NCLEX Psychiatric Nursing question & answers part 3

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NCLEX Psychiatric Nursing question & answers part 3

201. A cab driver, stuck in traffic, becomes lightheaded, tremulous, diaphoretic, tachycardic and dyspneic. A workup in an emergency department reveals no pathology. Which medical diagnosis should a nurse suspect, and what nursing diagnosis should be the nurse’s first priority?

1. Generalized anxiety disorder and a nursing diagnosis of fear

2. Altered sensory perception and a nursing diagnosis of panic disorder

3. Pain disorder and a nursing diagnosis of altered role performance

4. Panic disorder and a nursing diagnosis of anxiety

ANS: 4

Rationale: The nurse should suspect that the client has exhibited signs and symptoms of a panic disorder. The priority nursing diagnosis should be anxiety. Panic disorder is characterized by recurrent, sudden-onset panic attacks in which the person feels intense fear, apprehension, or terror.

202. A client diagnosed with panic disorder states, “When an attack happens, I feel like I am going to die.” Which is the most appropriate nursing response?

1. “I know it’s frightening, but try to remind yourself that this will only last a short time.”

2. “Death from a panic attack happens so infrequently that there is no need to worry.”

3. “Most people who experience panic attacks have feelings of impending doom.”

4. “Tell me why you think you are going to die every time you have a panic attack.”

ANS: 1

Rationale: The most appropriate nursing response to the client’s concerns is to empathize with the client and provide encouragement that panic attacks only last a short period. Panic attacks usually last minutes but can, rarely, last hours. When the nurse states that “Most people who experience panic attacks…” the nurse depersonalizes and belittles the client’s feeling.

203. A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred?

1. “Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder.”

2. “Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder.”

3. “Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks.”

4. “Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks.”

ANS: 1

Rationale: The student indicates learning has occurred when he or she states that clonazepam is a particularly effective treatment for panic disorder. Clonazepam is a type of benzodiazepine in which the major risk is physical dependence and tolerance, which may encourage abuse. It can be used on an as-needed basis to reduce anxiety and the related symptoms.

204. A family member is seeking advice about an older parent who seems to worry unnecessarily about everything. The family member states, “Should I seek psychiatric help for my mother?” Which is an appropriate nursing response?

1. “My mother also worries unnecessarily. I think it is part of the aging process.”

2. “Anxiety is considered abnormal when it is out of proportion to the stimulus causing it and when it impairs functioning.”

3. “From what you have told me, you should get her to a psychiatrist as soon as possible.”

4. “Anxiety is a complex phenomenon and is effectively treated only with psychotropic medications.”

ANS: 2

Rationale: The most appropriate response by the nurse is to explain to the family member that anxiety is considered abnormal when it is out of proportion and impairs functioning. Anxiety is a normal reaction to a realistic danger or threat to biological integrity or self-concept.

205. A client is experiencing a severe panic attack. Which nursing intervention would meet this client’s physiological need?

1. Teach deep breathing relaxation exercises.

2. Place the client in a Trendelenburg position.

3. Have the client breathe into a paper bag.

4. Administer the ordered prn buspirone (BuSpar).

ANS: 3

Rationale: The nurse can meet this client’s physiological need by having the client breathe into a paper bag. Hyperventilation may occur during periods of extreme anxiety. Hyperventilation causes the amount of carbon dioxide (CO2) in the blood to decrease, possibly resulting in lightheadedness, rapid heart rate, shortness of breath, numbness or tingling in the hands or feet, and syncope. If hyperventilation occurs, assist the client to breathe into a small paper bag held over the mouth and nose. Six to twelve natural breaths should be taken, alternating with short periods of diaphragmatic breathing.

206. A college student is unable to take a final exam owing to severe test anxiety. Instead of studying, the student relieves stress by attending a movie. Which priority nursing diagnosis should a campus nurse assign for this client?

A. Non-adherence R/T test taking

B. Ineffective role performance R/T helplessness

C. Altered coping R/T anxiety

D. Powerlessness R/T fear

ANS: C

Rationale: The priority nursing diagnosis for this client is altered coping R/T anxiety. The nurse should assist in implementing interventions that will improve the client’s healthy coping skills and reduce anxiety.

207. A client living in a beachfront community is seeking help with an extreme fear of bridges, which is interfering with daily functioning. A psychiatric nurse practitioner decides to try systematic desensitization. Which explanation of this treatment should the nurse provide?

1. “Using your imagination, we will attempt to achieve a state of relaxation.”

2. “Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a relaxation response for the anxiety response.”

3. “Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety.”

4. “In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate.”

ANS: 3

Rationale: The nurse should explain to the client that when participating in systematic desensitization he or she will go through a series of increasingly anxiety-provoking steps that will gradually increase tolerance. Systematic desensitization was introduced by Joseph Wolpe in 1958 and is based on behavioral conditioning principles.

208. A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization?

1. The client will refrain from ritualistic behaviors during daylight hours.

2. The client will wake early enough to complete rituals prior to breakfast.

3. The client will participate in three unit activities by day three.

4. The client will substitute a productive activity for rituals by day one.

ANS: 2

Rationale: An appropriate initial client outcome is for the client to wake early enough to complete rituals prior to breakfast. The nurse should also provide a structured schedule of activities and begin to gradually limit the time allowed for rituals.

209. A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions?

1. “I will need scheduled blood work in order to monitor for toxic levels of this drug.”

2. “I won’t stop taking this medication abruptly because there could be serious complications.”

3. “I will not drink alcohol while taking this medication.”

4. “I won’t take extra doses of this drug because I can become addicted.”

ANS: 1

Rationale: The client indicates a need for additional information about taking benzodiazepines when stating the need for blood work to monitor for toxic levels. This intervention is used when taking lithium (Eskalith) for the treatment of bipolar disorder. The client should understand that taking extra doses of a benzodiazepine may result in addiction and that the drug should not be taken in conjunction with alcohol.

210. A client diagnosed with an obsessive-compulsive disorder spends hours bathing and grooming. During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that the rituals generate. Which defense mechanism should the nurse identify?

1. Sublimation

2. Dissociation

3. Rationalization

4. Intellectualization

ANS: 4

Rationale: The nurse should identify that the client is using the defense mechanism of intellectualization when discussing the rituals of obsessive-compulsive disorder in detail while avoiding discussion of feelings. Intellectualization is an attempt to avoid expressing emotions associated with a stressful situation by using the intellectual process of logic, reasoning, and analysis.

211. A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this client’s problem?

1. Distract the client with other activities whenever ritual behaviors begin.

2. Report the behavior to the psychiatrist to obtain an order for medication dosage increase.

3. Lock the room to discourage ritualistic behavior.

4. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.

ANS: 4

Rationale: The nurse should discuss with the client the anxiety-provoking triggers that precipitate the ritualistic behavior. If the client is going to be able to control interrupting anxiety, he or she must first learn to recognize precipitating factors. Attempting to distract the client, seeking medication increase, and locking the client’s room are not appropriate interventions, because they do not help the client gain insight.

212. A nursing student questions an instructor regarding the order for fluvoxamine (Luvox) 300 mg daily for a client diagnosed with obsessive-compulsive disorder (OCD). Which instructor response is most accurate?

1. High doses of tricyclic medications will be required for effective treatment of OCD.

2. Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for treating depression, may be required for OCD.

3. The dose of Luvox is low because of the side effect of daytime drowsiness.

4. The dose of this selective serotonin reuptake inhibitor (SSRI) is outside the therapeutic range and needs to be questioned.

ANS: 2

Rationale: The most accurate instructor response is that SSRI doses in excess of what is effective for treating depression may be required in the treatment of OCD. SSRIs have been approved by the Food and Drug Administration for the treatment of OCD. Common side effects include headache, sleep disturbances, and restlessness.

213. A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a nurse to question this order?

A. History of alcohol use disorder

B. History of personality disorder

C. History of schizophrenia

D. History of hypertension

ANS: A

Rationale: The nurse should question a prescription of alprazolam for acute anxiety if the client has a history of alcohol use disorder. Alprazolam is a benzodiazepine used in the treatment of anxiety and has an increased risk for physiological dependence and tolerance. A client with a history of substance use disorder may be more likely to abuse other addictive substances.

214. During her aunt’s wake, a four-year-old child runs up to the casket before a mother can stop her. An appointment is made with a nurse practitioner when the child starts twisting and pulling out hair. Which nursing diagnosis should the nurse practitioner assign to this child?

A. Complicated grieving

B. Altered family processes

C. Ineffective coping

D. Body image disturbance

ANS: C

Rationale: Ineffective coping is defined as an inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources. This child is coping with the anxiety generated by viewing her deceased aunt by pulling out hair. If this behavior continues, a diagnosis of hair-pulling disorder, or trichotillomania, may be assigned.

215. A nursing instructor is teaching about the symptoms of agoraphobia. Which student statement indicates that learning has occurred?

1. Onset of symptoms most commonly occurs in early adolescence and persists until midlife.

2. Onset of symptoms most commonly occurs in the 20s and 30s and persists for many years.

3. Onset of symptoms most commonly occurs in the 40s and 50s and persists until death.

4. Onset of symptoms most commonly occurs after the age of 60 and persists for at least 6 years.

ANS: 2

Rationale: The onset of the symptoms of agoraphobia most commonly occurs in the 20s and 30s and persists for many years.

216. A college student has been diagnosed with generalized anxiety disorder (GAD). Which of the following symptoms should a campus nurse expect this client to exhibit? (Select all that apply.)

1. Fatigue

2. Anorexia

3. Hyperventilation

4. Insomnia

5. Irritability

ANS: 1, 4, 5

Rationale: The nurse should expect that a client diagnosed with GAD would experience fatigue, insomnia, and irritability. GAD is characterized by chronic, unrealistic, and excessive anxiety and worry.

217. A nurse is discussing treatment options with a client whose life has been negatively impacted by claustrophobia. Which of the following commonly used behavioral therapies for phobias should the nurse explain to the client? (Select all that apply.)

1. Benzodiazepine therapy

2. Systematic desensitization

3. Imploding (flooding)

4. Assertiveness training

5. Aversion therapy

ANS: 2, 3

Rationale: The nurse should explain to the client that systematic desensitization and imploding are the most common behavioral therapies used for treating phobias. Systematic desensitization involves the gradual exposure of the client to anxiety-provoking stimuli. Imploding is the intervention used in which the client is exposed to extremely frightening stimuli for prolonged periods of time.

218. A nurse has been caring for a client diagnosed with generalized anxiety disorder (GAD). Which of the following nursing interventions would address this client’s symptoms? (Select all that apply.)

1. Encourage the client to recognize the signs of escalating anxiety.

2. Encourage the client to avoid any situation that causes stress.

3. Encourage the client to employ newly learned relaxation techniques.

4. Encourage the client to cognitively reframe thoughts about situations that generate anxiety.

5. Encourage the client to avoid caffeinated products.

ANS: 1, 3, 4, 5

Rationale: Nursing interventions that address GAD symptoms should include encouraging the client to recognize signs of escalating anxiety, to employ relaxation techniques, to cognitively reframe thoughts about anxiety-provoking situations, and to avoid caffeinated products. Avoiding situations that cause stress is not an appropriate intervention, because avoidance does not help the client overcome anxiety and because not all situations are easily avoidable.

219. An attractive female client presents with high anxiety levels because of her belief that her facial features are large and grotesque. Body dysmorphic disorder (BDD) is suspected. Which of the following additional symptoms would support this diagnosis? (Select all that apply.)

1. Mirror checking

2. Excessive grooming

3. History of an eating disorder

4. History of delusional thinking

5. Skin picking

ANS: 1, 2, 5

Rationale: The DSM-5 lists preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others as a diagnostic criteria for the diagnosis of BDD. Also listed is that at some point during the course of the disorder, the person has performed repetitive behaviors, such as mirror checking, excessive grooming, skin picking, or reassurance seeking.

220. A nursing instructor is teaching about the Community Health Centers Act of 1963. What was a deterring factor to the proper implementation of this act?

1. Many perspective clients did not meet criteria for mental illness diagnostic-related groups.

2. Zoning laws discouraged the development of community mental health centers.

3. States could not match federal funds to establish community mental health centers.

4. There was not a sufficient employment pool to staff community mental health centers.

ANS: 3

Rationale: A deterring factor to the proper implementation of the Community Mental Health Centers Act of 1963 was that states could not match federal funds to establish community mental health centers. This act called for the construction of comprehensive community mental health centers to offset the effect of deinstitutionalization, the closing of state mental health hospitals.

221. A nurse is implementing care within the parameters of tertiary prevention. Which nursing action is an example of this type of care?

1. Teaching an adolescent about pregnancy prevention

2. Teaching a client the reportable side effects of a newly prescribed neuroleptic medication

3. Teaching a client to cook meals, make a grocery list, and establish a budget

4. Teaching a client about his or her new diagnosis of bipolar disorder

ANS: 3

Rationale: The nurse who teaches a client to cook meals, make a grocery list, and establish a budget is implementing care within the parameters of tertiary prevention. Tertiary prevention consists of services aimed at reducing the residual effects that are associated with severe and persistent mental illness. It is accomplished by preventing complications of the illness and promoting rehabilitation that is directed toward achievement of maximum functioning.

222. A nursing instructor is teaching about case management. What student statement indicates that learning has occurred?

1. “Case management is a method used to achieve independent client care.”

2. “Case management provides coordination of services required to meet client needs.”

3. “Case management exists mainly to facilitate client admission to needed inpatient services.”

4. “Case management is a method to facilitate physician reimbursement.”

ANS: 2

Rationale: The instructor evaluates that learning has occurred when a student defines case management as providing coordination of services required to meet client needs. Case management strives to organize client care so that specific outcomes are achieved within allotted time frames.

223. A client at the mental health clinic tells the case manager, “I can’t think about living another day, but don’t tell anyone about the way I feel. I know you are obligated to protect my confidentiality.” Which case manager response is most appropriate?

1. “The treatment team is composed of many specialists who are working to improve your ability to function. Sharing this information with the team is critical to your care.”

2. “Let’s discuss steps that will resolve negative lifestyle choices that may have increased your suicidal risk.”

3. “You seem to be preoccupied with self. You should concentrate on hope for the future.”

4. “This information is secure with me because of client confidentiality.”

ANS: 1

Rationale: The most appropriate response by the case manager is to explain that sharing the information with the treatment team is critical to the client’s care. This case manager’s priority is to ensure client safety and to inform others on the treatment team of the client’s suicidal ideation.

224. When intervening with a married couple experiencing relationship discord, which nursing action reflects an intervention at the secondary level of prevention?

1. Teaching assertiveness skills in order to meet assessed needs

2. Supplying the couple with guidelines related to marital seminar leadership

3. Teaching the couple about various methods of birth control

4. Counseling the couple related to open and honest communication skills

ANS: 4

Rationale: Counseling the couple related to open and honest communication skills is a reflection of a nursing intervention at the secondary level of prevention. Secondary prevention aims at minimizing symptoms and is accomplished through early identification of problems and prompt initiation of effective treatment.

225. A school nurse provides education on drug abuse to a high school class. This nursing action is an example of which level of preventive care?

1. Primary prevention

2. Secondary prevention

3. Tertiary prevention

4. Primary intervention

ANS: 1

Rationale: Providing nursing education on drug abuse to a high school class is an example of primary prevention. Primary prevention services are aimed at reducing the incidence of mental health disorders within the population.

226. A newly admitted homeless client diagnosed with schizophrenia states, “I have been living in a cardboard box for two weeks. Why did the government let me down?” Which is an appropriate nursing response?

1. “Your discharge from the state hospital was done prematurely. Had you remained in the state hospital longer, you would not be homeless.”

2. “Your premature discharge from the state hospital was not intended for patients diagnosed with chronic schizophrenia.”

3. “Your discharge from the state hospital was based on firm principles; however, the resources were not available to make the transition a success.”

4. “Your discharge from the state hospital was based on presumed family support, and this was not forthcoming.”

ANS: 3

Rationale: The most accurate nursing response is to explain to the client that the resources were not available to make transitioning out of a state hospital a success. There are several factors that are thought to contribute to homelessness among the mentally ill: deinstitutionalization, poverty, lack of affordable housing, lack of affordable health care, domestic violence, and addiction disorders.

227. An instructor is teaching nursing students about the difference between partial and inpatient hospitalization. In what way does partial hospitalization differ from traditional inpatient hospitalization?

1. Partial hospitalization does not provide medication administration and monitoring.

2. Partial hospitalization does not use an interdisciplinary team.

3. Partial hospitalization does not offer a comprehensive treatment plan.

4. Partial hospitalization does not provide supervision 24 hours a day.

ANS: 4

Rationale: The instructor should explain that partial hospitalization does not provide supervision 24 hours a day. Partial hospitalization programs generally offer a comprehensive treatment plan formulated by an interdisciplinary team. They have proved to be an effective method of preventing hospitalization.

228. When a home health nurse administers an outpatient’s injection of haloperidol decanoate (Haldol decanoate), which level of care is the nurse providing?

1. Primary prevention level of care

2. Secondary prevention level of care

3. Tertiary prevention level of care

4. Case management level of care

ANS: 3

Rationale: When administering medication in an outpatient setting, the nurse is providing a tertiary prevention level of care. Tertiary prevention services are aimed at reducing the residual effects that are associated with severe and persistent mental illness. It is accomplished by preventing complications of the illness and promoting rehabilitation that is directed toward achievement of maximum functioning.

229. A client diagnosed with schizophrenia is hospitalized owing to an exacerbation of psychosis related to non-adherence with antipsychotic medications. Which level of care does the client’s hospitalization reflect?

1. Primary prevention level of care

2. Secondary prevention level of care

3. Tertiary prevention level of care

4. Case management level of care

ANS: 2

Rationale: The client’s hospitalization reflects the secondary prevention level of care. Secondary prevention aims at minimizing symptoms and is accomplished through early identification of problems and prompt initiation of effective treatment.

230. When attempting to provide health-care services to the homeless, what should be a realistic concern for a nurse?

1. Most individuals that are homeless reject help.

2. Most individuals that are homeless are suspicious of anyone who offers help.

3. Most individuals that are homeless are proud and will often refuse charity.

4. Most individuals that are homeless relocate frequently.

ANS: 4

Rationale: A realistic concern in the provision of health-care services to the homeless is that individuals who are homeless relocate frequently. Frequent relocation confounds service delivery and interferes with providers’ efforts to ensure appropriate care.

231. A homeless client comes to an emergency department reporting cough, night sweats, weight loss, and blood-tinged sputum. Which disease, which has recently become more prevalent among the homeless community, should a nurse suspect?

1. Meningitis

2. Tuberculosis

3. Encephalopathy

4. Mononucleosis

ANS: 2

Rationale: The nurse should suspect that the homeless client has contracted tuberculosis. Tuberculosis is a growing problem among individuals who are homeless, owing to being in crowded shelters, which are ideal conditions for the spread of respiratory tuberculosis. Prevalence of alcoholism, drug addiction, HIV infection, and poor nutrition also impact the increase of contracted cases of tuberculosis.

232. Which of the following clients should a nurse recommend for a structured day program? (Select all that apply.)

1. An acutely suicidal teenager

2. A chronically mentally ill woman who has a history of medication non-adherence

3. A socially isolated older individual

4. A depressed individual who is able to contract for safety

5. A client who is hearing voices that tell the client to harm others

ANS: 2, 4

Rationale: The nurse should recommend a structured day program for a chronically mental ill woman who has a history of medication non-adherence and for a depressed individual who is able to contract for safety. Day programs (also called partial hospitalizations) are designed to prevent institutionalization or to ease the transition from inpatient hospitalization to community living.

233. Which of the following are characteristics of a Program of Assertive Community Treatment (PACT), as described by the National Alliance on Mental Illness (NAMI)? (Select all that apply.)

1. PACT offers nationally based treatment to people with serious and persistent mental illnesses.

2. PACT is a type of case-management program.

3. The PACT team provides services 24 hours a day, 7 days a week, 365 days a year.

4. The PACT team provides highly individualized services directly to consumers.

5. PACT is a multidisciplinary team approach.

ANS: 2, 3, 4, 5

Rationale: NAMI defines PACT as a service-delivery model that provides comprehensive, locally, not nationally, based treatment to people with serious and persistent mental illnesses. PACT is a type of case-management program that provides highly individualized services directly to consumers. It is a team approach and includes members from psychiatry, social work, nursing, substance abuse, and vocational rehabilitation. The PACT team provides these services 24 hours a day, 7 days a week, 365 days a year.

234. Which of the following have been assessed as the most common types of mental illness identified among homeless individuals? (Select all that apply.)

1. Schizophrenia

2. Body dysmorphic disorder

3. Antisocial personality disorder

4. Neurocognitive disorder

5. Conversion disorder

ANS: 1, 3, 4

Rationale: A number of studies have been conducted, primarily in large, urban areas, which have addressed the most common types of mental illness identified among homeless individuals. Schizophrenia is frequently described as the most common diagnosis. Other prevalent disorders include bipolar disorder, substance abuse and dependence, depression, personality disorders, and neurocognitive disorders.

235. A new mother is concerned about her ability to perform her parental role. She is quite anxious and ambivalent about leaving the postpartum unit. To offer effective client care, a nurse should be familiar with what information about this type of crisis?

1. This type of crisis is precipitated by unexpected external stressors.

2. This type of crisis is precipitated by preexisting psychopathology.

3. This type of crisis is precipitated by an acute response to an external situational stressor.

4. This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client.

ANS: 4

Rationale: The nurse should understand that this type of crisis is precipitated by normal life-cycle transitions that overwhelm the client. Reassurance and guidance should be provided as needed, and the client should be referred to services that can provide assistance.

236. A wife brings her husband to an emergency department after an attempt to hang himself. He is a full-time student and works 8 hours at night to support his family. He states, “I can’t function any longer under all this stress.” Which type of crisis is the client experiencing?

1. Maturational/developmental crisis

2. Psychiatric emergency crisis

3. Anticipated life transition crisis

4. Traumatic stress crisis

ANS: 2

Rationale: The nurse should determine that the client is experiencing a psychiatric emergency crisis. Psychiatric emergencies occur when crisis situations result in severe impairment, incompetence, or an inability to assume personal responsibility.

237. A client comes to a psychiatric clinic experiencing sudden extreme fatigue and decreased sleep and appetite. The client works 12 hours a day and rates anxiety as 8/10 on a numeric scale. What long-term outcome is realistic in addressing this client’s crisis?

1. The client will change his type A personality traits to more adaptive ones by one week.

2. The client will list five positive self-attributes.

3. The client will examine how childhood events led to his overachieving orientation.

4. The client will return to previous adaptive levels of functioning by week six.

ANS: 4

Rationale: The nurse should identify that a realistic long-term outcome for this client is to return to previous adaptive levels of functioning. The nurse should work with the client to develop attainable outcomes that reflect immediacy of the situation.

238. A high school student has learned that she cannot graduate. Her boyfriend will be attending a college out of state that she planned to attend. She is admitted to a psychiatric unit after overdosing on Tylenol. Which is the priority nursing diagnosis for this client?

1. Ineffective coping R/T situational crisis AEB powerlessness

2. Anxiety R/T fear of failure

3. Risk for self-directed violence R/T hopelessness

4. Risk for low self-esteem R/T loss events AEB suicidal ideations

ANS: 3

Rationale: The priority nursing diagnosis for this client is risk for self-directed violence R/T hopelessness. Nurses should prioritize diagnoses and outcomes based on potential safety risk to the client or others.

239. After threatening to jump off of a bridge, a client is brought to an emergency department by police. To assess for suicide potential, which question should a nurse ask first?

1. “Are you currently thinking about harming yourself?”

2. “Why do you want to harm yourself?”

3. “Have you thought about the consequences of your actions?”

4. “Who is your emergency contact person?”

ANS: 1

Rationale: The nurse should first assess the client for current harmful or suicidal thoughts to minimize risk of harm to the client and provide appropriate interventions. A suicidal client is experiencing a psychiatric emergency in which the crisis team should assess for client safety as a priority.

240. An involuntarily committed client when offered a dinner tray pushes it off the bedside table onto the floor. Which nursing intervention should a nurse implement to address this behavior?

1. Initiate forced medication protocol.

2. Help the client to explore the source of anger.

3. Ignore the act to avoid reinforcing the behavior.

4. With staff support and a show of solidarity, set firm limits on the behavior.

ANS: 4

Rationale: The most appropriate nursing intervention is to set firm limits on the behavior. Pushing food onto the floor should not warrant forced medication. This intervention may be too restrictive, considering the behavior. Exploring the source of anger may be more appropriate once the client has resolved the current emotion or in a therapeutic group setting. Ignoring the act may further upset the client and is not a method of teaching appropriate behavior.

241. A college student who was nearly raped while jogging, completes a series of appointments with a rape crisis nurse. At the final session, which client statement most clearly suggests that the goals of crisis intervention have been met?

1. “You’ve really been helpful. Can I count on your for continued support?”

2. “I work out in the college gym rather than jogging outdoors.”

3. “I’m really glad I didn’t go home. It would have been hard to come back.”

4. “I carry mace when I jog. It makes me feel safe and secure.”

ANS: 4

Rationale: The nurse should evaluate that the client who has developed adaptive coping strategies has achieved the goals of crisis intervention. The final phase of crisis intervention involves evaluating the outcome of the crisis intervention and anticipatory planning.

242. A despondent client who has recently lost her husband of 30 years tearfully states, “I’ll feel a lot better if I sell my house and move away.” Which nursing response is most appropriate?

1. “I’m confident you know what’s best for you.”

2. “This may not be the best time for you to make such an important decision.”

3. “Your children will be terribly disappointed.”

4. “Tell me why you want to make this change.”

ANS: 2

Rationale: During crisis intervention, the nurse should guide the client through a problem-solving process. The nurse should help the individual confront the source of the problem, encourage the individual to discuss changes he or she would like to make, and encourage exploration of feelings about aspects of the crisis that cannot be changed. The nurse should also assist the client in determining whether any changes are realistic.

243. An inpatient client with a known history of violence suddenly begins to pace. Which additional client behavior should alert a nurse to escalating anger and aggression?

1. The client requests prn medications.

2. The client has a tense facial expression and body language.

3. The client refuses to eat lunch.

4. The client sits in group with back to peers.

ANS: 2

Rationale: The nurse should assess that tense facial expressions and body language may indicate that a client’s anger is escalating. The nurse should conduct a thorough assessment of the client’s history of violence and develop interventions for de-escalation.

244. What is the best nursing rationale for holding a debriefing session with clients and staff after a take-down intervention has taken place on an inpatient unit?

1. Reinforce unit rules with the client population.

2. Create protocols for the future release of tensions associated with anger.

3. Process client feelings and alleviate fears of undeserved seclusion and restraint.

4. Discuss the situation that led to inappropriate expressions of anger.

ANS: 4

Rationale: The nurse should determine that the purpose for holding a debriefing session with clients and staff after a take-down intervention is to discuss the situation that led to inappropriate behavior. It is important to determine the factors leading to the inappropriate behavior in order to develop future intervention strategies. It is also important to help clients and staff process feelings about the situation.

245. An aggressive client has been placed in restraints after all other interventions have failed. Which protocol would apply in this situation?

1. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 1 hour of the initiation of the restraints.

2. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 2 hours of the initiation of the restraints.

3. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 3 hours of the initiation of the restraints.

4. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 4 hours of the initiation of the restraints.

ANS: 1

Rationale: The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]) requires that an in-person evaluation by physician or other licensed independent practitioner be conducted within 1 hour of the initiation of restraint or seclusion.

246. A combative adolescent client has been placed in seclusion after all other interventions have failed. Which protocol would apply in this situation?

1. The physician or other licensed independent practitioner must reissue a new order for restraints every 24 hours.

2. The physician or other licensed independent practitioner must reissue a new order for restraints every 8 hours.

3. The physician or other licensed independent practitioner must reissue a new order for restraints every 3 to 4 hours.

4. The physician or other licensed independent practitioner must reissue a new order for restraints every 1 to 2 hours.

ANS: 4

Rationale: The physician or other licensed independent practitioner must reissue a new order for restraints every 4 hours for adults and every 1 to 2 hours for children and adolescents. Restraints should be used as a last resort, after all other interventions have been unsuccessful, and the client is clearly at risk of harm to self or others.

247. A nursing instructor is teaching about the Roberts’ Seven-Stage Crisis Intervention Model. Which nursing action should be identified with Stage IV?

1. Collaboratively implement an action plan.

2. Help the client identify the major problems or crisis precipitants.

3. Help the client deal with feelings and emotions.

4. Collaboratively generate and explore alternatives.

ANS: 3

Rationale: The following are the stages of the Roberts’ Seven-Stage Crisis Intervention Model:

Stage I: Psychosocial and Lethality Assessment, Stage II: Rapidly Establish Rapport, Stage III: Identify the Major Problems or Crisis Precipitants, Stage IV: Deal with Feelings and Emotions, Stage V: Generate and Explore Alternatives, Stage VI: Implement an Action Plan, Stage VII: Follow-up.`

248. Which of the following nursing statements and/or questions represent appropriate communication to assess an individual in crisis? (Select all that apply.)

1. “Tell me what happened.”

2. “What coping methods have you used, and did they work?”

3. “Describe to me what your life was like before this happened.”

4. “Let’s focus on the current problem.”

5. “I’ll assist you in selecting functional coping strategies.”

ANS: 1, 2, 3

Rationale: In the assessment phase, the nurse should gather information regarding the precipitating stressor and the resulting crisis. Focusing on the current problem and selecting functional coping strategies would not occur until after a complete assessment.

249. Which of the following interventions should a nurse use when caring for an inpatient client who expresses anger inappropriately? (Select all that apply.)

1. Maintain a calm demeanor.

2. Clearly delineate the consequences of the behavior.

3. Use therapeutic touch to convey empathy.

4. Set limits on the behavior.

5. Teach the client to avoid “I” statements related to expression of feelings.

ANS: 1, 2, 4

Rationale: The nurse should determine that, when working with an inpatient client with difficulty expressing anger appropriately, it is important to maintain a calm demeanor, clearly define the consequences, and set limits on the behavior. The use of therapeutic touch may not be appropriate and could increase the client’s anger. Teaching would not be appropriate when a client is agitated.

250. Which of the following are behavior assessment categories in the Broset Violence Checklist? (Select all that apply.)

1. Confusion

2. Paranoia

3. Boisterousness

4. Panic

5. Irritability

ANS: 1, 3, 5

Rationale: The Broset Violence Checklist is a quick, simple, and reliable tool that can be used to assess the risk of potential violence. The behavior assessment categories include: confusion, irritability, boisterousness, physical threats, and verbal threats.

e.g. MCAT, pharma, bar exam, Spanish, Series 7

251. A nursing instructor is teaching about complementary therapies. Which student statement indicates that learning has occurred?

1. “Complementary therapies view all humans as being biologically similar.”

2. “Complementary therapies view a person as a combination of multiple, integrated elements.”

3. “Complementary therapies focus on primarily the structure and functions of the body.”

4. “Complementary therapies view disease as a deviation from a normal biological state.”

ANS: 2

Rationale: The nurse should understand that complementary therapies view a person as a combination of multiple, integrated elements. A complementary therapy is an intervention that is used in conjunction with, but is different from, traditional medicine.

252. A client reports taking St. John’s wort for major depressive episode. The client states, “I’m taking the recommended dose, but it seems like if two capsules are good, four would be better!” Which is an appropriate nursing response?

1. “Herbal medicines are more likely to cause adverse reactions than prescription medications.”

2. “Increasing the amount of herbal preparations can lead to overdose and toxicity.”

3. “FDA does not regulate herbal remedies, therefore, ingredients are often unknown.”

4. “Certain companies are better than others. Always buy a reputable brand.”

ANS: 2

Rationale: The nurse should advise the client that increasing the amount of herbal preparations can lead to overdose and toxicity. The use of herbal medicines, such as St. John’s wort, should be approached with caution and responsibility. This herb is generally recognized as safe when taken at recommended dosages (900 mg/day).

253. A client with chronic lower back pain says, “My nurse practitioner told me that acupuncture may enhance the effect of the medications and physical therapy prescribed.” What type of therapy is the nurse practitioner recommending?

1. Alternative therapy

2. Physiotherapy

3. Complementary therapy

4. Biopsychosocial therapy

ANS: 3

Rationale: The nurse practitioner is recommending a type of complementary therapy. Acupuncture is a healing technique based on ancient Chinese philosophies that has gained wide acceptance in the United States by both patients and physicians.

254. A client diagnosed with chronic migraine headaches is considering acupuncture. The client asks a clinic nurse, “How does this treatment work?” Which is the best response by the nurse?

1. “Western medicine believes that acupuncture stimulates the body’s release of pain-fighting chemicals called endorphins.”

2. “I’m not sure why he suggested acupuncture. There are a lot of risks, including HIV.”

3. “Acupuncture works by encouraging the body to increase its development of serotonin and norepinephrine.”

4. “Your acupuncturist is your best resource for answering your specific questions.”

ANS: 1

Rationale: The most appropriate response by the nurse is to educate the client on the medical philosophy that acupuncture stimulates the body’s release of endorphins. Acupuncture has been found to be effective in the treatment of asthma, insomnia, anxiety, depression, and many other conditions.

255. Alternative approaches refer to interventions that are used instead of conventional treatment. A client asks a nurse to explain the difference between alternative and complementary medicine. Which is an appropriate nursing response?

1. “Alternative medicine is a more acceptable practice than complementary medicine.”

2. “Alternative and complementary medicine are terms that essentially mean the same thing.”

3. “Complementary medicine disregards traditional medical approaches.”

4. “Complementary therapies partner alternative approaches with traditional medical practice.”

ANS: 4

Rationale: The nurse should explain to the client that complementary therapies partner alternative approaches with traditional medicine. More than $33 billion a year is spent on complementary and alternative therapies.

256. A lethargic client is diagnosed with major depressive disorder. After taking antidepressant therapy for 6 weeks, the client’s symptoms have not resolved. Which nutritional deficiency should a nurse identify as potentially contributing to the client’s symptoms?

1. Vitamin A deficiency

2. Vitamin C deficiency

3. Iron deficiency

4. Folic acid deficiency

ANS: 3

Rationale: The nurse should identify that an iron deficiency could contribute to depression. Iron deficiencies can result in feelings of chronic fatigue. Iron should be consumed by eating meat, fish, green leafy vegetables, nuts, eggs, and enriched bread and pasta.

257. A client inquires about the practice of therapeutic touch. Which nursing response best explains the goal of this therapy?

1. “The goal is to improve circulation to the body by deep, circular massage.”

2. “The goal is to re-pattern the body’s energy field by the use of rhythmic hand motions.”

3. “The goal is to improve breathing by increasing oxygen to the brain and body tissues.”

4. “The goal is to decrease blood pressure by body toxin release.”

ANS: 2

Rationale: The nurse should explain that the goal of the practice of therapeutic touch is to re-pattern the body’s energy field by the use of rhythmic hand motions. Therapeutic touch is based on the philosophy that the human body projects fields of energy that become blocked when pain or illness occurs. Therapeutic touch practitioners use this method to correct the blockages and relieve discomfort and improve health.

258. A nursing student, having no knowledge of alternative treatments, states, “Aren’t these therapies ‘bogus’ and, like a fad, will eventually fade away?” Which is an accurate nursing response?

1. “Like nursing, complementary therapies take a holistic approach to healing.”

2. “The American Nurses Association is researching the effectiveness of these therapies.”

3. “It is important to remain nonjudgmental about these therapies.”

4. “Alternative therapy concepts are rooted in psychoanalysis.”

ANS: 1

Rationale: The nurse is accurate when comparing complementary therapies to the holistic approach of nursing. The complementary therapies, as well as nursing process, view the person as consisting of multiple, integrated elements. Diagnostic measures are not based on one aspect, but include a holistic assessment of the person.

259. Herbs and plants can be useful in treating a variety of conditions. Which treatment should a nurse determine is appropriate for a client experiencing frequent migraine headaches?

1. Saint John’s wort combined with an antidepressant

2. Ginger root combined with a beta-blocker

3. Feverfew, used according to directions

4. Kava-kava added to a regular diet

ANS: 3

Rationale: The nurse should determine that the appropriate treatment for a client experiencing frequent migraine headaches is the herb feverfew. Feverfew is effective in either fresh leaf or freeze-dried form. It is considered to be safe in reasonable doses.

260. A nurse teaches a client about alternative therapies for back pain. When a practitioner corrects subluxation by manipulating the vertebrae of the spinal column, what therapy is the practitioner employing?

1. Allopathic therapy

2. Therapeutic touch therapy

3. Massage therapy

4. Chiropractic therapy

ANS: 4

Rationale: Chiropractic therapy involves the correction of subluxations by manipulating the vertebrae of the spinal column. The theory behind chiropractic medicine is that energy flows from the brain to all parts of the body through the spinal cord and spinal nerves.

261. Which of the following practices should a nurse describe to a client as being incorporated during yoga therapy? (Select all that apply.)

1. Deep breathing

2. Meridian therapy

3. Balanced body postures

4. Massage therapy

5. Meditation

ANS: 1, 3, 5

Rationale: Yoga therapy involves deep breathing, balanced body postures, and meditation. The objective of yoga is to integrate the physical, mental, and spiritual energies to enhance health and well-being.

262. A client inquires about pet therapy. Which of the following nursing responses provides the client with accurate information? (Select all that apply.)

1. “Pet therapy allows the therapist to assess the client’s social relationships.”

2. “Pet therapy decreases blood pressure.”

3. “Pet therapy enhances client mood.”

4. “Pet therapy improves sensory functioning.”

5. “Pet therapy mitigates the effects of loneliness.”

ANS: 2, 3, 5

Rationale: Pet therapy has been found to decrease blood pressure, enhance client mood, and mitigate the effects of loneliness. Evidence has shown that animals can directly influence a person’s mental and physical well-being.

263. A client who prefers to use St. John’s wort and psychotherapy in lieu of antidepressant therapy asks for tips on using herbal remedies. Which of the following teaching points should a nurse provide? (Select all that apply.)

1. Select a reputable brand.

2. Increasing dosage does not lead to improved effectiveness.

3. Monitor for adverse reactions.

4. Gradually increase dosage to gain maximum effect.

5. Most herbal remedies are best absorbed on an empty stomach.

ANS: 1, 2, 3

Rationale: When educating a client on the use of herbal remedies, the nurse should advise the client to select a reputable brand. The nurse should also advise the client to monitor for adverse reactions and to take the recommended dose, because increasing the dose does not lead to improved effectiveness. Herbal remedies are classified as dietary supplements by the Food and Drug Administration (FDA) and, therefore, they are not subject to FDA approval and lack uniform standards of quality control.

264. Which of the following statements reflect current attitudes toward complementary and alternative therapies? (Select all that apply.)

1. Some health insurance companies are beginning to cover treatments such as acupuncture and massage therapy.

2. The majority of third-party payers do not cover chiropractic client treatments.

3. A large number of U.S. medical schools, among them Harvard and Yale, now offer coursework in holistic methods

4. The AMA encourages members to be better informed regarding alternative medicine.

5. Interest in holistic health care is decreasing worldwide.

ANS: 1, 3, 4

Rationale: Some health insurance companies and health maintenance organizations (HMOs) appear to be bowing to public pressure by including providers of alternative therapies in their networks of providers for treatments such as acupuncture and massage therapy. Chiropractic care has been covered by some third-party payers for many years. Interest in holistic health care is increasing worldwide. A large number of U.S. medical schools—among them Harvard, Yale, Johns Hopkins, and Georgetown Universities—now offer coursework in holistic methods. The American Medical Association encourages its members to become better informed regarding the practices and techniques of alternative or unconventional medicine.

265. Which of the following are included in the U.S. Departments of Agriculture and Health and Human Services guidelines to promote health and prevent disease. (Select all that apply.)

1. Increase physical activity and reduce time spent in sedentary behaviors.

2. Limit total calorie intake to 2,000 mg per day.

3. Reduce daily sodium intake to 3,000 mg per day.

4. Consume less than 10 percent of calories from saturated fatty acids.

5. Limit alcohol consumption to one drink per day for women and two drinks per day for men.

ANS: 1, 4, 5

Rationale: The U.S. Departments of Agriculture and Health and Human Services guidelines to promote health and prevent disease include, but are not limited to, the following: Increase physical activity and reduce time spent in sedentary behaviors. Consume less than 10 percent of calories from saturated fatty acids. Limit alcohol consumption to one drink per day for women and two drinks per day for men. Control total calorie intake to manage body weight. For people who are overweight or obese, this will mean consuming fewer calories from foods and beverages. There is no specific daily calorie limit recommended. Reduce daily sodium intake to less than 2,300 mg, not 3,000 mg, and further reduce intake to 1,500 mg among persons who are 51 and older and those of any age who are African American or have hypertension, diabetes, or chronic kidney disease.

266. What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal?

1. Risk for injury R/T central nervous system stimulation

2. Disturbed thought processes R/T tactile hallucinations

3. Ineffective coping R/T powerlessness over alcohol use

4. Ineffective denial R/T continued alcohol use despite negative consequences

ANS: 1

Rationale: The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.

267. A nurse evaluates a client’s patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance addiction?

1. Narcotic pain medication is contraindicated for all clients with active substance use disorders.

2. Clients who are addicted to alcohol or benzodiazepines may develop cross-tolerance to analgesics and require increased doses to achieve effective pain control.

3. There is no need to assess the client for substance addiction. There is an obvious PCA malfunction, because these clients have a higher pain tolerance.

4. The client is experiencing alcohol withdrawal symptoms and needs accurate assessment.

ANS: 2

Rationale: The nurse should assess the client for substance addiction, because clients who are addicted to alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. Cross-tolerance is exhibited when one drug results in a lessened response to another drug.

268. On the first day of a client’s alcohol detoxification, which nursing intervention should take priority?

1. Strongly encourage the client to attend 90 Alcoholics Anonymous (AA) meetings in 90 days.

2. Educate the client about the biopsychosocial consequences of alcohol abuse.

3. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol.

4. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

ANS: 3

Rationale: The priority nursing intervention for this client should be to administer ordered chlordiazepoxide in a dosage according to protocol. Chlordiazepoxide is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal to reduce life-threatening complications.

269. Which client statement indicates a knowledge deficit related to a substance use disorder?

1. “Although it’s legal, alcohol is one of the most widely abused drugs in our society.”

2. “Tolerance to heroin develops quickly.”

3. “Flashbacks from LSD use may reoccur spontaneously.”

4. “Marijuana is like smoking cigarettes. Everyone does it. It’s essentially harmless.”

ANS: 4

Rationale: The nurse should determine that the client has a knowledge deficit related to substance use disorders when the client compares marijuana to smoking cigarettes and claims it to be harmless. Cannabis is the second most widely abused drug in the United States.

270.A lonely, depressed divorcée has been self-medicating with small amounts of cocaine for the past year. Which term should a nurse use to best describe this individual’s situation?

1. Psychological addiction

2. Physical addiction

3. Substance induced disorder

4. Social induced disorder

ANS: 1

Rationale: The nurse should use the term psychological addiction to best describe the client’s situation. A client is considered to be psychologically addicted to a substance when there is an overwhelming desire to use a drug in order to produce pleasure or avoid discomfort.

271. Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during the substance induced disorder of alcohol withdrawal?

1. Antagonist therapy

2. Deterrent therapy

3. Codependency therapy

4. Substitution therapy

ANS: 4

Rationale: Various medications have been used to decrease the intensity of symptoms in an individual who is withdrawing from, or who is experiencing the effects of excessive use of, alcohol and other drugs. This is called substitution therapy and may be required to reduce the life-threatening effects of alcohol withdrawal.

272. A client diagnosed with chronic alcohol addiction is being discharged from an inpatient treatment facility after detoxification. Which client outcome, related to AA, would be most appropriate for a nurse to discuss with the client during discharge teaching?

1. After discharge, the client will immediately attend 90 AA meetings in 90 days.

2. After discharge, the client will rely on an AA sponsor to help control alcohol cravings.

3. After discharge, the client will incorporate family in AA attendance.

4. After discharge, the client will seek appropriate deterrent medications through AA.

ANS: 1

Rationale: The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcohol addiction. It accepts alcohol addiction as an illness and promotes total abstinence as the only cure.

273. A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 48 hours. When the nurse reports to the ED physician, which client symptom should be the nurse’s first priority?

1. Hearing and visual impairment

2. Blood pressure of 180/100 mm Hg

3. Mood rating of 2/10 on numeric scale

4. Dehydration

ANS: 2

Rationale: The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal syndrome and should promptly report this finding to the physician. Complications associated with alcohol withdrawal syndrome may progress to alcohol withdrawal delirium in about the second or third day following cessation of prolonged alcohol use.

274. Which client statement demonstrates positive progress toward recovery from a substance use disorder?

1. “I have completed detox and therefore am in control of my drug use.”

2. “I will faithfully attend Narcotic Anonymous (NA) when I can’t control my cravings.”

3. “As a church deacon, my focus will now be on spiritual renewal.”

4. “Taking those pills got out of control. It cost me my job, marriage, and children.”

ANS: 4

Rationale: A client who takes responsibility for the consequences of substance use disorder or substance addiction is making positive progress toward recovery. This would indicate completion of the first step of a 12-step program.

275. A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse’s rationale for this intervention?

1. To assess for emotional strength

2. To assess for Wernicke-Korsakoff syndrome

3. To assess for tachycardia

4. To assess for fine tremors

ANS: 4

Rationale: The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, and coarse tremors.

276. A client presents with symptoms of alcohol withdrawal and states, “I haven’t eaten in three days.” A nurse’s assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97°F (36°C) with dry mucous membranes and poor skin turgor. What should be the priority nursing diagnosis?

1. Knowledge deficit

2. Fluid volume excess

3. Imbalanced nutrition: less than body requirements

4. Ineffective individual coping

ANS: 3

Rationale: The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements. The client is exhibiting signs and symptoms of malnutrition as well as alcohol withdrawal. The nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent feedings of nonirritating foods.

277. A client’s wife has been making excuses for her alcoholic husband’s work absences. In family therapy, she states, “His problems at work are my fault.” Which is the appropriate nursing response?

1. “Why do you assume responsibility for his behaviors?”

2. “I think you should start to confront his behavior.”

3. “Your husband needs to deal with the consequences of his drinking.”

4. “Do you understand what the term enabler means?”

ANS: 3

Rationale: The appropriate nursing response is to use confrontation with caring. The nurse should understand that the client’s wife may be in denial and enabling the husband’s behavior. Codependency is a typical behavior of spouses of alcoholics. Partners of clients with substance addiction must come to realize that the only behavior they can control is their own.

278. Which medication orders should a nurse anticipate for a client who has a history of benzodiazepine withdrawal delirium?

1. Haloperidol (Haldol) and fluoxetine (Prozac)

2. Carbamazepine (Tegretol) and donepezil (Aricept)

3. Disulfiram (Antabuse) and lorazepan (Ativan)

4. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

ANS: 4

Rationale: The nurse should anticipate that a physician would order chlordiazepoxide and phenytoin for a client who has a history of benzodiazepine withdrawal delirium. It is common for long-lasting benzodiazepines to be prescribed for substitution therapy. Phenytoin is an anticonvulsant used to prevent seizures.

279. A nurse is interviewing a client in an outpatient addiction clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish?

1. The client will identify one person to turn to for support.

2. The client will give up all old drinking buddies.

3. The client will be able to verbalize the effects of alcohol on the body.

4. The client will correlate life problems with alcohol use.

ANS: 4

Rationale: The nurse should expect that the client would initially correlate life problems with alcohol addiction. Acceptance of the problem is the first part of the recovery process.

280. A nurse is reviewing the stat laboratory data of a client in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur?

1. 50 mg/dL

2. 100 mg/dL

3. 250 mg/dL

4. 300 mg/dL

ANS: 2

Rationale: The nurse should expect that 100 mg/dL is the minimum blood alcohol level at which intoxication occurs. Intoxication usually occurs between 100 and 200 mg/dL. Death has been reported at levels ranging from 400 to 700 mg/dL.

281. A client diagnosed with major depressive episode and substance use disorder has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions?

1. Sedative-hypnotics are potentially addictive, and their effectiveness will be compromised owing to tolerance.

2. Sedative-hypnotics are expensive and have numerous side effects.

3. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep.

4. Sedative-hypnotics are known not to be as effective in promoting sleep as antidepressant medications.

ANS: 1

Rationale: The nurse should recommend nonpharmacological interventions to this client because sedative-hypnotics are potentially addictive, and their effectiveness will be compromised owing to tolerance. The effects of central nervous system depressants are additive with one another, capable of producing physiological and psychological addiction.

282. A client diagnosed with a gambling disorder asks the nurse about medications that may be ordered by the client’s physician to treat this disorder. The nurse would give the client information on which medications?

1. Escitalopram (Lexapro) and clozapine (Clozaril)

2. Citalopram (Celexa) and olanzapine (Zyprexa)

3. Lithium carbonate (Lithobid) and sertraline (Zoloft)

4. Naltrexone (ReVia) and ziprasidone (Geodon)

ANS: 3

Rationale: The SSRIs and clomipramine have been used successfully in the treatment of pathological gambling as a form of obsessive-compulsive disorder. Lithium, carbamazepine, and naltrexone have also been shown to be effective. The antipsychotic medications clozapine, olanzapine, and ziprasidone are not treatments of choice for this disorder.

283. A nurse is assessing a pathological gambler. What would differentiate this client’s behaviors from the behaviors of a non-pathological gambler?

1. Pathological gamblers have abnormal levels of neurotransmitters, whereas non-pathological gamblers do not.

2. Pathological gambling occurs more commonly among women, whereas non-pathological gambling occurs more commonly among men.

3. Pathological gambling generally runs an acute course, whereas non-pathological gambling runs a chronic course.

4. Pathological gambling is not related to stress relief, whereas non-pathological gambling is related to stress relief.

ANS: 1

Rationale: There is a correlation between pathological gambling and abnormalities in the serotonergic, noradrenergic, and dopaminergic neurotransmitter systems. This is not the case with non-pathological gambling. For a pathological gambler, the preoccupation with and impulse to gamble intensifies when the individual is under stress. This is not the case with non-pathological gambling. Pathological gambling occurs more commonly among men not women and generally runs a chronic not acute course.

284. A nursing instructor is teaching about the impaired nurse and the consequences of this impairment. Which statement by a student indicates that further instruction is needed?

1. “The state board of nursing must be notified with factual documentation of impairment.”

2. “All state boards of nursing have passed laws that, under any circumstances, do not allow impaired nurses to practice.”

3. “Many state boards of nursing require an impaired nurse to successfully complete counseling treatment programs prior to a return to work.”

4. “After a return to practice, a recovering nurse may be closely monitored for several years.”

ANS: 2

Rationale: Several state boards of nursing have passed diversionary laws that allow impaired nurses to avoid disciplinary action by agreeing to seek treatment. This may require successful completion of inpatient, outpatient, group, or individual counseling treatment program(s); evidence of regular attendance at nurse support groups or 12-step program; random negative drug screens; and employment or volunteer activities during the suspension period. When a nurse is deemed safe to return to practice, he or she may be closely monitored for several years and required to undergo random drug screenings.

285. Which of the following nursing statements exemplify the cognitive process that must be completed by a nurse prior to caring for clients diagnosed with a substance-related disorder? (Select all that apply.)

1. “I am easily manipulated and need to work on this prior to caring for these clients.”

2. “Because of my father’s alcoholism, I need to examine my attitude toward these clients.”

3. “I need to review the side effects of the medications used in the withdrawal process.”

4. “I’ll need to set boundaries to maintain a therapeutic relationship.”

5. “I need to take charge when dealing with clients diagnosed with substance disorders.”

ANS: 1, 2, 4

Rationale: The nurse should complete a cognitive process prior to caring for clients diagnosed with substance-abuse disorders. It is important for nurses to identify potential areas of need within their own cognitions that may affect their relationships with clients diagnosed with this problem.

286. A nursing instructor is teaching nursing students about cirrhosis of the liver. Which of the following statements about the complications of hepatic encephalopathy should indicate to the nursing instructor that further student teaching is needed? (Select all that apply.)

1. “A diet rich in protein will promote hepatic healing.”

2. “This condition results from a rise in serum ammonia, leading to impaired mental functioning.”

3. “In this condition, an excessive amount of serous fluid accumulates in the abdominal cavity.”

4. “Neomycin and lactulose are used in the treatment of this condition.”

5. “This condition is caused by the inability of the liver to convert ammonia to urea.”

ANS: 1

Rationale: The nursing instructor should understand that further teaching is needed if the nursing student states that a diet rich in protein will promote hepatic healing. The treatment of hepatic encephalopathy requires abstention from alcohol and temporary elimination of protein from the diet.

287. A clinic nurse is about to meet with a client diagnosed with a gambling disorder. Which of the following symptoms and/or behaviors is the nurse likely to assess? (Select all that apply.)

1. Stressful situations precipitate gambling behaviors.

2. Anxiety and restlessness can only be relieved by placing a bet.

3. Winning brings about feelings of sexual satisfaction.

4. Gambling is used as a coping strategy.

5. Losing at gambling meets the client’s need for self-punishment.

ANS: 1, 2, 4, 5

Rationale: In gambling disorder, the preoccupation with and impulse to gamble intensifies when the individual is under stress. Many impulsive gamblers describe a physical sensation of restlessness and anticipation that can only be relieved by placing a bet. Winning brings feelings of special status, power, and omnipotence, not sexual satisfaction. The gambler increasingly depends on this activity to cope with disappointments, problems, and negative emotional states.

288. A nursing supervisor is about to meet with a staff nurse suspected of diverting client medications. Which of the following assessment data would lead the supervisor to suspect that the staff nurse is impaired? (Select all that apply.)

1. The staff nurse is frequently absent from work.

2. The staff nurse experiences mood swings.

3. The staff nurse makes elaborate excuses for behavior.

4. The staff nurse frequently uses the restroom.

5. The staff nurse has a flushed face.

ANS: 2, 3, 4, 5

Rationale: A number of clues for recognizing substance impairment in nurses have been identified. They are not easy to detect and will vary according to the substance being used. There may be high absenteeism if the person’s source is outside the work area, or the individual may rarely miss work if the substance source is at work. Some other possible signs are irritability, mood swings, tendency to isolate, elaborate excuses for behavior, unkempt appearance, impaired motor coordination, slurred speech, flushed face, inconsistent job performance, and frequent use of the restroom.

289. A nursing supervisor is offering an impaired staff member information regarding employee assistance programs. Which of the following facts should the supervisor include? (Select all that apply.)

1. A hotline number will be available in order to call for peer assistance.

2. A verbal contract detailing the method of treatment will be initiated prior to the program.

3. Peer support is provided through regular contact with the impaired nurse.

4. Contact to provide peer support will last for one year.

5. One of the program goals is to intervene early in order to reduce hazards to clients.

ANS: 1, 3, 5

Rationale: The peer assistance programs strive to intervene early, to reduce hazards to clients, and increase prospects for the nurse’s recovery. Most states provide either a hotline number that the impaired nurse may call or phone numbers of peer assistance committee members, which are made available for the same purpose. Typically, a written, not verbal, contract is drawn up, detailing the method of treatment, which may be obtained from various sources, such as employee assistance programs, Alcoholics Anonymous, Narcotics Anonymous, private counseling, or outpatient clinics. Peer support is provided through regular contact with the impaired nurse, usually for a period of two years, not one year.

290. A nursing counselor is about to meet with a client suffering from codependency. Which of the following data would further support the assessment of this dysfunctional behavior? (Select all that apply.)

1. The client has a long history of focusing thoughts and behaviors on other people.

2. The client, as a child, experienced overindulgent and overprotective parents.

3. The client is a people pleaser and does almost anything to gain approval.

4. The client exhibits helpless behaviors but actually feels very competent.

5. The client can achieve a sense of control only through fulfilling the needs of others.

ANS: 1, 3, 5

Rationale: The codependent person has a long history of focusing thoughts and behavior on other people and is able to achieve a sense of control only through fulfilling the needs of others. Codependant clients are “people pleasers” and will do almost anything to get the approval of others. They usually have experienced abuse or emotional neglect as a child. They outwardly appear very competent, but actually feel quite needy, helpless, or perhaps nothing at all.

291. A nurse discovers a client’s suicide note that details the time, place, and means to commit suicide. What should be the priority nursing action, and why?

1. Administer lorazepam (Ativan) prn, because the client is angry about plan exposure.

2. Establish room restrictions, because the client’s threat is an attempt to manipulate the staff.

3. Place client on one-to-one suicide precautions, because specific plans likely lead to attempts.

4. Call an emergency treatment team meeting, because the client’s threat must be addressed

ANS: 3

Rationale: The priority nursing action should be to place this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide.

292. In planning care for a suicidal client, which correctly written outcome should be a nurse’s first priority?

1. The client will not physically harm self.

2. The client will express hope for the future by day three.

3. The client will establish a trusting relationship with the nurse.

4. The client will remain safe during hospital stay.

ANS: 4

Rationale: The nurse’s first priority should be that the client will remain safe during the hospital stay. Client safety should always be the nurse’s first priority. Outcomes should be client-centered, specific, realistic, measureable, and must also include a time frame.

293. A nurse administers 100% oxygen to a client during and after electroconvulsive therapy treatment (ECT). What is the rationale for this procedure?

1. To prevent increased intracranial pressure resulting from anoxia.

2. To prevent decreased blood pressure, pulse, and respiration owing to electrical stimulation.

3. To prevent anoxia resulting from medication-induced paralysis of respiratory muscles.

4. To prevent blocked airway, resulting from seizure activity.

ANS: 3

Rationale: The nurse administers 100% oxygen during and after ECT to prevent anoxia resulting from medication-induced paralysis of respiratory muscles.

294. Immediately after electroconvulsive therapy (ECT), in which position should a nurse place the client?

1. On his or her side, to prevent aspiration

2. In high Fowler’s position, to prevent increased intracranial pressure

3. In Trendelenburg’s position, to promote blood flow to vital organs

4. In prone position, to prevent airway blockage

ANS: 1

Rationale: The nurse should place a client who has received ECT on his or her side, to prevent aspiration.

295. A client is diagnosed with major depressive episode. Which nursing diagnosis should a nurse assign to this client, to address a behavioral symptom of this disorder?

1. Altered communication R/T feelings of worthlessness AEB anhedonia

2. Social isolation R/T poor self-esteem AEB secluding self in room

3. Altered thought processes R/T hopelessness AEB persecutory delusions

4. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia

ANS: 2

Rationale: A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of major depressive episode. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, curled-up position, and no attention to personal hygiene and grooming.

296. A client diagnosed with major depressive episode hears voices commanding self-harm. Which should be the nurse’s priority intervention at this time?

1. Obtaining an order for locked seclusion until client is no longer suicidal.

2. Conducting 15-minute checks to ensure safety.

3. Placing the client on one-to-one observation while continuing to monitor suicidal ideations.

4. Encouraging client to express feelings related to suicide.

ANS: 3

Rationale: The nurse’s priority intervention when a depressed client hears voices commanding self-harm is to place the client on one-to-one observation while continuing to monitor suicidal ideations. By providing one-to-one observation, the nurse will be able to interrupt any attempts at suicide.

297. A nurse assesses a client suspected of having the diagnosis of major depressive episode. Which client symptom would rule out this diagnosis?

1. The client is disheveled and malodorous.

2. The client refuses to interact with others and isolates self in room.

3. The client is unable to feel any pleasure.

4. The client has maxed-out charge cards and exhibits promiscuous behaviors.

ANS: 4

Rationale: The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior is exhibiting signs of mania. The DSM-5 criteria state that there must never have been a manic episode or a hypomanic episode to meet the criteria for the diagnosis of major depressive episode.

298. A client with a history of suicide attempts has been taking fluoxetine (Prozac) for one month. The client suddenly presents with a bright affect, rates mood at 9 out of 10, and is much more communicative. Which action should be the nurse’s priority at this time?

1. Give the client off-unit privileges as positive reinforcement.

2. Encourage the client to share mood improvement in group.

3. Increase the level of this client’s suicide precautions.

4. Request that the psychiatrist reevaluate the current medication protocol.

ANS: 3

Rationale: The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act out self-destructive behavior.

299.A nurse reviews the laboratory data of a client suspected of having the diagnosis of major depressive episode. Which lab value would potentially rule out this diagnosis?

1. Thyroid-stimulating hormone (TSH) level of 25 U/mL

2. Potassium (K+) level of 4.2 mEq/L

3. Sodium (Na+) level of 140 mEq/L

4. Calcium (Ca2+) level of 9.5 mg/dL

ANS: 1

Rationale: A diagnosis of major depressive episode may be ruled out if the client’s lab results reveal a TSH level of 25 U/mL. Normal levels of TSH range from 2 to 10 U/mL. High levels of TSH indicate low thyroid function. The client’s high TSH value may indicate hypothyroidism, which can lead to depressive symptoms. The DSM-5 criteria for the diagnosis of major depressive episode states that this diagnosis must not be attributable to the direct physiological effects of another medical condition.

300. A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. Which theoretical principle best explains the etiology of this client’s depressive symptoms?

1. According to psychoanalytic theory, depression is a result of negative perceptions.

2. According to object-loss theory, depression is a result of overprotection.

3. According to learning theory, depression is a result of repeated failures.

4. According to cognitive theory, depression is a result of anger turned inward.

ANS: 3

Rationale: The nurse should assess that, according to learning theory, this client’s depressive symptoms may have resulted from repeated failures. The learning theory is a model of “learned helplessness” in which multiple life failures cause the client to abandon future attempts to succeed.

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