Upon the client’s arrival on the patient care unit, the nurse begins implementation of the
nursing process. Of which nursing theorist should the nurse’s practice be most
reflective?
1. Ida Jean Orlando
2. Jean Watson
3. Dorothea Orem
4. Hildegard Peplau
Answer:
The nurse is teaching staff at a long-term health care facility about depression in older
adults. Which comment by staff indicates to the nurse the need for further teaching?
1. “Inability to organize and abstract information may indicate depression in older
adults.”
2. “Depressed older adults may exhibit an excessive preoccupation with chronic
constipation or pain.”
3. “Sadness or feeling blue are normal aspects of the aging process and are not a cause
for concern.”
4. “Lack of interest or apathy may be a sign of depression in older adults.”
Answer:
Which of the following interventions will increase the client’s likelihood of complying
with taking psychotropic medications?
1. Give family members information about the client’s medication.
2. Encourage the client to take all medication at the same time.
3. Give the client a pamphlet explaining the positive effects of psychotropic medication.
4. Encourage the client to use measures to manage side effects.
Answer:
A 14-year-old female inpatient, diagnosed with depression and self-mutilating behavior,
is scheduled to be discharged in the morning.
Her parents divorced when she was 10 and she hasn”t seen her father for almost a year,
but for the past three months she has been looking forward to his taking her to a special
concert a few days after discharge. Her father has just called to tell his daughter he will
not be able to make their “date” because he has been detained longer than expected on a
business trip. The client takes the phone receiver and begins hitting herself in the chest
with it. Which of the following nursing interventions will be most therapeutic in helping
the client deal with her anger?
1. Provide emotional support by telling the client she has a right to be angry.
2. Tell the client you understand how she feels.
3. Revoke the discharge and transfer the client to a more restrictive environment.
4. Suggest that the client write her father a letter telling him how she feels.
Answer:
The client with a diagnosis of borderline personality disorder shows the nurse multiple
superficial cuts to the arms that were made during the night. The client states, “I told the
night staff that I was feeling alone.” The nurse recognizes that the self-mutilation may
be a result of:
1. Manipulation.
2. Anxiety.
3. Splitting.
4. Impulsive behavior.
Answer:
The psychiatric”mental health nurse is asked to consult with an emergency room nurse
about a client who has been refusing to cooperate with lab work for over four hours.
The client appears frightened, answers questions reluctantly, and has no family present.
Which response of the psychiatric”mental health nurse demonstrates a
humanistic”interactional approach to the situation?
1. “Have you asked if the client wants to have a friend or family member to be here?”
2. “Have you offered medication for anxiety?”
3. “Give the client some time alone to decide whether or not to accept treatment.”
4. “I would ask for a full psychiatric evaluation before discharge.”
Answer:
A client, age 8, has just been prescribed pemoline (Cylert). The child’s parents ask about
the long-term effects of this medication. The nurse conducting patient teaching for the
parents about this medication will include which of the following statements?
1. “Photosensitivity is a problem with long-term use.”
2. “This is one of the drugs found to be safe for long-term use.”
3. “At the present time, there is limited information about this.”
4. “There seems to be a better outcome when the higher dose is given at bedtime.”
Answer:
The nurse utilizes a sound theoretical knowledge base about adolescent growth and
development to:
1. Integrate truth and fiction.
2. Differentiate between normal and abnormal.
3. Assess cognitive abilities.
4. Incorporate good and evil.
Answer:
A client who abuses alcohol has been placed on naltrexone (Trexan). What information
should be included in the client education about the effects of this medication?
1. The client may discontinue its use in alcohol abuse treatment.
2. If alcohol is ingested, the client may experience a lethal reaction.
3. The client needs to avoid use of over-the-counter products that contain alcohol.
4. If alcohol is ingested, the client will feel less “high.”
Answer:
An appropriate ongoing, long-term treatment goal for a victim who experienced sexual
abuse eight months ago is to:
1. Establish rapport and build a trusting nurse”client relationship.
2. Move from victim to survivor status.
3. Become aware of legal rights.
4. Involve significant others in the treatment plan.
Answer:
The nurse knows that basic suicide precautions may be started without a physician’s
order and maximum suicide precautions (or restrictions):
1. Need a physician’s order and a psychiatric consult.
2. May be started on the recommendation of the psychiatric nurse.
3. Can be instituted without a physician’s order only under emergency conditions.
4. Cannot be instituted without the client’s consent.
Answer:
The nurse knows that planning for recovery can begin:
1. At discharge.
2. Once the client expresses a need for greater autonomy.
3. At admission.
4. With an inflexible treatment team.
Answer:
The mother of an 8-year-old client being treated for conduct disorder says that the child
often threatens to “kung-fu” (kick and strike) the client’s sister just like a favorite
cartoon character does on TV. Based on behavioral theory, the nurse would suspect that
the child’s aggressive behavior could best be reduced by:
1. Administering a medication that will increase the neurotransmitter serotonin.
2. Engaging the client and sister in family therapy.
3. Providing positive reinforcement when the child exhibits nonaggressive behavior.
4. Identifying and reframing the negative thoughts that the child has toward the sister.
Answer:
The nurse expresses ambivalence about the use of electroconvulsive therapy (ECT).
How can this attitude influence client care?
1. This attitude may be communicated to the client and the family, thus hindering the
nursing care.
2. The client may be unaware of the nurse’s attitude.
3. The nurse’s attitude may spread to other staff members.
4. The nurse’s ambivalence will have no effect as long as the nurse is professional.
Answer:
Clients with antisocial personality disorder display a lack of empathy and will put their
own needs above the needs of others. Interventions for clients with antisocial
personality disorder will be targeted toward which of the following behaviors?
1. Displaying a great deal of responsibility toward others
2. Displaying a disregard for the rights of others
3. Displaying a great deal of self-control
4. Displaying a great deal of anxiety
Answer: