A young nurse charted that a 70-year-old client was “unable to perform ADL’s due to
old age.” What should the nursing supervisor do in response to this attitude?
1. Reassign the nurse to another unit with younger clients
2. Explain how aging does not prevent one from performing ADLs
3. Reprimand the nurse for charting opinions rather than facts
4. Suggest the young nurse encourage the client to be more independent
Answer:
The nurse is working with a client who has demonstrated an unwillingness to change
self-defeating behaviors. The nurse determines that the patient is exhibiting resistance.
Which of the following phenomena are forms of client resistance?
Standard Text: Select all that apply.
1. Overdisclosure
2. Negative transference
3. Acting-out
4. Countertransference
5. Positive transference
Answer:
Teaching clients and family members about the physical cues that indicate increasing
anxiety would include information on:
1. Short attention span.
2. Forgetfulness.
3. Urinary retention.
4. Urinary frequency.
Answer:
A college student tells the nurse that he sometimes cannot recall conversations or events
during times when he was drinking heavily. The nurse teaches the client that this
experience is indicative of which of the following symptoms?
1. Addiction
2. Confabulation
3. Delusion
4. Blackout
Answer:
The nurse observed that during a teaching session, the overall emotional tone of a client
remained unchanged. The nurse documents this as:
1. Affect that has range.
2. Flat affect.
3. Incongruent verbal and nonverbal responses.
4. Muted behavior.
Answer:
A nurse is seeking consultation on strategies to cope with the potential for burnout
while working on a psychiatric unit. Which of the following strategies demonstrates the
nurse’s ability to reduce the occurrence of burnout?
1. Focus on paperwork when the stress of listening to the clients becomes too much.
2. Pursue personal needs for social interactions during days off.
3. Take breaks often to relieve internal stress signals.
4. Maintain an accurate awareness of each client’s needs throughout inpatient stays.
Answer:
While taking care of a client at the mental health clinic, the student nurse notices scars
and healing lacerations on the client’s arms. The client states, “I did all of that.” The
student nurse knows this type of behavior is:
Standard Text: Select all that apply.
1. Self-destructive.
2. A prank.
3. A maladaptive measure.
4. A coping mechanism.
5. A waste of time.
Answer:
A client is informed that his family refuses to allow him to return to the family’s home
because of recent violent behavior. The client’s expression remains blank; there is no
apparent reaction to this statement. The client then asks what time dinner is served. The
client is exhibiting:
1. Inappropriate affect.
2. Blunted affect.
3. Flat affect.
4. Mutism.
Answer:
The client with bipolar disorder has been on lamotrigine (Lamictal) for three years and
has had a stable mood for one year and asks what the risks would be of just stopping all
the lamotrigine at once. Which nursing response is the most important point?
1. Stopping this medication is usually not problematic.
2. Stopping this medication could trigger a panic attack.
3. Stopping this medication may trigger headaches.
4. Stopping this medication abruptly carries the risk of seizures.
Answer:
When working with a client who has exhibited a pattern of violent outbursts followed
by remorse, a nurse’s plan of care should focus on:
1. Decreasing the client’s stressors.
2. Developing effective anger management techniques.
3. Offering the client family counseling.
4. Identifying the client’s strengths.
Answer:
A family member tells the nurse that much information is available on the internet
about medications. This family member asks the nurse to explain what
neurotransmitters are impacted by lithium. Which nursing response is correct?
1. Lithium interacts with GABA and opens the chloride channels.
2. Lithium lowers the amount of serotonin and norepinephrine available in the neural
synapses.
3. Lithium increases the amount of dopamine available at the postsynaptic receptor.
4. Lithium raises the norepinephrine levels in the neural synapse.
Answer:
A client comes to the clinic complaining of headaches. Further assessment reveals three
one-inch bald spots at different locations on the client’s scalp. The client states the
headache and the bald spots resulted from an “accident.” The client’s partner, who has
accompanied the client into the exam room, often finishes the client’s sentences. The
nurse should:
1. Ask the partner to remain in the waiting room while the client is examined.
2. Alert hospital security about the potential for violence.
3. Encourage the partner to remain with the client to provide information about the
client’s health.
4. Contact the local authorities.
Answer:
The nurse knows that teaching has been effective when the clients state that upon
awakening following electroconvulsive therapy they:
1. Should be assisted to ambulate.
2. May have water immediately.
3. May be confused and disoriented.
4. Should eat breakfast.
Answer:
Which of the following combinations of clinical presentations constitutes the most
compelling indication that a client may have been abused?
1. Poor eye contact, depressed mood, unwillingness to give history data
2. Multiple bruises and scars, low self-esteem
3. Acting-out behaviors, disobedience, trouble with the law
4. Sores around the mouth, brittle hair
Answer:
A nurse manager in a women’s clinic is meeting with the staff to discuss assessment of
substance abuse among pregnant clients. What would the group typically assess as the
most frequently abused substance by pregnant women?
1. Caffeine
2. Tobacco
3. Alcohol
4. Cocaine
Answer:
For the last three generations, the men of the family have worked in logging. The
younger son wants to go to college and become a marine biologist. His parents tell him
that “logging is what our family does” and refuse to discuss the issue. The son chooses
to pursue employment in logging rather than upset his parents’ desires for their son.
This family is experiencing:
1. Enmeshment.
2. Pseudohostility.
3. Pseudomutuality.
4. Schism.
Answer:
To complete a behavioral assessment during a sexual history, the nurse would ask:
1. “In what way(s) do you experience anxiety about sex?”
2. “What is your level of satisfaction with the frequency of your sexual activity?”
3. “Can you describe the type of love and affection in this relationship?”
4. “In what way(s) do you experience guilt about sex?”
Answer:
A 15-year-old client who has been diagnosed with conduct disorder has been prescribed
medication to control aggressive behavior. For which medication is the nurse likely to
be providing client education?
1. Methylphenidate (Ritalin)
2. Amitriptyline (Elavil)
3. Lithium carbonate (Lithobid)
4. Buspirone (BuSpar)
Answer:
A client and his wife are visiting in the day room of an inpatient psychiatric unit when a
client with acute psychosis experiencing auditory hallucinations sits down next to them
and begins talking to the “voices.” Which of the following nursing actions is most
appropriate?
1. Take the client with psychosis by the hand and lead the client to another area in the
day room.
2. Announce over the intercom that visiting hours are over.
3. Observe the situation and intervene only if the client with psychosis becomes
aggressive.
4. Remind the client with psychosis to respect the privacy of the other client and his
wife.
Answer:
An 84-year-old woman with a diagnosis of dementia lives with her daughter and
son-in-law. The client’s daughter tearfully tells the nursing student that she does not
know what’s wrong with her mother, who has begun accusing them of stealing her
lingerie and keeping her prisoner. Based on the above, the nursing student identifies the
following nursing diagnosis for the client:
1. Disturbed Thought Processes.
2. Defensive Coping.
3. Powerlessness.
4. Ineffective Coping.
Answer: