inform the client
that the behavior is unacceptable. | d. | Offer to assist
the client to an examination room until the physician is
notified. |
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14.
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A licensed practical nurse (LPN) is caring for a
client with a diagnosis of schizophrenia. The LPN observes behaviors indicative of paranoia and
reports these observations to the registered nurse (RN). The LPN assists the RN in developing a plan
of care for the client and suggests inclusion of which intervention in the plan of
care?
a. | Encourage the client to socialize with other
clients. | b. | Inform the client about support groups that are
available in the community. | c. | Encourage the
client to lead a support group. | d. | Avoid joking or
laughing in the presence of the client. |
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15.
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A nurse is assisting in developing a plan of care
for a client with a psychotic disorder who is experiencing altered thought processes. On review of
the client’s record, the nurse notes documentation that the client believes that the food is
being poisoned. The nurse develops strategies that will promote adequate nutrition and encourage the
client to discuss feelings, and plans to:
a. | Use open-ended questions and
silence. | b. | Instruct the client about the need for adequate
nutrition. | c. | Focus on the fact
that the client’s beliefs are untrue. | d. | Focus on the
components of adequate nutrition. |
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16.
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A client admitted with depression states to the
nurse, “My life has been such a failure; nothing I do turns out right.” Which of the
following responses by the nurse would be therapeutic?
a. | “I know just how you feel. I have those days
myself once in a while.” | b. | “You seem
very discouraged. Can you think of anything recently that went as you
planned?” | c. | “I disagree
with you; we all have some value and accomplishments in life.” | d. | “You are certainly entitled to your own
opinion.” |
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17.
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A client is admitted to the psychiatric unit with a
diagnosis of bipolar affective disorder and mania. The nurse would prioritize that which of the
following symptoms or behaviors requires immediate intervention?
a. | Constant physical activity and poor oral
intake | b. | Constant, incessant talking with sexual
innuendos | c. | Outlandish behaviors and wearing odd, eccentric
clothing | d. | Grandiose delusions of being the King of
England |
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18.
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A nurse is working with a client who is delusional.
The client says to the nurse, “The leaders of a religious cult are being sent to assassinate
me.” Which of the following is the best response by the nurse?
a. | “I don’t know about a religious cult. Are
you afraid that people are trying to hurt you?” | b. | “What makes you think that cult members are being sent to hurt
you?” | c. | “There are
no religious cults in this area that are going to kill you.” | d. | “I don’t believe that what you are telling me is
true.” |
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19.
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A mental health nurse is assigned to care for a
client with a diagnosis of schizophrenia, acute phase. The nurse uses which of the following
approaches when planning care for this client?
a. | Repeatedly points out inconsistencies in the
client's communication during initial treatment | b. | Lets the client act out initially and uses the quiet room and restraints as
needed | c. | Allows the client to set the goals for the plan of
care | d. | Provides assistance with grooming and nutrition until
the client's thinking is cleared |
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20.
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A nurse is employed at a drug abusers’
residential treatment center. The nurse is preparing for the arrival of a new client and prepares to
explain to the client that the emphasis of the center is on group and social interaction, and that
rules and expectations are mediated by peer pressure. The most likely focus of therapy of this
residential center is which of the following?
a. | Systematic desensitization | b. | Cognitive behavioral therapy | c. | Milieu therapy | d. | Aversion
conditioning |
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21.
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A nurse is caring for a client who was recently
admitted for anorexia nervosa. Upon entering the client’s room, the nurse finds the client in
the middle of a series of sets of rapid sit-ups. Which action should the nurse to take
initially?
a. | Interrupt the client and offer to take her for a
walk. | b. | Interrupt the client and weigh her
immediately. | c. | Allow the client
to complete her exercise program. | d. | Tell the client
that she is not allowed to exercise rigorously. |
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22.
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A nurse working in a detoxification unit is
admitting a client for alcohol withdrawal. The client’s spouse states, “I don't know
why I don’t get out of this rotten situation.” Which of the following would be the
therapeutic response by the nurse?
a. | “What would your spouse think about your
decision?” | b. | “This is not
a good time to make that decision.” | c. | “You seem to
have a good grip of this situation . . . you probably should get
out.” | d. | “What
aspects of this situation are the most difficult for
you?” |
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23.
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A nurse is monitoring a client with a history of
opioid abuse for signs of withdrawal. The nurse monitors this client for which of the following signs
and symptoms associated with opioid withdrawal?
a. | Increased appetite, irritability, anxiety, restlessness,
and altered concentration | b. | Depression, high
drug craving, fatigue with altered sleep (insomnia or hypersomnia), agitation, and
paranoia | c. | Increased pulse and blood pressure, low-grade fever,
yawning, restlessness, anxiety, craving, diarrhea, and mydriasis | d. | Tachycardia, mild hypertension and fever, sweating, nausea, vomiting, and
marked tremor |
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24.
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The wife of a client who abuses alcohol tells the
nurse she cannot “go it alone” any longer and asks the nurse about the availability of
any free support services for “people like me.” The nurse refers the client’s wife
to which of the following community groups?
a. | Families Anonymous | b. | Fresh Start | c. | Al-Anon | d. | Alcoholics
Anonymous |
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25.
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A nurse is asked to assist in changing the bed
assignments in a nursing unit after receiving a call from the admitting department about a client who
will require isolation on admission. The nurse must choose a roommate for a client who is in a state
of starvation due to anorexia nervosa. The nurse would avoid choosing which client as a roommate for
the client with anorexia nervosa?
a. | A client who had a myocardial
infarction | b. | A client who had
back surgery | c. | A client with
pneumonia | d. | A client with a fractured
pelvis |
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26.
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A hospitalized client with a history of alcohol
abuse tells a nurse, “I am leaving now. I don’t want help. I have other things to attend
to that are more important.” The nurse attempts to discuss the client’s concerns, but the
client dresses and begins to walk out of the hospital room. The nurse should take which action at
this time?
a. | Tell the client that readmission is not possible after
leaving against medical advice (AMA). | b. | Call the nursing
supervisor. | c. | Restrain the
client and call the physician. | d. | Call security to
block the exits from the nursing unit. |
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27.
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A nurse is collecting data on a client in crisis.
Which of the following questions would the nurse ask to determine the client’s perception of
the precipitating event that led to the crisis?
a. | “What do you usually do to feel
better?” | b. | “With whom
do you live?” | c. | “What leads
you to seek help now?” | d. | “Who is
available to help you?” |
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28.
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A client with a potential for violence is
exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments
to the other clients and is continually pacing in the hallway. Which of the following comments by the
nurse would be therapeutic at this time?
a. | “You are going to be restrained if you do not
change your behavior.” | b. | “Please stop
so I don’t have to put you in seclusion.” | c. | “What is causing you to become
agitated?” | d. | “Why are you
intent on upsetting the other clients?” |
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29.
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A client who was recently paroled as a sex offender
is in therapy for pedophilia. The client says, "I’ve served my sentence and I’m
still in therapy, so why does this group have posters of me all over the neighborhood? It has my
picture on it and tells all about me." Which of the following would be the therapeutic response
by the nurse?
a. | “You seem angry, but you must understand that your
neighbors are frightened because of your serious crimes against
children.” | b. | “Try to
realize how fortunate you are that our society doesn’t let the group escalate to more punitive
measures after your crimes against children.” | c. | “Are you saying that you understand people are afraid for their children
but that you feel you are being unfairly treated?" | d. | "It’s sad for you, but when children are hurt as you hurt them,
people want you identified and isolated." |
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30.
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A nurse is assigned to a client who is psychotic.
The client is pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines
that which of the following is the immediate priority of care?
a. | Provide the other clients on the unit with a sense of
comfort and safety by isolating the client. | b. | Assist in caring
for the client in a controlled environment, such as a quiet room. | c. | Provide safety for both the client and other clients on the
unit. | d. | Offer the client a less stimulating area in which to
calm down and gain control. |
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31.
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A client is diagnosed with catatonic stupor. The
client is lying on the bed, hidden under the sheets, with her body pulled into a fetal position. The
nurse should take which appropriate action?
a. | Sit beside the client in silence with occasional
open-ended questions. | b. | Ask direct
questions to encourage talking. | c. | Leave the client
alone but check on her every 30 minutes. | d. | Take the client
into the dayroom with other clients for added supervision. |
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32.
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A nurse is having a conversation with a depressed
client in an inpatient psychiatric unit. The client says to the nurse, “Things would be so much
better for everyone if I just weren’t around.” Which response by the nurse would be
appropriate at this time?
a. | “You sound very unhappy. Are you thinking of
harming yourself?” | b. | “Those
feelings will go away once your medication really takes effect.” | c. | “I know what you mean; everyone gets that way when they are
depressed.” | d. | “Have you
talked to anyone specifically about what is bothering
you?” |
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33.
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A nurse is caring for an elderly client whose
husband died approximately 6 weeks ago. The client says, "There’s no one left to care
about me. Everyone that I have loved is now gone." The nurse would make which appropriate
response?
a. | “I’m sure you have someone if you think hard
enough.” | b. | “It sounds
as though you are feeling all alone right now.” | c. | “I don't believe that, and I really don’t think you do
either.” | d. | “That
doesn’t sound like the real you talking!” |
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34.
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A client who attempted suicide by overdosing with a
very large number of antidepressant pills has been admitted to the psychiatric unit. The nurse, being
most concerned with the client’s safety, would take which immediate action?
a. | Have the client put on a hospital gown and remove the
client’s clothing from the room. | b. | Request that a
friend of the client remain with the client at all times. | c. | Stay with the client at all times. | d. | Suggest placing the client in a seclusion room where all potentially dangerous
articles are removed. |
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35.
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A client has been brought to the emergency
department after attempting to commit suicide by hanging. The nurse should take which nursing action
first?
a. | Encourage the client to talk about the
experience. | b. | Administer an
anxiolytic medication as prescribed at once. | c. | Examine the neck
area and assess the airway. | d. | Obtain a detailed
history of events leading to the attempt. |
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36.
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A client admitted with depression 3 days ago could
hardly get out of bed without coaxing and needed constant encouragement to get dressed and
participate in unit activities. Today the client appears in the dayroom dressed and well groomed,
without any guidance from the staff. The client appears to be calm and relaxed, yet more energetic
than before. The nurse should take which initial action after noting this client’s
behavior?
a. | Notify the staff of these observations at the team
meeting due to begin in 3 hours’ time. | b. | Speak to the
client personally about the nurse’s observations and ask if the client is thinking about
suicide. | c. | Document that the client is adapting to the unit and is
feeling safe. | d. | Continue to
monitor the client’s behavior from a distance. |
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37.
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A nurse reviews the plan of care for a suicidal
client admitted to the hospital. The nurse notes documentation of a nursing diagnosis of
Dysfunctional grieving related to the loss of a spouse. The client progresses well and is approaching
discharge. Which of the following is an appropriate outcome for this nursing diagnosis?
a. | The client verbalizes stages of grief and plans to
attend a community grief group. | b. | The client
verbalizes connections between significant losses and low self-esteem. | c. | The client verbalizes decreased desire for self-harm and discusses two
alternatives to suicide. | d. | The client reports
three additional coping strategies. |
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38.
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A nurse working in an urgent care center is
interviewing a woman with vague somatic complaints. Once the nurse is alone with the client, the
client states that she was raped a few weeks ago but still feels “as if it just happened to
me.” The nurse should make which therapeutic response to the client?
a. | "It is very, very hard to get over these types of
feelings after being raped." | b. | "It’s
hard, but try to keep a sense of perspective. After all, it’s been a while since the rape
occurred.” | c. | "What do you
think you should do to reduce the likelihood that you will be raped
again?" | d. | "Tell me more
about what happened, which causes you to feel like the rape just
occurred." |
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39.
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A client receiving long-term therapy with lithium
carbonate (Eskalith) exhibits muscle tremors, confusion, vomiting, and diarrhea. The nurse
anticipates that the results of the latest serum lithium level will be between:
a. | 0 and 0.5 mEq/L | b. | 0.6 and 1 mEq/L | c. | 1 and 1.3
mEq/L | d. | 1.5 and 2 mEq/L |
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40.
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A client diagnosed with depression is starting
therapy with imipramine hydrochloride (Tofranil). The nurse is concerned that the client will not
comply with the medication regimen. To encourage the client to continue taking the medication, the
nurse tells the client that it is normal not to feel beneficial effects of the medication
for:
a. | 3 to 5 days | b. | 5 to 7 days | c. | 1 to 2
weeks | d. | 2 to 3 weeks |
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41.
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A client taking buspirone hydrochloride (BuSpar)
for 1 month is scheduled for a follow-up appointment. The nurse gathers data from the client and
interprets that the medication is effective if the client reports an absence of:
a. | Palpitations and anxiety | b. | Delusions | c. | Alcohol withdrawal
symptoms | d. | Paranoid thoughts |
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42.
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A client has been given an order for chloral
hydrate (Somnote) for short-term use. The nurse includes which of the following nursing interventions
in caring for this client?
a. | Instruct the client to call for help to get out of
bed. | b. | Leave the lights on in the client’s
room. | c. | Perform a neurological assessment every 4
hours. | d. | Monitor the vital signs every 4
hours. |
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43.
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A client with schizophrenia has been started on
medication therapy with loxapine (Loxitane). The nurse determines that the client is experiencing the
intended effects of the medication if which of the following client behaviors is
observed?
a. | Decreased appetite and food
intake | b. | Taking sips of water for dry
mouth | c. | Presence of fixed stare | d. | Absence of delusional statements |
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44.
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A client has begun taking phenelzine (Nardil). At
the initiation of therapy, the nurse teaches the client that which of the following items are allowed
in the diet?
a. | Red wines such as Chianti or
sherry | b. | Avocados, figs, and raisins | c. | Lunchmeats such as bologna or salami | d. | Carrots, sweet potatoes, and squash |
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45.
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A client has been started on medication therapy
with alprazolam (Xanax). When the nurse teaches the client that the medication should not be
discontinued abruptly, the client asks why. The nurse should incorporate which of the following in
formulating a reply?
a. | Rebound central nervous system (CNS) excitation could
occur, including seizure activity. | b. | It will make the
medication much less effective if it must be restarted. | c. | The client is likely to become resistant to medication
effects. | d. | The client is likely to suffer irreversible kidney
damage. |
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46.
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A client’s medication sheet contains an order
for sertraline hydrochloride (Zoloft). To ensure safe administration of the medication, the nurse
would administer the dose:
a. | Evenly spaced around the
clock | b. | At the same time each evening | c. | On an empty stomach | d. | On an as-needed
basis when the client complains of depression |
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47.
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A client is receiving a daily dose of oral
fluphenazine (Prolixin). The nurse would teach the client to do which of the following to minimize
common side effects of this medication?
a. | Have blood pressure checked once a
week. | b. | Monitor pulse daily. | c. | Eat snacks at midmorning and bedtime. | d. | Use hard, sour candy or sugarless gum. |
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